Hypertension treatment Flashcards by Anna Coull

what methods can be used to identify true hypertension during ‘out of hours’

must use ABPM - ambulatory blood pressure monitoring - 24/48 hours - measures as you are moving around, living your life normally, have device on you

or HBPM - home blood pressure monitoring - 1 week of measurements

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NICE definition of stage 1 hypertension

Clinic blood pressure is 140/90 mmHg or higher

ABPM daytime average 135/85 mmHg or higher

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NICE definition of stage 2 hypertension

Clinic blood pressure is 160/100 mmHg or higher

ABPM daytime average 150/95 mmHg or higher

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NICE definition of severe hypertension

Clinic systolic blood pressure is 180 mmHg or higher or diastolic blood pressure is 110 mmHg or higher.

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Risk factors contributing to hyperstension (7)

Previous MI, stroke, IHD / Family history
(heart disease)
Smoking
Diabetes mellitus
Hypercholesterolaemia
Renal disease
Male
Age
LV hypertrophy
Alcohol
Race

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define end organ damage

damage occurring in major organs fed by the circulatory system

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Left ventricular hypertrophy LVH

enlargement and thickening of the walls left ventricle

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what investigations can be done to look for LVH

ECG - electrocardiogram

Echocardiogram

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What is ACR? and what does it assess

Urine albumin to creatinine ratio ACR

kidney disease

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Alongwith ACR what else can be used to assess kindey damage

renal ultrasound

eGFR - Glomerular Filtration Rate

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In general, what treatable causes are screened for with BP measurement? (4)

Renal artery stenosis - narrowing of one of the renal arteries

Cushings disease - benign tumor called an adenoma forms in the pituitary gland

Conn’s syndrome - excess production of the hormone aldosterone from the adrenal glands, resulting in low renin levels

sleep apnoea

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what is used to assess risk correctly

assign risk calculator/ Q-risk

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when should treatment of hypertension be started

at an overall CVD risk of 20% /10 years

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why do we treat hypertension? (2)

reduce cerebrovascular disease by 40-50%

reduce MI by 16-30% (heart attack)

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How do we treat hypertension?

stepped approach
use low doses of several drugs
This approach minimises adverse events and maximises patient compliance

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describe the ‘stepped approach’ for treatment of hypertension

Do not continuously change antihypertensive medication

Instead add new medication to current therapy until the target BP is achieved

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what do BHS guidelines suggest for treatment of a young person with high renin

ACE Inhibitor/ARB

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what is renin?

Renin converts angiotensinogen, which is produced in the liver, to the hormone angiotensin I. An enzyme known as ACE or angiotensin-converting enzyme found in the lungs metabolises angiotensin I into angiotensin II.

Angiotensin II causes blood vessels to constrict and blood pressure to increase.

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what do BHS guidelines suggest for treatment of an elderly person with low
renin

Calcium Channel Blocker

Thiazide –Type Diuretic

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treatment of stage 1 hypertension

Offer antihypertensive drug treatment to people aged under 80 years with >140/90 with one or more of the following:

target organ damage
established cardiovascular disease
renal disease
diabetes
a 10-year cardiovascular risk equivalent to 20% or greater.

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treatment of stage 2 hypertension

ABPM> 150/95

Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.

what do you do with a patient under the age of 40 with stage 1 hypertension or greater?

get more detailed assessment of potential target organ damage

specialist evaluation of secondary causes of hypertension

what do you do with a patient over the age of 80 with stage 1 hypertension or greater?

Offer the same antihypertensive drug treatment as people aged 55–80 years, taking into account any co-morbidities.

Blood Pressure target is different
<145/85

what is the white coat effect? what should you consider for these individuals

when someone’s blood pressure is higher in medical setting than at home
Consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment etc

when would a calcium - channel blocker not be a suitable treatment option

if patient has oedema or intolerance | if there is evidence of heart failure or a high risk of heart failure

what would you offer if patient couldn't have calcium channel blocker drug

thiazide-like diuretic

step 1 hypertensive treatment for people aged >55 and to black people of African or Caribbean origin of any year

calcium-channel blocker CCB | or thiazide diuretic

step 1 treatment if under 55

angiotensin converting enzyme inhibitors ACEI/ARB

who can't have angiotensin converting enzyme inhibitors

afro-caribbean people | women of child baring age

step 2 treatment

add thiazide-type diuretic such as clortalidone or indapamide to the CCB or ACEI/ARB

step 3 treatment

add CCB, ACEI, Diuretic together

step 4 treamtent

consider further diuretic therapy be cautious of people with reduced estimated GFR due to risk of hyperkalaemia consider higher dose thiaizde-like diuretic treatment if blood potassium level is higher than 4.5mmol/L

general summary of treatment of hypertension

If there are no contraindications start treatment according to age and other pathology If over 55 years a calcium channel blocker or diuretic If young An ACEI of ARB if a single agent doesn’t control BP Then use combination

Angiotensin Converting Enzyme Inhibitors

Competitively inhibit the actions of angiotensin converting enzyme (ACE) RAMIPRIL, Perindopril

contraindications (reasons they shouldn't take it) with treatment of hypertension (3)

Renal artery stenosis Renal failure Hyperkalaemia

Adverse drug reactions (5)

``` cough first dose hypotension taste disturbance renal impairment angioneurotic oedema ```

what drug-drug interactions occur with hypertensive drugs (3)

NSAIDs- precipitate acute renal failure by increasing BP too much potassium supplements - hyperkalaemia - can cause abnormal heart rhythms potassium sparing diuretics - hyperkalaemia

Angiotensin II Antagonists (ARB)

angiotensin II antagonists competitively block the actions of angiotensin II at the angiotensin AT1 receptor

examples of calcium channel blockers (2)

vasodilator - amlodipine/Felodipine rate limiting - verapamil/diltiazem

how do calcium channel blockers work?

blocking the L type calcium channels selectivity between vascular and cardiac L type channels relaxing large and small arteries and reducing peripheral resistance reducing cardiac output

Benefits (2), contraindications (3), adverse drug reactions (4) with CCBs

- Benefit in the elderly patient with systolic Hypertension - Rarely cause postural hypotension contraindications- Acute MI, Heart failure, bradycardia (rate limiting CCBs) ``` adverse drug reactions - Flushing Headache Ankle oedema - vasodilation of smaller peripheral vessels - discontinuation of capillaries - fluid seeps through gaps Indigestion and reflux oesophagitis ```

contraindications of thiazide-type diuretics (2)

Adverse drug reactions are not common but include gout and impotence (no effect)

less commonly used agents

centrally acting agent - methyldopa | alpha-adrenoceptor antagonist - doxazosin

methyldopa:- use, action, ADRs

Main use is in the treatment of hypertension of pregnancy Converted to alpha-methylnoradrenaline which acts on CNS alpha- adrenoceptors which decrease central sympathetic outflow Adverse Drug reactions Sedation and drowsiness Dry mouth and nasal congestion Orthostatic hypotension

hypertension during pregnancy

second most common cause of maternal and fetal death | during norm pregnancy blood pressure falls

commonest causes of hypertension by age:- newborn infants infants

``` Newborn infants:- Renal artery thrombosis Renal artery stenosis Congenital renal malformations Coarctation ``` ``` Infants – 6 years:- Renal parenchymal disease Coarctation Renal artery stenosis primary hypertension ```

hypertensive emergencies

Reduce mean arterial pressure by less than or equal to 25% Patients with a hypertensive emergency are best managed with a continuous infusion of a short acting, titratable antihypertensive agent.

which type of drug delivery should not be used for hypertensive medication

sublingual and intramuscular | intermittent as required therapy, oral or IV

signs of hypertension

elevated BP | retina vascular changes

Pulmonary hypertension

arterial pressure >35 mmHg at rest RF - family history, HIV, smoking Signs - left parasternal heave, loud P2 sound, peripheral/pulm oedema symptoms - SOB, fatigue, weakness, angina, syncope Diagnosis/investigation - CXR, ECG, Echo, cMRI, routine bloods, liver ultrasound Management - exercise, avoid pregnancy - high mortality, O2 during plane travel, flu vaccine, diuretics, anticoagulants