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B3. Cardiovascular system > Treatment of Hypertension in Adults > Flashcards

Treatment of Hypertension in Adults Flashcards

1
Q

What are ABPM & HBPM?

A

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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2
Q

What are the problems with HBPM?

A

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

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3
Q

Define Stage 1 Hypertension?

A

Clinical BP - 140/90mmHg

ABPM average daytime pressure - 135/85 mmHg

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4
Q

Define Stage 2 Hypertension?

A

Clinical BP - 160/100 mmHg

ABPM average daytime pressure - 150/90 mmHg

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5
Q

Define Severe Hypertension?

A

Clinical BP - Systolic 180 or Diastolic 110.

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6
Q

What happens to BP at night?

A

It should always dip a little lower than daytime.

If they lose it their risk of stroke skyrockets

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7
Q

What are the main risk factors that compound hypertension?

A 
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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8
Q

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

A

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

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9
Q

What is an ACR test?

A

A urine albumin to creatine ratio

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10
Q

What is eGFR?

A

Estimated Glomerular Filtration Rate.

A good measure of renal function

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11
Q

What common causes of hypertension can we screen for?

A
  • Renal artery stenosis or Fibromuscular Dysplasia
  • Cushing’s Disease
  • Conn’s Syndrome
  • Sleep Apnoea
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12
Q

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

A

The Assign Risk Calculator (Q-Risk)

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13
Q

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

A

Asign a target blood pressure.

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

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14
Q

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

A

20% risk of CVD within the next 10 years

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15
Q

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

A

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

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16
Q

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

A

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

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17
Q

Whats the difference between hypertension in the young and old?

A

The young have High Renin Hypertension

The old have Low Renin Hypertension

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18
Q

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

A

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

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19
Q

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

A

An ACE inhibitor

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20
Q

What drug type do we start with in the elderly?

A

A calcium channel blocker or thiazide type diuretic

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21
Q

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

A

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

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22
Q

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

A

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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23
Q

Do we treat everyone with stage 2 hypertension?

A

Yes no matter theyre age.

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24
Q

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

A

Refer to a specialist for:

  • Evaluation of target organ damage
  • Evaluation of possible secondary causes
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25
Q

What should we consider before treating the elderly?

A

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

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26
Q

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

A

With ABPM or HBPM

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27
Q

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

A

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

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28
Q

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

A

A calcium channel blocker?

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29
Q

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

A

A thiazide Type Diuretic

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

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30
Q

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

A

An ACE inhibitor or ARB

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31
Q

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

A

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

32
Q

What do we add for step 2 treatment?

A

A thiazide Type Diuretic for both age groups

33
Q

What do we add for step 3 treatment?

A

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

34
Q

What do we do for step 4 treatment?

A

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

35
Q

Whats an ARB?

A

Angiotensin II antagonist

36
Q

Name 2 ACE inhibitors?

A

Ramipril & Perindopril

37
Q

What effect will ACEIs have physiologically?

A

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

38
Q

What are 3 contraindications for ACEIs?

A

Renal ARtery Stenosis
Renal Failure
Hyperkalemia

39
Q

Name 5 Adverse Drug Reactions to ACEIs?

A
  • Cough
  • 1st dose hypotension
  • Taste Disturbance
  • Renal Impairment
  • Angioneurotic Oedema
40
Q

Name 3 drugs with which ACEIs react and the reactions:

A

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

41
Q

What are ARBs?

A

Angiotensin II antagonists

42
Q

Compare ARBs to ACEIs:

A

ACEIs are more effective

ARBs have far fewer side effects, almost removes the cough

43
Q

What is the pharmacological action of ARBs?

A

They competetively inhibit angiotensin II at the AT1 receptor

44
Q

Name 4 ARBs:

A

Losartan
Candesartan
Valsartan
Irbesartan

45
Q

What are the 2 types of CCBs?

A

Vasodilators, used commonly

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

46
Q

Name 3 vasodilating CCBs:

A

Amlodipine
Felodipine
Nifedipine

47
Q

Name 2 Rate Limiting CCBs?

A

Verapamil

Diltiazem

48
Q

Whats the action of CCBs?

A

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

49
Q

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

A

A vasodilating CCB such as Amlodipine or Felodipine

50
Q

What are 3 contraindications of CCBs?

A

Acute MI
Heart Failure
Bradycardia

51
Q

What are 6 ADRs of CCBs?

A 
Flushing
Headache
Ankle Oedema
Indigestion and reflux oesophagitis
Bradycardia - Rate Limiting only
Constipation - Rate Limiting Only
52
Q

Name 2 Thiazide Type Diuretics?

A

Indapamide

Clortalidone

53
Q

Whats the action of TTDs?

A

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

54
Q

Name 2 ADRs of TTDs?

A

Gout

Impotence

55
Q

How long do TTDs take to work?

A

Can be weeks for the full effect

56
Q

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

A

Afro-Carribeans

57
Q

Name 3 classes of less common hypertension medications:

A
  • Centrally Acting Agents
  • Alpha-Adrenoreceptor antagonists
  • Vasodilators
58
Q

Name 2 centrally acting agents:

A

Methyldopa

Moxonidine

59
Q

When is methyldopa used over other high bp meds?

A

During pregnancy

60
Q

How does methyldopa work?

A

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

61
Q

Name 5 ADRs of methyldopa?

A 
Sedation
Drowsiness
Orthostatic Hypotension
Nasal Congestion
Dry Mouth
62
Q

What does moxonidine do?

A

It acts as a centrally acting imidazine agonist

63
Q

Name 2 vasodilators used less commonly in hypertension treatment:

A

Hydralazine

Minoxidil

64
Q

Name a alpha-adrenoreceptor antagonist?

A

Doxazosin

65
Q

What does Doxazosin do?

A

Opposes smooth muscle contraction by blocking post synaptic alpha1-adrenoreceptors

66
Q

Give 4 ADRs of Doxazosin?

A

Dizziness
Dry Mouth
Headache
1st Dose hypotension

67
Q

Give a brief common treatment regime for someone over 55:

A

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?

68
Q

Give a brief common treatment regime for a young person:

A

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?

69
Q

What do we call Hypertension in pregnancy with proteinuria?

A

Pre-Eclampsia

70
Q

How may hypertension arise in pregnancy?

A
  • Existing Primary Hypertension
  • May rise during pregnancy, Gestational Hypertension (without proteinuria)
  • May rise suddenly after 20 weeks with proteinuria (>300mg/24 hours)
71
Q

What is pre-eclampsia then?

A

Hypertension during pregnancy with proteinuria, often starting after 20 weeks

72
Q

What can you give hypertensive women pre-pregnancy?

A

Not an ACEI or ARB

Nifedipine modified release (basically slow release)
Methyldopa (centrally acting agent)
Atenolol or Labetalol (B blockers)

73
Q

What would you give a hypertensive woman during pregnancy?

A

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

74
Q

What would you give someone with pre-eclampsia?

A

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

75
Q

What must you remember amount Nifedipine?

MAKE MCLAY ANGERY

A

Never use immediate release nifedipine only sustained release

B3. Cardiovascular system (49 decks)

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