Hypertension Flashcards
(112 cards)
1
Q
Stages of HTN in terms of clinical BP
A
Stage 1 - > 140/90
Stage 2 - > 160/100
Severe - >180/110
2
Q
Stages of HTN in terms of ABPM daily average
A
Stage 1 - >135/85
Stage 2 - 150/95
3
Q
What % of HTN has an identifiable cause?
A
5 - 10%
4
Q
What does sustained HTN produce?
A
End organ damage to blood vessels, heart and kidney
5
Q
Causes of secondary HTN
A
Renal disease Drug induced Pregnancy Endocrine causes Vascular Sleep apnoea
6
Q
What renal diseases can cause secondary HTN?
A
Chronic pyelonephritis
Fibromuscular dysplasia
Renal artery stenosis
Polycystic kidneys
7
Q
What drugs can cause HTN?
A
NSAIDs
Oral contraceptives
Corticosteriods
8
Q
What condition in pregnancy is especially associated with HTN?
A
Pre eclampsia
9
Q
What endocrine conditions can cause secondary HTN?
A
Conns syndrome Cushings disease Phaechromocytoma Hypo and hyperthyroidism Acromegaly
10
Q
What vascular condition can especially cause HTN?
A
Coarctation of the aorta
11
Q
What non modifiable factors does BP tend to increase with?
A
Age
Genetics
FH
Race (afrocarribean)
12
Q
What in the environment can increase your BP?
A
Stress
13
Q
What can raise BP?
A
Co morbidities
Age
Weight (sodium intake and diet)
Alcohol intake
14
Q
Relationship between birth weight and HTN
A
Lower the birth weight, higher the likelihood of developing HTN and heart disease
15
Q
Definition of primary HTN
A
HTN where there is no identifiable cause
16
Q
Definition of secondary HTN
A
HTN where there is an identifiable cause
17
Q
What % of cases are primary HTN?
A
95%
18
Q
What % of cases are secondary HTN?
A
5 - 10%
19
Q
Risk factors for HTN
A
Smoking DM Renal disease Male Hyperlipidaemia Previous MI or stroke LVH Sedentary lifestyle
20
Q
What are the prime contributors to BP?
A
Cardiac output
- SV
- HR
Peripheral vascular resistance
21
Q
What does the sympathetic nervous system activation cause?
A
Vasoconstriction
Reflex tachycardia
Increased cardiac output
= INCREASED BP
22
Q
What is pivitol in long term blood pressure control?
A
RAAS
23
Q
What does RAAS stand for?
A
Renin angiotensin aldosterone system
24
Q
The RAAS is responsible for what?
A
Maintenance of sodium balance
Control of blood volume
Control of BP
25
What is the RAAS stimulated by?
Fall in BP
Fall in circulating volume
Sodium depletion
26
What happens when RAAS is stimulated?
1. Renin release from juxtaglomerular apparatus
2. Renin converts angiotensin to angiotensin I
3. Angiotensin I is converted to angiotensin II by angiotensin converting enzyme (ACE)
4. Angiotensin II constricts, and stimulates aldosterone release from adrenal glands
27
What does angiotensin II do?
Potent
- vasoconstrictor
- anti natriuretic peptide
- stimulator of aldosterone release from the adrenal glands
- hypertrophic agent which stimulates myocyte and smooth muscle hypertrophy in the arterioles
28
What does aldosterone do?
Potent
- anti-natriuretic peptide
- antidiuretic peptide
29
What are poor prognostic indicators in patients with HTN?
Myocyte and smooth muscle hypertrophy
30
Examples of end organ damage that HTN can cause
```
Retinopathy
Peripheral vascular disease
Coronary heart disease
Heart disease
Renal failure
Proteinuria
Stroke
Cognitive decline
LVH
MI
```
31
HTN treatment goal elderly vs young people
Elderly target BP is higher than in young people
32
How may HTN be identified?
ABPM ambulatory blood pressure monitoring
| HBPM home blood pressure monitoring
33
How do we assess renal function?
eGFR
34
How do we assess cardiac function?
ECG
| ECHO
35
What treatable causes of HTN must be screened for?
Renal artery stenosis / FMD
Cushings disease
Conns syndrome
Sleep apnoea
36
What should be an ideal target BP to be obtained on treatment?
< 135/80-85mmHg
37
When should treatment for BP be started?
Overall CVD risk of 20% / 10 years
38
What should be used to treat young for HTN?
ACE inhibitor
| ARB
39
Do the young have high or low renin?
High
40
What should be used to treat the elderly for HTN?
CCBS
| Thiazide type diuretic
41
Do the elderly have high or low renin?
Low
42
Who should ACE inhibitors / ARBs not be used in in the young group?
Young women
43
Who should the treatment for stage 1 HTN be given to?
If < 80 y/o with ABPM > 135/80 with 1 or more of
- target organ damage
- established CVD
- Renal disease
- DM
- 10 yr CV risk equivalent to 20% or greater
If < 40 y.o get specialist advise
44
What BP is stage 1 HTN?
ABPM > 135 / 85
45
What BP is stage 2 HTN?
ABPM > 150 / 95
46
Who should the treatment for stage 2 HTN be given to?
Any people of any age with stage 2 HTN - the risk does not matter here
47
Treatment for HTN for > 55 y/o or black people of any age
CCB
| TTD if oedema / intolerance / HF
48
Treatment for HTN for < 55 y/o
ACEI or ARB
49
Why do afro-carribeans not get treated with ACEIs/ARBs?
Susceptible to swelling of the epiglottis/face
50
Step 2 treatment for HTN
Add TTD to CCB or ACEI/ARB
51
Step 3 treatment for HTN
Add the other drug that you haven't used - so add CCB, ACEI and diuretic together
52
Treatment for resistant HTN
Low dose spironolactone (25mg once daily) if blood K+ is <4.5mmol/l
TTD if blood K+ is over 4.5mmol/l
53
Why should treatment with spironolactone be cautioned with in reduced eGFR?
They have an increased risk of hyperkalaemia
54
Examples of ACEIs
Ramipril
| Perindopril
55
What does ACEIs stand for?
Angiotensin converting enzyme inhibitors
56
What do ACEIs do?
Completely inhibit actions of angiotensin converting enzyme (ACE)
57
Contraindications to ACEIs
Renal artery stenosis
Renal failure
Hyperkalaemia
58
Adverse drug reactions of ACEIs
```
Cough
1st dose HTN
Taste disturbance
Renal impairment
Hyperkalaemia
Angioneurotic oedema
```
59
Drug drug interactions of ACEIs
NSAIDs
Potassium supplements
Potassium sparing diuretics
60
What would ACEIs and NSAIDs together result in?
Precipitation of acute renal failure
61
What would potassium supplements and potassium sparing diuretics with ACEIs result in?
Hyperkalaemia
62
Examples of ARBs
Losartan
Valsartan
Candesartan
Irbesartan
63
What do ARBs stand for?
Angiotensin II antagonists
64
What do ARBs do?
Competitively block the actions of angiotensin II at the angiotensin AT1 receptor
65
Why do ARBs have an advantage over ACEIs?
They do not cause a cough
66
What is the most effective ARB?
Losartan
67
Types of CCBs
Vasodilators
| Rate limiting
68
Examples of vasodilator CCBs
Amlodipine
| Felodipine
69
Examples of rate limiting CCBs
Verapamil
| Diltiazem
70
How do CCBs work?
Block the L type calcium channels
Selectivity between vascular and cardiac L type channels
Relaxing small and large arteries and reducing peripheral resistance
Reducing CO
71
Who are vasodilator CCBs the antihypertensive of choice in?
> 55 y/o
| Women of child bearing age
72
Contraindications of CCBs
Acute MI
Heart failure
Bradycardia (rate limiting CCBs)
73
S/Es of CCBs
Flushing
Headache
Ankle oedema
Indigestion and reflux oesophagitis
74
What do rate limiting CCBs also cause?
Bradycardia
| Constipation
75
Examples of TTDs
Indapamide
| Clortalidone
76
Who is TTDs commonly the 1st line treatment in?
Mild - moderate HTN in afro-carribeans
77
How do TTDs work?
Block reabsorption of sodium and enhance urinary sodium loss
78
The full effects of TTDs as anti-HTNs may take how long?
Weeks
79
S/Es of TTD
(Not common)
Gout
Impotence
Hypokalaemia
80
Centrally acting agents like methyldopa can cause what?
Depression
81
Examples of vasodilators
Hydralazine
| Minoxidil
82
S/Es of vasodilators
Dry mouth
| Bad dreams
83
Effects of NSAIDs
Salt and water retention - causing increased BP
| Shuts off prostaglandin production
84
What causes a displaced apex?
LVH
85
What does LVH stand for?
Left ventricular hypertrophy
86
What else can be looked for in LVH?
4th heart sound - diastolic knock
87
What murmur causes a collapsing pulse?
AR
88
How should BP be checked?
Lying
Standing
Both sides
89
Man with HTN aged 48 y/o, what investigations should be done?
```
U and Es (esp Na+ and K+)
Lipids
Urine dipstick
LFTs
Thyroid
Glucose
ECG
ECHO
Kidneys/adrenal glands via USS
```
90
Potassium level in conns syndrome
Decreases
91
Potassium level in phaeochromocytoma
Increases
92
What does acute alcohol intake do to BP?
Decreases BP
93
What does chronic alcohol do to BP?
Increases BP
94
If BP >140/90, what should be offered to confirm the diagnosis?
ABPM
95
LVH on ECG
S wave on V2 and V5 added together, if > 30mm = LVH
96
S/Es of alpha blockers
Postural hypotension
| HF
97
Contraindication to alpha blockers
Urinary incontinence
98
When should there be a caution in using BBs?
DM
99
S/Es of ARBs
Hyperkalaemia
100
S/Es of spironolactone
Hyperkalaemia
101
What treatment should be added onto poorly controlled HTN already on an ACEI, CCB and a standard dose TTD with a K > 4.5mmol/l?
Alpha or beta blocker
102
What do ACEIS cause (in terms of electrolytes) as a S/E?
Hyperkalaemia
103
What do diuretics' cause (in terms of electrolytes) as a S/E?
Hypokalaemia
104
BP target for a clinic reading and < 80 y/os
< 140 / 90
105
Max dose of amlodipine
10mg
106
Max dose of ramipril
5mg
107
If a patient cannot tolerate and ACEI due to the S/Es, what should be done to the medication?
Stop the ACEI
| Change to an ARB
108
Give an example of an ARB
Candesartan
109
1st line treatment for a newly diagnosed patient with HTN who has T2DM
ACEI or ARB - REGARDLESS of age
110
Pharmacological options for treatment of orthostatic hypotension
Fludrocortisone
| Midodrine
111
Treatment of orthostatic hypotension
1. Lifestyle measures - increased Na and H20 intake
2. Discontinuation of vasoactive drugs e.g. nitrates, anti-HTNs, neuroepileptic agents, dopaminergic drugs
3. If symptoms persist, consider compression garments, fludrocortisone, midodrine, counter pressure manouvres, head up tilt sleeping
112
Target BP for a T1DM who has HTN, but no albuminuria
< 135/85
