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MD3001 > Treatment of Hypertension > Flashcards

Treatment of Hypertension Flashcards

1
Q

What are some factors which make it such that hypertension is not treated as often as it should ?

A
  • Lack of symptoms/Unaware (potentially millions of people in UK undiagnosed)
  • poor health literacy
  • poor concordance (adherence)
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2
Q

What are the factors which influence the probability of harm due to hypertension ?

A
  • How high blood pressure is
  • How long the person has had high BP
  • Whether any relevant concurrent health problems (such as high cholesterol or diabetes)
  • Concordance with meds / lifestyle changes.
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3
Q

What is a problem if hypertension goes untreated for a while ?

A

Can lead to vascular and renal changes leading to treatment-resistant state.

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4
Q

Which demographic groups does CVS disease affect more, in Scotland ?

A

Both incidence and prevalence of CVD are higher amongst men, the elderly and in deprived areas of Scotland.

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5
Q

What proportion of the Scottish population over the age of 16 had a CV disease ? What proportion of all deaths in Scotland is CV disease responsible for ?

A

15%

Cardiovascular disease caused more than a quarter of all deaths in Scotland in 2015.”

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6
Q

What are the goals of hypertension treatment ?

A
  • Reduce arterial blood pressure to recommended targets
  • Reduce risk of end organ damage (cardiovascular, renal, cerebrovascular)
  • Reduce risk of mortality due to Cardiovascular disease
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7
Q

What do ABPM and HBPM stand for ?

A

ABPM: ambulatory blood pressure monitoring
HBPM: home blood pressure monitoring

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8
Q

When are anti-hypertensive drugs indicated?

A
  1. People of any age with stage 2 or 3 hypertension
  2. People with stage 1 hypertension who have one or more of the following:
    • target organ damage
    • established cardiovascular disease (CHD,CVA)
    • renal disease
    • diabetes
    • a 10-year cardiovascular risk equivalent to 20% or greater.
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9
Q

How may CV risk be calculated ?

A 
Based on: 
• BP
• Age
• Weight/Height
• Gender
• Smoking
• cholesterol
• Ethnicity
• Social class
• Family history
• Diabetes, rheumatoid arthritis, renal function
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10
Q

Identify tools which allow the calculation of CV risk.

A
  1. ASSIGN
  2. Qrisk
  3. JBS3
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11
Q

What are the BP targets that we usually want to achieve in hypertension treatment ?

A

STANDARD PATIENTS: <140 / 90 mmHg
OVER 80 YEAR OLD: <150 / 90 mmHg
CARDIAC/RENAL DISEASE/DIABETES: <130 / 80 mmHg

But also individualise targets based on appropriateness, tolerability and frailty (patient centered!).

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12
Q

Why is it important to review the patient’s current drugs before commencing hypertension treatment ?

A

Because increase in BP are possible with:
• NSAIDS (e.g. Ibuprofen, diclofenac)
• Oral steroids (e.g. Prednisolone)
• Venlafaxine anti-depressant)
• Oral sympathomimetic decongestants (e.g. Pseudoephedrine – “Sudafed”)
• Soluble or dispersible drugs
• Illicit drug use

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13
Q

Identify all the main drug classes used in hypertension treatment.

A
  • Renin-Angiotensin system inhibitors (ACE inhibitors and Angiotensin AT1 receptor blockers/ARBs)
  • Calcium channel blockers
  • Diuretics (Thiazide-like diuretics and high dose loop diuretics)
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14
Q

Give examples of drugs in each main drug class.

A 
RENIN ANGIOTENSIN SYSTEM INHIBITORS
1) ACE Inhibitors
• Ramipril, lisinopril, captopril
2) ARBs
• Losartan, candesartan, irbesartan

CALCIUM CHANNEL BLOCKERS
1) Dihydropyridine-like CCBs
• Amlodipine, felodipine, lercanidipine

DIURETICS
1) Thiazide-like diuretics
• Indapamide, bendroflumethiazide
2) High dose loop diuretics
• Furosemide
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15
Q

What is the problem with using certain diuretics for hypertension treatment ?

A
  • Thiazide-like diuretics – often essential at step 2 or 3, but not effective in moderate to severe renal impairment
  • High dose loop diuretics may be used instead for raised BP in renal failure
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16
Q

What are the treatments for resistant hypertension ? Mention how they work.

A 
SNS ANTAGONISTS
1) Beta Blockers
• atenolol, bisoprolol
2) a1 Adrenoreceptor Blockers (block vasoconstriction, resulting in vasodilatation)
• doxazosin
KIDNEY FUNCTION MODIFIERS
1) Potassium Sparing Diuretics
• amiloride
2) Aldosterone Antagonists
• spironolactone
17
Q

What is the shortcoming of beta blockers in terms of hypertension treatment ?

A

Beta blockers are less effective at reducing cardiac events and stroke

18
Q

Explain how ACE inhibitors, and ARBs work (both renin-angiotensin system inhibitors)

A

ACE Inhibitors
Inhibit the ACE enzyme, which catalyses the conversion of Angiotensin I into Angiotensin II

ARBs
Prevent binding of Angiotensin II with AT1 receptors

Normally, Angiotensin I → Angiotensin → AT1 receptor → Vascular growth (hyperplasia and hypertrophy) + Vasoconstriction (directly, and via increased NA release from sympathetic nerves) + Salt retention (via aldosterone secretion and tubular Na+ reabsorption)
Hence, ACE Inhibitors and ARBs reduce vascular growth, salt retention, and vasoconstriction.

19
Q

Explain how Calcium channel blockers work.

A

• In general, block entry of calcium through slow channels in cardiac and smooth muscle

Particularly, in hypertension, we use Dihydropyridine-like CCBs (e.g. amlodipine, felodipine, lercanidipine) :
• greater impact on vascular smooth muscle, reduces PR, less effect on myocardium

20
Q

Explain how Kidney function modifiers work.

A

Diuretics in general, block reabsorption of sodium (i.e. increase exretion of sodium and water). E.g.

1) Thiazide-like diuretics
Inhibit Na+Cl- co-transporter in distal tubule
Also cause vasodilation

2) High dose loop diuretics
Inhibits Sodium Potassium Chloride (K+, Na+ and 2Cl- out) co-transporter in thick ascending loop
Do not have same effect as thiazide-like diuretics on vascular smooth muscle

3) Aldosterone antagonists (e.g. spironolactone)
“Bind to receptor in the collecting tubule to prevent aldosterone binding (inhibit Na+Cl- pump)

All of these inhibit sodium reabsorption in nephron, which results in reduced sodium and water retention (in the blood), Increased diuresis, decreased blood volume and decreased BP

21
Q

How do beta blockers work in addressing hypertension ?

A

Block the effects of adrenaline, resulting in reduced HR and force of contraction

22
Q

How do a1 adrenoreceptor blockers work in addressing hypertension ?

A

They block noraderenaline binding to a1 adrenoreceptors, which prevents blood vessels from contracting.

23
Q

Identify the common side effects of ACE inhibitors.

A

• Persistent dry cough (15%, due to ACE inhibitors releasing bradykinin)
• Slight increased risk of angioedema (particularly in patients with African/Caribbean ethnicity, so would use ARBs for that group)
(effect possibly also due to release of bradykinin)
• Tiredness
• Dizziness, headaches
• Risk of hyperkalaemia (care with drug interactions)
• Renal impairment - monitor (though can be reno-protective also)
• Avoid in bilateral renal artery stenosis
• teratogenic (so avoid in pregnant women, use beta blockers in young women of child beating age)

24
Q

Identify the common side effects of ARBs.

A
  • Back/leg pain
  • Dizziness, headaches
  • Risk of hyperkalaemia
  • Renal impairment
  • Avoid in bilat renal artery stenosis
  • teratogenic
25
Q

Identify the common side effects of Dihydropyridine like calcium channel blockers.

A

• Dizziness, headaches, flushing, ankle oedema (due to vasodilation in peripheries. Can be long-standing, so can be reason to withdraw that treatment unlike the other side effects)

26
Q

Identify the common side effects of Thiazide-like diuretics.

A
  • Hypokalemia, hyponatraemia, gout, impotence
  • Monitor for dehydration
  • Ineffective in moderate to severe renal impairment (GFR<30mls/min)
27
Q

Identify the common side effects of Aldosterone antagonist diuretics.

A
  • Hyperkalaemia
  • Renal impairment
  • GI upset
  • Spironolactone - oestrogen (spironolactone has effects on receptors in other parts of body) related side-effects such a menstrual irregularities, testicular atrophy
28
Q

What are the pros and cons of multi-drug treatment of hypertension ?

A

PROS
• Reduced mortality/morbidity
• Each drug class working at different sites on body – can achieve BP treatment targets more quickly
• Reduces dose burden of individual drugs thereby minimising side-effects

CONS
• Concordance problem (“The aim of concordance is the establishment of a therapeutic alliance between the clinician and patient”)
“I felt fine before I started these drugs!”
“I keep forgetting to take all these drugs”

  • Side-effects may be more frequent
  • Increased drug costs to NHS

MD3001 (75 decks)

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