W2 Clinical Management of Hypertension Flashcards
What is the diagnosis point of hypertension?
How many stages of hypertension?
Clinic BP >140/90 mmHg AND ABPM/HBPM >135/85 mmHg
3
Measuring blood pressure (for info)
- Measure blood pressure in a relaxed, temperate setting, with the
person quiet and seated and their arm outstretched and supported. - Automated devices may not be accurate where there is a pulse irregularity – take brachial pulse for one minute
- Pulse provides information on heart beat (rhythm) and heart contraction (pulsatile volume/strength)
- Strength: weak (0), faint (1+), strong (2+), bounding (3+)
- Rhythm: regular, regularly irregular, irregularly irregular
What are the conditions of taking in-clinic blood pressure? (when to take another reading)
- Both arms – if the difference between arms is more than 15 mmHg use higher
side for subsequent readings and document - If in-clinic BP > 140/90 mmHg, take another reading. If substantially different, take a third reading. Record lower of 2nd or 3rd reading as clinic BP.
- If 140/90 mmHg to 180/120 mmHg offer ABPM (or HBPM if ABPM unavailable).
- If > 180/120 mmHg more urgent investigations/treatment esp. if symptomatic – e.g. chest pain, confusion
What two pulse measurements do you take?
What can you offer a patient to measure their blood pressure?
Radial pulse and Brachial pulse
Ambulatory BP monitoring and Home BP monitoring
What does it mean to assess for ‘target organ damage?”
What tests do these include? (6)
Test for damage to organs such as the heart, brain, kidneys and eyes
- Test for haematuria
- Blood tests… urine albumin, Hba1C (to test for diabetes)
- Electrolytes
- Urine albumin
- Examine the fundi (for presence of hypertensive retinopathy)
- 12-lead electrocardiograph
How can you assess cardiovascular risk?
Q-RISK3
- % will tell you the risk of myocardial infarction or stroke over a 10-year period.
What are the modifiable risk factors for hypertension and hyperlipidemia?(4)
- smoking
- cholesterol
- blood pressure
- BMI
What are the non-modifiable risk factors for hypertension and hyperlipidemia? (7)
- age
- sex
- FHx
- migraine
- RA (Rheumatoid arthritis)
- SLE (lupus)
- severe mental illness
What are the types of Pharmacological treatment for hypertension? (7)
- ACE inhibitors- (Angiotensin converting enzyme)
e.g. ‘prils’ - ARB- (angiotensin ll receptor blockers)
e.g. ‘sartan’ - Dihydropyridine CCB
- Thiazide-like diuretics
- Beta blockers e.g. ‘olol’
- Alpha blockers
- Mineralocorticoid Receptor Antagonists (MRA)
Angiotensin-converting enzyme (ACE) Inhibitors
Role in treating hypertension:
Dose?
Side effects?
- DOSE:
- Initially ramipril 1.25-2.5mg OD, max. 10mg OD
- Others: perindopril, lisinopril, enalapril
- Titrate up to control BP to target
- DURATION: usually lifelong
- Rationale: blocks the production of angiotensin II to prevent vasoconstriction
- Side effects:
- Cough
- Angioedema
- Alopecia
- Electrolyte imbalance
- Hypotension
- Dry mouth
- Altered taste
- C/I: Hx of angioedema with ACEI
- Cautions: African-Carribbean patients may not respond
as well, 1st dose hypotension
Monitoring:
* Renal function
* Electrolytes (potassium)
* Blood pressure
When?
* Before starting
* After initiation
* After dose increase
* Periodically thereafter
- Notes
- ACE inhibitor should be titrated up to control BP to target
Counselling:
* Take first dose sitting down or before b
Angiotensin Receptor Blockers (ARB)
Role in treating hypertension as pharmacological treatment:
Drug names + Dose?
Side effects?
DOSE:
* Initially losartan 50mg OD, max. 100mg OD
* Others: candesartan, valsartan, irbesartan
* Titrate up to control BP to target
* DURATION: usually lifelong
* Rationale: blocks action of angiotensin II at AT1 receptors
Side effects:
* GI disturbances
* Hypotension
* Anaemia
* Angioedema
* Hypoglycaemia
* Electrolyte imbalance
- C/I: none
- Cautions: heart valve stenosis, elderly, Hx of angioedema
Monitoring:
* Renal function
* Electrolytes (INC potassium)
* Blood pressure
When?
* Before starting
* After initiation
* After dose increase
* Periodically thereafter
Counselling:
* Take first dose sitting down or before bed
Notes
* ARB should be titrated up to control BP to target Angiotensin Receptor Blockers (ARB)
Dihydropyridine Calcium Channel Blockers (CCB)in treating htn
Drug names + Dose?
Side effects?
Cautions and Notes?
DOSE:
* Amlodipine: 5mg OD, increased if necessary to 10mg OD
* Felodipine: 5mg OD, increased if necessary to 10mg OD
* Lercanidipine: 10mg OD, increased if necessary to 20mg OD
Side effects:
* Peripheral oedema
* Flushing
* Headaches
* Angioedema
* Arrhythmias
* C/I: Aortic stenosis, Unstable angina
Cautions:
* Heart failure patients (except amlodipine)
* Elderly patients= higher risk of s/e; start at a lower starting dose usually
Monitoring:
* Blood pressure
Notes
* Should not stop taking abruptly
Thiazide-like Diuretics
Role in treating hypertension as pharmacological treatment:
Drug names + Dose?
Side effects?
DOSE:
* Indapamide: 2.5mg in the morning OR 1.5mg m/r in the morning
Side effects:
* Electrolyte imbalance
* GI disturbances
* ED
* Hyperglycaemia
* Skin reactions
C/I:
* Addison’s
* Hypercalcaemia
* Hyponatraemia
* Hypokalaemia
* Symptomatic hyperuricaemia
Cautions:
* Diabetes
* Gout
* Risk of hypokalaemia
* SLE
- Monitoring:
- Renal function
- Electrolytes (↓K/Na)
- Blood pressure
When? - Before starting
- After initiation
- After dose increase
- Periodically thereafter
Beta Blockers
Role in treating hypertension as a pharmacological treatment:
Drug names + Dose?
Side effects?
Atenolol: 25mg daily, max. 50mg daily
Bisoprolol 5-10mg daily, max 20mg daily
Rationale: slows HR and makes heart beat with less force, reducing BP
Side effects:
* Bradycardia
Contra/I:
* Asthmatics
* Hypotension
* Bradycardia
Cautions:
* Diabetes – may mask symptoms of low blood sugar
* Hx of COPD
Monitoring:
* Heart rate
* Lung function in patients with Hx of COPD
Alpha Blockers
Role in treating hypertension as pharmacological treatment:
Drug names + Dose?
Side effects?
Side effects:
* Arrythmias
* Dizziness
* Drowsiness
* Hypotension
C/I:
* Hx of postural ypotension
* Monotherapy in bladder overflow or anuria
Duration: Usually lifelong
Cautions:
* First dose postural hypotension
* Cataract surgery
* Elderly
* Heart failure
