Week 7 - HTN & HF Flashcards by Tilly Walker

What are the causes of secondary HTN?

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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What are the classifications of HTN?

What action should you take at each stage?

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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What are the complications of having HTN?

• 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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What is the definition of whit coat HTN?

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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What is the commonest cause of HTN?

Essential HTN

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What are the strong indications and contraindications of diuretics?

Indications: HF
Contraindications: Gout, renal failure

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What are the strong indications and contraindications of Beta Blockers?

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

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What are the strong indications and contraindications of ACE i?

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

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What are the strong indications and contraindications of CCBs?

Indications: Elderly, Angina
Contraindications: ?right HF

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What are the strong indications and contraindications of alpha blockers?

Indications: Prostatism
Contraindications: Urinary incontinence

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

Methyldopa
Nifedipine (CCB)

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Which antihypertensives cant you use in pregnancy?

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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How do you calculate ARR?

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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How do you calculate NNT?

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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What is a common side effect of ACE i?

Dry cough

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

Chande to ARB - Angiotensin receptor blocker

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Name a common ARB and ACE i?

ACE i - Lisinopril

ARB - Losartan

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What is the effect of losartan on the kidneys?

Nephrotoxic

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

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

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

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

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

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)

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

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

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

Beta blocker

ACE i

What general advise is offered to patients who have HF?

•	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

What are the aims of treatment in pts with HF?

``` 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) ```

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

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

What are the common adverse effects of loop diuretics?

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

What are the common adverse effects of ACE i?

cough, renal impairment, hyperkalaemia, hypotension, angioedema

What are the common adverse effects of ARBs?

renal impairment, hyperkalaemia, hypotension

What are the common adverse effects of Beta blockers?

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

What are the common adverse effects of Spironolactone?

hyperkalaemia, gynaecomastia

What are the common adverse effects of Digoxin?

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

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

BP – high or low • If hypotensive – cant use GTN as nitrates make you hypotensive Asthma – avoid β blockers Renal - Toxicity of ACEi and ARB

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

* Rapid onset breathlessness * Classical signs – raised JVP, ankle oedema, crackles in chest * Needs emergency treatment in hospital

What is the goals of treatment of chroniuc HF?

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

Do you use beta blockers in acute HF?

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

What drugs can we use in acute AND chronic HF?

Loop diuretics - e.g furosemide, bumetanide

What drugs do we use in acute HF?

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

What drugs do we use in chronic HF?

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)

What is the use of furosemide in HF?

Acutely used IV in combo with oxygen therapy, used to shift fluid (put in a catheter) Chronic – figure out what dose ~40mg

What is the use of Diamorphine in HF?

Acute phase breathlessness

What is the use of GTN in HF?

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

What is the use of Inotropes in HF?

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

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

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

What is the use of ACE I in HF?

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

What is the use of ARB in HF?

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

What is the use of Digoxin in HF?

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