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Cardiology > Pharmacology Antihypertensives > Flashcards

Pharmacology Antihypertensives Flashcards

1
Q

The Clinical Management of Hypertension is one of the most common interventions in primary care.

What are the types of Hypertension medications used?

A

3 angiotensin converting enzyme inhibitors
7 β-adrenoceptor antagonists
8 calcium channel entry blockers
18 thiazide and related diuretics
24 α-adrenoceptor antagonists
25 angiotensin receptor antagonists
60 aldosterone antagonists
6P (63) potassium sparing diuretics with other diuretics

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2
Q

Explain the Renin Angiotensin System.

A
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3
Q

Explain how ACE inhibitors work

A

ACE inhibitors inhibit the action of angiotensin-converting enzyme (ACE) which reduces the conversion of angiotensin 1 to angiotensin 2.

Angiotensin 2 is the vasocontrictor and stimulates aldosterone secretion therefore we want to block this action.

This reduces the peripheral resistance of blood vessels and increases the excretion of salt and water.

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4
Q

What are the most widely prescribed ACE inhibitors in UK?

A

Ramipril, Lisinopril, and enalapril.

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5
Q

What type of drug is Ramipril and Enalapril?

A

ACE inhibitors

They are specifically Liver Pro drugs.

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6
Q

What are some adverse effects of ACE inhibitors?

(3 different ones)

A

1- Bradykinin-mediated - . A persistent cough and angioedema are both attributed to enhancing bradykinin activation of peripheral nerves. The persistent cough which occurs in 1 in 5 patients will require a change in antihypertensive therapy and the angioedema is much less frequent but more serious and potentially life-threatening event.

2- Angiotensin Lack - . In patients with renal artery stenosis, the reduction in angiotensin II can induce renal failure

3- A reduction in aldosterone reduces potassium excretion. Risk of hyperkalaemia - do not use with K-sparing diuretics.

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7
Q

ACE inhibitors also are known for breaking down the bradykinin, so when a person takes a ACE inhibitor bradykinin are thought to collect and create which symptom

A

A cough reflex

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8
Q

Taking ACE inhibitors means that there is decreased aldosterone production. What is aldosterone important for and what can the reduction of this result in ?

A

Aldosterone causes sodium to be absorbed and potassium to be excreted.

Hyperkalemia

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9
Q

Other than Hypertension when else can ACE inhibitors be used ?

A
  • To treat heart failure
  • Secondry prevention of major adverse cardiovascular events eg after an MI.
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10
Q

Explain how Angiotension Receptor Blockers (ARBs) work.

A

Instead of inhibiting the conversion of angiotensin 1 to angiotensin 2 like ACE inhibitors do..

ARBS block the action of Angiotensin 2 from binding to receptors.

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11
Q

What are the most common ARBS prescribed in the UK ?

A

losartan, candesartan and irbesartan which are all liver prodrugs

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12
Q

Explain how calicum channel blockers work to reduce hypertention.

A

Calcium channel blockers reduce the entry of calcium across the cell membrane of vascular smooth muscle inducing vasodilatation, and reducing peripheral resistance.

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13
Q

What is the most common Calcium Channel Blocker Prescribed?

A

Today, amlodipine is by far the most widely prescribed CCB in primary care in the UK having a longer half-life allowing once daily therapy with improved patient compliance

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14
Q

When would calcium channel blockers be indicated?

A

Therapeutic Use

Hypertension
peripheral vasodilator

monotherapy of mild hypertension in
- the elderly (55+)
- Afro/Caribbean patients of any age
co-existing - airway disease, peripheral vascular disease, ischaemic heart disease not a problem
disadvantage - co-existing heart failure

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15
Q

What adverse effects are associated with calcium channel blockers ?

A

Adverse Effects

flushing, headache
(arteriolar dilatation)

ankle oedema
(reduced capillary hydrostatic pressure)

palpitations
(reflex tachycardia)

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16
Q

Explain NICE recommended guidance for hypertension (step 1).

A
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17
Q

What type of Diuretic can be prescribed for hypertension?

Give an example …

A

Thiazide Diuretic

Indapamide

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18
Q

How does a Thiazide Diuretic work as an antihypertensive

A

The effect of thiazide inhibiting the reabsorption of sodium and therefore increasing sodium excretion is an effective antihypertensive mechanism.

Thiazides increase sodium excretion generating about 2 litres of urine, reducing the extracellular fluid volume back to normal

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19
Q

What are some adverse effects of prescribing thiazide diuretics ?

A

Risk of hypokalemia - K should be monitored and controlled, potentially use potassium supplements or combined with potassium-sparing diuretics.

20
Q

What BP value is typically indicates to starts drug therapy ?

A

140/90

21
Q

Explain typical drug therapy steps for anyone aged 55 and under suffering from hypertension.

A

1 - ACE Inhibator
2 - ACE + Calcium channel blocker
3- ACE + CCB + Thiazide-like diuretic.

If blood pressure still remains over 140/90 mm/Hg with the patient taking 3 antihypertensive drugs, the hypertension is defined as resistant hypertension and a fourth drug maybe required. Step 4 is to add either a further diuretic or inhibit the sympathetic nervous system with alpha or beta adrenoceptor blockers

22
Q

Explain typical drug therapy steps for anyone aged 55 and over or a black person of African or Caribbean family origin of any age suffering from hypertension.

A

Step 1 - Calcium- Channel Blocker

Step 2- CCB + ACE

Step 3 - CCB + ACE + Thiazide-like diurtetic

If blood pressure still remains over 140/90 mm/Hg with the patient taking 3 antihypertensive drugs, the hypertension is defined as resistant hypertension and a fourth drug maybe required. Step 4 is to add either a further diuretic or inhibit the sympathetic nervous system with alpha or beta adrenoceptor blockers

23
Q

What is the fourth drug that can be given for resistance hypertension?

A

The additional diuretic is spironolactone, an aldosterone receptor antagonist.

Spironolactone antagonises the effect of aldosterone on the distal nephron, inhibiting sodium reabsorption, enhancing its excretion. However, potassium excretion is reduced potentially leading to hyperkalaemia. If the plasma potassium exceeds 4.5 mmol/l , the dose of the thiazide may be increase since it enhances potassium excretion.

24
Q

If the fourth line of treatment (spiralactolone) for resistance hypertension is ineffective what else can be given ?

A

A beta blocker or an alpha-blocker may be prescribed.

Beta-blockers reduce systemic blood pressure by a combined effect on the heart and kidney. Antagonism of the beta1 adrenoceptor in the heart decreases cardiac output producing negative inotropic and chronotropic effects.

The effect on the kidney is also mediated through the beta1 adrenoceptor by inhibition of the release of renin, reducing the level of angiotensin II.

25
Q

What patients can propanolol not be given to and why ?

A

Asthma patients

It is a non selective beta blocker that antagonises both the beta1 adrenoreceptors on the heart and the lungs.

26
Q

What is the most common beta blocker prescribed ?

A

Bisoprolol

27
Q

If a patient has high blood pressure what does it put them at risk of ?

A

stroke,
myocardial infarction,
heart failure,
chronic kidney disease,
cognitive decline
premature death.

28
Q

Name a alpha-adrenoceptor antagonist

A

doxazosin

29
Q

Name a angiotensin receptor antagonist

A

They include irbesartan, valsartan, losartan and candesartan.

30
Q

Name a aldosterone antagonist

A

Spiralactolone

31
Q

Bisoprolol is an antagonist at which type of peripheral receptor?

A

Beta- 1 adrenoreceptor

32
Q

What drug is the first choice when initiating treatment for hypertension in a 40-year-old caucasian patient?

A

Losartan

33
Q

Which ion channel or transport protein is inhibited by bendroflumethiazide in the treatment of hypertension?

A

NA/CL symporter

34
Q

Angiotensin 2 receptor blockers (ARB) reduce the circulating levels of which adrenal hormone?

A

Aldosterone

35
Q

Where is the receptor for the aldosterone antagonist spironolactone, a diuretic for resistant forms of hypertension ?

A

Cell cytoplasm

36
Q

Which CVS drug is most likely to induce flushing, peripheral oedema and postural hypotension?

A

Amlodipine

37
Q

a 27-year-old female is seen in the nephrology clinic. She has a PMH of CKD, focal segmental glomerulosclerosis and HTN which she is taking ramipril 7.5 daily. She mentions she is hoping to start a family soon and wonders wether her medication is suitable.

What advice would you give?

A

Stop ramipril and change to labetalol before conception

38
Q

Which drug is first choice when initiating treatment for hypertension in a patient of Afro-Caribbean origin ?

A

Amlodipine

39
Q

What change in atenolol, a water-soluble drug excreted unchanged, would you expect to see in a patient with renal failure?

A

High plasma concentrations

40
Q

Which one is a common adverse effect of propanolol to discuss with your patients ?

A

Fatigue

41
Q

A 72 year old is admitted by her GP as she has not opened her bowels for 5 days. She denies any pain and feels well in herself.

Her blood chemistry shows her K is 2.7 mmol/l (3.5-5).

What common HTN diuretic could be causing this?

A

Bendroflumethazide

42
Q

When should you stop ACE Inhibitor wiht an EGFR

A

Should not start when eGFR <20% or a

or a 25% drop (CHECK)

43
Q

When should you repeat blood after starting an ACE inhibitor

A

2 weeks

44
Q

What blood test do you need before starting an ACE inhibator?

Why ?

A

Baseline EGFR

PREVENT RENAL STENOSIS

45
Q

Would you just ACE or ARB in a patient with a cough and renal stenosis ?

A

ARB

46
Q
A

Cardiology (18 decks)

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