Deck 3

Question 1

Q. What blood pressure is clinically suspected hypertension (HTN) ?

Answer 1

A. BP 140/90 mmHg or higher

Question 2

Q. Which chronic heart pattern is hypertension closest linked to?

Answer 2

A. Atrial fibrillation – chaotic heart pattern, predisposed to blood clotting and embolism (independent stroke risk)

Question 3

Q. In the NICE HTN guidelines what is first line treatment for: A) Pt under 55 years B) Pt over 55 years or Afro-Caribbean? Give an example for each

Answer 3

A. ACE inhibitor (prevents angiotensin I to II) or low-cost angiotensin II receptor blocker (prevents angiotensin II from acting)
ACE inhibitor: e.g. Ramipril, enalapril, perindopril, trandolapril
ARB: e.g. candesartan, valsartan, telmisartan, losartan, irbesartan

B. Calcium-channel blocker
e.g. Amlodipine, nifedipine, diltiazem, felodipine, lacidipine, verapamil

Question 4

Q. In the NICE HTN guidelines what is second line treatment?

Answer 4

A. Add in calcium channel blocker (centrally acting – sympathetic NS)

Question 5

Q. In the NICE HTN guidelines what is third line treatment?

Answer 5

A. Add a thiazide-like diuretic

Question 6

Q. Why are afro-caribbeans and over 55 year olds treated with CCBs initially?

Answer 6

A. They are less likely to be affected by RAAS/renal hypertension than the younger population so calcium channels are targeted initially

Question 7

Q. What conditions are ACE inhibitors used to treat?

Answer 7

A. HTN, HF, diabetic nephropathy

Question 8

Q. Name two ACE inhibitors

Answer 8

A. Ramipril, enalapril, perindopril, trandolapril

Question 9

Q. Which two reactions do angiotensin II blockers inhibit?

Answer 9

A. Angiotensin to angiotensin II

B. Bradykinin to inactive peptides (reduced bradykinin breakdown = cough in some pts)

Question 10

Q. Name 4 adverse effects of ACE inhibitors

Answer 10

A. Cough (dry, chronic)– 10% of patients
B. Rash (common adverse effect)
C. Anaphylactoid reactions

Question 11

Q. Which patients are contraindicated?

ACE-I

Answer 11

A. Pregnancy – teratogenic

Question 12

Q. What conditions are angiotensin II receptor blockers used to treat?

Answer 12

A. HTN, diabetic nephropathy, HF (when ACE-I contracindicated)

Question 13

Q. Name two angiotensin II receptor blockers

Answer 13

A. Candesartan, valsartan, telmisartan, losartan, irbesartan

Question 14

Q. Which receptors to angiotensin II receptor blockers block?

Answer 14

A. Blocks AT-1 receptors

Question 15

Q. What mechanism do angiotensin II receptor blockers reduce?

Answer 15

A. Blocks angiotensin II from activating AT-1 receptors: (which usually increases BP, stimulates release of aldosterone etc)

Question 16

Q. Name 4 adverse effects of angiotensin II receptor blockers (generally well tolerated)

Answer 16

A. Symptomatic hypotension (especially volume deplete patients)
B. Hyperkalaemia - increased K conservation
C. Potential for renal dysfunction
D. Rash – allergy related
E. Angio-oedema – allergy related
F. Contraindicated in pregnancy
G. Generally, very well tolerated

Question 17

Q. Which patients are contraindicated?

A2RB

Answer 17

A. Contraindicated in pregnancy

Question 18

Q. What conditions are CCBs used to treat?

Answer 18

A. Hypertension, Ischaemic heart disease (IHD) – angina, Arrhythmia (tachycardia)

Question 19

Q. Name two CCBs

Answer 19

A. Amlodipine, nifedipine, diltiazem, felodipine, lacidipine, verapamil

Question 20

Q. How do CCBs affect calcium channels?

Answer 20

A. L-type calcium channel blockers (causes channel to close)

Question 21

Q. What are the three main classes of CCB? Describe the action of each class

Answer 21

A. Dihydropyridines: nifedipine, amlodipine, felodipine, lacidipine
a. Preferentially affect vascular smooth muscle – vasodilators – lower BP
b. Peripheral arterial vasodilators
c. (most clinically relevant)
B. Phenylalkylamines: verapamil
a. Acts differently - Main effects on the heart
b. Negatively chronotropic, negatively inotropic (reduces HR and contractility of heart)
C. Benzothiazepines: diltiazem
a. Intermediate heart/peripheral vascular effects (reduces HR and contractility of heart and acts as a vaspodilator)

Question 22

Q. Name a drug from each class of CCBs

Answer 22

A. Dihydropyridines: nifedipine, amlodipine, felodipine, lacidipine
B. Phenylalkylamines: verapamil
C. Benzothiazepines: diltiazem

Question 23

Q. Name 4 adverse effects of CCBs

Answer 23

1. Due to peripheral vasodilatation (mainly dihydropyridines)
   Flushing
   Headache
   Oedema – swelling, typically ankles (gravity)
   Palpitations – relax tachycardia due to vasodilation
2. Due to negatively chronotropic effects (mainly verapamil/diltiazem)
   Bradycardia
   Atrioventricular block – impulse blockage, often in pts with prev weak conduction
3. Due to negatively inotropic effects (mainly verapamil)
   Worsening of cardiac failure
4. Verapamil causes constipation – smooth muscle of intestines - calcium

Question 24

Q. What conditions are BBs used to treat?

Answer 24

Ischaemic heart disease (IHD) – angina, Heart failure, Arrhythmia, Hypertension

Question 25

Q. Name two BBs

Answer 25

bisoprolol, carvedilol, propranolol, metoprolol, atenolol, nadolol

Question 26

Q. Which nervous system do BB affect?

Answer 26

Sympathetic

Question 27

Q. Describe the action of B1/2/3 receptors

Answer 27

A. Beta 1: increase HR (+ve chronotropic), conduction velocity, stroke volume Increase renin secretion from juxtaglomerular cells of kidney, increase ghrelin secretion from the stomach B. Beta 2: smooth muscle relaxation (symp) (bronchi, GI tract to decrease motility), vasodilation of blood vessels (skeletal), lipolysis in adipose tissue C. Beta 3: lipolysis in adipose tissue

Question 28

Q. Which BBs are B-1 selective? Which are B1/B2 (nonselective)

Answer 28

A. B-1 selective: Metoprolol, bisoprolol B. Combined: Atenolol C. B1/B2: Propanolol, nadolol, carvedilol Selectivity (relative rather than absolute) The term “cardioselective” is often used to imply β-1 selectivity. This is a misnomer since up to 40% of cardiac β-adrenoceptors are β-2 .

Question 29

1. Q. Name 4 adverse effects of BB blockers

Answer 29

``` Main adverse effects: (effects on cerebral) 1. Fatigue 2. Headache 3. Sleep disturbance/nightmares ``` (due to blocking of adrenaline…) 4. Bradycardia 5. Hypotension 6. Cold peripheries 7. Erectile dysfunction Worsening of: 8. Asthma (may be severe) or COPD 9. PVD – Claudication or Raynaud’s 10. Heart failure – if given in standard dose or acutely

Question 30

Q. Which patients are contraindicated?

Answer 30

Asthmatics (PVD, HF

Question 31

Q. What conditions are diuretics used to treat?

Answer 31

HTN, HF

Question 32

Q. Name the four groups of diuretics; which part of the renal system do they affect? Name an example of each

Answer 32

1. Thiazides and related drugs (distal tubule) e.g. Bendrofluemethiazide, Hydrochlorothiazide, Chlorthalidone 2. Loop diuretics (loop of Henle) – potent e.g. furosemide, bumetanide 3. Potassium-sparing diuretics e.g. spironolactone, eplerenone, emiloride, triamterine 4. Aldosterone antagonists

Question 33

Q. Name 4 adverse effects of diuretics

Answer 33

A. Hypovolaemia (mainly loop diuretics- as they most potent) B. Hypotension (mainly loop diuretics) C. Low serum potassium (hypokalaemia) D. Low serum sodium (hyponatraemia) E. Low serum magnesium (hypomagnesaemia) F. Low serum calcium (hypocalcaemia) G. Raised uric acid (hyperuricaemia – gout) H. Erectile dysfunction (mainly thiazides) Impaired glucose tolerance (mainly thiazides) - diabetes

Question 34

Q. Name one other antihypertensive

Answer 34

A. α-1 adrenoceptor blockers e.g. doxazosin D. Centrally acting anti-hypertensives e.g. moxonidine, methyldopa G. Direct renin inhibitor e.g. aliskiren