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Cardiovascular block > Treatment of hypertension > Flashcards

Treatment of hypertension Flashcards

1
Q

Why do we need to identify true hypertension ?

A

Because the normal day to day variation in BP we need 20-30 clinic readings to be certain of true BP
Must use ABPM or HBPM

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2
Q

What are the risk factors we need to assess ?

A 
Previous stroke, MI, IHD
Smoking 
Diabetes mellitus 
Hypercholesterolaemia 
Family history 
Physical examination
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3
Q

What investigations are used for end organ damage ?

A

ECHO/ECG- LVH
Urine analysis- proteinuria
renal ultrasound
renal function

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4
Q

What treatable causes would we screen for ?

A 
Obesity
Renal artery stenosis/ FMD
Conn's, Cushing's, Pheochromocytoma
Coarctation 
Drug induced
Sleep apnoea
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5
Q

What risk assessment tools can be used to quantify risk ?

A

Assign risk calculator/ Q-risk

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6
Q

What are the reasons for treating hypertension ?

A

Reduce cerebrovascular disease

Reduce MI by 16-30%

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7
Q

How do we treat hypertesnion ?

A

Stepped approach
Use low doses of several; drugs
This approach minimises adverse events and maximises pateint compliance

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8
Q

What is the treatment of hypertension un <55yrs ?

A

ACEI/ ARB

Beta-blocker

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9
Q

What is the treatment of hypertension in >55yrs or afro-Caribbean ?

A

Calcium channel blocker

Thiazide- type diuretic

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10
Q

What is the treatment of stage 1 hypertension ?

A

Offer antihypertensive drug treatment to people ages under 80 years with ABPM >135/85 with one or more of the following:

- target organ damage 
- established cardiovascular disease
- renal disease
- diabetes
- a 10yr cardiovascular risk equivalent to 10% or greater
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11
Q

What is the treatment for stage 2 hypertension ?

A

Offer antihypertensive drug treatment to people of any age with stage 2 hypertension

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12
Q

What is the treatment for people <40yrs with stage 1 hypertension ?

A

Seek specialist evaluation of secondary causes of hypertension
More detailed assessment of potential target organ damage

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13
Q

What is the treatment of the elderly pateint ?

A

Offer people aged 80ys or above the same antihypertensive drug treatment as people ages 55-80 years, taking into account any co-morbidities
BP target is different in the pateints >80yrs
<145/85

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14
Q

How should we choose the right antihypertensive drug ?

A

Step 1 treatment in those people ages over 55yrs and black people of any age:

- start treatment with:
- calcium channel blocker 
- thiazide like diuretic
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15
Q

What is step 1 treatment ?

A

Patient under 55 years offer ACE/ARB
Not:
- African or Caribbean- less effective and higher risk of angioedema
- women of child bearing age- teratogenic

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16
Q

What is step 2 treatment ?

A

Add thiazide-type diuretic such as indapamide to CCB or ACEI/ARB

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17
Q

What is step 3 treatment ?

A

Add CCB, ACEI, diuretic toghether

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18
Q

What is the treatment of resistant hypertension ?

A

Step 4 treatment

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19
Q

What is step 4 treatment ?

A

Consider compliance issues
Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5mmol/l
Consider further diuretic therapy with low-dose spironolactone 25mg once daily) if blood
potassium level is <4.5mmol/l

20
Q

If there are no contraindications should we start treatment for resistant hypertension ?

A

Yes, start treatment according to age and other pathology
If over 55 years:
- a CCB or thiazide-like diuretic
Dont use max dose as side effects more common

21
Q

For resistant hypertension, what should we use if pateint is young and male ?

A

An ACEI or ARB

If single agent doesn’t control BP, then add a second agent

22
Q

What does ACE inhibitors do ?

A

Completely inhibit the actions of angiotensin converting enzymes- ACE
ACE converts angiotensin I to active angiotensin II which is a potent vasoconstrictor

23
Q

What are examples of ACEI ?

A

Ramipril

Perindopril

24
Q

What are the contraindications of ACEI ?

A 
Renal artery stenosis:
  - may precipitate renal failure of renal infacrtion
Impaired renal function:
  - renal failure
Hyperkalaemia:
  - worsens it 
Fertile female:
  - teratogenic
25
Q

What are the drug-drug interactions of ACEI ?

A 
NSAIDs:
       - precipitate acute renal failure 
Potassium supplements:
       - hyperkalaemia
Potassium sparing diuretics:
       - hyperkalaemia
26
Q

What is the most common side effect of ACEI ?

A

Cough

27
Q

What do angiotensin II receptor blockers do ?

A

Angiotensin II antagonists competitively block the actions of angiotensin II at the angiotensin AT1 receptor

28
Q

What are examples of ARBs ?

A

Losartan
Valsartan
Candesartan
Irbesartan

29
Q

What are the vasodilating calcium channel blockers and what do they do ?

A

Amlodipine/felodipine

Reduce peripheral resistance

30
Q

What are the rate limiting CCBs and what do they do ?

A

Verapamil/diltiazem

Block the L-type calcium channel in the myocytes of the vasculature and heart

31
Q

Vasodilating CCBs are the choice when ?

A

Over 55yrs
Women of child bearing age (nifedipine modified release), compliance is high
Benefit in the elderly pateint with systolic hypertension
Rarely cause postural hypotension

32
Q

What are the adverse drug effect of CCBS ?

A

Flushing
Headache
Ankle oedema
Indigestion and reflux oesophagitis

33
Q

What are the contraindications to CCBs ?

A

Acute MI

Heart failure, bradycardia (rate limiting)

34
Q

What can rate limiting agents cause ?

A

Bradycardia

Constipation

35
Q

What is the common first line treatment for mild-moderate hypertension in people of African origin ?

A

Thiazide-type diuretics

36
Q

What are examples of Thiazide type diuretics ?

A

Indapamide

Clortalidone

37
Q

What are the mechanisms of action of thiazide type diuretics ?

A

Urinary excretion of sodium

Resistance vessel dilatation

38
Q

What are the adverse drug effects of thiazide type diuretics ?

A

Gout

ED

39
Q

What are commonly less used agents ?

A 
Alpha-adrenoceptor antagonists:
    - Doxazosin
Centrally acting agents:
    - Methyldopa
    - Moxonidine
Vasodilators:
    - Hydralazine
    - Minoxidil
40
Q

What are examples of Alpha-adrenoreceptor blocker ?

A

Doxazosin
Methyldopa
Moxonidine

41
Q

What is the mechanism of action of Doxazosin ?

A

Selectively block post synaptic alpha1- adrenoreceptors

Oppose vascular smooth muscle contraction in arteries

42
Q

What are the adverse drug reactions of doxazosin ?

A

First dose hypertension
Dizziness
Dry mouth
Headache

43
Q

When is methyldopa used ?

A

Hypertension in pregnancy

44
Q

What are the adverse drug effects of Methyldopa ?

A

Sedation and drowsiness
Dry mouth and nasal congestion
Orthostatic hypotension

45
Q

What is the action of Moxonidine ?

A

Centrally acting imidazoline agonist

Ideal pateint population in which it should be used has not be defined

46
Q

What are the common treatment regimes for pateints >55yrs ?

A 
Start CCB- no or incomplete effect
Add thiazide-like diuretic- incomplete effect 
Add ACEI - still incomplete effect 
Add B-blocker- still incomplete effect 
Add one of the less commonly used agents
47
Q

What is the treatment regime for young pateints ?

A

Start ACEI
If female of child bearing age start CCB or B-blocker
No or incomplete effect
Add thiazide type diuretic- incomplete effect
Add CCB- still incomplete effect
Add B-blocker- still incomplete effect
Add one of the less commonly used agents

Cardiovascular block (28 decks)

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