Hypertension

Question 1

Define Hypertension

Answer 1

A blood pressure which is associated with significant cardiovascular risk

Question 2

What is the cause of essential (primary) hypertension?

Answer 2

Unknown, may be multifactorial

Question 3

What is the cause of secondary hypertension?

Answer 3

Renal disease
Renovascular disease
Conn's syndrome
Cushing's syndrome
Hyperthyroidism
Phaechromoycytoma
Pregnancy
Drugs

Question 4

How do ACEIs work?

Answer 4

ACE Inhibitors inhibit Angiotensin Converting Enzyme
Prevents AI-AII
AII causes vasoconstriction/converted to aldosterone
Reduced aldosterone = reduced salt/water retention

Question 5

Give several named examples of ACEIs

Answer 5

Ramipril
Lisinopril
Enalapril
Captopril
Perindopril

Question 6

What are the main side effects of ACEIs?

Answer 6

Cough (potentiated bradykinin)
Increase K+
Angioedema
Worsening of renal function
Severe first dose hypotension

Question 7

When should ACEIs be avoided, and why?

Answer 7

Renovascular disease

Renin-dependent hypertension, ACEIs lead to renal underperfusion and SEVERE HYPOTENSION

Question 8

When should ACEIs be given preferentially, and why?

Answer 8

In patients with diabetes - Prevention of nephropathy

Question 9

What should be monitored before/during treatment with ACEIs?

Answer 9

Creatinine levels - indicator of renal function

Question 10

What are ATRAs/ARBs?

Answer 10

AT1 receptor antagonists

Question 11

How do ATRAs/ARBs work?

Answer 11

Block the action of AII at AT1 receptors

Similar effect to ACEIs but no cough

Question 12

What are the two main classes of clinical vasodilators?

Answer 12

Calcium Channel Blockers

Alpha-Blockers

Question 13

How do Calcium Channel Blockers work?

Answer 13

Inhibit voltage operated calcium channels on vascular smooth muscle
Vasodilation and reduced BP

Question 14

Give several named examples of Calcium Channel Blockers

Answer 14

Diltiazem
Verapamil
Dihydropyridines (Amlodipine, Nifedipine, Felodipine)

Question 15

How do dihydropyridines differ from Verapamil?

Answer 15

Verapamil exerts most of its effects on the heart

Dihydropyridines exerts most of their effects on arteriole smooth muscle

Question 16

How do Alpha-Blockers work?

Answer 16

Competitive receptor antagonists of a1-adrenoceptors

Question 17

Why are Alpha-Blockers last choice antihypertensives?

Answer 17

Widespread side effects make them poorly tolerated

ie. postural hypotension

Question 18

How do Thiazides/Thiazide-like diuretics work?

Answer 18

Inhibit Na+/Cl- in the DCT

Reduce circulating volume AND cause vasodilatation

Question 19

Give several named examples of Thiazides/Thiazide-like diuretics

Answer 19

Thiazide-like (Chlortalidone, Indapamide)

Thiazides (Bendroflumethiazide)

Question 20

When are Thiazides/Thiazide-like diuretics ineffective, and what is the exception to this?

Answer 20

Moderate renal impairment

Metolazone

Question 21

What are the main side effects of Thiazides/Thiazide-like diuretics?

Answer 21

Hypokalaemia
Postural hypotension
Impaired glucose control (diabetogenic)
Urination
Altered lipid profile
Impotence?

Question 22

When should Thiazides/Thiazide-like diuretics never be used?

Answer 22

Patients suffering from Gout

Question 23

What should be monitored before and during treatment with Thiazides/Thiazide-like diuretics?

Answer 23

Creatinine - indicator of renal function

Question 24

How do Beta-Blockers work?

Answer 24

MoA unclear
Reduce sympathetic drive to the heart, reducing CO
Reduce sympathetically evoked renin release

Question 25

What are the main side effects of, and contraindications for, Beta-Blockers?

Answer 25

May block bronchial B2 receptors Contraindicated in asthma, cause bronchospasm Caution in COPD Reduce hypoglycaemic awareness

Question 26

Give named examples of Beta-Blockers

Answer 26

Atenolol | Propranolol

Question 27

What are the main side effects of Calcium Channel Blockers?

Answer 27

Peripheral oedema Postural hypotension Constipation (some)

Question 28

What are the key lifestyle changes that should be made when first treating hypertension?

Answer 28

``` Reduce alcohol consumption Weight reduction Reduce excess caffeine Reduce fat/salt intake Increase fruit/oily fish in the diet Increase exercise Stop smoking ```

Question 29

How, and when, should hypertension be confirmed?

Answer 29

After implementation of lifestyle changes ~14 ambulatory measurements Home devices, both arms

Question 30

Describe the staging for hypertension

Answer 30

Stage 1 - <140/>90 Stage 2 - >160/>100 Severe - >180/110

Question 31

Which patients should be treated with antihypertensive medication?

Answer 31

``` Stage 1 patients with one or more: End organ damage Diabetes CV disease/high risk CV risk All Stage 2 patients ```

Question 32

What are the compelling indications for ACEIs/ATRAs?

Answer 32

Heart failure LV hypertrophy Diabetic nephropathy

Question 33

What are the contraindications for ACEIs/ATRAs?

Answer 33

Renovascular disease

Question 34

What are the compelling indications for Calcium Channel Blockers?

Answer 34

Afro-Caribbean ethnicity DHPs in isolated systolic HT Diltiazem/Verapamil in angina

Question 35

What Calcium Channel Blockers are contraindicated in CHF?

Answer 35

Diltiazem | Verapamil

Question 36

What are the compelling indications for Thiazides/Thiazide-like diuretics?

Answer 36

Elderly

Question 37

What are the contraindications for Thiazides/Thiazide-like diuretics?

Answer 37

Gout

Question 38

What are the compelling indications for Beta-Blockers?

Answer 38

Myocardial Infraction IHD CHF

Question 39

What are the contraindications for Beta-Blockers?

Answer 39

Asthma/COPD | Heart block

Question 40

What are the compelling indications for Alpha-Blockers?

Answer 40

Resistance to other drugs | Prostatic hypertrophy

Question 41

What is the first stage of treatment for <55/non-black/high renin patients?

Answer 41

ACEIs/ATRAs

Question 42

What is the first stage of treatment for >55/black/low renin patients?

Answer 42

Calcium Channel Blockers

Question 43

What is the second stage of treatment in all patients?

Answer 43

ACEIs/ATRAs + Calcium Channel Blockers

Question 44

What is the third stage of treatment in all patients?

Answer 44

ACEIs/ATRAs + Calcium Channel Blockers + Diuretic

Question 45

What drugs can be added in stage four of treatment (resistance)?

Answer 45

Alpha Blocker Spironolactone Diuretic Beta-Blocker

Question 46

When should the use of statins be considered?

Answer 46

All patients at high risk of CVD, even with 'normal' cholesterol