Pharmacological treatment of Hypertension Flashcards
What increases the chances of harm of hypertension?
- How high the blood pressure is
- How long the person has had high blood pressure
- Whether any relevant concurrent health problems (such as high cholesterol or diabetes)
- Concordance with meds / lifestyle changes
How does each 2mmHg increase affect the chances of heart disease and stroke?
- 7% from heart disease
- 10% from stroke
What percentage of adults over the age of 16 have any CVD condition?
15%
What are the main goals of hypertensive treatment?
- Reduce arterial blood pressure to recommended targets
- Reduce risk of end organ damage (cardiovascular, renal, cerebrovascular)
- Reduce risk of mortality due to Cardiovascular disease
With effective hypertensive treatment how much can the risk of coronary heart diseae be reduced?
20%
With effective hypertensive treatment how much can the risk of cerebrovascular diseae be reduced?
30%
At what blood pressure should blood pressure only be checked every 5 years?
when under 140/90 mmHg (ABPM/HBPM under 135/85 mmHg)
When are anti-hypertensive drugs indicated?
- People of any age with stage 2 or 3 hypertension
- People with stage 1 hypertension who have on or more of the following:
- Target organ damage
- Established cardiovascular disease (CHD,CVA)
- Renal disease
- Diabetes
- A 10-year CV risk equivalent to 10% or greater - Use clinical judgement for people of any age with frailty or multimorbidity
What are some of the CV risk score calculators called?
- ASSIGN
- Qrisk
- JBS3
What are some of the factors that increase CV risk?
- BP
- Age
- Weight/height
- Gender
- Smoking
- Cholesterol
- Ethnicity
- Social class
- Family history
- Diabetes, rheumatoid arthritis, renal function
- Atrial fibrilation
What is the bp goal for ‘standard’ patients?
< 140 / 90 mmHg
What is the bp goal for patients over 80 years old?
< 150 / 90 mmHg
What drugs can increase bp?
- NSAIDs
- Oral steroids
- Venlafaxine (anti-depressant)
- Oral sympathomimetic decongestants (e.g Pseudoephedrine - ‘sudafed’)
- Soluble or dispersible drugs - contain SALT!
- Illicit drug use
What is the step 1 treatment for a patient with hypertension under the age of 55 and without black ethnicity. Also any patient with both hypertension and type 2 diabetes?
ACEi or ARB
What is the step 1 treatment of a patient with hypertension without type 2 diabetes who is over 55 (or of any age but is black)?
CCB
What is the step 2 treatment for a patient with hypertension under the age of 55 and without black ethnicity. Also any patient with both hypertension and type 2 diabetes?
ACEi or ARB + CCB or thiazide-like duiretic
What is the step 2 treatment of a patient with hypertension without type 2 diabetes who is over 55 (or of any age but is black)?
CCB + ACEi or ARB or thiazide-like diuretic
What is the step 3 treatment for hypertension?
ACEi or ARB + CCB + thiazide-like duiretic
What is the step 4 treatment for hypertension?
- Confirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypertension and discuss adherence
- Consider seeking expert advice or adding a:
- Low dose spironalactone if blood potassium levels are <4.5 mmol/l
- Alpha-blocker or beta-blocker if blood potassium levels are >4.5 mmol/l
What does ACDC stand for?
- ACE 1 or ARB
- Calcium channel blocker
- Diuretic (thiazide-like)
- Call for help (resistant hypertension)
What type of drugs are RAAS inhibitors?
- Angiotensin converting enzyme inhibitors
- Angiotensin AT1 receptor blockers
Name 3 ACEi
- Ramipril
- lisinopril
- captopril
Name 3 ARBs (angiotensin receptor antagonists)
- Losartan
- Candesartan
- Irbesartan
Name 3 CCBs (calcium channel blockers)
- Amlodipine
- Felodipine
- Lercanidipine
What are the two major classes of diuretics?
- Thiazide-like diuretics
- High dose loop diuretics
What class of drugs cannot be used when a patient has renal impairment?
Thiazide-like diuretics
Name 2 drugs which are classed as thiazide-like diuretics
- Indapamide
- Bendroflumethiazide
Name a high dose loop diuretic
Furosemide
What is resistant hypertension?
Hypertension that is poorly responsive to treatment and requires the use of multiple medications to achieve acceptable blood pressure ranges
What additional classes of drugs can be used to treat resistant hypertension?
- Sympathetic nervous system antagonists
(Beta-blockers and arenoreceptor blockers) - Kidney function modifiers
(Potassium sparing diuretics and aldosterone antagonists)
When are Kidney function modifiers not used to treat resistant hypertension?
- When K+ > 4.6 mmol/l
- Caution in renal impairment
At what level of potassium are sympathetic nervous sytem antagonists used?
If K+ > 4.5 mmol/l
Name 2 beta-blockers
Atenolol, bisoprolol
Name a a1 blocker
Doxazosin
Name 2 specific kidney function modifying drugs used to treat resistant hypertension
- Amiloride
- Spironolactone
How does doxazosin work to treat resistant hypertension?
- It blocks alpha 1 resecptors
- Blocking vasoconstriction
- Resulting in vasodilation
- Reducing resistance
- decreasing bp
What kind of drugs are used as a first line post MI and HF?
RAAS inhibitors
What muscle cells do DHP-like CCBs have the greatest effect on?
- Vascular smooth muscle
What are the two major classes of kidney function modifiers?
- Thiazide-like diuretics
- Aldosterone antagonists
Name an aldosterone antagonist
Spironolactone
How do thiazide-like diuretics reduce bp?
- Inhibit Na+ reabsorption in nephron
- Also have a direct relaxant effect on vascular smooth muscle
What are the common side-effects of ACEi?
- Oersistant dry cough (15%), dizziness, tiredness, headaches
- Slight increased risk of angioedema African/Caribbean ethnicity
- Risk of hyperkalaemia (care with drug interactions)
- Renal impairment - monitor (though can be reno-productive also)
- Avoid in bilateral renal artery stenosis
- Teratogenic
What are the common side-effects of ARBs?
- Dizziness, headaches, back/leg pain
- Risk of hyperkalaemia, renal impairment
- Avoid in bilat renal artery stenosis
- Teratogenic
What are the common side-effects of Dihydropyridine like calcium channel blockers?
- FLushes
- Headaches
- Ankle oedema
- Dizziness
What are the common side-effects of thiazide-like diuretics?
- Hypokalemia, hyponatraemia, gout, impotence
- Monitor for dehydration
- Ineffective in moderate to severe renal impairment (GFR<30mls/min)
What are the common side-effects of aldosterone antagonist diuretics?
- Hyperkalaemia
- Renal impairment
- GI upset
- Spironalactone
- Oestrogen related side-effects
What are the pros of multi-drug treatment of hypertension?
- Reduced mortality/morbidity
- Each drug class working at different sites on body - can achieve BP treatment targets more quickly
- Reduces dose burden of individual drugs thereby minimising side-effects
What are the cons of multi-drug treatments for hypertension?
- Concordnace problem
- Side-effects may be more frequent
- Increased drug cost to the NHS
What should the target blood pressure be for a patient who presents with a blood pressure of 150/95 mmHg
< 140/90 mmHg
What course of action shoulld you take for a patient who presents with a bp of 140/90 to 179/119?
- Offer home or ambulatory bp
- Investigate target organ damge
- Assess CV risk
What should the course of action be for a patient with an ABP of 135/85 to 149/94? who is under 40?
Consider specialist evaluation of secondary causes and assessment of long-term benefits and risks of treatment
What should the course of action be for a patient with an ABP of 135/85 to 149/94? who is under 60 with 10-year CVD risk <10%?
- Offer lifestyle advice and consider drug treatment
What should the course of action be for a patient who presents with a clinic BP of 180/120 mmHg or more?
- Assess for target organ damage as soon as possible
- Consider starting drug treatment immeadetly without ABPM/HBPM if target organ damage
- Repeat clinic BP in 7 days if no target organ damage
- Refer for same-day specialist review if:
- Retinal haemorrhage or papilloedema )accelerated hypertension or life-threatening symptoms or suspected pheochromocytoma
