Evidence based medicine for treatment of hypertension

Question 1

what is an NHS health check

Answer 1

1. a health check for adults in England aged 40-74

2. designed to spot early signs of stroke, kidney disease, heart disease, type 2 diabetes, or dementia

Question 2

what information is gathered during an NHS health check

Answer 2

1. family history, smoking, drinking, physical activity
2. weight and height
3. age, gender and ethnicity
4. blood pressure and pulse taken
5. blood test to check cholesterol and blood sugar level

Question 3

what symptoms may occur in high blood pressure

Answer 3

• headaches, dizziness, recurrent epistaxis, palpitations, sweating, weight and hair loss
• or may be asymptomatic

Question 4

what is ambulatory blood pressure monitoring

Answer 4

1. takes blood pressure every 30 minutes
2. need at least 14 daytime readings for diagnosis
3. mean daytime blood pressure

Question 5

what is home blood pressure monitoring

Answer 5

1. alternative to ABPM
2. at least 4 days and ideally 7 days
3. 2 readings morning and 2 readings evening at least 1 minute apart
4. discard day 1 readings and then average blood pressure from all other days

Question 6

what are the top tips for taking blood pressure

Answer 6

1. patient needs to be relaxed
2. take the pulse for 1 minute
3. arm should be supported at heart level
4. the correct cuff should be used
5. no talking
6. back supported, feet lat on floor
7. take 2 readings
8. use the same arm for blood pressure monitoring

Question 7

what are the consequences of high blood pressure

Answer 7

could lead to:

• organ damage
• stroke
• heart failure
• vision loss
• heart attack
• kidney disease

Question 8

describe the investigation for target organ damage and to establish CV risk

Answer 8

1. urinalysis for blood and protein
2. renal function- blood test
3. electrolytes- blood test
4. HbA1c- blood test
5. lipid profile- blood test
6. TFT and LFT
7. ECG
8. eyes- optician

Question 9

what is the QRISK3 risk calculator

Answer 9

1. calibrated for UK population
2. calculates risk of having a heart attack or stroke over next 10 years
3. based on data from GPs
   - annually updated to remain accurate
4. this is for a primary prevention patient

Question 10

what is primary prevention of hypertension

Answer 10

90-95%

- no identifiable cause

Question 11

what is secondary prevention of hypertension

Answer 11

5-10%

• cause identified
• often rapid progression with very high blood pressure

Question 12

give examples of ace inhibitors and when they would be used

Answer 12

• enalipril, ramipril
• first line in younger caucasian patients
• diabetics
• primary and secondary prevention of CVD
• heart failure

Question 13

what cautions should be taken with use of ace inhibitors

Answer 13

• avoid k+ sparing diuretics and NSAIDs
• care with diuretic therapy
• caution with aortic stenosis
• contraindications include bilateral renal artery stenosis
• don’t use in pregnancy

Question 14

give examples of ARBs and when they are used

Answer 14

• candesartan, losartan
• an alternative to ace inhibitor
• for black patients of African or Caribbean origin
• lower risk of angio oedema

Question 15

give examples of dihydropyridine calcium channel blockers and when they are used

Answer 15

• amlodipine, nifedipine
• vasodilation of coronary and peripheral arteries and relax vascular smooth muscle
• also used in treatment of stable angina

Question 16

what are the side effects of dihydropyridine calcium channel blockers

Answer 16

flushing, headaches, ankle swelling (peripheral oedema)

Question 17

where are CCBs metabolised

Answer 17

all metabolised by liver

Question 18

what are the 2 classes of calcium channel blockers

Answer 18

dihydropyridine and non dihydropyridine

Question 19

give examples of non dihydropyridine calcium channel blockers and what they are used for

Answer 19

• phenylalkalamines (verapamil)
• benzothiazepines (diltiazem)
• also used to treat angina and arrhythmias

Question 20

what is a common side effect of non dihydropyridine calcium channel blockers

Answer 20

constipation

Question 21

describe how non dihydropyridine calcium channel blockers work

Answer 21

interfere with myocardial conduction

• slow the heart rate ( don’t use verapamil and beta blocker)
• contractility may be reduced, therefore not used in heart failure

Question 22

give an example of a thiazide diuretic

Answer 22

indapamide

Question 23

what should be monitored with use of thiazide diuretics

Answer 23

• renal function
• electrolytes
• lipid profile
• gout

Question 24

give an example of a loop diuretic

Answer 24

furosemide or bumetanide

Question 25

what should be monitored with use of loop diuretics

Answer 25

check renal function and electrolytes within one month of starting

Question 26

give an example of a K+ sparing diuretic

Answer 26

spironolactone, amiloride

Question 27

give an example of an alpha blocker and describe how they work

Answer 27

- doxazosin, tamsulosin - vasodilator of vascular smooth muscle - care with initial dose - no effect on heart rate - may cause drowsiness/dizziness - used for BPH (older men)

Question 28

describe the main properties of beta blockers

Answer 28

1. intrinsic sympathomimetic activity (ISA)- partial agonist, stimulate and block adrenergic receptors - cause less bradycardia/cold extremities - acebutolol, oxprenolol 2. water soluble- cause less sleep disturbances - renal excreted, reduce dose in renal impairment - atenolol 3. cardioselective (not specific)- cause less bronchospasms - atenolol, bisoprolol, metoprolol 4. prolong QT interval- sotalol

Question 29

give examples of vasodilators and when they are used

Answer 29

- hydralazine: monitor LFTs - minoxidil: causes hypertrichosis - potent/rapid reduction in blood pressure - used for severe/resistant hypertension - can cause fluid retention/tachycardia, therefore caution if used alone - other agents often co prescribed

Question 30

give examples of centrally acting pharmacological therapy and when they would be used

Answer 30

1. methyldopa- used in pregnancy - monitor FBC for blood dyscrasias -LFTs 2. clonidine- caution with driving - not recommended as sudden withdrawal may cause hypertensive crisis 3. moxonidine- avoid in liver disease - reduce dose in renal impairment all cause CNS effects- dry mouth, drowsiness

Question 31

give examples of renin inhibitors in pharmacological therapy

Answer 31

1. aliskiren- licensed for hypertension only - rarely used - expensive

Question 32

what factors are involved when choosing a treatment option

Answer 32

1. age- increased risk of side effects - renal impairment 2. ethnicity- afro-caribbean patients respond less well to ACE/ARBs 3. co morbidities- diabetes, renal disease, previous CV event 4. current drug therapy- choose OD prep if possible 5. onset and severity 6. pregnancy

Question 33

what special considerations must be taken into account when choosing a treatment option

Answer 33

1. elderly- limited evidence >80 - treat if persistent - consider any co morbidities - targets higher if >80 - consider postural hypotension and frailty - CCB first line therapy 2. isolated systolic hypertension- treat same as patients with raised SBP and DPB 3. diabetes- treatment prevents macro and microvascular complications - ACE inhibitor drug of choice 4. renal disease- target 130/80 or lower if proteinuria >1g in 24 hours - ACE inhibitor if proteinuria present 5. pregnancy- labeiolol or methyldopa

Question 34

describe the adjunct therapy that can be used

Answer 34

1. aspirin 75mg daily- not for primary prevention - only prescribed if established CVD disease 2. statins- primary prevention - CV risk assessment using validated tool - secondary prevention: known CV disease - CKD, type 1 diabetes