PPT Flashcards
what is ambulatory BP?
measures BP throughout day and night
after ambulatory blood pressure monitoring (ABPM) a patient may be described as normotensive, what does this mean?
ABPM daytime average below 135/85mmHg
after ambulatory blood pressure monitoring (ABPM) a patient may be described as stage 1 hypertensive, what does this mean?
ABPM daytime average 135/85 or higher
after ambulatory blood pressure monitoring (ABPM) a patient may be described as stage 2 hypertensive what does this mean?
ABPM daytime average above 150/95
a patient after having ABPM is shown to have readings at day and night of less than 10% difference, what does this suggest?
blood pressure would normally dip at night
could be an underlying cause such as sleep apnoea for why this is happening
after having ABPM a patient is found to have a daytime average below 135/85 yet a clinical blood pressure persistently over 140/90. what does this suggest?
white coat hypertension
a patient is 75 and has ABPM of 140/90. when should antihypertensive drug treatment be given?
the patient is under 80 with stage 1 hypertension. these patients should be given treatment if they have any of the following:
- target organ damage
- established CVD
- renal disease
- diabetes mellitus
- 10 yr CV risk 20% or higher
a patient is found to have hypertension, what assessment should be offered?
- albumin:creatinine ratio
- test for haematuria using a reagent strip
- plasma glucose
- electrolytes and creatinine
- estimated glomerular filtration rate
- serum total cholesterol and HDL cholesterol
- examine the fundi for the presence of hypertensive retinopathy
- 12-lead electrocardiograph
what drugs are used in the treatment of hypertension (8)?
- ACE Inhibitors
- Angiotensin receptor blockers
- Beta blockers
- Calcium channel blockers
- Thiazide-like/thiazide diuretics
- Spironolactone (aldosterone antagonist)
- Alpha-receptor blockers
- Loop diuretics
describe the step approach of hypertension treatment and what are the exceptions to this?
- ACE inhibitor/ARB
- calcium channel blocker
- thiazide diuretic
- spironolactone
except in patients older than 55 or of afro-caribean origin
how long should you wait before evaluating the therapeutic effect of hypertension treatment and what BP should be aimed for?
1 month
<140/90 in clinic
<135/85 at home
what is a typical drug and dose given in the inital treatment of hypertension in a white patient under 50?
ramipril 2.5mg oral daily
what would be the first step of hypertension treatment in a patient over 55 or of afro-caribbean origin?
calcium channel blocker
what are the potential side effects of ACE inhibitors?
- dry cough (bradykinins)
- hypotension (usually on first dose)
- angioedema (sporadic and unpredictable)
when are the use of ACE inhibitors cautioned?
patients with renal disease
what are the potential drug interactions of ACE inhibitors?
- with spironolactone-hyperkalaemia
- with NSAID-AKI in patients with renal disease due to reduced perfusion
are there any sick day rules for antihypertensives?
yes
don’t take if unwell due to dehydration
describe cholesterol management in primary prevention of CVD?
QRISK >10%
atorvastatin 20mg
What class of drugs are statins?
HMG-CoA reductase inhibitor
describe the main pathway of lipoprotein formation and metabolism?
- lipids and fatty acids in gut emulsified by bile acids
- transported in chylomicrons to liver
- circulated as cholesterol and triglycerides to tisses in VLDL
- endothelial LPL liberates FFA in adipose and muscle for storage or metabolism
- this LDL is returned to hepatocytes via LDL receptors or taken up by LDL receptors in extrahepatic tissues
- here they are oxidised and contribute to atherogenesis
- HDL pool comes from chylomicrons following action of LPL and the reverse cholesterol pathway returns HDL to liver via receptors
when should patients on statins take it?
simvastatin and pravastatin-short half life-taken before bed to maximise effect as HMG-CoA reductase more active at night
atorvastatin and rosuvastatin-longer half life so can be taken when convenient
what is the mechanism of action of statins?
- inhibit HMG-CoA reductase
- reduces intracellular cholesterol
- activates a protease
- this cleaves sterol regulatory element binding protein (SREBPs) from ER
- these translocate to nucleus and upregulate expression of LDL receptor gene
- increases receptor mediated endocytosis of LDL and lowers serum LDL
- HMG-CoA reductase also reduces intracellular levels of isoprenoids which are intermediates of cholesterol biosynthesis
what are the most common side effects of statins?
-headache
-GI disturbances
-muscle-aches, myopathy, rhabdomyolysis
rise in liver enzymes
in what patients should statins be used in with caution?
- hepatic impairment
- excreted by kidneys so dose should be reduced in patients with renal impairment
- avoided in pregnancy (stop if trying to conceive)
- avoid if breastfeeding