Hypertension - Treatment Flashcards
What investigation is essential to confirm it is true hypertension?
ABPM (gives true reading)
At what time of the day are ABPM readings usually taken?
daytime, nighttime is best but can be uncomfortable for patient.
What are the risk factors of morbidity to look out for in the history of a hypertensive?
(6)
- Previous MI, stroke, IHD
- Smoker
- Diabetes
- Hyperlipidaemia
- Family history (of CVD)
- Physical Examination
Other than ABPM, outline other investigations which may be carried out to diagnose hypertension.
(4)
- ECG
- Bloods
- Urine dipstick
- Renal ultrasound/tests
What is an ECG used to look for in hypertensives?
Left ventricular hypertrophy
assess end-organ damage
What is a urine dipstick used to look for in hypertensives?
2
- haematuria
- proteinuria
What conditions should be screened for, which are treatable causes of secondary hypertension (secondary)?
(5)
- Renal artery stenosis
- Cushings disease
- Conn’s Syndrome
- Sleep apnoea
- Coarctation of the aorta
What are the signs of hypertension picked up on an ECG? (2)
What do these indicate?
- deep S waves in V1
- tall R waves in V5
Left ventricular hypertrophy
The BHS suggest target pressure should be < ________ mmHg.
135/80-85
Why do we treat hypertension?
2
- to reduce risk of further complications
- e.g. MI, stroke, CVD, renal impairment, retinopathy
What type of approach is taken to treat hypertension? (1)
Why is this approach used? (1)
- stepped
- increasing the dose of the initial medication comes with an increased likelihood of side effects.
- therefore it is better to use low doses of several drugs.
What is the first step of medication treatment for younger hypertensives (<55)?
Why this specific drug?
ACE inhibitor/ARB
Young people have higher levels of renin.
What is the first step of medication treatment for older/black population hypertensives (>55)?
- Ca2+ channel blockers (old)
- thiazide-type diuretic (blacks)
Anti-hypertensive treatment should be offered to patients <80 with ___________ plus one of the following what?
(1)
(5)
ABPM of 135/85mmHg (Type I)
- target organ damage
- established cardiovascular disease (LVH, CHF, CHD)
- renal disease
- diabetes
- a 10-year cardiovascular risk equivalent to 20% or greater
Anti-hypertensive treatment should be offered to which type II hypertensives?
What will their ABPM be if they are stage 2 hypertensive?
People of any age
150/95mmHg
Who should be referred to a specialist for further evaluation?
Why should they be referred to a specialist?
Patients <40 with type I hypertension or greater.
They are likely to have secondary hypertension, and further investigation is required to find the treatable cause.
How does treatment of hypertension differ in people aged 80 or greater?
(2)
- they are offered the same anti-hypertensive drugs as age group 55-80.
- they have a higher target BP = <145/85
What must be carried out or measured when a patient is suspected of white coat hypertension?
ABPM or HBPM
What is the step 1 treatment of hypertensives >55 and for black populations?
(2)
- calcium channel blockers
- given to black people of any age (not only >55)
Why might a calcium channel blocker be unsuitable i.e. what might it lead to?
(3)
- intolerance
- oedema
- evidence/risk of heart failure
What alternative drug may be offered if CCBs are unsuitable e.g. intolerance?
- thiazide-type diuretics
How should you treat if the BP does not seem to be lowering after starting a CCB?
- add on treatment of another drug
- do not increases dosage of original drug
Who should ACE inhibitors and ARBs not be offered to?
Why?
- black/afro-caribbean: less effective, leads to angioedema
- women of child baring age: teratogenicity
What is step 2 of treatment for hypertension?
- add thiazide-type diuretic to treatment regime (on top of ACEI or CCB depending on age)
What is step 3 of treatment for hypertension?
- Add CCB, ACEI, thiazide-type
diuretic together – see what happens.
What is the main issue at step 3 of anti-hypertensive treatment?
compliance in taking medications
What is step 4 of treatment for hypertension?
3
Refer for add on therapy (diuretic):
- spironolactone (if low K level)
- alpha-blocker
- beta-blocker
What side effect does spirnolactone have an increased risk of?
hyperkalaemia
When initiating or changing a diuretic what should be offered?
a thiazide-like diuretic (as opposed to a thiazide-type diuretic)
Name some thiazide-like diuretics?
2
- chlortalidone
- indapamide
What type of hypertension should be treated by step 4 treatment?
resistant hypertension
What is the step 4 treatment of hypertensives with high potassium levels or reduced GFR?
higher-dose thiazide-like diuretic treatment
Name the ACE inhibitor widely used?
Ramipril
What is the advantage of ACE inhibitors? (1)
Prevent end-organ damage
What are the contraindications of ramipril?
3
- Renal artery stenosis
- Renal failure
- Hyperkalaemia
What are the adverse drug reactions of ramipril?
5
- cough
- first dose hypotension
- taste disturbance
- renal impairment
- angioneurotic oedema
What are possible harmful Drug-Drug interactions involving ramipril?
What can they lead to?
(3)
NSAIDS - acute renal failure
Potassium supplements - hyperkalaemia
Potassium sparing diuretics - hyperkalaemia
Name the common ARBs (Angiotensin II receptor blockers) used?
(4)
- losartan
- valsartan
- candesartan
- irbesartan
What are ARBs mechanism of action i.e. what do they interact with?
block the actions of AT II at the AT1 receptor.
What is the advantage of ARBs over ACE inhibitors?
no cough
Name the common CCBs (Calcium channel blockers) used? (4)
Which are the more common drugs used? (2)
- amlodipine
- felodipine
- verapamil
- diltiazem
- amlodipine & felodipine
How do amlodipine and felodipine work?
- vasodilators
How do verapamil and diltiazem work?
- heart rate limiting
How do CCBs work?
5
- blocking L type calcium channels.
- selectivity between vascular and cardiac L type channels.
- relaxes large and small arteries.
- reduced TPR.
- reduced CO.
What are the contraindications of CCBs?
- acute MI
- heart failure, bradycardia (rate limiting CCBs)
What are the adverse drug reactions caused by CCBs?
4
- Flushing
- Headache
- Ankle oedema
- Indigestion and reflux oesophagitis
What are the adverse drug reactions caused by rate limiting CCBs specifically?
(2)
- constipation
- bradycardia
Name the common thiazide-type diuretics used?
2
- Indapamide
- Clortalidone
What do thiazide-type diuretics reduce the risks of?
2
- stroke
- MI
What are thiazide-type diuretics mechanism of action?
Increase urinary secretion of Na
natriuresis
What are the side effects (uncommon) of indapamide?
2
- gout
- impotence
What is the alpha-blocker less commonly used to treat hypertension?
doxasozin
What are the contraindications of alpha-blockers?
4
- First dose hypotension
- Dizziness
- Dry mouth
- Headache
What are the less commonly used centrally acting agents for treating hypertension?
(2)
- Methyldopa
- Moxonidine
When is methyldopa likely to be used?
pregnant women
What are the adverse drug reactiona of methyldopa?
3
- Sedation and drowsiness
- Dry mouth and nasal congestion
- Orthostatic hypotension
What are the less commonly used vasodilators? (2)
Why are they used less frequently?
- Hydralazine
- Minoxidil
they have horrendous side effects.
What is a common treatment regime for a hypertensive for >55?
- CCB
- thiazide-type diuretics
- ACE inhibitor
- B-blocker
- add-on therapy
What is a common treatment regime for a hypertensive for <55?
- ACE inhibitor or CCB (pregnant/child baring age)
- thiazide-type diuretic
- CCB
- B-blocker
- add-on therapy
What does blood pressure normally do during pregnancy?
falls
What is the hypertension that develops during pregnancy called?
gestational hypertension
Sometimes BP rises severely from about week 20 in pregnancy to BP>140/90 mmHg and proteinuria >300mg/24h.
What is this known as?
Preeclampsia
What is the treatment for hypertension in a woman prepregnancy?
- nifedipine MR
- methyl dopa
- atenolol (predictable)
- labetalol (more predictable)
What is the treatment for hypertension in woman during pregnancy?
add thiazide diuretic and/or amlodipine.
Which drugs are given to a pregnant woman with preeclampsia?
normal drugs during pregnancy plus:
- IV hydralazine
- esmolol
- labetalol
______ _______ – severely elevated BP with evidence of acute target organ damage.
Hypertensive emergency
