Hypertension - Treatment Flashcards
What is the first step to diagnose hypertension?
Must use ambulatory blood pressure monitoring (ABPM)
or home blood pressure monitoring (HBPM)
What does ABPM stand for?
Ambulatory blood pressure monitoring
What does HBPM stand for?
Home blood pressure monitoring
What are the different stage of hypertension?
Stage 1
Stage 2
Severe
What is stage 1 hypertension?
Clinic blood pressure of 140/90mmHg
ABOM daytime average of 135/85mmHg
What is stage 2 hypertension?
Clinic blood pressure of 160/100mmHg
ABPM daytime average of 150/95mmHg
What is severe hypertension?
Clinic systolic blood pressure of 180mmHg
or
Diastolic blood pressure os 110mmHg
What is the unit of blood pressure?
mmHg
What 3 things must be done after diagnosing hypertension?
Assess the risk
Assess end organ damage
Screen for treatable causes
What are examples of things that change the risks of having hypertension?
Previous myocardial infarction, stroke ischaemic heart disease
Smoking
Diabetes mellitus
Hypercholesterolemia
Family history
Physical examination
What tests can be done to assess end organ damage?
ECG
Echocardiogram
Proteinuria
Renal ultrasound
Renal function
What are examples of treatable causes of hypertension that can be screened for?
Renal artery stenosis
Cushing’s disease
Conn’s syndrome
Sleep apnoea
How can people check there own risk?
Using online risk calculators
What does the BHS suggest target blood pressure should be?
<135/80-85mmHg
When should treatment for high blood pressure start?
Overall cardiovascular disease risk of 20% in the next 10 years
Why do we treat hypertension?
Reduces cardiovascular disease by 40-50%
Reduces myocardial infarction by 16-30%
By what percentage does treating hypertension reduce risk of cardiovascular disease?
40-50%
By what percentage does treating hypertension reduce risk of myocardial infarction?
16-30%
How do you describe the approach of treating hypertension?
Stepped approach
What does a stepped approach to the treatment of hypertension mean?
Do not continuously change antihypertensive medication
Add new medication to current therapy until the target blood pressure is achieved
How kind of doses and number of drugs are used to treat hypertension?
Low doses of several drugs to minimise adverse effects and maximise patient compliance
What needs to be remembered about all drugs?
They have side effects
How can you describe the renin of young people compared to elderly people?
Young people have high renin whereas elderly have low
What kinds of drugs are recommended for use on young people?
ACE inhibitor
Angiotensin II receptor blockers (ARBS)
What does ARBs stand for?
Angiotensin II receptor blockers
What kind of drugs are recommended for elderly people?
Calcium channel blocker
Thiazide-type diuretic
Should treatment always be offered for stage 1 hypertension?
No, only if they are young than 80 and have at least one of the following:
Target organ damage
Established cardiovascular disease
Renal disease
Diabetes
10 year cardiovascular risk greater than 20%
When should treatment be offered for stage 1 hypertension?
Young than 80 with at least one of the following:
Target organ damage
Established cardiovascular disease
Renal disease
Diabetes
10 year cardiovascular risk greater than 20%
Should treatment always be given for stage 2 hypertension?
Yes
Does age impact whether treatment is given for stage 1 hypertension?
Yes, only give treatment if younger than 80
Does age impact whether treatment is given for stage 2 hypertension?
No
What should you do for people younger than 40 with hypertension?
Seek specialist evaluation of secondary causes and a more detailed assessment of potential target organ damage
For what age group is the target blood pressure different?
People over 80
What is the target blood pressure for people over 80?
<145/85mmHg
How can blood pressure be monitored?
Clinic blood pressure measurements
ABPM (ambulatory blood pressure monitoring) or HBPM (home blood pressure monitoring)
How many steps are there in the stepped approach of hypertension treatment?
4
What is step 1 treatment for someone over 55?
Calcium channel blocker (CCB)
If CCB unsuitable use thiazide-like diuretic instead
Who should a calcium channel blocker (CCB) be offered to as step 1 treatment?
People over 55 and black people
Who should an ACE inhibitor not be offered to?
Black people and pregnant woman
Why would a calcium channel blocker (CCB) be unsuitable?
Oedema
Intolerance
What does CCB stand for?
Calcium channel blocker
What is step 2 tratement for hypertension?
Add thiazide-type diuretic such as cloralidone or indapamide to CCB or ACEI/ARB
What should be used for step 1 treatment of hypertension for people younger than 55 who are not black?
ACE inhibitor or angiotensin II receptor blocker (ARBs)
What is step 3 treatment for hypertension?
Add CCB, ACEI and diuretic together
What is step 4 treatment for?
Resistant hypertension
What is given for step 4 treatment of hypertension?
Consider further diuretic therapy with low dose spironolactone (25mg once daily) if the blood potassium level is 4.5mmol/L or lower
Consider higher dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5mmol/L
What factor decides what is used for step 4 treatment?
If potassium level is smaller or greater than 4.5mmol/L
What should be given for step 4 treatment of hypertension if potasium level is 4.5mmol/L or lower?
Further diuretic therapy with low dose spironolactone (25mg once daily)
When should further diuretic therapy with low dose spironolactone be uses as step 4 treatment?
When potassium levels are 4.5mmol/L or lower
When should you have caution using further diuretic therapy with lose dose spironolactone treatment even when potassium levels are 4.5mmol/L or less?
With people with a reduced estimated glomerular filtration rate (GFR) because they have an increased risk of hyperkalaemia
What does GFR stand for?
Glomerular filtration rate
What is hyperkalaemia?
High blood potassium levels
What are high blood potassium levels called?
Hyperkalaemia
What should be used for step 4 treatment of hypertension when potassium levels are greater than 4.5mmol/L?
Higher dose of thiazide-like diuretic treatment
When should a higher dose of thiazide-like treatment be used as step 4 treatment for hypertension?
When potassium levels are greater than 4.5mmol/L
What should you do if a single agent doesn’t control blood presssure?
Use two together
When should you start treatment?
According to age and other pathology if there are no contraindications
What does ACEI stand for?
Angiotensin converting enzyme inhibitor
What is an example of a angiotensin converting enzyme inhibitor (ACEI)?
Ramipral
How does ramipral work?
Competitively inhibits the actions of angiotensin converting enzyme (ACE)
What are contraindications of angiotensin converting enzyme inhibitor (ACEI)?
Renal artery stenosis
Renal failure
Hyperkalaemia
What are some signs to an adverse drug reaction to angiotensin converting enzyme inhibitors (ACEI)?
Cough
First dose hypotension
Taste disturbance
Renal impairment
Angioneurotic oedema
What are some potential drug-drug interactions of angiotensin converting enzyme inhibitors (ACEI)?
NSAIDS
Potassium supplements
Potassium sparing diuretics
What does the drug interaction between ACEI and NSAIDS cause?
Precipate acute renal failaure
What does the drug interaction between ACEI and potassium supplements cause?
Hyperkalaemia
What does the drug interaction between potassium sparing diuretics and ACEI cause?
Hyperkalaemia
What are examples of angiotensin II antagonists (ARBs)?
Losartan
Valsartan
Candesartan
Irbesartan
How do angiotensin II antagonists work?
Competatively block the actions of angiotensin II at the angiotensin AT1 receptor
What is the advantage of ARBs over ACEI?
No cough as a side effect
Which of ARBs and ACEI can lead to a cough as a side effect?
ACEI
What are examples of calcium channel blockers (CCB)?
Amlodipine/Felodipine
Verapamil/Diatiazem
How do CCBs 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
What CCB is a vasodilator?
Amlodipine/Felodepine
What CCB is a rate limiter?
Verapamil/Diatiazem
Who are vasodilating CCBs the choice for?
Over 55 years
Woman of child bearing age
Why are vasodilating CCBs the choice for people over 55 and woman of child bearing age?
Compliance is high
Benefit in the elderly patient with systolic hypertension
Rarely cause postural hypotension
What is postural hypotension?
Person’s blood pressure drops abnormally when they stand up after sitting or lying down
What is it called when a person’s blood pressure drops abnormally when they stand up after sitting or lying down?
Postural hypotension
What are contraindications of vasodilating CCBs?
Acute myocardial infarction
Heart failure
What is a contraindication of rate limiting CCBs?
Bradycardia
What are adverse drug reactions of vasodilating CCBs?
Flushing
Headache
Ankle oedema
Indigestion and reflux oesophagitis
What are adverse drug reactions of rate limiting CCBs?
Bradycardia
Constipation
What are examples of thiazide-like diuretics?
Indapamide
Clortalidone
What is the mechanism of action of thiazide-like diuretics?
Excretion of sodium through urine
What are some adverse drug reactions of thiazide-like diuretics?
Not common but includes:
Gout
Impotence
What is gout?
Form of arthritis caused by excess uric acid in the bloodstream
What is a form of arthritis caused by excess uric acid in the bloodstream?
Gout
What is impotence?
Inability of a man to achieve an erection or orgasm
What is the inability of a man to achieve an erection of orgasm called?
Impotence
What is a key advantage of thiazide-like diuretics?
Can be used with an other antihypertensive agent
What do thiazide-like diuretics have a proven benefit in?
Stroke and myocardial infarction reduction
What are some less commonly used agents used to treat hypertension?
Alpha-adrenoceptor antagonist
Centrally acting agents
Vasodilators
What is an example of an alpha-adrenoceptor antagonist?
Doxazosin
How do alpha-adrenoceptor antagonists work?
Selectively block post synaptic A1 adrenoceptors and oppose vascular smooth muscle contraction in arteries
What are some adverse drug reactions of alpha-adrenoceptor antagonists?
First dose hypotension
Dizziness
Dry mouth
Headache
What are some examples of centrally acting agents?
Methyldopa
Moxonidine
How do centrally acting agents work?
Converted to a-methylnoradrenaline which acts on the CNS alpha adrenoceptors which decrease central sympathetic outflow
What are some adverse drug reactions of centrally acting agents?
Sedation and drowsiness
Dry mouth and nasal congestion
Orthostatic hypotension
What is orthostatic hypotension?
Decrease in systolic blood pressure of 20mmHg or a decreased in diastolic blood pressure of 10mmHg within 3 minutes of standing up
What is a decrease in systolic blood pressure of 20mmHg or a decreased in diastolic blood pressure of 10mmHg within 3 minutes of standing up called?
Orthostatic hypotension
What are examples of vasodilators?
Hydralazine
Minoxidil
What is the common treatment regimen for someone over 55?
1) Start CCB
2) If no or incomplete effect add thiazide-type diuretic
3) If incomplete effect add ACE inhibitor
4) If incomplete effect add beta blocker
5) If incomplete effect add one of the less commonly used agents
6) No change after this is likely due to non-compliance
What is a common treatment regimen for someone younger than 55?
1) Start ACEI, if woman of child bearing age use CCB or beta blocker
2) If no or incomplete effect add thiazide-like diuretic
3) If incomplete effect add CCB
4) If incomplete effect add beta blocker
5) If incomplete effect add a less commonly used agent
If there is still no change at the final step of treatment what is it likely due to?
Non-compliance
What cause of maternal and featal death is hypertension?
Second most common
What do 30% of woman who have hypertension during pregnancy develop?
Preeclampsia
What is preeclampsia?
Pregnancy complication characterised by high blood pressure and signs of damage to another organ system, most often the liver and kidneys
What organ systems are most often damaged due to preeclampsia?
Liver and kidneys
What is a pregnancy complication characterised by high blood pressure and signs of damage to another organ system called?
Preeclampsia
Other than preeclampsia, what other conditions can hypertensive pregnancy woman get?
Chronic hypertension
Gestational hypertension
What is gestational hypertension?
Blood pressure higher than 140/90mmHg measured on two seperate occastions more than 6 hours apart without the presence of protein in the urine and diagnosed after 20 weeks gestation
What should happen to blood pressure during a normal pregnancy?
It should fall
What happens to blood pressure in a pregnant woman with existing hypertension?
Sometimes blood pressure rises and patient develops hypertension during pregnancy (gestational hypertension)
Sometimes blood pressure rises severely from about 20 weeks to greater than 140/90mmHg and proteinuria more than 300mg/24 hours (preeclampsia)
What is used for the treatment of hypertension during pregnancy?
Nifedipine MR, methyldopa, atenolol, labetalol
Then add thiazide diuretic and/or amlodipine
What medication should never be used for hypertension during pregnancy?
ACE or ARB
What difference is there between the treatment of hypertension during pregnancy and the treatment of preeclampsia?
Normal treatment plus intravenous hydralazine, esmolol and labetalol
