Treatment of Hypertension in Adults Flashcards by Ben Johnston

What are ABPM & HBPM?

Ambulatory Blood Pressure Monitoring, automatically takes BP every 1/2 hour
Home Blood Pressure Monitoring, the patient has to take it themselves a few times a day

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What are the problems with HBPM?

Patients will often keep taking their pressures till they get a good result.
Or even just forget to do it

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Define Stage 1 Hypertension?

Clinical BP - 140/90mmHg

ABPM average daytime pressure - 135/85 mmHg

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Define Stage 2 Hypertension?

Clinical BP - 160/100 mmHg

ABPM average daytime pressure - 150/90 mmHg

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Define Severe Hypertension?

Clinical BP - Systolic 180 or Diastolic 110.

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What happens to BP at night?

It should always dip a little lower than daytime.

If they lose it their risk of stroke skyrockets

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What are the main risk factors that compound hypertension?

Any previous MI, Stroke or IHD
Smoking
Diabetes Mellitus
Hypercholesterolaemia
Family History of Heart Disease

Can also assess risk by physical examination

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How do we assess the level of end-organ damage caused by hypertension?

ECG + ECHO —-> LVH
ACR —-> Proteinuria —> Renal Disease
Renal Ultrasound + eGFR —> Renal Disease

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What is an ACR test?

A urine albumin to creatine ratio

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What is eGFR?

Estimated Glomerular Filtration Rate.

A good measure of renal function

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What common causes of hypertension can we screen for?

Renal artery stenosis or Fibromuscular Dysplasia
Cushing’s Disease
Conn’s Syndrome
Sleep Apnoea

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What tool do we use for assessing risk of cardiac disease/stroke based on someones hypertension?

The Assign Risk Calculator (Q-Risk)

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What do we do after assessing someones risk before we plan treatment?

Asign a target blood pressure.

Recommended to aim for <135/80mmHg (145/85 in people over 80)

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What level of CVD risk are we recommended to start treatment at?

20% risk of CVD within the next 10 years

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We take a ‘stepped’ approach to treatment, what does this mean?

We introduce one new drug to current treatment at a time until they begin to work

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Why do we use low doses of several drugs instead of one high dose?

Low doses prevent serious side effects but have almost the same biological action

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Whats the difference between hypertension in the young and old?

The young have High Renin Hypertension

The old have Low Renin Hypertension

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What are the 3 classes of drugs used for hypertension treatment?

A - ACE Inhibitor (angiotensin converting enzyme inhibitor)
C - Calcium Channel Blocker
D - Thiazide Type Diuretic

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What kind of drug do we start with in young hypertensives?

An ACE inhibitor

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What drug type do we start with in the elderly?

A calcium channel blocker or thiazide type diuretic

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Why should we avoid ACE inhibitors in young women if possible?

ACE inhibitors are teratogenic, so if the women happen to fall pregnant it can cause congenital disorders,

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We don’t always treat stage 1 hypertension, in what case would we?

If theyre under 80 with stage 1 hypertension and any of the following:

Target Organ Damage
Establised CVD
Renal Disease
Diabetes
A 20% CVD risk over 10 years

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Do we treat everyone with stage 2 hypertension?

Yes no matter theyre age.

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The patient is <40 yrs old with atleast stage 1 hypertension, what extra do you do for them?

Refer to a specialist for:

Evaluation of target organ damage
Evaluation of possible secondary causes

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What should we consider before treating the elderly?

Side effects, they will effect the elderly more and you dont want to do more harm than good,

How do you monitor the BP of someone your treating if they 'white coat effect'?

With ABPM or HBPM

Do we treat black people differently because they're genetic salt retainers?

Yes we treat black people of any age the same as we treat other races over 55 yrs.

What do we offer as step 1 treatment for those over 55 or afro-carribeans of any age?

A calcium channel blocker?

What do we offer as an alternative step 1 treatment to over 55s and why would we need to?

A thiazide Type Diuretic We cant give a CCB if theres evidence of oedema, intolerance or Heart Failure.

What do we give under 55s for step 1 treatment?

An ACE inhibitor or ARB

How do we treat women of child-baring age for step 1 treatment?

With a CCB, don't want them getting pregnant and having squibs

What do we add for step 2 treatment?

A thiazide Type Diuretic for both age groups

What do we add for step 3 treatment?

All 3 together. A CCB, ACEI/ARB and Diuretic.

What do we do for step 4 treatment?

Depends on blood potassium level: If <4.5mmol/L give further diuretics and low dose spironolactone (25mg once a day) If >4.5mmol/L give higher dose Thiazide Type Diuretics

Whats an ARB?

Angiotensin II antagonist

Name 2 ACE inhibitors?

Ramipril & Perindopril

What effect will ACEIs have physiologically?

They will prevent Angiotensin II forming and so cause vasodilation and reduced water reabsorption. They also lower future organ damage, to which angiotensin II is a main contributor

What are 3 contraindications for ACEIs?

Renal ARtery Stenosis Renal Failure Hyperkalemia

Name 5 Adverse Drug Reactions to ACEIs?

- Cough - 1st dose hypotension - Taste Disturbance - Renal Impairment - Angioneurotic Oedema

Name 3 drugs with which ACEIs react and the reactions:

NSAIDs - Acute Renal Failure Potassium supplement - Hyperkalemia Potassium Sparing Diuretics - Hyperkalemia

What are ARBs?

Angiotensin II antagonists

Compare ARBs to ACEIs:

ACEIs are more effective | ARBs have far fewer side effects, almost removes the cough

What is the pharmacological action of ARBs?

They competetively inhibit angiotensin II at the AT1 receptor

Name 4 ARBs:

Losartan Candesartan Valsartan Irbesartan

What are the 2 types of CCBs?

Vasodilators, used commonly | Rate limiting CCBs, used by specialist clinics when other options are exhausted

Name 3 vasodilating CCBs:

Amlodipine Felodipine Nifedipine

Name 2 Rate Limiting CCBs?

Verapamil | Diltiazem

Whats the action of CCBs?

Block L type Calcium channels. Can be selective between smooth muscle in vessels and cardiac muscle. Therefore TPR and CO go down

What is the treatment of choice for over 55s and women of child bearing age?

A vasodilating CCB such as Amlodipine or Felodipine

What are 3 contraindications of CCBs?

Acute MI Heart Failure Bradycardia

What are 6 ADRs of CCBs?

``` Flushing Headache Ankle Oedema Indigestion and reflux oesophagitis Bradycardia - Rate Limiting only Constipation - Rate Limiting Only ```

Name 2 Thiazide Type Diuretics?

Indapamide | Clortalidone

Whats the action of TTDs?

They block sodium reabsorption and icnrease the amount lost in the urine

Name 2 ADRs of TTDs?

Gout | Impotence

How long do TTDs take to work?

Can be weeks for the full effect

In what group are TTDs most commonly used as a 1st step treatment?

Afro-Carribeans

Name 3 classes of less common hypertension medications:

- Centrally Acting Agents - Alpha-Adrenoreceptor antagonists - Vasodilators

Name 2 centrally acting agents:

Methyldopa | Moxonidine

When is methyldopa used over other high bp meds?

During pregnancy

How does methyldopa work?

1) Converted to alpha-methylnoradrenaline 2) Acts on CNS alpha-adrenoreceptors 3) Decreases Symp. Outflow 4) Lowers MAP

Name 5 ADRs of methyldopa?

``` Sedation Drowsiness Orthostatic Hypotension Nasal Congestion Dry Mouth ```

What does moxonidine do?

It acts as a centrally acting imidazine agonist

Name 2 vasodilators used less commonly in hypertension treatment:

Hydralazine | Minoxidil

Name a alpha-adrenoreceptor antagonist?

Doxazosin

What does Doxazosin do?

Opposes smooth muscle contraction by blocking post synaptic alpha1-adrenoreceptors

Give 4 ADRs of Doxazosin?

Dizziness Dry Mouth Headache 1st Dose hypotension

Give a brief common treatment regime for someone over 55:

Step 1: CCB (probably vasodilating) e.g. Felodipine Step 2: TTD e.g. Imdapamide Step 3: ACEI/ARB e.g. Ramipril/Losartan Step 4: Beta Blocker? Step 5: One of the less commonly used agents or spironolactone?

Give a brief common treatment regime for a young person:

Step 1: ACEI/ARB. If woman of child bearing age stick to CCB Step 2: Thiazide Type Diuretic Step 3: CCB Step 4: Beta Blocker? Step 5: Less common agent or spironolactone?

What do we call Hypertension in pregnancy with proteinuria?

Pre-Eclampsia

How may hypertension arise in pregnancy?

- Existing Primary Hypertension - May rise during pregnancy, Gestational Hypertension (without proteinuria) - May rise suddenly after 20 weeks with proteinuria (>300mg/24 hours)

What is pre-eclampsia then?

Hypertension during pregnancy with proteinuria, often starting after 20 weeks

What can you give hypertensive women pre-pregnancy?

Not an ACEI or ARB Nifedipine modified release (basically slow release) Methyldopa (centrally acting agent) Atenolol or Labetalol (B blockers)

What would you give a hypertensive woman during pregnancy?

Add a thiazide diuretic and/or amlodipine (vasodilating CCB) to the pre-pregnancy treatment.

What would you give someone with pre-eclampsia?

The same pre-pregnancy treatment and the thiazide diuretic or amlodipine adding once pregnancy started. Specifically for pre-eclampsia patients add IV esmolol, labetalol & hydralazine

What must you remember amount Nifedipine? | MAKE MCLAY ANGERY

Never use immediate release nifedipine only sustained release