Hypertension

Question 1

Primary/Essential Hypertension

Answer 1

A blood pressure which is associated with significant cardiovascular risk

Question 2

Causes of Primary/Essential Hypertension

Answer 2

Not really known - multifactorial

Obesity? - Angiotensinogen produced by adipocytes

Insulin Resistance?
Excessive Alcohol Consumption
Genetics? - Activity of RAAS
Environment?
Foetal Programming? Low birth weight?
Salt sensitivity?
Age? - Stiffening of aorta
Ethnicity?

Question 3

Causes of Secondary Hypertension

Answer 3

Renal Disease
Renovascular Disease
Conn's Syndrome - Increased aldosterone levels where patient retains Na+ and thus fluid
Cushing's Syndrome
Hyperthyroidism
Phaeochromocytoma
Pregnancy
Drugs (NSAIDs, Corticosteroids, Sympathomimetics)

***Don’t memorise these

Question 4

NICE Hypertension Treatment Targets

Answer 4

SBP < 140mmHg (<140mmHg in diabetes/<130 with complications)

DBP < 90mmHg (<80mmHg in diabetes)

Question 5

Goals of hypertension treatment

Answer 5

Reduction in cardiovascular damage
Preservation of renal function
Limitation or reversal of LV hypertrophy
Prevention of Ischaemic Heart Disease
Reduction in mortality due to stroke & MI

Question 6

Formula for BP

Answer 6

Cardiac Output x Total Peripheral Resistance

Question 7

Role of ACEIs in hypertension treatment

Answer 7

Renin is produced when kidneys detect low BP, Na+ or sympathetic stimulation

This makes Angiontensin I which is converted to AII via ACE. This then controls BP by:

• Reducing arterial and venous vasoconstriction
• Reduced salt & water retention

Question 8

What does RAAS have a very significant effect on

Answer 8

Blood Pressure

Question 9

Effect of Bilateral Renal Artery Stenosis on RAAS

Answer 9

Increases renin production significantly, increasing BP

Question 10

AT1 Receptor Antagonists

Answer 10

Block action of Angiotensin II at AT 1 Receptor

Similar effect to ACEis without cough as a side effect

Question 11

Vasodilators/Ca2+ channel inhibitors for Hypertension treatment

Answer 11

Inhibit voltage operated Ca2+ channels on vascular SM
- Leads to vasodilation and reduction in TPR thus BP

Dihydropyridines (e.g. amlodipine) best for hypertension as they don’t depress cardiac tissue

Rate-limiting (e.g. verapamil) has greater effects on cardiac tissue

Question 12

Diurtetics for Hypertension Treatment

Answer 12

Thazide-like (e.g. Indapamide)
- Second line antihypertensives

Inhibit Na+/Cl- in distal convoluted tubule
Reduction in circulating volume

Important Side Effects

• Hyperkalaemia
• Postural Hypotension
• Impaired glucose tension

Question 13

Alpha blockers

Answer 13

Last-line antihypertensives
- Widespread side effect

Competitive receptor antagonists of a1-adrenoceptors

e.g. Doxazosin, prazosin

Question 14

Beta-blockers for hypertension treatment

Answer 14

Reduction in sympathetic drive to heart, reducing cardiac output and cuase a reduction in sympathetically evoked renin release

Some Beta-blockers are B1 selective (Atenolol) while others are B non-selective (Propranolol)

Blocks renin from juxtaglomerular cells
May block bronchial B2 receptors - contraindicated in Asthma and caution in COPD

Question 15

Adverse Effects of ACEIs

Answer 15

Cough
Severe first dose hypertension
Renal Damage

Question 16

Adverse Effects of Calcium Channel Blockers

Answer 16

Peripheral Oedema (e.g. swollen ankles) as they cause vasodilation of small arterioles
Postural Hypotension
Some constipation

Question 17

Adverse Effects of Thiazides

Answer 17

Diabetogenic
Alter Lipid Profile
Hypokalaemia
Postural Hypotension

Question 18

Adverse Effects of Beta Blockers

Answer 18

Bronchospasm

Question 19

Adverse Effects of Alpha-blockers

Answer 19

Widespread
Postural hypotension

(affects sympathetic control of BP)

Question 20

Lifestyle changes to treat hypertension

Answer 20

Alcohol consumption should be reduced
Weight Reduction
Avoiding excess caffeine
Reducing fat and salt intake
Increasing fruit & oily fish in diet
Increasing exercise

Question 21

Importance of smoking cessation in hypertension treatment

Answer 21

Smoking does not increase BP, but it does increase risk of cardiovascular incidents

Question 22

Choice of antihypertensive in diabetics

Answer 22

ACE Inhibitors

Question 23

Choice of antihypertensive in ischaemic heart disease

Answer 23

Beta Blockers

Question 24

Choice of antihypertensive in patients with CHF

Answer 24

ACE Inhibitors

Question 25

Treatment of Hypertension with:
Type 2 Diabetics
<55 years & non-black

Answer 25

Step 1
ACEi/AT1 RA

Step 2
ACEi/AT1 RA + CCI or Diuretic

Step 3
ACEi/AT1 RA + CCI + Diuretic

Step 4
Referral, Add spironolactone, a-blocker or Beta blockers

**ACD Guidance

Question 26

Treatment of Hypertension for patients >55 years or black

Answer 26

Step 1
CCI

Step 2
CCI + ACEi/AT1 RA or Diuretic

Step 3
CCI + ACEi/AT1 RA + Diuretic

Step 4
Referral, Add spironolactone, a-blocker or Beta blockers

**ACD GUIDANCE

Question 27

Centrally Acting Antihypertensives

Answer 27

Act on brain to reduce BP

Types
Alpha-methyl dopa: False substrate result in an analogue of NA acting at central a2-adrenoceptors
- Used to treat hypertension in pregnancy as it is safe to use

Moxonidine: An imidazoline which activates central imidazoline receptors

Clonidine: a2-adrenoceptor agonist which acts centrally to decrease sympathetic output

***They’re really not that important don’t stress about them

Question 28

What anti-hypertensives are very contraindicated in pregnancy

Answer 28

ACE Inhibitors