Treatment of hypertension Flashcards
How do you assess the risk of hypertension
Previous MI, stroke, IHD Smoking Diabetes mellitus Hypercholesterolaemia Family history ( heart disease) Physical Examination
What must you asses on clinical finding of hypertension
Assses for end organ damage,
What are the different techniques used to assess for end organ damage in hypertension
Heart -
ECG + Echocardiogram
Renal -
Renal ultrasound
Assses renal function - GFR
On the assessment of hypertension, what types of treatable cases do you screen for
Renal artery stenosis/FMD
Cushings disease
Conn’s Syndrome
Sleep apnoea
At what percentage risk factor for CVD should treatment be started
20% risk
why should people with low risk at a young age but high BP be treated
As damage will increase with time, as the overall risk is only low now due to your age
Why should women with low risk but high blood pressure be treated
As women going on to become pregnant at a much higher risk of pre-eclampia which threatens both mothers and childs life
What method is used in the treatment plan of hypertension
A stepped approach using the low does of several drugs
using lowest dose and working way up, try and minimise constant change of drug
When would you offer stage one hypertensive treatment
people aged under 80 years with ABPM >140/90
with one or more of the following:
target organ damage
established cardiovascular disease
renal disease
diabetes
a 10-year cardiovascular risk equivalent to 20% or greater.
When would you offer stage 2 treatment of hypertension
ABPM> 160/100
risk and age doesn’t matter now
What strength of treatment does those over 80 years receive, and what is take into consideration
same antihypertensive drug treatment as people aged 55–80 years
co morbidities
What is the blood pressure target for those over 80 years, and why is it this
<140/90
Blood pressure is a higher target, so have a little more risk but therefore have a lower risk of falling over - improve quality of life
In step 1 hypertensive treatment when do you offer a calcium channel blocker
to people aged over 55 years and to black people of African or Caribbean family origin of any age
When would a calcium channel blocker be unsuitable in stage 1 hypersensitivity what would be offered an alternative
intolerance or if there is evidence of heart failure - oedema
or
high risk of heart failure
thiazide like diuretic
When would you offer ACEI/ARB in step 1 hypertension treatment
Patient under 55
Who is not suitable for ACEI/ ARB in step 1 hypertension treatment
Afro Caribbean
Women of child bearing
patients over 55
What is step 2 hypertension treatment
Add Thiazide-type diuretic such as clortalidone or indapamide to
CCB or ACEI/ARB
What is stage 3 hypertension treatment
Add CCB, ACEI, Diuretic together
When would you consider step 4 hypertension treatment and what do you need to take into account
For treatment of resistant hypertension
blood potassium level
What is stage 4 treatment if the blood potassium level is 4.5 mmol/l or lower
Consider further diuretic therapy with low-dose spironolactone (25 mg once daily)
What is stage 4 treatment if the blood potassium level is higher than 4.5 mmol/l
Consider higher-dose thiazide-like diuretic treatment
What patients do you have to be cautious of in stage 4 treatment
patients with a reduced estimated GFR because they have an increased risk of hyperkalaemia.
Examples of Angiotensin Converting Enzyme
Inhibitors
Ramipril, Perindopril
How does ACEI work
Competitively inhibit the actions of angiotensin converting enzyme (ACE) prevents the activation of angiotensin II
preventing vasocontriction and and prevents hypertrophogenic
Patients with what conditions should not receive ACEI and why
Patients with
Renal artery stenosis / Renal failure
(ACEI reduces rena function further)
Diabetes - underlying renal impairment
Hyperkalaemia
(going to increase potassium levels further)
What is the side effect of ACEI
cough first dose hypotension taste disturbance renal impairment angioneurotic oedema
What drug interactions with ACEI can cause Hyperkalaemia
Potassium supplements
Potassium sparing diuretics
What is the result of ACEI and NSAIDS interactions
Precipitate acute renal failure
What is examples of Angiotensin II Antagonists (ARB)
LOSARTAN, VALSARTAN, CANDESARTAN, IRBESARTAN
How does Angiotensin II Antagonists (ARB) work
angiotensin II antagonists competitively block the actions of angiotensin II at the angiotensin AT1 receptor
What is the advantage of ARB over ACEI
No cough
How does ACEI cause hyperkalemia
Because its a Potassium conservation
What is examples of calcium channel blockers
Vasodilator
Amlodipine/Felodipine
Rate limiting
Verapamil/Diltiazem
How does calcium channel blockers work
blocking the L type calcium channels
selectivity between vascular and cardiac L type channels
relaxing large and small arteries and reducing peripheral resistance
reducing cardiac output
What is the side effects of CBB
Flushing
Headache
Ankle oedema (Heart failure/MI)
Indigestion and reflux oesophagitis
Rate limiting agents:
Bradycardia
Constipation
What is examples Thiazide Type Diuretics
Indapamide, Clortalidone
What is the further benefit of Thiazide Type Diuretics
Proven benefit in treating stoke and myocardial infarction reduction
What is the mechanism of action of the thiazide type diuretics
Block reabsorption of sodium,
Increasing urine concentration
therefore reducing blood volume
What is examples of less commonly used agents in the treatment of hypertension
Alpha-adrenoceptor antagonists -
Centrally acting agents
Vasodilators
Beta blockers
What is an examples of a Alpha-adrenoceptor antagonists
DOXAZOSIN
How does Alpha-adrenoceptor antagonists work
Selectively block post synaptic 1-adrenoceptors
Prevent arterial constriction
What is the side effects of Alpha-adrenoceptor antagonists
First dose hypotension
Dizziness
Dry mouth
Headache
What is an example of a Centrally Acting Agents
METHYLDOPA
MOXONIDINE -
How does central acting agents work
lower your heart rate and reduce your blood pressure. They work by preventing your brain from sending signals to your nervous system to speed up your heart rate and narrow your blood vessels
When are central acting agents most likely to be used
Main use is in the treatment of hypertension of pregnancy
What is the side effect of central acting agents
Sedation and drowsiness
Dry mouth and nasal congestion
Orthostatic hypotension
What is the recommended drugs pre pregnancy and during pregnancy
Pre - CBB(Nifedipine MR) Centrally acting agents (Methyl dopa) Beta Blockers (Atenolol, Labetalol) Pregnant - add thiazide diuretic and/or amlodipine
How do you treat preeclampsia
Usual anithypertensive medication
Plus intravenous
beta blockers - esmolol, labetalol
Vasodilators - hydralazine
what is the common risk factor for preeclampsia
existing hypertension
What are the signs of preeclampsia
from about 20 weeks BP>140/90 mmHg
