Hypertension 1

Question 1

What does it mean that cardiac disorders exist as a complex web?

Answer 1

They often lead to each-other

Question 2

What are determinants of cardiovascular disorders?

Answer 2

• lifestyle

- genetics

Question 3

how is blood pressure usually written?

Answer 3

systolic/diastolic

Question 4

What is systolic blood pressure?

Answer 4

pressure while heart is contracting (maximum pressure)

Question 5

What is diastolic blood pressure?

Answer 5

pressure while heart is filling (minimum pressure)

Question 6

What is the pulse pressure?

Answer 6

Difference between systolic and diastolic pressure

Question 7

What is hypotension and what could it be caused by?

Answer 7

decreased BP (could be caused by antihypertensive drugs acting too much)

Question 8

What measurements do we use to quantify hypertension?

Answer 8

diastolic measurements

Question 9

What are the different stages of hypertension?

Answer 9

• Stage 1, mild hypertension – 90-100 mmHg
• Stage 2, medium – 100-120 mm Hg
• Stage 3 – severe - >120 mm Hg

Question 10

What is white code hypertension?

Answer 10

when someone is nervous about getting a blood pressure measurement and it goes up just because of presence of doctor

Question 11

How are ambulatory blood pressure measurements carried out?

Answer 11

patient carries around a belt mounted device connected to cuff on their arm through the entire day giving measurements of blood pressure

Question 12

How many hypertensive patients are adequately controlled and how many are at optimal blood pressure?

Answer 12

• 60% adequately controlled

- 10% at optimal blood pressure

Question 13

Why is there an estimated 70 million untreated hypertensive patients in the world’s top 7 economies?

Answer 13

 Maybe inadequate access to healthcare

 Many people may not know they have hypertension – silent killer

Question 14

What are primary and secondary hypertension?

Answer 14

• Primary (essential or idiopathic) hypertension – cause unknown
• Secondary hypertension – identified cause such as polycystic renal disease, renal artery stenosis and phaeochromocytoma (tumour of adrenal medulla – stimulates production of large quantity of adrenaline)

Question 15

What may contribute to primary hypertension?

Answer 15

- Lifestyle contributors 
 Obesity 
 Insulin resistance
 High alcohol intake 
 High sodium, low potassium intake 
 Age 
- Genetic factors 
 Up to 65% (twin studies) 
 Around 10 genes identified that alter salt/water balance 
 Other genes may affect obesity, alcohol use etc 
 Epigenetics: maternal diet

Question 16

What are consequences of hypertension?

Answer 16

• High sustained arterial BP increases mortality from:
   Coronary artery disease
   Stroke
   Cerebral haemorrhage
   Thrombosis (ischaemic) and thromboembolism
   Heart failure (heart reacts to sustained increase in blood pressure by remodelling it’s muscle and becoming less efficient

Question 17

What is the NICE care package for hypertension?

Answer 17

• Stage 1 hypertension (unless age>80, or organ damage)
   Lifestyle interventions
   Education, support, and annual monitoring
   If under 40 get specialist referral
• Stage 2 hypertension
   Offer antihypertensive therapy in addition to lifestyle interventions

Question 18

What are some lifestyle modifications that are suggested with hypertension?

Answer 18

• lose weight
• limit alcohol intake
• increase aerobic activity
• reduce sodium intake
• maintain K+ intake
• maintain Ca2+ and Mg2+ intake
• Stop smoking
• reduce dietary fat and cholesterol

Question 19

What are first line and second line treatments?

Answer 19

• First line treatment: the drugs that are usually chosen as the initial treatment for a patient. If they don’t work then doctors will move on to second line treatments or may use adjunct treatments
• Second line treatments: What is tried next. If it is in addition to the first line treatment, then it is described as adjunct or adjuvant treatment

Question 20

How do you work out blood pressure?

Answer 20

cardiac output x peripheral resistance

Question 21

What is the basic principle in blood pressure control by drugs?

Answer 21

interfere with control mechanisms. But do not compromise cardiovascular reflexes

Question 22

Are most patients taking one medication or more to treat hypertension?

Answer 22

More than one

Question 23

What happened with the ASCOT trial?

Answer 23

(Anglo Scandinavian Cardiac Outcomes Trial)
- Compared amlodipine (+ perindopril) newish with atenolol (+ Bendroflumethiazide) older treatments
- Amlodipine – calcium channel blocker
- Perindopril – angiotensin converting enzyme inhibitor
- Atenolol – beta adrenoceptor antagonist
- Bendroflumethiazide – diuretic
- Two arms
 1 arm – people were given amlodipine and supplemented with perindopril if needed additional help
 2 arm – people were given atenolol and supplemented with Bendroflumethiazide if needed additional help
- Results
1. Blood pressure reduced in both arms of study
2. Reduced incidence of associated CV disease with amlodipine
3. Conclusion: Calcium channel blocker (+ ACE inhibitors) should replace ‘older’ treatments

Question 24

Which trial underlies NICE recommendations?

Answer 24

ASCOT trial

Question 25

What happened with the ALLHAT trials?

Answer 25

- Antihypertensive and Lipid-lowering treatment to prevent heart attack trial) - Compared chlorthalidone (thiazide-like diuretic) with amlodipine or lisinopril (another angiotensin converting inhibitor) - Results: 1. Blood pressure controlled in all three but chlorthalidone superior 2. Risk of heart attack similar with all three 3. Risk of some associated CVS lower with chlorthalidone 4. Conclusion: thiazide diuretic superior to calcium channel blockers or ACE inhibitors

Question 26

What trial underlies American Association recommendations?

Answer 26

ALLHAT trial

Question 27

What are the overall conclusions to do with the treatment of hypertension?

Answer 27

- Calcium channel blockers or ACE inhibitor or ATII antagonist or thiazide-like diuretic should be primary treatment - May need to add in other drugs e.g. beta blocker