General Practice week 1 Flashcards
(142 cards)
1
Q
What is apixaban used for?
A
- Prophylaxis of stroke
- Used in DVT to reduce risk of recurrence of pulmonary embolism
- Can be given to those after knee or hip replacement therapy
2
Q
What are the side effects of apixaban?
A
- Bleeding such as nosebleeds and bruising
- Coughing up blood and blood from anus
- A skin rash
3
Q
What type of drug is apixaban?
A
A factor Xa inhibitor anticoagulant
4
Q
Mechanism of action of apixaban.
A
Inhibits factor Xa independent of antithrombin III. Also inhibits prothrominase which both effects prevent formation of a thrombus.
5
Q
When would the dose of apixaban need to be adjusted?
A
In end stage renal disease
6
Q
What is Chiari malformation?
A
Cerebellum at the back of the skull bulges through a normal opening in the skull where it joins the spinal canal.
7
Q
What causes chiari malformation?
A
Excess leaking of spinal fluid from the lumbar of thoracic areas of the spine.
Syrinx - cyst in spinal cord
8
Q
What are the symptoms of chiari malformation?
A
- Scoliosis
- Headaches - located at back of head and neck often made worse by exertion
- Hydrocephalus (obstruction of flow of CSF that is found inside the ventricles inside the brain)
- Sleep apnea
- Hoarseness
- Difficulty swallowing
- Rapid side to side eye movements (nystagmus)
- Muscle weakness, lack of balance, abnormal reflexes
- Nerve problems, including paralysis
9
Q
What antibiotics are used in chest infections?
A
- Amoxacillin a beta lactam
- Macrolide antibiotics: azithromycin, clarithromycin
- Tetracycline: doxycycline
- Levaquin (fluoroquinolone antibiotic)
10
Q
What is Gabapentin taken for?
A
Epilepsy and nerve pain
11
Q
What is the mechanism action of gabapentin?
A
Inhibits the release of excitatory neurotransmitters. Appears to inhibit the action of a2d-1 subunits and so decreases the density of presynaptic voltage gated calcium channels and subsequent release of excitatory neurotransmitters.
12
Q
What can gabapentin not be used for?
A
Is ineffective in absence seizures - used in caution in those with mixed seizure disorders
13
Q
What is tamsulosin?
A
Alpha adrenoreceptor blocker (with specificty for alpha-1A and alpha-1D subtypes which are more common in the prostate and submaxillary tissue.
14
Q
Why would tamsulosin be prescribed?
A
To treat symptomatic benign hyperplasia and chronic prostasis
15
Q
Mechanism of action of tamsulosin.
A
- By blocking the adrenoreceptors smooth muscle in the prostate is relaxed and urinary flow is improved.
- Blocking of alpha 1D adrenoceptors relaxes the detrusor muscles of the bladder which prevents storage symptoms.
16
Q
Tamsulosin side effects.
A
Serious:
- a light-headed feeling, like you might pass out;
- penis erection that is painful or lasts 4 hours or longer; or
- severe skin reaction - fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.
COMMON;
- low blood pressure;
- dizziness, drowsiness, weakness;
- nausea, diarrhea;
- headache, chest pain;
- abnormal ejaculation, decreased amount of semen;
- back pain;
- blurred vision;
- tooth problems;
- fever, chills, body aches, flu symptoms;
- runny or stuffy nose, sinus pain, sore throat, cough;
- sleep problems (insomnia); or
- decreased interest in sex.
17
Q
What are the red flags of Cauda Equina syndrome?
A
- Bilateral sciatic pain
- Neurotpathic pain
- Fecal incontinence (can’t feel it come out)
- Urinary incontinence
- Weakness in lower limbs
- Urinary retention
- Saddle anaesthesia
18
Q
What is Cauda Equina syndrome?
A
Damage to the cauda equina, the nerve roots arising from the terminal end of the spinal cord, due to trauma or compression. Without urgent surgical intervention, it can result in paralysis, loss of sensation in the legs, and bladder and bowel incontinence.
19
Q
How would you perform a knee joint steroid injection?
A
18 gauge needle.
- Find patella, can be done medially or laterally.
- Find medial joint line - just a few cm above this inject under the patella - feel for soft area.
20
Q
What are the uses of bendroflumethazide?
A
- High BP treatment
- Used to get rid of extra fluid (oedema)
?- To suppress lactation
21
Q
How do thiazides cause vasodilation?
A
By activating calcium activated potassium channels in vascular smooth muscles and inhibiting various carbonic anhydrases in vascular tissue.
22
Q
What is the mechanism of action of bendroflumethiazide?
A
- inhibits active chloride resorption at the early distal tubule via Na-Cl cotransporter, resulting in an increase in excretion of sodium, chloride and water.
- Also inhibits sodium ion transport across the renal tubular epithelium through binding to thiazide sensitive sodium-chloride transporter - this results in increase in potassium excretion via sodium potassium exchange mechanism.
Antihypertensive mechanism may be mediated through action on carbonic anhydrases in smooth muscle or action on large conductance calcium-activated potassium channel. (also found in smooth muscle)
23
Q
What are the side effects of Bendroflumethiazide?
A
- Fall in BP standing up
- Dizziness
- Lethargy
- Muscle cramps
24
Q
What type of drug is Ramipril?
A
An ACE inhibitor
25
What is the use of Ramipril?
- Mild to severe hypertension management
- To reduce cardiovascular mortality following MI in haemodynamically stable individuals who develop clinical signs of congestive heart failure within a few days.
- To reduce rate of death, MI and stroke in individuals who are high risk of cardiovascular events
- To slow progression of renal disease in those with hypertension, diabetes mellitus and microalbuinuria or overt nephropathy.
26
What is the mechanism of action of Ramipril?
- Inhibits RAAS ACE
- There is a decrease in angiontensin II, so less activation of G-protein coupled receptors: angiotensin receptor I and angiontensin receptor II.
- Angiotensin receptor 1 mediates vasoconstriction, inflammation, fibrosis and oxidative stress. Decreased activation of the receptor by ramipril mediates the renoprotective, antihypertensive, and cardioprotective effects by reducing inflammation and vasoconstriction.
27
What causes the side effect of dry cough in ACE inhibitors?
ACE is responsible for breaking down bradykinin. The resulting build u of bradykinin thought to mediate characteristic dry cough of ACE inhibitors.
28
What are some side effects of Ramipril?
- Weakness
- Dizziness
- Loss of appetite
- Skin rashes
29
What type of drug is Amlodipine?
Calcium channel blocker.
30
What are the uses of Amlodipine?
- Useful in combination with other antihypertensive and antianginal agents
- Hypertension
- Coronary artery disease
- Chronic stable angina
- Vasospastic angina
- Angiographically documented coronary artery disease in patients without heart failure or an ejection fraction<40%
31
Amlodipine mechanism of action on blood pressure.
- Peripheral artery vasodilator - action directly on vascular smooth muscle to lead to reduction in peripheral vascular resistance - causing decrease in BP
- Dihydropyridine calcium antagonist - inhibits influx of calcium ions into both vascular smooth muscle and cardiac muscle.
- Stronger effect on smooth muscle cells than cardiac muscle
- Action on smooth muscle reduces BP
32
Amlodipine mechanism of action on angina.
- Reduces total peripheral resistance (afterload) against which cardiac muscle functions. - as HR remains stable after admission, reduced work of the heart reduces both myocardial use and oxygen requirements.
- Dilation of coronary arteries and arterioles causes an increase in myocardial oxygen delivery in patients.
33
Side effects of Amlodipine.
- Headache
- Dizziness
- Fatigue
- Nausea
- Fluid retention - ankle swelling
34
What type of drug is Bisoprolol?
Beta-1 adrenergic blocking agent.
35
What is Bisoprolol used for?
- Mild-moderate hypertension.
- May be used off-label to treat heart failure, AF and angina pectoris.
36
What is Bisoprolol mechanism of action?
- Antagonism of B1 adrenoceptors results in lower cardiac output
- Bisoprolol is cardiac-selective, competitive B1 adrenergic antagonist
- When B1 receptors are activated by adrenergic neurotransmitters such as epinephrine, both BP and HR increase > greater cardiovascular work > increased demand for oxygen
- Thought to reduce output of renin by the kidneys
37
What are some side effects of bisoprolol?
- Breathing difficulty
- Fatigue
- Cold extremities
- Sleep disturbances
38
What is Atorvastatin?
A HMG-CoA reductase inhibitor (drug)
39
What is Atorvastatin used in?
- Dyslipidaemias
- To prevent cardiovascular events in patients with cardiac risk factors and/or abnormal lipid profiles.
- Preventative agent for MI, stroke, revascularisation and angina.
- Prescribing statins is standard practive following any cardiovascular events and people with moderate - high risk of CVD development.
- Statin indicated conditions (diabetes mellitus, clinical atherosclerosis, Abdomical aortic aneurysm, CKD, severely elevated LDL-c levels
40
Atorvastatin mechanism of action.
- HMG-CoA reductase catalyses conversion of HMG-CoA to mevalonate an early rate limiting step in cholesterol synthesis
- Decreased hepatic cholesterol concentrations stimulate upregulation of hepatic LDL receptors - statins stop this/
41
Side effects of Atorvastatin.
- Insomnia
- Abdominal pain
- Flatulence
- Diarrhoea
- Nausea
42
What comorbidities can increase the risk of developing CVD?
Hypertension, diabetes mellitus, chronic kidney disease, dyslipidaemia, rheumatoid arthritis, influenza, serious mental health problems and periodontitis
43
What is the current health check programme for CVD in England?
o Everyone 40-74 years not already diagnosed with CVD, diabetes or CKD is invited every 5 years for health check.
o Health check involves CVD risk assessment, assessment of alcohol consumption, physical activity, cholesterol level, BMI, assessment for dementia in ages 65-74 years, & screening for diabetes mellitus and CKD in those at increased risk of developing these conditions.
44
Who are considered high risk for CVD?
Those with type I diabetes, or CKD stages 3,4,5.
45
How can 10 year CVD risk be assessed in patients every 5 years?
Using QRISK score.
46
Why may we not need to use the QRISK score on some people?
They already have CVD, a high risk of developing CVD or are over 85.
47
How can most people reduce their risk of CVD?
By lifestyle changes and drug treatment if appropriate.
48
When given CVD assessment what lifestyle advice should you provide a patient with?
Smoking, weight loss, eating healthy diet, Keeping alcohol consumption within recommended limits, being physically active.
49
When should statin treatment be offered to a patient?
Should be offered as primary prevention of CVD to people with estimated 10 year risk of 10% or more if lifestyle interventions have not been effective.
50
What is the recommended statin for primary prevention of CVD?
Atorvastatin 20mg/ day if patient decides to take it after discussion of benefits and harms and also lifestyle advice. There must also be no contraindications.
51
What must be considered before offering statin treatment for primary prevention of CVD?
o Use clinical findings, lipid profile and family history to judge likelihood of familial lipid disorder.
o Exclude possible secondary causes of dyslipidaemia ( excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome)
o Discuss the benefit of lifestyle modifications and optimise management of all other modifiable CVD risk factors, including relevant comorbidities that may not be optimally treated.
Offer opportunity to reassess CVD risk again after they have tried to change lifestyle
Recognise people may need support to change their lifestyle – referaly to programmes for exercise or smoking cessation.
52
When should statin treatment be offered for primary prevention of CVD?
If lifestyle modification is ineffective or inappropriate.
53
What lifestyle factors increase the risk of stroke?
- Smoking
- Excessive alcohol intake
- Diet high in salt and saturated fats
- Obesity
- Lack of exercise
- Previous stroke or TIA
- High blood pressure
- Diabetes
- High cholesterol
- Heart disease (Atrial fibrillation) Warfarin can be used to treat AF
54
What is atrial fibrillation?
AF is the most common sustained cardiac arrhythmia, characterized by irregularly irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation
55
How does AF come about?
Chaotic electrical activity of the atria is conducted to the ventricles in a random manner resulting in a rapid and irregular pulse rate.
56
What is loss of active ventricular filling associated with? (this occurs in AF)
o Stagnation of blood in the atria leading to thrombus formation and risk of embolism, increasing the risk of CVA
o Reduction in cardiac output (especially during exercise) which may lead to heart failure
57
How many people does AF affect?
Prevelence of 0.5% of the adult population and increases with advancing age, affecting 9% of people aged 80 or over.
58
Why do people with AF have a 2 fold increase in mortality?
Mainly due to association with underlying heart disease but also due to resultant systemic embolism and stroke.
59
How does AF present on ECG
With fibrillatory or F waves from fibrillating atria.
60
What is AF usually associated with?
Hypertension, Valvular heart disease, heart failure or obstructive sleep apnea.
61
What are the symptoms experienced with AF?
Some patients are asymptomatic and only have a vague sense of fatigue/decreased exercise tolerance.
Others experience: palpatiations, lightheadedness and dyspnea at rest or on exertion.
62
What are the complications of AF?
Acute embolic stroke, tachycardia-mediated ventricular dysfunction. Some patients may be realised to have AF after presenting with these.
63
What are the three groups that AF patients can be placed in?
Paroxysmal:
When episodes terminate within 7 days of onset
Persistent:
When episodes are consistent for more than 7 days
Long-standing persistent:
Episodes have continued for more than 12 months.
64
How is AF diagnosis suspected?
Based on history and physical examination: irregularly irregular pulse, usually with tachycardia, and is confirmed with ECG.
65
What 2 goals is management of AF based around?
1. Anticoagulation to prevent embolic stroke in those at increased risk
2. Symptom management with rate or rhythm control strategy.
66
What are the anticoagulation recommendations in AF based on stroke risk?
Non-valvular AF use CHA₂DS₂-VASc risk score to determine stroke risk. Men with score of 2 or greater and women with score of 3 or greater are at elevated risk and should be anticoagulated with non vitamin K oral anticoagulant.
- Patients with valvular AF regardless of score should be given warfarin for anticoagulation.
67
When is anticoagulation before cardioversion in AF omitted?
When duration of AF is no longer than 48hrs, stroke risk is lower and anticoagulation before cardioversion is omitted.
68
What is the stroke risk in AF?
1 in 5 strokes due to AF
69
What are the causes of AF?
o Previous myocardial infarction
o Heart failure
o Thyroid disease
o Alcohol or drug] abuse
o Valvular heart disease (particularly mitral)
o Family history
o Anaemia
o Sepsis.
70
What are some echocardiographic predictors of AF?
o Large atria
o Diminished ventricular function
o Increased left ventricular wall thickness
71
In what patients should AF be considered?
Patients with:
o Breathlessness
o Palpitations
o Syncope/ dizziness
o Chest discomfort
o Stroke/TIA
72
How may some patients with AF be clinically unstable?
o Tachycardia
o Hypotension
o Signs of decompensated heart failure
o Uncontrolled angina
73
What further investigations should be undertaken in those suspected of having AF?
o Lab tests to check for potential underlying causes or related complications of AF: FBC, kidney fucntions, thyroid function
o Transthoracic echocardiogram: if suspicion of structural or functional heart disease, If rhythm control strategy that includes cardioversion is being considered, if a baseline echocardiogram is important for long term management
o Transoesophagal echocardiogram: if TTE demonstrates abnormality needing further assessment, if the TTE is technically difficult or questionable quality, if TOE guided cardioversion is being considered.
74
In patients with symptomatic AF what is the priority in these patients?
Relieving the symptoms.
75
When should rhythm control strategies be considered in AF?
In those with:
o New onset AF
o A reversible cause for the AF
o Heart failure thought to be primarily caused by AF
76
In patients where rate control is the first line strategy for AF what therapeutics should they be offered?
Standared beta blocker (not sotalol) or rate limiting calcium channel blocker (diltiazem or verapamil) as initial monotherapy to control heart rate and symptoms.
77
When would Digoxin be considered as first line rate control in those with AF?
Persistent or permanent atrial fibrillation in patients who are sedentary (do no or very little physical exercise).
78
If monotherapy for first line strategy of rate control in AF doesn't control symptoms, what is the next step?
NICE recommends combination therapy with any 2 of a beta blocker, diltiazem or digoxin.
If patient remains symptomatic after this they should be referred to cardiologist with 4 weeks as cardioversion may be needed.
79
What is the risk of taking a beta blocker and diltiazem in combination?
There is a risk of bradycardia, hypotension and cardiodepression.
80
In AF treatment when should diltiazem and verapamil be avoided?
In patients with HF who have left ventricular ejection fraction below 40%.
81
What is the drug treatment for long term rhythm control in AF?
A standard beta blocker should be used (not sotolol).
If this fails then second line choices can be considered taking into account comorbidities: dronedarone, amiodarone, flecanide, propafenone.
82
When is Amiodarone especially considered in AF treatment?
In people with left ventricular impairment or HF.
83
When is Flecanide especially considered in AF treatment?
Can be used by patients with infrequent symptomatic episodes of AF.
84
When can electrical cardioversion be used?
o Patients with fast AF who are cardiovascularly unstable ( tachycardic, hypotensive, signs of cardiogenic shock) may need this urgently
o Pateints who present with symptomatic AF within 48hrs of onset of symptoms may also be suitable for early electrical cardioversion.
o If symptoms have been present for more than 48hrs patients must be on therapeutic dose of anticoagulant for at least 3 weeks before cardioversion. Offer rate control as appropriate in this period.
85
What should be done if a patient with AF is not suitable for drug treatment?
Catheter ablation: but need to be referred to cardiologist for this.
86
What four direct oral anticoagulants are licensed for use in the UK in AF?
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
87
When should dabigatran dose be reduced or avoided?
Reduce the dose in patients 80 years and over, or those also on verapamil. Consider reducing the dose in patients if they are 75 to 79 years, are at increased risk of bleeding, or if their creatinine clearance is 30 mL/min to 50 mL/min.
Avoid dabigatran in patients whose creatinine clearance is less than 30 mL/min
88
When should Apixaban dose be reduced or avoided?
Reduce the dose in patients with at least two of the following characteristics: age 80 years and over, body weight 60 kg or less, or serum creatinine 133 micromol/L and over. Reduce the dose in patients with a creatinine clearance of 15 ml/min to 29 mL/min.
Avoid apixaban in those whose creatinine clearance is less than 15 mL/min
89
When should Rivaroxaban dose be reduced or avoided?
Reduce the dose in patients if their creatinine clearance is less than 50ml/min.
Avoid rivaroxaban in those whose creatinine clearance is less than 15 mL/minute
90
When should Edoxaban dose be reduced or avoided?
Reduce the dose in patients with creatinine clearance 15 mL/min to 50 mL/min or with a body weight 60kg or less.
Avoid in those whose creatinine clearance is less than 15 mL/min.
91
What drug reverses the anticoagulant effect of dabigatran?
Idarucizumab
92
What drug reverses the effect of apixaban and rivaroxaban?
Andexanet alfa
93
Why should patients not miss a dose of their DOAC?
The short half-life of the DOACs means that the benefit of anticoagulation is lost if the patient misses a dose.
94
What guidelines should be followed if you are on warfarin?
• Patients taking warfarin must have a balanced diet. Major changes in dietary intake may affect warfarin therapy. It is safe to drink alcohol if national guidelines are followed. Binge drinking must be avoided. Patients taking warfarin should also avoid consuming large amounts of green leafy vegetables and cranberry juice.
95
What are the side effects of oral anticoagulants?
Bleeding
Bruising
Nosebleeds
96
In what circumstances should patients with AF who are not taking anticoagulants be reviewed?
- At age 65
- Diabetes
- HF
- Peripheral arterial disease
- Coronary artery disease
- Stroke, TIA or systemic thromboembolism
97
What is poor anti-coagulation control indicated by?
• Two INR values over 5 or one INR value over 8 in the last six months
• Two INR values less than 1.5 in the past six months
• A TTR of less than 65%.
98
If your patient has poor anticoagulation control what contributing factors should you consider?
• Adherence to therapy
• Cognitive function
• Illness
• Interacting drugs
• Lifestyle factors such as diet and alcohol consumption.
99
What beta blocker should be used to treat AF alone?
Atenolol (50-100mg a day)
100
What beta blocker should be used for people with AF and have had previous MI (without HF)?
Metoprolol, propanolol, atenolol
101
What beta blocker should be used for people with AF and heart failure?
Bisoprolol, carvedilol, nebivolol
102
What beta-blocker should be used in people with AF and diabetes mellitus?
- Cardioselective beta-blocker: atenolol, bisoprolol, metoprolol, nebivolol and acebutolol (to a lesser extent) is preferred.
- Avoid Beta blockers in those who experience frequent hypoglycaemia
103
Who should you not prescribe beta blockers to?
- History of obstructive airways disease, however if no alternative a cardioselective beta-blocker should be used under supervision. – look out for dyspnea
- Cardiogenic shock
- 2nd or 3rd degree heart block
- Sick sinus syndrome
- Sinus bradycardia
- Severe hypotension
- Severe PAD
- Uncontrolled heart failure
104
Who should beta-blockers be used with caution in?
- Diabetes
- First-degree AV block
- Myasthenia gravis
- Portal hypertension – risk of deteriorating liver function
- Psoriasis
105
What are the adverse effects of beta-blockers?
- Bradycardia
- Bronchospasm
- Cold extremities, numbness
- Conduction disorders
- Dizziness
- Dyspnoea
- Exacerbation of psoriasis
- Exacerbation of raynaud’s
- Fatigue
- GI disturbance
- Headache
- HF
- Hyperglycaemia, hypoglycaemia
- Hypotension
- Impotence and loss of libido
- Paraesthesia
- Peripheral vasoconstriction
- Psychoses
- Purpura
- Sleep disturbance
- Thrombocytopenia
- Vertigo
- Visual disturbances
106
What are the risks associated with hypertension?
- Cardiovascular disease
- Cerebrovascular disease
107
What is stage 1 hypertension?
Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average ranging from 135/85 mmHg to 149/94 mmHg
108
What is stage 2 hypertension?
Clinic blood pressure ranging from 160/100 mmHg to 179/119 mmHg and subsequent ABPM daytime average or HBPM average is 150/95 mmHg or higher
109
What is stage 3 or severe hypertension?
Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 120 mmHg or higher.
110
What types of device are used to measure BP in primary care?
- Mercury sphygmomanometers
- Aneroid sphygomomanometers
- Automated sphygmomanometers
111
When should you repeat BP?
- Measure BP in both arms and if ther eis more than a 15mmHg difference you should repeat both measurements. If the difference remains you should use arm with higher measurement for subsequent BP measurements.
112
Who should you look for postural hypotension in?
Patients who:
- Are elderly
- Have diabetes
- Have had dizziness or falls
113
How to measure for postural hypotension?
Check standing BP and also sitting BP to assess this. If systolic BP falls by 20mmHg when the patient stands then you should review medication and consider referring to specialist if symptoms persist.
114
In response to initial BP measurements - when should a patient be admitted as a medical emergency?
- Symptoms or signs of a cardiovascular event
- Clinic BP 180/120 mmHg or higher with signs of papilloedema or retinal haemorrhages or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney failure.
- Signs and symptoms of phaeochromocytoma (postural hypotension, headache, palpitations, pallor, abdominal pain and diaphoresis
- If patient has severe hypertension (clinic measurement of 180/120) but no indications for a same day referral, you should investigate for target organ damage as soon as possible.
115
What should be done if target organ damage is identified?
Consider starting antihypertensive treatment immediately, in combination with advice on lifestyle changes. You should also request ambulatory or home blood pressure monitioring but do not wait for results before treating.
116
If the patient has severe hypertension (180/120) but no target organ damage is identified what should be done?
BP measurement should be repeated in 7 days
117
What should be done if BP doesn't require immediate action but is greater than 140/90mmHg in clinic what should be done?
Then you should take a second reading in the same consultation. If second BP is greatly different from the first, you should take a third BP measurement and record the lower of the second 2 measurements as the clinic BP.
If BP remains between 140/90mmHg and 180/120mmHg as the first consultation you should offer ABPM to confirm the diagnosis. For patients that prove intolerant of ABPM, you should offer HBPM using an automated device.
118
When is a diagnosis of hypertension confirmed?
In people with clinic BP measurement of 140/90mmHg or higher and ABPM daytime average or HBPM average of 135/85mmHg or higher.
119
what category of patients should a diagnosis of hypertension be referred to a specialist?
Patients under 40 years of age.
120
In patients with new hypertension diagnosis what further steps should be taken?
you should begin management with an assessment of the patient’s risk of cardiovascular disease
Should include a clinical evaluation, including history, clinical examination and a limited number of clinical investigations.
121
In patients with a new diagnosis of hypertension what should you ask in the history to determine CVD risk?
Risk factors for CVD:
- Age
- Sex
- Socioeconomic group
- Smoking habits throughout the patient’s lifetime
- FH of CVD (particularly in a first degree relative when they were less than 60)
- Personal history of diabetes, kidney disease, elevated cholesterol
Symptoms suggesting cardiac complications of hypertension (ischaemia, infarction, or congestive HF) include:
- Chest pain
- Breathlessness
- Ankle swelling
- Palpatations
122
What is secondary hypertension?
Secondary hypertension occurs in 5% to 15% of people with hypertension and describes the situation where high BP is due to an underlying (secondary) disease.
123
What are some of the causes of secondary hypertension?
- Chronic renal disease
- Cushing’s syndrome
- Primary aldosteronism
- Thyrotoxicosis
- Phaeochromocytoma
124
What are common clinical features of secondary hypertension?
- Age younger than 30
- Sudden worsening of hypertension
- Poor response to treatment
125
What are common findings on clinical investigation in secondary hypertension?
- Elevated serum creatinine on initial assessment (suggesting renal disease)
- Hypokalaemia (may suggest renovascular hypertension or hyperaldosteronism)
- A large rise in serum creatinine after starting ACE inhibitor (suggests renovascular hypertension)
- Consider referral for specialist investigation in patients with signs and symptoms suggesting a secondary cause.
126
What should you look for in clinical examination for hypertension?
Look for signs of hypertensive complications:
- Fundoscopy for evidence of retinal haemorrhage or papilloedema
- Observation of neck veins if distended shows raised JVP suggestive congestive cardiac failure
- Assessment of apex beat to look for left ventricular hypertrophy
- Auscultation of the heart for murmurs (indicating valve disease or cardiac failure)
- Auscultation of the lungs for basal crepitations (suggesting congestive cardiac failure)
- Palpation of radial, popliteal and foot pulses – weak or absent pulses in lower limbs indicate peripheral vascular disease.
- Assessment of ankles and sacrum for any evidence of oedema
- Auscultation of carotid arteries for bruits (may indicate carotid stenosis which carries increased risk of stroke)
127
What clinical investigations should be done to look out for complications of hypertension?
- Urinalysis to detect protein and blood as possible markers for kidney disease and send sample for urinary albumin:creatinine ratio
- A resting 12-lead ECG (to look for evidence of left ventricular hypertrophy, MI, old MI, or arrhythmias such as AF)
- Serum biochemistry: electrolytes and creatinine; glycated haemoglobin (HbA1C), serum lipid profile, eGFR
128
What are the three main options in managing hypertension?
- Refer
- Start treatment
- Monitor
129
When should you consider referring a patient with hypertension?
- Suspected secondary hypertension
- Drop in systolic BP of over 20mmHg when standing and persistent symptoms of postural hypotension.
- Poor response to antihypertensive drug treatment
130
What lifestyle advice should be offered to those with hypertension?
- Weight reduction (10kg of weight loss leads to a mean reduction in systolic BP of 5 to 10mmHg)
- Physical activity
- Alcohol intake
o Pint of lager/beer/cider contains 2 units
o 175ml glass of wine is 2.3 units
o Standard 25ml of spirit is 1 unit
- Dietary changes
o Reduce salt intake
o Processed foods have high salt levels: make patients aware of this
o Diet plans such as Dietary Approaches to Stop Hypertension (DASH) can support dietary changes
- Measures that do not reduce blood pressure but reduce total risk of cardiovascular disease:
o Stopping smoking
o Increasing consumption of oily fish
o Replacing saturated fats with monounsaturated fats
131
When should antihypertensive drug treatment be offered to patients with hypertension?
Should offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension.
Discuss starting drug treatment in addition to lifestyle advice with adults less than 80 years who have persistent stage 1 hypertension and one or more of the following:
o Target organ disease
o Established cardiovascular disease
o Renal disease
o Diabetes
o Estimated 10 year risk of cardiovascular disease of 10% or more
Should consider antihypertensive treatment in addition to lifestyle advice in adults ages less than 60 years who have stage 1 hypertension and an estimated 10 year risk of cardiovascular disease below 10% and also in people aged over 80 years who have a clinic BP measurement above 150/90mmHg
132
What are the 5 classes of antihypertensive drugs used in treating hypertension?
- Thiazide diuretics
- ACE inhibitors
- Angiotensin II receptor blockers
- Calcium channel blockers
- Beta blockers (preferably cardioselective)
133
What is step one of antihypertensive drug treatment for those under 55 and not of carribbean or african american origin?
Offer an ACE inhibitor to adults with type 2 diabetes (E.G. lisinopril 10mg once daily, max 80mg daily).
134
What is step one of antihypertensive drug treatment for those who do not tolerate ACE inhibitor?
Offer an Angiotensin Receptor blocker. Candesartan (2, 4, 8, 16, 32mg)
135
What is step 1 of anti-hypertensive drug treatment in those over 55 any age if of black-African or African-Caribbean family origin.?
Calcium channel blockers (Amlodipine 5mg/10mg)
136
If Amlodipine not tolerated as first line of antihypertensive treatment what treatment should be tried instead?
- Offer a thiazide diuretic if CCB is not tolerated or if there is evidence of heart failure (a thiazide-like diuretic (e.g. indapamide) is preferred over a conventional thiazide diuretic (bendroflumethiazide) if starting or changing treatment for hypertension:
Felodipine (2.5mg, 5mg, 10mg)
137
For patients who's BP is not controlled with step 1 treatment of ACE inhibitor or ARB what antihypertensive treatment should be offered in combination?
A Calcium channel blocker or thiazide like diuretic if intolerant of amlodipine. Amlodipine (5mg, 10mg)
Felodipine (2.5,5,10mg)
138
For patients who's BP is not controlled with step 1 treatment of calcium channel blocker what antihypertensive treatment should be offered in combination?
Offer and ACE inhibitor, or ARB or thiazide like diuretic in addition.
Lisinopril
Candesartan
(For adults of African American or carribean origin who do not have type 2 diabetes, offer ARB in preference to ACE in addition to step 1 treatment.)
139
For patients who's BP is not controlled with step 1 treatment of thiazide like diuretic what antihypertensive treatment should be offered in combination?
ACEi or ARB
140
If after addition of another antihypertensive blood pressure is still not controlled what further antihypertensives can be added?
Offer a combination of three drugs: ACE or ARB, a CCB and a thiazide like diuretic.
(indapamide/ bendroflumethiazide)
141
If BP is still not controlled after being on the 3 antihypertensive drugs what should be the next step?
Should confirm BP measurements using ABPM or HBPM and assess patient for postural hypertension and review adherance before further treatment.
If resistant hypertension confirmed add a 4th drug.
If blood potassium is less than 4.5mmol/L then low-dose spirinolactone (25, 50, 100mg)
If blood potassium more than 4.5mmol/L then an alpha-blocker or beta-blocker should be considered (Bisoprolol, Doxazosin (alpha blocker))
142
Give an example of a cardio selective beta blocker.
Bisoprolol
