Treatment of hypertension

Question 1

how to find if true hypertension and why

Answer 1

ABPM (ambulatory blood pressure monitoring) and HPBM (home blood pressure monitoring) because normal day to day BP can be very variable so need 20-30 clinical readings (nocturnal dip or loss of nocturnal dip)

Question 2

do you want nocturnal pressure to be high or low

Answer 2

low. high is very poor prognostic indication

Question 3

white coat hypertension

Answer 3

gets high BP at doctors but not normally. this can be an indication of future heart problems so not benign

Question 4

masked hypertension

Answer 4

high BP becomes low when measured at doctors but is normally high

Question 5

treatment process

Answer 5

assess risk factors, physical examination, assess end organ damage, screen for treatable causes, quantify risk

Question 6

how to assess end organ damage

Answer 6

ECG, echocardiogram, proteinuria, renal ultrasound, renal function

Question 7

screen for treatable causes eg

Answer 7

obesity, drugs, sleep apnoea, renal artery stenosis, conns, cushings, phaechromyocytoma, coarctation

Question 8

how to quantify risk

Answer 8

assign risk calculator, once risk assessed then set a target BP to be obtained, should be perhaps 135/80-85mmHg. treatment started if CVD risk is over 10%

Question 9

how to treat with drugs

Answer 9

stepped approach, low doses of several drugs, minimises adverse events and maximise patient compliance

Question 10

what is used to treat hypertension

Answer 10

A (ACE inhibitor/ARB),(high renin) C (calcium channel blocker), D (thiazide- type diuretic) (low renin)

Question 11

stage 1 hypertension under 80 and ABPM 135/85 are offered antihypertensive drug treatment when

Answer 11

if target organ damage, established cardiovascular disease, renal disease, diabetes, 10 year cardiovascular risk equivalent to 10% or greater

Question 12

stage 2 hypertension under 80 and ABPM 150/95 are offered antihypertensive drug treatment when

Answer 12

offer antihypertensive drug treatment to anyone of any age with stage 2 hypertension

Question 13

stage 1 hypertension under 40 and ABPM 135/85 treatment

Answer 13

seek specialist evaluation of secondary causes, more detailed assessment of potential target organ damage

Question 14

blood pressure target in patients over 80

Answer 14

145/85 so slightly higher

Question 15

step 1 treatment antihypertensive drug choices

Answer 15

CCB or thiazide like diuretic (African or Caribbean thiazide, caucasian CCB)

Question 16

who should be offered ACE inhibitors / ARB

Answer 16

patients under 55 but not African or Caribbean as less effective and higher risk of angioedema, women of child baring age as teratogenic

Question 17

step 2 treatment antihypertensive drug choices

Answer 17

thiazide type diuretic such as indapamide to CCB or ACE1 / ARB

Question 18

step 3 treatment antihypertensive drug choices

Answer 18

add CCB, ACEI, diuretic together

Question 19

step 4 treatment antihypertensive drug choices (resistant hypertension)

Answer 19

consider compliance issues, consider higher dose thiazide like diuretic treatment if blood potassium level is higher than 4.5mmol/l, consider further diuretic theory with low dose spironolactone if BP level is less than 4.5mmol/l. (caution in people with reduced eGFR because increased risk of hyperkalaemia)

Question 20

ACE inhibitors used

Answer 20

(angiotensin converting enzyme inhibitors) ramipril or perindopril. competitively inhibit the actions of angiotensin converting enzyme ACE converts angiotensin I to activa angiotensin II which is a potent vasoconstrictor

Question 21

contraindications to ACE inhibitors

Answer 21

renal artery stenosis, impaired renal function, hyperkaleamia, fertile female (teratogenic),

Question 22

ACE inhibitors drug drug interactions

Answer 22

NSAIDs predicate racute renal failure, potassium supplements cause hyperkalaemia, potassium sparing diuretics cause hyperkalaemia

Question 23

angiotensin II antagonists (ARB)

Answer 23

losartan, valsartan, candesartan, irbesartan. angiotensin II antagonists competitively block the actions of angiotensin II at the angiotensin AT1 receptor. fewer side effects than ACE inhibitors but same outcome

Question 24

calcium channel blockers

Answer 24

amlodipine/ felodipine (vasodilator for reducing peripheral resistance) or verapamil/ diltiazem (reduces heart rate and produce some vasodilation). block the L type calcium channel in the myocytes of the vasculature and heart

Question 25

thiazide type diuretic

Answer 25

indapamide, clortalidone, enhance urinary excretion of sodium, resistance vessel dilatation, can be used in combination with any other antihypertensive agents, proven benefit in reducing risk of stroke and MI. not common adverse reactions but can be erectile dysfunction and gout

Question 26

adverse drug reactions of CCB

Answer 26

flushing, headache, ankle oedema, indigestion, reflux

Question 27

contraindications of CCB

Answer 27

acute MI, heart failure, bradycardia

Question 28

contraindications of CCB

Answer 28

acute MI, heart failure, bradycardia

Question 29

rate limiting agents CCB cause

Answer 29

bradycardia , constipation

Question 30

less commonly used agents

Answer 30

alpha adrenoceptor antagonist, centrally acting agents, vasodilators

Question 31

common treatment regimes if elderly

Answer 31

CCB to thiazide type diuretic to ACE inhibitor to beta blocker to one of less commonly used agents

Question 32

common treatment regimes if under 55

Answer 32

ACE1 (CCB if female of child bearing age) to thiazide type diuretic to CCB to beta blocker to one of less commonly used agents