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PMY2204: Clinical Pharmacology and Therapeutics 1 > Hypertension > Flashcards

Hypertension Flashcards

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1
Q

What is hypertension?

A

A clinic blood pressure of 140/90 mmHg or higher confirmed by a subsequent ambulatory BP monitoring daytime average (or home BP monitoring average) of 135/85mmHg or higher

Often referred to as the ‘silent killer’ due to its asymptomatic nature.

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2
Q

What is the ideal blood pressure range?

A

90/60mmHg to 120/80mmHg

Blood pressure is measured in mmHg units.

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3
Q

What is the formula for cardiac output (CO)?

A

CO = Heart rate x Stroke volume

Main determinant of systolic blood pressure.

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4
Q

What percentage of adults over 60 years have hypertension according to WHO?

A

60%

Prevalence increases with advancing age.

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5
Q

What are the two categories of risk factors for hypertension?

A
  • Modifiable
  • Non-modifiable

Modifiable factors can be altered by the individual, while non-modifiable cannot.

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6
Q

List some modifiable risk factors for hypertension.

A
  • Excess salt
  • Alcohol consumption
  • Physical activity levels
  • Obesity and poor diet
  • Mental health and stress

These are lifestyle factors that can be changed to lower risk.

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7
Q

List some non-modifiable risk factors for hypertension.

A
  • Family history/genetics
  • Gender
  • Deprivation and socioeconomic status
  • Ethnicity

Certain ethnic groups, such as those of black African and Caribbean origin, are at higher risk.

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8
Q

What is postural hypotension? Who should be assessed for postural hypotension? Different types of PH + when do they occur?

A

A reduction in systolic BP of at least 20mmHg or diastolic BP of 10mmHg after standing for at least one minute
Assessed: type 2 diabetes, symptomatic of PH, >80yrs
Classical = w/in 3mins of standing
Delayed = >3mins of standing

It occurs when the mechanisms for regulating orthostatic BP fail.

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9
Q

What is the significance of measuring blood pressure correctly?

A

Errors can arise from incorrect positioning, tight clothing, and improper technique

All patients should be informed of their blood pressure results.

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10
Q

What are the symptoms of accelerated hypertension?

A
  • Headache
  • Visual disturbances
  • Seizures
  • Nausea and vomiting
  • Chest pain

Often associated with blood pressure exceeding 180/120mmHg.

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11
Q

What is the clinic blood pressure threshold for diagnosing hypertension?

A

≥ 140/90mmHg

This threshold is used to confirm hypertension diagnosis.

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12
Q

What is the recommended action if a patient has severe hypertension?

A

BP in clinic 180/120mmHg
→ Same day referral if; signs of retinal haemorrhage/papilloedema/pheochromocytoma, life threatening symptoms e.g. acute confusion, chest pain, heart failure symptoms or AKI
→ If no signs warranting same-day referral:
→→ Assess for target organ damage
→→→ Present = start therapy w/out ABPM/HBPM
→→→ None = repeat clinic BP in 7 days, or consider ABPM/HBPM w/in 7 days

Especially if there are signs of retinal haemorrhage or life-threatening symptoms.

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13
Q

What does the QRISK3 tool measure?

A

Individual’s 10-year risk of developing cardiovascular disease

Used to help determine the treatment pathway for patients.

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14
Q

What are the two well-established treatment strategies for lowering blood pressure?

A
  • Lifestyle changes
  • Drug treatment

Lifestyle modifications may benefit some, but many require medication.

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15
Q

What does NICE NG136 recommend for patients under 80 years regarding hypertension management?

A

Specific targets for blood pressure control

These guidelines help tailor treatment to individual needs.

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16
Q

What are the effects of a 10mmHg reduction in blood pressure according to a systematic review?

A
  • 17% reduction in coronary heart disease
  • 27% reduction in stroke
  • 28% reduction in heart failure
  • 13% reduction in all-cause mortality

These reductions highlight the importance of blood pressure control.

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17
Q

What is the mechanism of action for Angiotensin-converting enzyme (ACE) inhibitors?

A

Block the action of ACE, preventing conversion of Angiotensin I to Angiotensin II

This reduces peripheral vascular resistance and lowers blood pressure.

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18
Q

What blood pressure measurement is considered Stage 2 Hypertension?

A

160/100mmHg to <180/120mmHg

This classification helps in determining treatment strategies.

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19
Q

What should be done if a patient with hypertension has target organ damage?

A

Commence therapy without waiting for ABPM or HBPM

Immediate treatment is crucial in these cases.

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20
Q

What is the recommended follow-up for patients with normal blood pressure?

A

Repeat BP at least every 5 years

Regular monitoring is important for ongoing health.

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21
Q

What do Angiotensin-converting enzyme (ACE) inhibitors do?

A

Block the action of ACE preventing conversion of Angiotensin I to Angiotensin II

Examples include Lisinopril and Perindopril

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22
Q

What is the initial dose of Lisinopril + Perindopril erbumine?

A

Lisinopril = 10mg OD, MDD = 80mg
Perindopril erbumine = 4mg OD, MDD = 8mg

Usual maintenance dose is 20mg once daily, maximum daily dose is 80mg

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23
Q

What are common adverse effects of ACE inhibitors?

A
  • Hypotension
  • Persistent dry cough (13%)
  • Hyperkalaemia
  • Angioedema
  • Abdominal discomfort
  • Alopecia
  • GI upset
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24
Q

Name contraindications for ACE inhibitors.

A

Pregnancy and breastfeeding
Bilateral renal artery stenosis
Hx of angioedema
Hyperkalaemia (K+ > 5.5)

Also contraindicated in bilateral renal artery stenosis and history of angioedema

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25
What should be monitored when starting ACE inhibitors?
Renal function and serum electrolytes before and 1-2 weeks after starting treatment ## Footnote Also check blood pressure 4 weeks after each dose increase
26
When are Angiotensin receptor blockers (ARBs) used for?
Used when ACE inhibitors are not tolerated due to cough ## Footnote Recommended for patients of African and Caribbean family origin as per NICE NG 136
27
What is the mechanism of action of ARBs?
Block the action of Angiotensin II on the Angiotensin type 1 receptor Blockade of binding, reduces peripheral vascular resistance (afterload) Dilates the efferent glomerular arteriole which ↓ intraglomerular pressure and slows the progression of CKD ↓ aldosterone reduces Na+ and water retention- this can reduce venous return (pre-load) ## Footnote Reduces peripheral vascular resistance and dilates the efferent glomerular arteriole
28
What is the typical starting dose for Losartan + Candesartan? What is the MDD?
Losartan = 50mg once daily MDD = 100mg Candesartan = 8mg OD MDD = 32mg ## Footnote Can be increased to 100mg if needed
29
List some adverse effects of ARBs.
* Hypotension * Hyperkalaemia * Dizziness * Abdominal pain * Nausea and vomiting
30
What is the mechanism of action of Dihydropyridine calcium channel blockers?
Decrease Ca2+ entry into vascular and cardiac cells, causing relaxation and vasodilation ## Footnote This lowers blood pressure
31
What is the first + second -line dihydropyridine calcium channel blocker?
1st = Amlodipine 5mg OD, up to 10mg OD 2nd = lercanidipine 10mg OD, up to 20mg OD
32
What are common adverse effects of calcium channel blockers?
* Ankle swelling * Flushing * Headaches * Palpitations
33
What is the mechanism of action of thiazide-like diuretics?
Inhibit the Na+/Cl- co-transporter in the distal convoluted tubules Prevents re-absorption of Na+ and therefore water by osmosis Results in diuresis causing an initial fall in extracellular fluid volume
34
What is a common thiazide-like diuretic?
Indapamide tablets 2.5mg OD/1.5mg MR OD
35
What are some adverse effects of thiazide-like diuretics?
* Postural hypotension * Hyperglycaemia * Electrolyte disturbances * Mild GI upset * Erectile dysfunction * Gout * Small ↑ in lipid profiles
36
What is the mechanism of action of Spironolactone? When is it used?
Blocks the action of aldosterone, increasing sodium and water excretion while retaining potassium Also known as potassium-sparing diuretics Patient must have a potassium level of <4.5mmol/l and resistant hypertension ## Footnote This reduces blood pressure
37
What is the typical dose of Spironolactone?
25mg once daily ## Footnote This is often unlicensed
38
What are common side effects of beta-blockers?
* Fatigue * Cold extremities * Headache * GI disturbance * Masks hypoglycaemia
39
What is a contraindication for beta-blockers?
Asthma ## Footnote Risk of bronchospasm; cardio-selective beta-blockers are preferred
40
What is the mechanism of action of alpha-blockers?
Blockade of alpha1 adrenoreceptors in blood vessel smooth muscle, causing vasodilatation ## Footnote This leads to a fall in blood pressure
41
What is the initial dose of Doxazosin?
1mg once daily, increasing at 1-2 week intervals in 2mg increments Max 16mg per day
42
Name a significant drug interaction with alpha-blockers.
Phosphodiesterase 5 inhibitors (e.g., Viagra) ## Footnote Risk of hypotension
43
What are the preferred drug choices for heart failure?
* ACE-I or ARB * Spironolactone * Beta blocker * Diuretic e.g. furosemide
44
What is a key counselling point for patients on hypertension medication?
Importance of adherence ## Footnote Also, understanding common and severe side effects and monitoring requirements
45
What should be monitored when using thiazide-like diuretics?
* Plasma sodium levels * Plasma potassium levels * Renal function * Liver function
46
What is systolic blood pressure?
Left ventricles contracts + pushes blood into aorta
47
What is diastolic blood pressure?
Heart is at rest + ventricles are relaxed
48
Equation for blood pressure?
BP = CO x Peripheral resistance
49
Daily circadian variation in BP?
Non-HTN ~ BP naturally ↓ by 10-20mmHg overnight, ↑ when awake for 1st hrs of the day
50
BP variation throughout life?
Systolic BP ↑ w/ age ~ loss of natural elasticity in blood vessels
51
BP variation in elderly patients?
More variable ~ ↓ baroreflex buffering + ↑ arterial stiffness Exaggerated BP drops can occur after meals, exercise, during postural changes ~ ↑ risk of falls
52
What causes hypertension?
Primary hypertension ~ essential hypertension Secondary hypertension ~ renal disease, endocrine disease, vascular causes, drugs
53
Drugs that can cause hypertension?
Alcohol, Ciclosporin, Cocaine/amphetamine, Corticosteroids, Leflunomide, Liquorice, NSAIDs, Oestrogens (CCP/HRT), ADHD stimulants, Sympathomimetics, Venlafaxine
54
Different types of BP measurement equipment?
Manual Automated Ambulatory blood pressure monitoring (ABPM) Home blood pressure monitoring (HBPM)
55
What is manual BP measurement?
Brachial pressure cuff and auscultation of the brachial artery to identify the appearance of and disappearance of Korotkoff sounds
56
What is automated BP measurement?
Electronic or digital sphygmomanometer that measures blood pressure without the need for a stethoscope or manual inflation Less accurate if irregularity of the patient’s pulse is present
57
What is ABPM measurement?
Non-invasive method of obtaining a blood pressure reading over a 24-hour period The blood pressure cuff is attached to a small monitor that the person wears for a 24-hour period The blood pressure cuff inflates at regular intervals Allows you to obtain blood pressure measurements over a 24-hour period while the person is carrying out normal activities
58
What is HBPM measurement?
Patient monitors their own blood pressure at home Can be done by a monitor loaned by GP practice or hospital or patient may purchase their own Patient needs educated on how to monitor correctly Patient must be well motivated Monitor must be from an approved list, clinically validated and requires calibration to ensure accurate
59
How to measure manual BP + diagnose HTN?
Allow the person to sit quietly 5 mins (if possible), with their outstretched arm supported at the level of their heart. Feet should be flat on the floor, uncrossed Locate and check the radial and brachial pulses Ensure cuff size is appropriate and apply cuff correctly 2-3cm above antecubital fold Palpate the radial pulse while inflating the cuff to determine the systolic blood pressure (SBP) estimate Inflate the cuff to 20-30 mmHg above the estimated SBP and then deflate at approx.. 2 mmHg per second Use phase I (appearance) and phase V (disappearance) Korotkoff sounds to identify SBP and DBP respectively Measure BP in both arms initially provided there are no contraindications to this, if: The difference between arms is >15 mmHg, repeat both measurements The difference remains >15 mmHg, measure subsequent BP in the arm with the higher reading If clinic BP is >140 / 90 mmHg, take a 2nd measure. If the 2nd measurement is significantly different from the first measurement, take a 3rd measurement. Record the lower of the second and third measurements as clinic BP If BP is between 140 / 90 mmHg and 180 / 120 mmHg, offer ABPM or HBPM to confirm HTN diagnosis
60
How to measure BP w/ automated monitor?
The patient should be seated in a chair with a backrest and feet flat on the floor, legs uncrossed, for at least 5 minutes. The patient should be relaxed and not speak. Check the patient’s pulse at the radial artery. If any irregularity is found, do not use the automated device. The blood pressure in this instance should be measured by a manual method. The patient’s arm should be supported at the level of the heart, resting on a cushion, pillow or arm rest. Ensure there is no tight clothing restricting the patient’s arm Place the cuff neatly 2cm above the brachial artery and align the artery mark. The bladder of the cuff should encircle at least 80% of the arm, but not more than 100% Use the cuff recommended by the manufacturer Repeat three times and record the measurement as displayed. Initially test blood pressure in both arms (provided there is no contraindication to this) and use the arm with the highest reading for subsequent measurements
61
Which organ systems can be damaged from HTN mediated target organ damage?
Heart ~ MI, left ventricular hypertrophy, ischaemic heart disease, heart failure Brain ~ stroke/TIA, vascular dementia Eyes ~ fundal haemorrhage, hypertensive retinopathy Kidneys ~ CKD, proteinuria Vasculature ~ peripheral arterial disease
62
Clinical presentation of accelerated HTN?
BP excess of 180/120mmHg, sometimes over 220/120mmHg Associated w/ signs of retinal haemorrhage and/or papilloedema (swelling of optic nerve)
63
How is HTN diagnosed?
Clinic BP > 140/90mmHg + <180/120mmHg - refer pt for ABPM to confirm diagnosis -- pt unsuitable/can't tolerate ABPM, offer HPBM --- HTN diagnosis confirmed if clinic >140/90mmHg + ABPM/HBPM >135/85mmHg When waiting to confirm diagnosis, carry out investigations to assess for target organ damage + calculate CVD risk
64
What to assess for target organ damage?
Urinalysis to look for haematuria Urinalysis to look for protein in the urine and send to lab for an ACR test Blood test to check for the presence of diabetes- HBA1C Blood test to assess kidney function- U&E and eGFR Examination of the back of the eye- fundoscopy ECG to detect left ventricular hypertrophy Auscultation (listen) of the heart and carotid arteries Neurological examination and cognitive status Cholesterol test to measure serum cholesterol and high-density lipoproteins (HDL cholesterol) Patients with evidence of target organ damage may need specialist investigations
65
Stage 1 HTN readings in clinic + ABPM/HBPM
Clinic = 140/90 - 159/99mmHg ABPM/HBPM = 135/85 - 149/94mmHg
66
Stage 2 HTN readings in clinic + ABPM/HBPM
Clinic = 160/100 - <180/120mmH ABPM/HBPM = 150/95mmHg or higher
67
Stage 3/severe HTN readings in clinic + ABPM/HBPM
Clinic = systolic > 180mmHg, diastolic > 120mmHg ABPM/HBPM = no values provided in guidance
68
How do we monitor patients who are confirmed not to have HTN?
Optimal BP <120/80mmHg = repeat BP every 5yrs Normal BP 120-129/80-84mmHg = repeat BP at least every 3yrs High normal BP 130-139/85-89mmHg = repeat BP at least annually
69
Different terms to describe different types of HTN?
Normotension White coat HTN ~ >10/20mmHg between clinic + ABPM/HBPM Masked HTN Sustained HTN Secondary HTN ~ <40yrs, or those w/ accelerated HTN, or where their signs/history point toward an underlying cause
70
What is the recommended lifestyle advice?
Ask about diet + exercise patterns Alcohol consumption + encourage reduced intake (<14 units) ↓ coffee ↓ Na intake Don't offer Ca, Mg or K supplements Smoking cessation Signpost to local initiatives Follow-up verbal advice in written form
71
What happens if ACE is inhibited?
Angiotensin II is a vasoconstrictor and stimulates the release of aldosterone- both of which increase blood pressure Blockade of the conversion, reduces peripheral vascular resistance (afterload) Dilates the efferent glomerular arteriole which ↓ intraglomerular pressure and slows the progression of CKD ↓ aldosterone reduces NA+ and water retention- this can reduce venous return (pre-load)
72
NI formulary ACEi examples?
Lisinopril Perindopril erbumine
73
NI formulary ARB examples?
Losartan Candesartan
74
C/Is for ARBs?
Renal artery stenosis, acute kidney injury, pregnancy and breastfeeding, hyperkalaemia
75
Monitoring for ARBs?
Measure renal function and serum electrolytes before commencing treatment, 1-2 weeks after commencing and after each dose increase. Then check annually unless patient parameters warrant more frequent monitoring Check BP 4 weeks after each dose increase
76
C/Is for CCBs?
Severe aortic stenosis, uncontrolled heart failure, unstable angina, recent MI
77
Important drug interaction w/ CCBs?
Max licensed dose of simvastatin with amlodipine is 20mg
78
Monitoring for CCBs?
Titrate at intervals of 4 weeks following BP checks Re-check BP 4 weeks after each dose change
79
Regarding CCBS, what sort of preparations should be used?
Longer-acting
80
Cautions + C/Is for thiazide-like diuretics?
Ineffective when eGFR<30ml/min Gout, diabetes and systemic lupus Pregnancy Use in caution in elderly with co-existing gout or diabetes Severe liver disease Patients with electrolyte derangements Pregnancy
81
Monitoring for thiazide-like diuretics?
Plasma sodium levels before starting and then at regular intervals Plasma potassium levels before starting, during the first week and then regularly during treatment Renal function before starting and then at regular intervals Liver function before starting and monitor if any suspected or known liver impairment
82
Interaction of note w/ thiazide-like diuretic?
↑ risk of diabetes w/ β-blockers ~ caution needed in pts in risk of diabetes
83
C/Is w/ spironolactone?
Severe renal impairment, hyperkalaemia, pregnancy/breastfeeding
84
Side effects w/ spironolactone?
Gynaecomastia, altered libido, electrolyte disturbances (hyperkalaemia STOP)
85
Interaction regarding spironolactone?
Caution with other medications which can increase potassium levels- e.g. ACE inhibitors/ARBs
86
Monitoring for spironolactone?
Serum electrolytes and creatinine clearance before starting, then following one month of treatment the repeat as per clinical judgement Monitor BP
87
Mechanism of action of β-blockers?
Reduce force of contraction and speed of conduction in the heart Prolong the refractory period at the AV node Reduce renin secretion from the kidneys
88
NI formulary examples of β-blockers?
Bisoprolol 5mg OD, maintenance dose 10mg OD, increased if needed to 20mg OD Labetalol - pregnancy HTN
89
Interaction w/ β-blockers?
In combination with thiazides - increased risk of diabetes Avoid with rate limiting non-dihydropyridine calcium channel blockers- diltiazem/verapamil- risk of heart block
90
Monitoring for β-blockers?
BP and pulse before starting and then 2-4 weeks after starting and with each dose change until stable. Aim to keep >55bpm
91
NI formulary example of α-blocker?
Doxazosin
92
Side effects of α-blockers?
Postural hypotension, dry mouth, headache, urinary disorders, lethargy, first-dose hypotension, sexual dysfunction
93
Cautions + C/Is of α-blockers?
History of postural hypotension, heart failure, pregnancy and breastfeeding
94
Monitoring for α-blocker?
Monitor BP baseline and at 2-4 weeks post induction and dose increases until stable
95
Other drugs less commonly used for HTN?
Rate-limiting dihydropyridine calcium channel blockers (diltiazem/verapamil) Many interactions inhibit Cytochrome P450 enzymes, do not use with beta blockers (risk heart block) Other diuretics Loop (furosemide, bumetanide). Less anti-HTN effect but may be useful in those needing more potent diuresis, e.g. heart failure with oedema K-sparing diuretics (e.g. amiloride). Reserved for hypokalaemic patients Centrally acting-antihypertensives (e.g. methyldopa) Reserved for resistant hypertension. Methyldopa used in HTN in pregnancy

PMY2204: Clinical Pharmacology and Therapeutics 1 (1 decks)

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