hypertension

Question 1

what is the clinic measurement of high blood pressure

Answer 1

a clinic blood pressure of 140/90mmhg or more

```
systolic = 140 or more
(diastolic = 90 or more)
~~~

Question 2

what are the 3 stages of hypertension and their clinic blood measurements

Answer 2

stage 1 = from 140/90mmhg (clinic bp). (home/ambulatory bp 135/85mmhg)

stage 2= from 160/100 mmhg . (150/95 for home/ambulatory bp)

stage 3 (severe)= a systolic of 180mmhg + or a diastolic of 120mmhg+

note all of these are clinic blood pressures not home blood pressure monitoring

Question 3

what is accelerated (or malignant) hypertension

Answer 3

when your blood pressure suddenly raises to more than 180mmhg and you have signs of retinal haemorrhage or papilloedema (swelling of the optic nerve)

Question 4

when should you refer patients with hypertension for a same day specialist appointment

Answer 4

• if they have severe hypertension (systolic = 180mmhg+ or diastolic= 120mmhg+) with or without symptoms such as: retinal haemorrhage, accelerated hypertension, chest pain, confusion, acute kidney injury or signs of heart failure
• signs of phaeochromocytoma (tumour on the adrenal glands) such as postural hypotension, headache, palpitations, abdominal pain, pale skin (pallor)

Question 5

what is the target blood pressure patients UNDER 80 years old

Answer 5

clinic blood pressure = 140/90mmhg

home blood pressure monitor (HBPM) = 135/85 mmhg

Question 6

what is the target blood pressure for patients OVER 80 years old

Answer 6

clinic blood pressure = 150/90 mmhg

home blood pressure monitor (HBPM)= 145/85 mmhg

Question 7

when should you consider starting a patient on anti-hypertensive drug treatment

Answer 7

• under 80 with stage 1 hypertension and target organ damage or with a 10 year cardiovascular risk of > 10%
• all patients with stage 2 hypertension regardless of age
• severe hypertension (same day specialist referral). Start IV antihypertensives immediately
• if under 40 with stage 1 hypertension, seek specialist advice for secondary causes of hypertension

Question 8

what should you do if a patient is under 40 with stage 1 hypertension

Answer 8

get specialist advice for secondary causes of hypertension

Question 9

which patients do you need to assess their cardiovascular risk

Answer 9

need to assess cardiovascular risk of all patients with confirmed hypertension using clinic blood pressure measurements

Question 10

what monitoring should occur when you assess a patients cardiovascular risk

Answer 10

• glycated haemoglobin
• electrolytes
• creatinine
• estimated glomular filtration rate (EGFR)
• total and HDL cholesterol
• tests for the presence of proteinuria, haematuria, and hypertensive retinopathy undertaken
• 12-lead ECG performed

Question 11

what must be controlled before aspirin is given

Answer 11

blood pressure

Question 12

why is aspirin not recommended for PRIMARY prevention of cardiovascular disease

Answer 12

because there is limited benefit of its use in primary cardiovascular disease but there is still an increased risk of bleeding

Question 13

what can be used in primary prevention of cardiovascular disease

Answer 13

a lipid-lowering drug (statin)

*note statins used in both primary + secondary CVD prevention)

Question 14

what patients should start a low dose of atorvastatin for primary prevention of cardiovascular disease

Answer 14

• those with 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator)
• patients with chronic kidney disease
• type 1 diabetes and 40+ years old
• have had type 1 diabetes for more than 10 years
• type 1 diabetes with nephropathy or other CVD risks

Question 15

what is the target for non-HDL cholesterol when taking statins

Answer 15

a 40% or more reduction in non-HDL cholesterol

if this is not achieved, check adherence and lifestyle

Question 16

when would ezetimibe be used in primary prevention of cardiovascular disease

Answer 16

if a patient had a high CVD risk but statins were contraindicated and in patients with familial hypercholesterolaemia

Question 17

what should be discussed at the annual review of a patient taking statins

name some monitoring tests

Answer 17

• non-fasting, non-HDL cholesterol concentration
• CVD risk factors
• medication adherence
• lifestyle modifications

montoring tests:

• liver function (statins can cause liver damage)
• creatine kinase (test myalgia + rhabdomyolysis)

Question 18

what should be checked 3 months after starting a high intensity statin

Answer 18

• total cholesterol, HDL-cholesterol, and non-HDL-cholesterol concentration
• liver function test

aiming for a 40%+ reduction in non-HDL cholesterol

Question 19

name the 3 high intensity statins and their doses

Answer 19

• atorvastatin (20mg or over dose)
• rosuvastatin (10mg or over dose)
• simvastatin (80mg dose)

Question 20

what antiplatelets are used in secondary prevention of cardiovascular disease

Answer 20

• low dose aspirin (75mg daily)

- clopidogrel in patients who are intolerant to aspirin or aspirin is contra-indicated

Question 21

why is high dose simvastatin generally avoided unless a patient has been stable on it for at least one year

Answer 21

there is a high risk of myopathy (muscle weakness)

Question 22

what is the first line treatment for patients with:

• type 2 diabetes + hypertension
• type 1 diabetes + hypertension
• <55 years old + hypertension and NOT black african / caribbean
• name examples of drugs

Answer 22

first line treatment =

ACE inhibitor e.g ramipril, lisinopril, enalapril

or

ARB e.g candersartan, losartan, irbersartan, valsartan

Question 23

name 3 examples of ace inhibitors

Answer 23

they end in “ril”

rampiril, lisinopril, enalapril

Question 24

name 3 examples ARB (angiotensin receptor blockers)

Answer 24

end in “sartan”

candesartan, losartan, irbersartan, valsartan,

Question 25

why would you switch a patient from an ACE inhibitor to ARB

Answer 25

if they can a persistent dry cough on the ACE inhibitor (common side effect) so couldn't tolerate the ACE inhibitor.

Question 26

what is the first line treatment for hypertension in patients: - more than 55 years old - black african / Caribbean (any age) - name examples of drugs

Answer 26

calcium channel blockers (CCB) e.g amlodipine, felodipine, nifedipine *if intolerant offer thiazide-like diuretic*

Question 27

name 3 examples of calcium channel blockers (CCB)

Answer 27

dihydropyridines: amlodipine, felodipine, nifedipine non-dihydropyridines: diltiazem, verapamil

Question 28

what is the 2nd line + 3rd line treatment for hypertension

Answer 28

add whichever class of drugs the patient wasn't already taking. choose from: ACE inhibitor, ARB, CCB, Thiazide-like diuretics 2nd line: two treatments (*note avoid ACE inhibitors in black african/caribbean, give ARB instead*) 3rd line: three treatments 4th line (known as resistant hypertension): consider adding spironolactone or a beta/alpha blocker *at each step, optimise to max dose before adding*

Question 29

name 3 examples of thiazide-like diuretics used for hypertension

Answer 29

end in "ide" indapamide, bendroflumethiazide, chlortalidone

Question 30

what is hypertension in the first 20 weeks of pregnancy known as

Answer 30

chronic hypertension

Question 31

what is hypertension AFTER the first 20 weeks of pregnancy known as

Answer 31

gestational hypertension

Question 32

what is pre-eclampsia give examples of some symptoms

Answer 32

high blood pressure and protein in urine (proteinuria) that can occur from 20 weeks of pregnancy symptoms: - severe headache, - vision problems - severe pain below ribs - vomiting - sudden swelling of hands, feet or face

Question 33

what should you do in all pregnant woman with hypertension

Answer 33

refer to specialist

Question 34

what increases a pregnant women's risk of pre-eclampsia

Answer 34

high risk: - chronic kidney disease - diabetes mellitus - autoimmune disease - chronic hypertension - if they have had hypertension during a previous pregnancy moderate risk: - 40+ year olds - first pregnancy - BMI above 35 kg/m² - family history

Question 35

what drug is given to pregnant women with increased risk of pre-eclampsia

Answer 35

aspirin (75-150mg) from week 12 of pregnancy till birth *note this is given to women with any high risk factors or more than one moderate risk factor*

Question 36

what is the first line anti-hypertensive treatment for women with pre-eclampsia, gestational or chronic hypertension

Answer 36

oral labetalol hydrochloride to achieve a target blood pressure of less than 135/85 mmHg. If labetalol is unsuitable, consider nifedipine. if nidepine + labetalol not suitable, consider methyldopa *note labetalol is a beta blocker*

Question 37

what lifestyle advice can you give to reduce hypertension

Answer 37

- reduce salt intake - reduce caffeine intake - reduce alcohol intake if excessive - smoking cessation - increase exercise

Question 38

what are the common side effects of ACE inhibitors

Answer 38

ACE inhibitors= ramipril, lisinopril, perindopril side effects: dry cough, angioedema, hyperkalemia, sleep disorder

Question 39

which antihypertensives can cause hyperkalemia (high potassium)

Answer 39

ACE inhibitors, ARB

Question 40

what are the common side effects of ARB

Answer 40

similar to ACE inhibitors (hypotension, hyperkalemia) but no dry cough

Question 41

name 3 medicines that ACE inhibitors and ARB interact with

Answer 41

- Lithium : (they reduce the excretion of lithium so there is an increase lithium concentration. risk of lithium toxicity) - NSAIDS : increased risk of renal failure - potassium sparing diuretics : increased risk of hyperkalemia

Question 42

what are the 2 classes of calcium channel blockers (CCB) name some examples

Answer 42

dihydropyridines: amlodipine, felodipine, nifedipine non-dihydropyridines: diltiazem, verapamil

Question 43

what is the difference between dihydropyridines and non-dihydropyridines calcium channel blockers (CCB)

Answer 43

dihydropyridines are selective for blood vessels. e.g amlodipine, felodipine, nifedipine non-dihydropyridines are also known as rate-limiting CCBs. They are selective for the heart reduce myocardial contractility and heart rate. e.g diltiazem, verapamil *note both have the same effectiveness for hypertension*

Question 44

name some common side effects of calcium channel blockers

Answer 44

headache, flushing, swelling ankle

Question 45

name some common side effects of thiazide-like diuretics

Answer 45

- hypo: na+, k+, mg2+ - hypercalcemia (ca2+) - can exacerbate diabetes + gout

Question 46

beta blockers are generally not preferred to initially treat hypertension. When may they be used for treatment

Answer 46

- younger people who are intolerant to ACE inhibitors and ARBs - women of childbearing age/ pregnant. (only use labetalol) - people with increased sympathetic drive

Question 47

when do patients with severe hypertension start antihypertensives

Answer 47

patients with 180/120mmg (severe), start antihypertensives immediately

Question 48

name some examples of the "target organ damage" we would check for once a patient has been diagnosed with hypertension

Answer 48

examples of target organ damage: - left ventricular hypertrophy - chronic kidney disease - hypertensive retinopathy - renal disease - established CVD

Question 49

TRUE OR FALSE: for antihypertensives, it is recommended to prescribe drugs that are taken once daily

Answer 49

true

Question 50

what is the target blood pressure in pregnant women taking antihypertensives

Answer 50

135/85 mmhg

Question 51

name some risk factors for hypertension

Answer 51

age, ethnicity, dietary salt, exercise, alcohol, caffeine, smoking, weight gain secondary cause: renal disease, endocrine causes (hyper/hypo thyroidism)

Question 52

why should you ask patients to report muscle pain/weakness if they are taking statins

Answer 52

because statins can cause myopathy and rhabdomyolysis creatinine kinase and alt tests used to monitor this

Question 53

When are all ACE inhibitors contraindicated

Answer 53

- history of angioedema (e.g hereditary or idiopathic) before starting treatment with ACE inhibitors - hypersensitivity to ACE inhibitors (including angioedema) *idiopathic angiodema= swelling under skin that happens regularly without known cause)

Question 54

name some common side effects of all ACE inhibitors

Answer 54

- alopecia - angina pectoris - angioedema (more common in black patients) - cough - dry mouth - renal impairment - electrolyte imbalance - GI side effects

Question 55

if a pregnant woman was already receiving antihypertensive treatment, what drugs should be stopped

Answer 55

Stop ACE inhibitors, ARBs, thiazide or thiazide-like diuretics due to an increased risk of congenital abnormalities

Question 56

what monitoring should occur before/ during treatment with ACE inhibitors

Answer 56

Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if side effects mentioned are present

Question 57

How does renal impairment affect treatment with ACE inhibitors

Answer 57

renal impairment increases the risk of side effects such as hyperkalemia

Question 58

name some common side effects of all ARBs (angiotensin 2 receptor blockers)

Answer 58

- abdominal/ back pain - asthenia (weakness/lethargy) - hyperkalemia - postural hypotension - cough - nausea + vomiting

Question 59

what monitoring should occur when a patient is on ARBs (angiotensin 2 receptor blockers)

Answer 59

Monitor plasma-potassium concentration (side effect is hyperkalemia) , especially in the elderly and in patients with renal impairment

Question 60

what time of the day is the first dose of an ACE inhibitor usually taken

Answer 60

first dose at night

Question 61

name some common side effects of all CCB (calcium channel blockers)

Answer 61

- abdominal pain - dizziness - flushing - skin reactions - tachycardia - peripheral edema

Question 62

what are the symptoms of calcium-channel blocker (CCB) poisoning what is the treatment (antidote) for this

Answer 62

- nausea + vomiting - dizziness - confusion - agitation - coma (in severe poisoning) - metabolic acidosis - hyperglycaemia treatment: - activated charcoal if within 1st hour or modified release preparation given - calcium chloride or calcium gluconate is given by injection if patient has significant features of poisoning - atropine sulfate can be given to correct bradycardia, insulin + glucose for hypotension and heart failure

Question 63

why should you not suddenly withdraw treatment from calcium channel blockers (CCB)

Answer 63

it is associated with an exacerbation (worsening) of myocardial ischaemia. *note myocardial ischaemia = blood flow in coronary artery completely / partially blocked due to artherscleortic plaque)

Question 64

when are all thiazide-like diuretics contraindicated

Answer 64

- Addison’s disease - hypercalcaemia - hyponatraemia - refractory hypokalemia - symptomatic hyperuricaemia (high uric acid levels)

Question 65

name the common side effects of all thiazide-like diuretics

Answer 65

- Alkalosis hypochloraemic (excessive loss of chloride) - electrolyte imbalance (e.g hypokalemia) - erectile dysfunction - hyperglycaemia - hyperuricaemia (high uric acid levels)