W6: CVS II; Pressure; Peripheral Exchange; BP Control

Question 1

Define hypertension.

Answer 1

1º - no cause; 2º - underlying, YOUNGER PRES.

Stage 1 - 140/90+, ABAM: 135/85

Stage 2 - 160/100+, 150/95

Stage 3 - 180-120+

Question 2

Know the aetiology of hypertension.

Answer 2

1º: Polygene, polyfactorial, ↑reactivity of resistance vessels, ↑TRP, PRESSURE NATRIURESIS

2º:

• ectatic ao.
• renal (fibromuscular dysplasia), renal art. stenosis
• DRUG-INDUCED NSAIDS, oral contraceptive, corticosteroids, cocaine
• PREGNANCY
• ENDOCRINE: aldosterone+++ (CONN’S SYNDROME) common, adenoma idiopathic
• Cushing’s Syndrome: pituitary adenoma
• phaecrocytoma: adrenal malignancy +/-thryroid: CATECHOLAMINES (urine)
• coarctation: hypertens. RHS, hypotensive LHS d/t stenosis
• sleep apnoea

*younger, acute end organ dmg, no other risk factors, severe/resistant

Question 3

Diagnostic tests for HT

Answer 3

• renal funct.
• lipids
• urinanalysis (proteins = renal); 24hr catecholamines = phaecrocytoma
• Aldosterone

=> 20-30 BP measurements of ABPM / HBPM

Question 4

• Be able to discuss the outcome of untreated hypertension.

Answer 4

↑age = ↑↑risk

Question 5

Recognise the effectiveness of treatment for hypertension in both the young and elderly population.

Answer 5

FIRST LINE

1. YOUNG
   => ACE I (RAMIPRIL) / ARB (VALSARTAN)
2. ELDERLY, AFRICAN HERITAGE BG.
   => CBB (AMLODIPINE) / THIAZIDE DIURETIC

ii. thiazide
iii. alternative
iv. beta blocker
v. less common agent

Question 6

ACE INHIBITORS

Answer 6

ramipril, perindoril (ACE I-ILs endings)

• comp. inhib of ACE and prevent Ang I to Ang II
• NSAIDs interaction
• potassium and creatinine levels and the GFR d/t renal impairment
• teratogenic risk!
  • DRY COUGH

Question 7

ARB

Answer 7

valsartan, irbesartan (you get a TAN at ARBys)

• comp. inhib of Ang II via AT1 receptor
• lower sfx, no cough but no outcome benefit
• syncope, headache
• CI: low GFR <80, DM, prego

Question 8

CCB

Answer 8

amlodipine, felodipine (cock block => peen block, -peen ending)

• vasodilator type, reduce peripheral res. (55y/o+, childbearing age)
• sfx rare w/ ankle swelling, flushing, palpitations possible
• sfx: syncope!

verapamil, diltiazem (vera is always constipated)
* ↓HR, L-Type Ca channel, SFX = bradycard., constipation !females,

Question 9

Thiazide Diuretics

Answer 9

indapamide

↑Na excretion = ↓MAP
vasodilation = ↓periph. resistance
long action
SFX = gout, erectile dysfunct.

Question 10

Pregnancy HT

Answer 10

1. chronic HT (existing) VS gestational HT (developed)
   = Nifedipine (mod. rel.) | Methyl Dopa | Labetalol
2. Pre-eclampasia (post HT; end-organ)
   = IV labetalol/hydralazine/comolol + “ “

• pre-pregnancy planning for known-HT
  => “Tx planning is L.M.N.tary my dear Watson!”
  (L for Labetalol, M for Methyl Dopa, N for Nifedipine (Mod. real))

Question 11

Ht Emergency & Urgency; comparison and qualifiers and aims + Tx

Answer 11

1. EMERGENCY: 180/120 w/ organ dmg. 2º care: BP reduction
   * ↓20%/10% aim: 160/100 (6hrs)
   => oral medication / IV (labetalol, nitrates, nicardipine)
   ! never ACE I or ARB (renal)
2. URGENCY: high BP nil organ dmg. 1º care.
   => dual oral rx.

• common organ dmg ID: retinal haemorrhage or papilloedema, oedema
• other LT-symptoms: confusion, HF, AKI

Question 12

Orthostatic HYPO: aetiology; pres.; management

Answer 12

Fall in BP when Pt. stands up (3 mins);

*aging, DM, antiHT drugs; AuImm.; Neurolog. sydrome (autonomic failure)

=> syncope, HF, AF, Dementia, CVD Stroke CAD risk

non-pharma: manoeuvres, sleeping positions, ice cold water
pharma: ↓dosage or move to nighttime dosage
=> fludrocortisone: worsens HT
=> MIDODRINE: neurogenic
=> a1-AR agonist: ↑vasoconstr. and ↑peripheral resistance