Cardiovascular Therapeutics- Hypertension

Question 1

What are the stages of HTN?

Answer 1

Stage 1- Clinic >140/90, ABPM 135/85
Stage 2- Clinic >160/100, ABPM 150/95
Stage 3- Clinic >180/110 (systolic or diastolic above this)

Question 2

What is the first line management of hypertension in someone under 55? (Not black person)

Answer 2

ACE Inhibitor

ARB if the cough is troublesome

Question 3

What is the first line management of hypertension in someone over 55 or black?

Answer 3

Calcium channel blocker

Question 4

What is second line management for HTN

Answer 4

Combine either ACEi or ARB and Calcium Channel Blocker

Question 5

What is third line management for HTN?

Answer 5

Add in a thiazide like diuretic to second line therapy

Question 6

What is the fourth step? What is this hypertension now called?

Answer 6

This is now called resistant hypertension.
Adding in another diuretic, alpha or beta blocker should be considered
Refer on to a specialist

Question 7

What is it important to do at each stage?

Answer 7

Check patient is complying to the regime

Question 8

What is a common side effect of ACEi?

Answer 8

Dry cough- due to bradykinin metabolism in the lung

Question 9

Give an example of an ACEi

Answer 9

Ramipril

Lisinopril

Question 10

What is a rare side effect to ACEi?

Answer 10

Angioedema

Question 11

What are some contraindications to ACEi?

Answer 11

Pregnancy
Breast feeding
Bilateral renal artery stenosis- ACEi further reduces renal artery perfusion and can cause kidney damage

Question 12

Give an example of an ARB

Answer 12

Losartan, Candesartan

Question 13

What are contraindications to ARBs?

Answer 13

Pregnancy
Breast feeding
Renal artery stenosis
(As with ACEi)

Question 14

What are the two types of calcium channel blocker? How do they work?

Answer 14

Calcium channel blockers block L-type calcium channels and so prevent smooth muscle contraction leading to vasodilation
Two types are dihydropyridines and non-dihydropyridines

Question 15

Give an example of a dihydropyridine

Answer 15

Amlodipine
Felodipine
Nifedipine
(These are first line for HTN in black people or over 55)

Question 16

What is a side effect of dihydropyridines?

Answer 16

Ankle oedema
Gum enlargement- gingival hyperplasia
Acid reflux
Flushing

Question 17

Give an example of a non-dihydropyridine

Answer 17

Verapamil (cardiospecific)

Diltiazem (heart and blood vessels)

Question 18

Which form of calcium channel blocker is rate limiting?

Answer 18

Non dihydropyridines

Question 19

What are some side effects of verapamil?

Answer 19

Worsening heart failure
Bradycardia
Heart block
Constipation

Question 20

Give another use for diltiazem

Answer 20

Cluster headaches and migraine

Question 21

How do thiazide diuretics work?

Answer 21

Block Na/Cl co-transporter in distal convoluted tubule and so reduce sodium re-absorption from the filtrate leading to diuresis

Question 22

Give an example of a thiazide diuretic

Answer 22

Bendroflumethiazide

Question 23

Give an example of a thiazide like diuretic

Answer 23

Indapamide

Chlortalidone

Question 24

What are some side effects of thiazides?

Answer 24

Hyponatraemia
Gout
Erectile dysfunction
Hypercalcaemia

Question 25

What is a loop diuretic? How does it work?

Answer 25

Furosemide Inhibits NKCC2 in thick ascending limb Causes potent diuresis

Question 26

What are some side effects of furosemide?

Answer 26

Hyopnatraemia Hypokalaemia Hypocalcaemia Digoxin toxicity

Question 27

When is furosemide commonly used?

Answer 27

Heart failure Ascites Pulmonary oedema

Question 28

What is a potassium sparing diuretic?

Answer 28

Diuretic that does not cause potassium losses at the kidney

Question 29

Give an example of a potassium sparing diuretic

Answer 29

Aldosterone Receptor Antagonist- Spironolactone | Amiloride, Triamtrene

Question 30

What triggers aldosterone release and what is it's normal effect?

Answer 30

Aldosterone is released due to low sodium delivery to the macula densa. This results in activation of the RAAS. Aldosterone causes increases sodium re-abosption from the filtrate and increased potassium excretion.

Question 31

What are some side effects of spironolactone?

Answer 31

Gynaecomastia Hyperkalaemia Hyponatraemia

Question 32

When else might spironolactone be used?

Answer 32

Conn's Syndrome (tumour producing aldosterone) | Hyperaldosteronism

Question 33

Why are beta blockers used for the treatment of HTN?

Answer 33

B1 receptors cause increased cardiac contraction and force B2- causes vasodilation and bronchodilation Blocking them reduces heart rate, force of contraction, reduces TPR and reduces beta mediated release of renin

Question 34

Give an example of a cardio-selective beta blocker

Answer 34

Metoprolol | Bisoprolol

Question 35

What is the first line for treatment of HTN in pregnancy?

Answer 35

Labetalol- beta blocker with weat alpha blocking activity

Question 36

What are some side effects of beta blockers?

Answer 36

Tiredness Cold periphery Bronchoconstriction Erectile dysfunction

Question 37

What is a contra-indication to beta-blocker use?

Answer 37

Asthma is an absolute contra-indication | Relative contraindications include peripheral vascular disease and acute heart failure

Question 38

How do alpha blockers work?

Answer 38

Prevent alpha mediated vasoconstriction

Question 39

Give an example of an alpha blocker

Answer 39

Doxazosin | Terazosin

Question 40

What is another use of alpha blockers?

Answer 40

BPH

Question 41

What is the definition of postural hypotension?

Answer 41

Drop of 20mmHg in SP or more when standing | Drop of 10mmHg in DP or more when standing

Question 42

What are some causes of postural hypotension?

Answer 42

Antihypertensive drugs Diuretic use Adrenal insufficiency- Addisons Autonomic failure- diabetes, parkinon's

Question 43

What non- pharmacological ways could postural hypotension be treated?

Answer 43

Increasing fluid intake Remove causative medications Standing slowly Compression socks

Question 44

What pharmacological ways could postural hypotension be treated?

Answer 44

Fludrocortisone- if aldosterone insufficient this is a mineralocorticoid Desmopressin- ADH analogue Doxydropa Midorine- Alpha agonist