Lecture 8 - pharmaceutical care in hypertension

Question 1

what are key risk factors for cardiovascular and other complications?

Answer 1

coronary heart disease

stroke heart failure

renal failure

retinopathy

Question 2

describe how we measure blood pressure

Answer 2

measure in both arms (use arm with the highest BP thereafter)

take the mean of at least 2 findings

unless exceptionally high, hypertension should be confirmed by repeat measurements over several weeks

Question 3

how do we act on the sustained clinic blood pressure measurements and ABPM

Answer 3

BP <140/90MMHG; Monitor every 1-5 years

BP >/ 140/90mmhg; treat if high risk (eg target organ damage, exciting CVD, diabetes, 10 year CVD risk >/ 20%)

AND
ABPM average is above or equal to 135/85 mmHg

Question 4

what is the target bp If diabetic with complications existing CVD

Answer 4

/<130/ /<80mmHg

Question 5

what are the therapeutic options for pharmacological managements of hypertension

Answer 5

ACE-1/ ARB
Beta blocker
Calcium channel blocker
Diuretic (thiazide like/ thiazide)

others (eg alpha blocker, vasodilator, centrally acting agent)

Question 6

what is the A (b) / C(D) rule?

Answer 6

Based on renin status
Start with agent most likely to be effective, progress to logical combinations

White and <55 years; high renin (ACE-I/ARB)

Afro-Caribbean and/or ≥55 years; low renin (CCB or Diuretic)

Combine from the other group i.e. A + C or D

Use all 3 if necessary i.e. A + C + D (little evidence to guide us)

Thereafter add alpha-blocker or spironolactone or Beta-blocker

Question 7

when are beta blockers considered?

Answer 7

if white and <55 years as an alternative to A

Question 8

what combined linked to diabetes

Answer 8

avoid combining B with D

Question 9

when is aspiring used as primary prevention and what is the dose?

Answer 9

aspirin 75mg daily

used as primary prevention when
- BP controlled to <150 / 90 mmHg
- traget organ damage present and/ or estimated 10 year CVD risk is >/20 %
- unlicensed
- consider risk - benefit - counselling

Question 10

when are stains used in primary prevention of hypertension?

Answer 10

10 year cvd risk >/ 20%
consider in diabetes
no cholesterol target
check liver function tests

Question 11

when are static used in secondary prevention in hypertension?

Answer 11

commence regardless of level - simvastatin 40mg

aim for <4mmol/L or LDL <2mmol/lL

statin potency becomes important

check LFTs and educate patient

Question 12

what are exacerbating (problem causing) drugs associated with hypertension?

Answer 12

NSAIDs

Oestrogens (eg in oral contraceptives)

sympathomimetics

corticosteroids and other fluid-retaining drugs

medicines with a high sodium-retaining content (eg soluble tablets, some antacids)