Lecture 9 Hypertension I

Question 1

Why does hypertension often co-exists in patients with angina heart failure and myocardial infarction

Answer 1

Because it is one of the major risk factors for all of those cardiovascular diseases

Question 2

Complete this phase. Hypertension is an important ________ ______ of premature ______ (poor health hospital admissions etc) and _______

Answer 2

Preventative cause morbidity mortality

Question 3

Give examples of conditions which hypertension is a major risk factor

Answer 3

Ischaemic and haemorrhagic stroke myocardial infarctions heart failure chronic renal disease cognitive decline

Question 4

What is the effect of hypertension on the atria

Answer 4

Hypertension increases the risk of atrial fibrillation. This is because increases in blood pressure raise the afterload on the heart causing dilation of the atria. This can in turn cause problems with electrical conduction

Question 5

What are the two-separate mechanism by which hypertension increases the risk of stroke

Answer 5

It can increase the risk of both haemorrhagic and ischaemic strokes directly due to the effects of raised peripheral blood pressure but also can lead to atrial fibrillation. Atrial fibrillation has its own independent risk of causes stroke

Question 6

What are the implications of a 2mmHg increase in blood pressure

Answer 6

A 7% increased risk of mortality from IHD and a 10% increase in mortality from stroke

Question 7

Why when patients first present with high blood pressure in the clinic it is referred to as suspected hypertension

Answer 7

Because a number of spurious factors may mean that their clinic blood pressure is higher than normal. This could be due to the anxiety of going to the clinic as well as a number of other situational factors

Question 8

What is the threshold for diagnosis of suspected hypertension

Answer 8

A clinic blood pressure 140/90mmHg or higher

Question 9

What is usually done when a patient first presents with suspected hypertension

Answer 9

People with suspected hypertension are offered ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension. This is a cuff the patients wear for 24hrs to measure the blood pressure over a sustained period of time in an environment the patient is comfortable in

Question 10

What is the main benefit of ambulatory blood pressure monitoring in terms of diagnosing the cause of a patients’ hypertension

Answer 10

ABPM also measures heart rate this allows you to determine if the high blood pressure can be associated with increased heart rates

Question 11

ABPM blood pressures are usually higher than clinic blood pressures T or F

Answer 11

F – vice versa

Question 12

What is the threshold for diagnosis of stage 2 hypertension

Answer 12

A clinic blood pressure consistently around 160/100mmHg and a ABPM consistently around 150/95mmHg

Question 13

What blood pressures are associated with severe hypertension

Answer 13

Systolic pressures >180mmHg and diastolic pressures >110mmHg

Question 14

What are the two different categories of hypertension

Answer 14

Primary (essential) hypertension where the is no obvious cause of the hypertension. Secondary hypertension where the patient is usually young and resistant to blood pressure treatment. This is where there is an underlying cause associated with the kidney or endocrine system

Question 15

Give some examples of conditions that could cause secondary hypertension

Answer 15

Cushing’s syndrome Liddle’s syndrome

Question 16

Alongside antihypertensive drug therapy what additional treatments are recommended for patients with primary hypertension

Answer 16

Lifestyle modifications such as diet and exercise smoking cessation and a lower salt intake

Question 17

Antihypertensive drugs are only administered to patients aged under 80 years with stage 1 hypertension how have one or more of which risk factors

Answer 17

Diabetes target organ damage (left ventricular hypertrophy) renal disease (microalbuminuria) established cardiovascular disease (MI stroke heart failure) or a 10-year cardiovascular risk of 20% or greater

Question 18

What system is used to calculate a patient’s 10-year cardiovascular risk

Answer 18

QRISK2 score

Question 19

Antihypertensive drug treatments are prescribed to people of any age with stage 2 hypertension T of F

Answer 19

T

Question 20

What are the ideal blood pressure targets for antihypertensive drugs

Answer 20

Under 80 years – <140/90mmHg clinic blood pressure (<135/85mmHg ABPM). Over 80 years – <150/90mmHg clinic blood pressure (<145/85mmHg ABPM)

Question 21

Why are clinicians less inclined to lower the blood pressure of patients over 80

Answer 21

There can be a number of issues with lowering an elderly patients blood pressure too much such as cognitive decline syncope and confusion

Question 22

What are the two main variables that are increased in patients with hypertension

Answer 22

Peripheral resistance and cardiac output

Question 23

What is the predominant cause of the high blood pressure in patients with primary hypertension

Answer 23

An increase in peripheral resistance

Question 24

Interplay between which two systems causes an increase in peripheral resistance

Answer 24

Sympathetic nervous system and RAAS

Question 25

Local vascular mediators can also account for a patients hypertension T or F

Answer 25

T

Question 26

Why is cardiac output not an ideal therapeutic target in patients with hypertension

Answer 26

Cardiac output is usually normal in most patients with hypertension

Question 27

Aside from its stimulation of Na+ and water retention through the release of aldosterone how has angiotensin II also been implicated in causing hypertension

Answer 27

It also stimulates vascular growth causing hyperplasia and hypertrophy

Question 28

What are the 9 different targets that can intervene with the neurohumoral response by the sympathetic nervous system and RAAS system

Answer 28

Renin inhibitors ACE inhibitors angiotensin receptor blockers aldosterone antagonists β adrenoceptor antagonists α adrenoceptor antagonists (thiazide) diuretics Ca2+ channel blockers and centrally acting sympathetic drugs

Question 29

Which are the main classes of diuretics used in hypertension

Answer 29

Thiazide-like diuretics and aldosterone antagonists

Question 30

Give some examples of diuretics used in hypertension

Answer 30

Bendroflumethiazide hydrochlorothiazide chlorthalidone and spironolactone

Question 31

Why is spironolactone sometimes used in hypertension

Answer 31

It can be the case that the patients hypertension can be driven by high aldosterone levels. This could be due to Conn’s syndrome or adrenal tumours that increase the secretion of aldosterone. Hence using an aldosterone antagonist that is also a K+ sparing diuretic may be very beneficial

Question 32

What are the main side effects associated with the types of diuretics used in hypertension

Answer 32

Hyponatremia hypokalaemia hypomagnesaemia hypocalcaemia hyperuricaemia (gout) impaired glucose tolerance and erectile dysfunction

Question 33

What are the main clinical indications for β blockers

Answer 33

Ischaemic heart disease heart failure arrhythmia hypertension

Question 34

How does the dose of β blockers differ in hypertension compared to heart failure

Answer 34

Whereas in heart failure where doses are started low and gradually increase you can prescribe higher levels of β blockers in hypertension

Question 35

Give some examples of β blockers licenced for use in hypertension

Answer 35

Bisoprolol carvedilol metoprolol atenolol propranolol nadolol

Question 36

What is the difference between selective and non-selective β blockers

Answer 36

Selective β blockers are always selective for the β1 adrenoceptor whereas non-selective β blockers bind both β1 and β2 adrenoceptors

Question 37

Give some examples of non-specific β blockers

Answer 37

Nadolol carvedilol propranolol

Question 38

Give some examples of specific β blockers

Answer 38

Metoprolol bisoprolol

Question 39

What can be said about the selectivity of atenolol

Answer 39

It is an intermediate selectivity between being β1-selective and non-selective

Question 40

What is meant by a cardioselective β blocker and why is this a misnomer

Answer 40

Cardioselective is used to imply β1AR selectivity as the airway receptors are mainly β2 receptors. However this is a misnomer as up to 40% of cardiac βARs are β2 adrenoceptors

Question 41

What condition majorly contraindicate the use of β blockers in hypertension

Answer 41

Asthma – due to any potential antagonism of the β2ARs in the airway causing bronchoconstriction

Question 42

What are the main adverse effects of β blockers

Answer 42

Fatigue due to blocking sympathetic nervous system headache sleep disturbance/nightmares bradycardia hypotension cold peripheries due to a shutting down of peripheral circulation to maintain central blood pressure and finally erectile dysfunction

Question 43

Which conditions can β blockers often worsen

Answer 43

Asthma (may be severe) or COPD – because of the β2 effects peripheral vascular disease causing claudication (cramping because of decreased blood flow) or Raynaud’s and also it can worsen heart failure