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4TH YEAR - CPTP > Week 7 - HTN & HF > Flashcards

Week 7 - HTN & HF Flashcards

1
Q

What are the causes of secondary HTN?

A
  • Renal disease, renal artery stenosis (fibromuscular hyperplasia in this age group), pre-eclampsia,
  • Conn’s syndrome (primary hyperaldosteronism causes sodium retention and low potassium),
  • Cushing’s syndrome, Coarctation, Phaeochromocytoma, Acromegaly
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2
Q

What are the classifications of HTN?

What action should you take at each stage?

A

Stage 1 hypertension:
• Clinic blood pressure (BP) is 140/90 mmHg or higher and
• ABPM (24 hr) or HBPM average is 135/85 mmHg or higher.

Stage 2 hypertension:
• Clinic BP 160/100 mmHg is or higher and
• ABPM or HBPM daytime average is 150/95 mmHg or higher.

Severe hypertension:
• Clinic BP is 180 mmHg or higher or
• Clinic diastolic BP is 110 mmHg or higher.

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3
Q

What are the complications of having HTN?

A

• MI
• Left ventricular hypertension → very tall QRS
• Stroke → Cerebral infarction, brain haemorrhage, Lacunar syndromes, Multi-infarct disease
• Hypertensive nephrosclerosis → monitor protein urea. Also monitor urine for Albumin-creatinine ratio (ACR). ACR<2 is normal. Haematuria if a bad sign, especially in men, of kidney damage.
• Eyes → Earliest HTN sign is silver wiring – silver look to the arteries. Severe = papilloedema.
• Dissecting aortic aneurysm → severe tearing pain… measure BP in both arms, it will be significantly lower in the left arm than the right arm.
• Peripheral Vascular disease → especially in combination with smoking and diabetes
• Accelerated (malignant) Hypertension – Medical emergency (SBP >200)
o Headache, Visual impairment, Renal impairment, Cardiac failure, Neurological signs, Microangiopathic haemolytic anaemia, Fundal changes

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4
Q

What is the definition of whit coat HTN?

A

A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis

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5
Q

What is the commonest cause of HTN?

A

Essential HTN

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6
Q

What are the strong indications and contraindications of diuretics?

A

Indications: HF
Contraindications: Gout, renal failure

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7
Q

What are the strong indications and contraindications of Beta Blockers?

A

Indications: Angina, Post MI, Tachycardia
Contraindications: Asthma, COPD, Heart block

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8
Q

What are the strong indications and contraindications of ACE i?

A

Indications: HF, LV dysfunction, Post MI, Diabetic nephropathy
Contraindications: Pregnancy, Hyperkalaemia, Bilateral renal artery stenosis

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9
Q

What are the strong indications and contraindications of CCBs?

A

Indications: Elderly, Angina
Contraindications: ?right HF

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10
Q

What are the strong indications and contraindications of alpha blockers?

A

Indications: Prostatism
Contraindications: Urinary incontinence

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11
Q

What HTN treatment should you give to patients who are trying/are pregnant?

A 
Methyldopa
Nifedipine (CCB)
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12
Q

Which antihypertensives cant you use in pregnancy?

A

Beta blocker (except labetolol)
• Unsafe in pregnancy after 28 weeks (growth retardation)
Thiazides
• Unsafe in pregnancy (oligohydramnios)
ACE Inhibitors
• Unsafe throughout pregnancy (congenital malformations (1st trimester exposure) and ACEI fetopathy (2nd trimester exposure).

A2 Antagonists also contraindicated.

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13
Q

How do you calculate ARR?

A

ARR = Current risk x percentage risk reduction of treatment

i. e - 21.3% Q risk, treatment reduces risk 25%
21. 3 x 0.25 = ARR = 5.3%

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14
Q

How do you calculate NNT?

A

1/ARR = NNT
i.e - pt with 21.3% Q risk, treatment reduces risk 25%
ARR = 21.3 x 0.25 = 5.3%
NNT = 1/ARR = 1/0.053 = 18.8 = 19 people of the same Q risk needed to treat to save 1 life.

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15
Q

What is a common side effect of ACE i?

A

Dry cough

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16
Q

If a patient on ACE i experiences a dry cough, what should you do?

A

Chande to ARB - Angiotensin receptor blocker

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17
Q

Name a common ARB and ACE i?

A

ACE i - Lisinopril

ARB - Losartan

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18
Q

What is the effect of losartan on the kidneys?

A

Nephrotoxic

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19
Q

What is the process of treatment for a patient who is under 55 with HTN?

A

1) ACE i
2) ACE i + CCB
3) ACE i + CCB + thiazide-like diuretic
4) (resistant HTN)
ACE i + CCB + thiazide-like diuretic
+ consider further diuretic or alpha/beta blocker

20
Q

What is the process of treatment for a patient who is over 55/black with HTN?

A

1) CCB
2) ACE i + CCB
3) ACE i + CCB + thiazide-like diuretic
4) (resistant HTN)
ACE i + CCB + thiazide-like diuretic
+ consider further diuretic or alpha/beta blocker

21
Q

When do you treat patients with spironolactone instead of thiazide like diuretics?

A

In step 4 - resistant HTN either add:
High dose Thiazide like diuretic - Potassium more than 4.5
or
Spironolactone - Potassium less than 4.5 (K sparing)

22
Q

What is the 1st line treatment for patients in acute HF?

A
  • Sit patient up, give high flow oxygen, iv access
  • Furosemide 40-120mg i.v. (lower dose with diuretic naïve patient)
  • (do not offer diamorphine )
  • NICE does not suggest i.v.nitrates but being increasingly used
23
Q

After you have stabilised your patient in acute HF, what treatment should you offer?

A

Beta blocker

ACE i

24
Q

What general advise is offered to patients who have HF?

A 
•	Weight loss, restrict salt and alcohol intake, take exercise providing heart failure controlled (rehabilitation), 
•	ACEI
•	Beta blocker
•	Loop diuretic (as needed for symptoms)
•	Stop the NSAIDs if at all possible
STOP SMOKING
25
Q

What are the aims of treatment in pts with HF?

A 
Symptom relief
•	reduce SOB, fluid retention
•	diuretics, ACEI
•	digoxin if still symptomatic on optimal dose ACEI/diuretics
Survival benefit
•	ACEI
•	Beta Blocker
•	Spironolactone (post MI)
26
Q

What are the drugs we use in chronic HF? What are the effects of each?

A

Furosemide
• Use to control oedema and breathlessness. Monitor U/E and weight. Effect on survival untested
ACE inhibitor*
• Titrate to effective dose. Monitor U/E and BP. Consider A2 if ACE-specific adverse effects (e.g. cough)
Beta blockade*
• Start with low dose and increase cautiously. Intensify diuretics and ACEI if symptoms develop
Spironolactone*
• Monitor U/E (esp. K+)
Digoxin
• Only in pts with persistent symptoms or AF. Improves symptoms but not survival

*Improve survival

27
Q

What are the common adverse effects of loop diuretics?

A

urinary frequency, hypokalaemia, volume depletion, renal impairment, gout, urinary retention

28
Q

What are the common adverse effects of ACE i?

A

cough, renal impairment, hyperkalaemia, hypotension, angioedema

29
Q

What are the common adverse effects of ARBs?

A

renal impairment, hyperkalaemia, hypotension

30
Q

What are the common adverse effects of Beta blockers?

A

bradyarrhythmias, cold extremities, bronchospasm, fatigue, worsening HF, intermittent claudication

31
Q

What are the common adverse effects of Spironolactone?

A

hyperkalaemia, gynaecomastia

32
Q

What are the common adverse effects of Digoxin?

A

dig toxicity - nausea, vomiting, abdo pain, confusion, brady and tachyarrhythmias

33
Q

What co-morbidities do you need to be aware of when treating HF?

A

BP – high or low
• If hypotensive – cant use GTN as nitrates make you hypotensive

Asthma – avoid β blockers

Renal - Toxicity of ACEi and ARB

34
Q

What are the signs, symptoms and needed actions in acute HF?

A
  • Rapid onset breathlessness
  • Classical signs – raised JVP, ankle oedema, crackles in chest
  • Needs emergency treatment in hospital
35
Q

What is the goals of treatment of chroniuc HF?

A

Needs long term management, fine tuning drug choices to:
o Improve symptoms
o Reduce adverse effects
o Reduce mortality

36
Q

Do you use beta blockers in acute HF?

A

NO!!! - If used in acute heart failure you could patient into cardiogenic shock and kill them. Need to wait until HF has stabilized.

37
Q

What drugs can we use in acute AND chronic HF?

A

Loop diuretics - e.g furosemide, bumetanide

38
Q

What drugs do we use in acute HF?

A

Inotropes - e.g dobutamine (acute/cardiogenic shock)
Opiates - Diamorphine
Nitrates - e.g GTN

39
Q

What drugs do we use in chronic HF?

A

ACE i - e.g lisinopril, ramipril
ARB - e.g losartan
Beta blockers - e.g Atenolol, metoprolol
K sparing diuretics - e.g - spironolactone
Cardiac glycosides - e.g digoxin (especially if AF)

40
Q

What is the use of furosemide in HF?

A

Acutely used IV in combo with oxygen therapy, used to shift fluid (put in a catheter)

Chronic – figure out what dose ~40mg

41
Q

What is the use of Diamorphine in HF?

A

Acute phase breathlessness

42
Q

What is the use of GTN in HF?

A

offload the preload of the heart (give the heart a rest), but cause hypotension so be careful

43
Q

What is the use of Inotropes in HF?

A

help continue to perfuse kidneys but can cause arrhythmias. Often used in short term for patients with catastrophic valve failure or acute MI.

44
Q

What is the use of K+ sparing diuretics in HF?

A

Spironolactone - often used in combo with loop diuretics to fine tune treatment in chronic.
Can cause hyperkalaemia.

45
Q

What is the use of ACE I in HF?

A

Chronic - Start with a low dose and titrate up, checking kidney function as you go. Common side effect is the dry cough.

46
Q

What is the use of ARB in HF?

A

Chronic - Start with a low dose and titrate up, checking kidney function as you go. Alternate if ACE cause bad side effects.

47
Q

What is the use of Digoxin in HF?

A

Use in AF, very narrow therapeutic range → can cause digoxin toxicity.

4TH YEAR - CPTP (19 decks)

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