Case 8 - Hypertension - Progress Test

Question 1

What is the pharmacology of ACE-i?

Answer 1

Inhibit the conversion of angiotensin I to angiotensin II

Question 2

What are common side effects of ACE-i?

Answer 2

Cough
Angioedema
Hyperkalaemia

Question 3

What patients should ACE-i be avoided in?

Answer 3

Pregnant women

Less effective in Afro-Caribbean patients

May worse renal function in patients with renovascular disease

Question 4

What is the pharmacology of calcium channel blockers?

Answer 4

Block voltage-gated calcium channels, relaxing vascular smooth muscle and force of myocardial contraction

Question 5

What are common side effects of calcium channel blockers?

Answer 5

Flushing
Ankle swelling
Headache

Question 6

What is the pharmacology of thiazide-like diuretics?

Answer 6

Inhibit sodium absorption at the beginning of the distal convoluted tubule

Question 7

What are common side effects of thiazide-like diuretics?

Answer 7

Hyponatraemia
Hypokalaemia
Dehydration

Question 8

What is the pharmacology of ARBs?

Answer 8

Block the effects of angiotensin II and the AT1 receptor

Question 9

What are common side effects of ARBs?

Answer 9

Hyperkalaemia

Question 10

What is the suffix used for ARBs?

Answer 10

• sartan

Question 11

What are ARBs used?

Answer 11

Generally when ACE-i haven’t been tolerated well or in Afro-Caribbean patients

Question 12

What is the first line hypertension medication for people under 55 years old?

Answer 12

ACE-i

Question 13

What is the first line antihypertensive medication for people with type 2 DM?

Answer 13

ACE-i

Question 14

What is the first line anti-hypertensive for patients over 55 years old?

Answer 14

Calcium channel blocker

Question 15

What is the first line anti-hypertensive for patients of Afro-Caribbean origin?

Answer 15

Calcium channel blocker

Question 16

What is the second line anti-hypertensive?

Answer 16

ACE-i (/ARB) + Calcium channel blocker

or ACE-i + thiazide-like diuretic

Question 17

What is 3rd line anti-hypertensive?

Answer 17

ACE-i + CCB + thiazide-like diuretic

Question 18

What is 4th line anti-hypertensive?

Answer 18

If K <= 4.5 –> low-dose spironolactone

If K > 4.5 –> beta blocker / alpha blocker

Question 19

What is 5th line antihypertensive?

Answer 19

Refer for specialist review

Question 20

What are some secondary renal causes of hypertension?

Answer 20

• GN
• Chronic pyelonephritis
• Adult polycystic kidney disease
• Renal artery stenosis

Question 21

What are some seconadry endocrine causes of hypertension?

Answer 21

• Primary hyperaldosteronism
• Phaeochromocytoma
• Cushing’s syndrome
• Liddle-s syndrome
• Congenital adrenal hyperplasia
• Acromegaly

Question 22

What are some other seconadary causes of hypertension?

Answer 22

• Glucocorticoids
• NSAIDs
• Pregnancy
• Coarctation of the aorta
• Combined oral contraceptive pill

Question 23

How many stages of hypertension are there?

Answer 23

3

Question 24

What BP is stage 1 hypertension?

Answer 24

Clinic BP >= 140/90 and ABPM >= 135/85

Question 25

What BP is stage 2 hypertension?

Answer 25

Clinic BP >= 160/100 and ABPM >= 150/95

Question 26

What BP is severe hypertension (Stage 3)?

Answer 26

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHG

Question 27

What management should be done if clinic BP is >= 180/120

Answer 27

Admit for specialist assessment if: - signs of retinal haemorrhage or papilloedema (accelerated hypertension) - life-threatening signs eg. new-onset confusion, chest pain, signs of HF, AKI Refer for specialist assessment if phaechromocytoma is suspected If not admitting, arrange urgent investigation for end-organ damage If end organ damage is found: - Start anti-hypertensive immediately If no target organ damage is identified: - repeat clinic BP within 7 days

Question 28

When should you treat a patient with stage 1 hypertension on ABPM (>= 135/85)?

Answer 28

If < 80 AND: - target organ damage or - established cardiovascular disease or - renal disease or - diabetes or - 10-year cardiovascular risk equivalent is 10% or greater

Question 29

When should you start anti-hypertensives in patients with stage 2 hypertension on ABPM (>=150/95) ?

Answer 29

Offer drug treatment to all patients with stage 2 hypertension

Question 30

What is the target BP for patients over 80?

Answer 30

Clinic BP <= 150/90 ABPM <= 145/85

Question 31

What is involved in the RAAS system?

Answer 31

A fall in BP or fluid volume triggers renin release from the kidney Renin converts angiotensinogen (produced by the liver) to angiotensin I Angiotensin-converting enzyme (released from the lungs) converts angiotensin I to angiotensin II Angiotensin II acts directly on the blood vessels triggering vascoconstriction Angiotensin II also acts on the adrenal gland to stimulate the release of aldosterone Aldosterone acts of the kidneys to stimulate reabsoption of NaCl and H2O