Treatment of Hypertension and Heart Failure

Question 1

What are the 2 elements of control of blood pressure?

Answer 1

The autonomic nervous system, and the RAAS system

Question 2

What is RAAS?

Answer 2

Renin-angiotensin-aldosterone system which allows the kidney to control blood pressure

Question 3

Describe the mechanism of action of the RAAS system.

Answer 3

Decreased renal perfusion due to low blood pressure causes increased release of renin.
Renin converts angiotensinogen to angiotensin 1.
ACE converts angiotensin 1 to angiotensin 2.
Angiotensin 2 causes 3 things to happen:
1. Increased aldosterone output
2. Direct salt and water retention in kidney
3. Causes vasoconstriction

Question 4

What are the 3 BHS classifications of hypertension?

Answer 4

Grade 1 (mild) 140-159/90-99
Grade 2 (moderate) 160-179/100-109
Grade 3 (severe) >180/>110

Question 5

What are the first line treatments for hypertension in pts under 55?

Answer 5

ACE inhibitor or ARB if not tolerated

Question 6

What are the second line treatments for hypertension in pts under 55?

Answer 6

Combining a calcium channel blocker with the ACEI/ARB

Question 7

What are the third line treatment for hypertension in pts under 55?

Answer 7

ACEI/ARB + Calcium channel blocker + thiazide diuretic

Question 8

What are the fourth line treatments for hypertension in pts under 55?

Answer 8

ACEI/ARB + Calcium Channel blocker + Thiazide diuretic + Low does spironolactone

Question 9

What are the first line treatments for hypertension in pts over 55 or of African or Caribbean origin?

Answer 9

Calcium Channel blocker

Or

Thiazide diuretic if CCB not tolerated

Question 10

What are the second line treatments for hypertension in pts over 55 or of Africa or Caribbean origin?

Answer 10

CCB or Thiazide diuretic, + ACEI/ARB

Question 11

What are the third line treatment for hypertension in pts over 55 or of African or Caribbean origin?

Answer 11

ACEI/ARB + Calcium Channel blocker + Thiazide diuretic

Question 12

What are the fourth line treatment for hypertension in pts over 55 or of African or Caribbean origin?

Answer 12

ACEI/ARB + Calcium Channel blocker + Thiazide diuretic + Low does spironolactone

Question 13

How do ACE inhibitors work?

Answer 13

By competitively inhibiting ACE to reduce angiotensin 2 formation

Question 14

What are the most commonly used ACE inhibitors?

Answer 14

Ramipril
Lisinopril
Enalapril

Question 15

What are the main side effects associated with ACE inhibitors?

Answer 15

Dry cough (10-15%)
Hyperkalaemi
Renal failure

Question 16

How do ARBs work?

Answer 16

Bind to angiotensin 1 to prevent conversion to AT2 to prevent aldosterone production and vasoconstriction of renal artery.

Question 17

Are ARBs well tolerated?

Answer 17

Generally, yes. They have few side effects.

Question 18

What are the few side effects of ARBs?

Answer 18

Renal failure

Hyperkalaemia

Question 19

What are the commonly used ARBs?

Answer 19

Losartan
Valsartan
Candesartan

Question 20

How many classes of calcium channel blockers are there?

Answer 20

3

Question 21

How do calcium channel blockers work?

Answer 21

Bind to specific alpha subunits of L-type calcium channels to reduce cellular calcium entry.

Question 22

What are the three classes of calcium channel blockers?

Answer 22

1. Dihydropyridines
2. Phenylalkylamines
3. Benzothiazepines

Question 23

Which calcium channel blockers come under the category of dihydropyridines?

Answer 23

Nifedipine

Amlodipine

Question 24

Which calcium channel blockers come under the category of benzthiazepines?

Answer 24

Diltiazem

Question 25

Which calcium channel blockers come under the category of phenylalkyamines?

Answer 25

Verapamil

Question 26

What effect do calcium channel blockers have on the body?

Answer 26

- Peripheral vasodilation - Coronary artery vasodilation - Pulmonary artery vasodilation

Question 27

Which calcium channel blockers are good for rate control?

Answer 27

Verapamil | Diltiazem

Question 28

Which calcium channel blockers are good for ischaemic heart disease and heart failure?

Answer 28

Amlodipine | Nifedipine

Question 29

Are amlodipine and nifedipine used in the acute setting?

Answer 29

No as they a large volume of distribution so therapeutic levels take a while to establish

Question 30

Which kind of calcium channel blockers are good for use in heart failure?

Answer 30

Dihydropyridines i.e. amlodipine and nifedipine, as the others can worsen heart failure.

Question 31

How do thiazide diuretics work?

Answer 31

Reduce distal tubular resorption of Na+

Question 32

What are the ADRs associated with thiazide diuretics?

Answer 32

Hypokalaemia Hyperuraemia Impaired glucose tolerance

Question 33

A diabetic patient i started on bendroflumethiazide and atenolol. What is the worry here?

Answer 33

The combination of those 2 drugs can impair glucose tolerance

Question 34

Which condition is a contraindication for thiazide diuretics?

Answer 34

Gout

Question 35

If a pt has angina as well as high blood pressure, what additional drug may be beneficial for both conditions?

Answer 35

Beta blocker

Question 36

Name some beta bockers.

Answer 36

Atenolol Bisoprolol Nebivolol

Question 37

Which condition are beta blockers contraindicated in?

Answer 37

Asthma

Question 38

Other than the commonly used drugs and beta blockers, which other drug classes can lower BP?

Answer 38

Alpha blockers Direct renin inhibitors Centrally acting agents

Question 39

Give and example of an alpha blocker?

Answer 39

Doxazosin

Question 40

In which position do alpha blockers have the most effect on blood pressure?

Answer 40

The upright position i.e. they can cause postural hypotension

Question 41

Which centrally acting agents can lower BP?

Answer 41

- Methylopa - Clonidine - Moxoxidil

Question 42

What is the aetiology of heart failure?

Answer 42

``` IHD HTN Cardiomyopathies Valvular disease Conduction pathway pathology ``` This leads to LV dysfunction