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Cardiovascular system > hypertension > Flashcards

hypertension Flashcards

1
Q

what is the clinic measurement of high blood pressure

A

a clinic blood pressure of 140/90mmhg or more

```
systolic = 140 or more
(diastolic = 90 or more)
~~~

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2
Q

what are the 3 stages of hypertension and their clinic blood measurements

A

stage 1 = from 140/90mmhg (clinic bp). (home/ambulatory bp 135/85mmhg)

stage 2= from 160/100 mmhg . (150/95 for home/ambulatory bp)

stage 3 (severe)= a systolic of 180mmhg + or a diastolic of 120mmhg+

note all of these are clinic blood pressures not home blood pressure monitoring

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3
Q

what is accelerated (or malignant) hypertension

A

when your blood pressure suddenly raises to more than 180mmhg and you have signs of retinal haemorrhage or papilloedema (swelling of the optic nerve)

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4
Q

when should you refer patients with hypertension for a same day specialist appointment

A
  • if they have severe hypertension (systolic = 180mmhg+ or diastolic= 120mmhg+) with or without symptoms such as: retinal haemorrhage, accelerated hypertension, chest pain, confusion, acute kidney injury or signs of heart failure
  • signs of phaeochromocytoma (tumour on the adrenal glands) such as postural hypotension, headache, palpitations, abdominal pain, pale skin (pallor)
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5
Q

what is the target blood pressure patients UNDER 80 years old

A

clinic blood pressure = 140/90mmhg

home blood pressure monitor (HBPM) = 135/85 mmhg

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6
Q

what is the target blood pressure for patients OVER 80 years old

A

clinic blood pressure = 150/90 mmhg

home blood pressure monitor (HBPM)= 145/85 mmhg

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7
Q

when should you consider starting a patient on anti-hypertensive drug treatment

A
  • under 80 with stage 1 hypertension and target organ damage or with a 10 year cardiovascular risk of > 10%
  • all patients with stage 2 hypertension regardless of age
  • severe hypertension (same day specialist referral). Start IV antihypertensives immediately
  • if under 40 with stage 1 hypertension, seek specialist advice for secondary causes of hypertension
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8
Q

what should you do if a patient is under 40 with stage 1 hypertension

A

get specialist advice for secondary causes of hypertension

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9
Q

which patients do you need to assess their cardiovascular risk

A

need to assess cardiovascular risk of all patients with confirmed hypertension using clinic blood pressure measurements

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10
Q

what monitoring should occur when you assess a patients cardiovascular risk

A
  • glycated haemoglobin
  • electrolytes
  • creatinine
  • estimated glomular filtration rate (EGFR)
  • total and HDL cholesterol
  • tests for the presence of proteinuria, haematuria, and hypertensive retinopathy undertaken
  • 12-lead ECG performed
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11
Q

what must be controlled before aspirin is given

A

blood pressure

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12
Q

why is aspirin not recommended for PRIMARY prevention of cardiovascular disease

A

because there is limited benefit of its use in primary cardiovascular disease but there is still an increased risk of bleeding

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13
Q

what can be used in primary prevention of cardiovascular disease

A

a lipid-lowering drug (statin)

*note statins used in both primary + secondary CVD prevention)

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14
Q

what patients should start a low dose of atorvastatin for primary prevention of cardiovascular disease

A
  • those with 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator)
  • patients with chronic kidney disease
  • type 1 diabetes and 40+ years old
  • have had type 1 diabetes for more than 10 years
  • type 1 diabetes with nephropathy or other CVD risks
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15
Q

what is the target for non-HDL cholesterol when taking statins

A

a 40% or more reduction in non-HDL cholesterol

if this is not achieved, check adherence and lifestyle

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16
Q

when would ezetimibe be used in primary prevention of cardiovascular disease

A

if a patient had a high CVD risk but statins were contraindicated and in patients with familial hypercholesterolaemia

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17
Q

what should be discussed at the annual review of a patient taking statins

name some monitoring tests

A
  • non-fasting, non-HDL cholesterol concentration
  • CVD risk factors
  • medication adherence
  • lifestyle modifications

montoring tests:

  • liver function (statins can cause liver damage)
  • creatine kinase (test myalgia + rhabdomyolysis)
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18
Q

what should be checked 3 months after starting a high intensity statin

A
  • total cholesterol, HDL-cholesterol, and non-HDL-cholesterol concentration
  • liver function test

aiming for a 40%+ reduction in non-HDL cholesterol

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19
Q

name the 3 high intensity statins and their doses

A
  • atorvastatin (20mg or over dose)
  • rosuvastatin (10mg or over dose)
  • simvastatin (80mg dose)
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20
Q

what antiplatelets are used in secondary prevention of cardiovascular disease

A
  • low dose aspirin (75mg daily)

- clopidogrel in patients who are intolerant to aspirin or aspirin is contra-indicated

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21
Q

why is high dose simvastatin generally avoided unless a patient has been stable on it for at least one year

A

there is a high risk of myopathy (muscle weakness)

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22
Q

what is the first line treatment for patients with:

  • type 2 diabetes + hypertension
  • type 1 diabetes + hypertension
  • <55 years old + hypertension and NOT black african / caribbean
  • name examples of drugs
A

first line treatment =

ACE inhibitor e.g ramipril, lisinopril, enalapril

or

ARB e.g candersartan, losartan, irbersartan, valsartan

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23
Q

name 3 examples of ace inhibitors

A

they end in “ril”

rampiril, lisinopril, enalapril

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24
Q

name 3 examples ARB (angiotensin receptor blockers)

A

end in “sartan”

candesartan, losartan, irbersartan, valsartan,

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25
Q

why would you switch a patient from an ACE inhibitor to ARB

A

if they can a persistent dry cough on the ACE inhibitor (common side effect) so couldn’t tolerate the ACE inhibitor.

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26
Q

what is the first line treatment for hypertension in patients:

  • more than 55 years old
  • black african / Caribbean (any age)
  • name examples of drugs
A

calcium channel blockers (CCB) e.g amlodipine, felodipine, nifedipine

if intolerant offer thiazide-like diuretic

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27
Q

name 3 examples of calcium channel blockers (CCB)

A

dihydropyridines: amlodipine, felodipine, nifedipine

non-dihydropyridines: diltiazem, verapamil

28
Q

what is the 2nd line + 3rd line treatment for hypertension

A

add whichever class of drugs the patient wasn’t already taking. choose from: ACE inhibitor, ARB, CCB, Thiazide-like diuretics

2nd line: two treatments (note avoid ACE inhibitors in black african/caribbean, give ARB instead)

3rd line: three treatments

4th line (known as resistant hypertension): consider adding spironolactone or a beta/alpha blocker

at each step, optimise to max dose before adding

29
Q

name 3 examples of thiazide-like diuretics used for hypertension

A

end in “ide”

indapamide, bendroflumethiazide, chlortalidone

30
Q

what is hypertension in the first 20 weeks of pregnancy known as

A

chronic hypertension

31
Q

what is hypertension AFTER the first 20 weeks of pregnancy known as

A

gestational hypertension

32
Q

what is pre-eclampsia

give examples of some symptoms

A

high blood pressure and protein in urine (proteinuria) that can occur from 20 weeks of pregnancy

symptoms:

  • severe headache,
  • vision problems
  • severe pain below ribs
  • vomiting
  • sudden swelling of hands, feet or face
33
Q

what should you do in all pregnant woman with hypertension

A

refer to specialist

34
Q

what increases a pregnant women’s risk of pre-eclampsia

A

high risk:

  • chronic kidney disease
  • diabetes mellitus
  • autoimmune disease
  • chronic hypertension
  • if they have had hypertension during a previous pregnancy

moderate risk:

  • 40+ year olds
  • first pregnancy
  • BMI above 35 kg/m²
  • family history
35
Q

what drug is given to pregnant women with increased risk of pre-eclampsia

A

aspirin (75-150mg) from week 12 of pregnancy till birth

note this is given to women with any high risk factors or more than one moderate risk factor

36
Q

what is the first line anti-hypertensive treatment for women with pre-eclampsia, gestational or chronic hypertension

A

oral labetalol hydrochloride to achieve a target blood pressure of less than 135/85 mmHg. If labetalol is unsuitable, consider nifedipine. if nidepine + labetalol not suitable, consider methyldopa

note labetalol is a beta blocker

37
Q

what lifestyle advice can you give to reduce hypertension

A
  • reduce salt intake
  • reduce caffeine intake
  • reduce alcohol intake if excessive
  • smoking cessation
  • increase exercise
38
Q

what are the common side effects of ACE inhibitors

A

ACE inhibitors= ramipril, lisinopril, perindopril

side effects: dry cough, angioedema, hyperkalemia, sleep disorder

39
Q

which antihypertensives can cause hyperkalemia (high potassium)

A

ACE inhibitors, ARB

40
Q

what are the common side effects of ARB

A

similar to ACE inhibitors (hypotension, hyperkalemia)

but no dry cough

41
Q

name 3 medicines that ACE inhibitors and ARB interact with

A
  • Lithium : (they reduce the excretion of lithium so there is an increase lithium concentration. risk of lithium toxicity)
  • NSAIDS : increased risk of renal failure
  • potassium sparing diuretics : increased risk of hyperkalemia
42
Q

what are the 2 classes of calcium channel blockers (CCB)

name some examples

A

dihydropyridines: amlodipine, felodipine, nifedipine

non-dihydropyridines: diltiazem, verapamil

43
Q

what is the difference between dihydropyridines and non-dihydropyridines calcium channel blockers (CCB)

A

dihydropyridines are selective for blood vessels. e.g amlodipine, felodipine, nifedipine

non-dihydropyridines are also known as rate-limiting CCBs. They are selective for the heart reduce myocardial contractility and heart rate. e.g diltiazem, verapamil

note both have the same effectiveness for hypertension

44
Q

name some common side effects of calcium channel blockers

A

headache, flushing, swelling ankle

45
Q

name some common side effects of thiazide-like diuretics

A
  • hypo: na+, k+, mg2+
  • hypercalcemia (ca2+)
  • can exacerbate diabetes + gout
46
Q

beta blockers are generally not preferred to initially treat hypertension. When may they be used for treatment

A
  • younger people who are intolerant to ACE inhibitors and ARBs
  • women of childbearing age/ pregnant. (only use labetalol)
  • people with increased sympathetic drive
47
Q

when do patients with severe hypertension start antihypertensives

A

patients with 180/120mmg (severe), start antihypertensives immediately

48
Q

name some examples of the “target organ damage” we would check for once a patient has been diagnosed with hypertension

A

examples of target organ damage:

  • left ventricular hypertrophy
  • chronic kidney disease
  • hypertensive retinopathy
  • renal disease
  • established CVD
49
Q

TRUE OR FALSE:

for antihypertensives, it is recommended to prescribe drugs that are taken once daily

A

true

50
Q

what is the target blood pressure in pregnant women taking antihypertensives

A

135/85 mmhg

51
Q

name some risk factors for hypertension

A

age, ethnicity, dietary salt, exercise, alcohol, caffeine, smoking, weight gain

secondary cause: renal disease, endocrine causes (hyper/hypo thyroidism)

52
Q

why should you ask patients to report muscle pain/weakness if they are taking statins

A

because statins can cause myopathy and rhabdomyolysis

creatinine kinase and alt tests used to monitor this

53
Q

When are all ACE inhibitors contraindicated

A
  • history of angioedema (e.g hereditary or idiopathic) before starting treatment with ACE inhibitors
  • hypersensitivity to ACE inhibitors (including angioedema)

*idiopathic angiodema= swelling under skin that happens regularly without known cause)

54
Q

name some common side effects of all ACE inhibitors

A
  • alopecia
  • angina pectoris
  • angioedema (more common in black patients)
  • cough
  • dry mouth
  • renal impairment
  • electrolyte imbalance
  • GI side effects
55
Q

if a pregnant woman was already receiving antihypertensive treatment, what drugs should be stopped

A

Stop ACE inhibitors, ARBs, thiazide or thiazide-like diuretics due to an increased risk of congenital abnormalities

56
Q

what monitoring should occur before/ during treatment with ACE inhibitors

A

Renal function and electrolytes

should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if side effects mentioned are present

57
Q

How does renal impairment affect treatment with ACE inhibitors

A

renal impairment increases the risk of side effects such as hyperkalemia

58
Q

name some common side effects of all ARBs (angiotensin 2 receptor blockers)

A
  • abdominal/ back pain
  • asthenia (weakness/lethargy)
  • hyperkalemia
  • postural hypotension
  • cough
  • nausea + vomiting
59
Q

what monitoring should occur when a patient is on ARBs (angiotensin 2 receptor blockers)

A

Monitor plasma-potassium concentration (side effect is hyperkalemia) , especially in the elderly and in patients with renal impairment

60
Q

what time of the day is the first dose of an ACE inhibitor usually taken

A

first dose at night

61
Q

name some common side effects of all CCB (calcium channel blockers)

A
  • abdominal pain
  • dizziness
  • flushing
  • skin reactions
  • tachycardia
  • peripheral edema
62
Q

what are the symptoms of calcium-channel blocker (CCB) poisoning

what is the treatment (antidote) for this

A
  • nausea + vomiting
  • dizziness
  • confusion
  • agitation
  • coma (in severe poisoning)
  • metabolic acidosis
  • hyperglycaemia

treatment:
- activated charcoal if within 1st hour or modified release preparation given

  • calcium chloride or calcium gluconate is given by injection if patient has significant features of poisoning
  • atropine sulfate can be given to correct bradycardia, insulin + glucose for hypotension and heart failure
63
Q

why should you not suddenly withdraw treatment from calcium channel blockers (CCB)

A

it is associated with an exacerbation (worsening) of myocardial ischaemia.

*note myocardial ischaemia = blood flow in coronary artery completely / partially blocked due to artherscleortic plaque)

64
Q

when are all thiazide-like diuretics contraindicated

A
  • Addison’s disease
  • hypercalcaemia
  • hyponatraemia
  • refractory hypokalemia
  • symptomatic hyperuricaemia (high uric acid levels)
65
Q

name the common side effects of all thiazide-like diuretics

A
  • Alkalosis hypochloraemic (excessive loss of chloride)
  • electrolyte imbalance (e.g hypokalemia)
  • erectile dysfunction
  • hyperglycaemia
  • hyperuricaemia (high uric acid levels)

Cardiovascular system (8 decks)

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