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4TH YEAR - CPTP > Hypertension/HF > Flashcards

Hypertension/HF Flashcards

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1
Q

What are the symptoms of acute heart failure?

A

Sudden onset breathlessness, crackles, fatigue, oedema, cough/wheeze, pink phlegm

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2
Q

What are the causes of acute heart failure?

A
  • Infection
  • Allergic reaction
  • PE
  • Bypass surgery
  • MI
  • Arrhythmias
  • Acute on chronic
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3
Q

How is acute heart failure treated?

A

1st - LMNOP - furosemide, morphine, nitrates, high flow oxygen, position
(NICE do not recommend nitrates but they are being increasingly used)

DONT GIVE B BLOCKERS

2nd - NIV, mechanical ventilation, inotropes, surgery for vascular disease

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4
Q

What do you give to patients with acute heart failure after they have stabilised?

A
  • Beta blocker and ACEi
  • Salt/fluid restriction
  • DVT prophylaxis - tinzaparin
  • Increase furosemide, add thiazide, monitor U&E
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5
Q

How is heart failure diagnosed?

A

Pro-BNP and cardiac abnormalities on ECHO

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6
Q

What are the symptoms of chronic heart failure?

A

Shortness of breath, wheeze, fatigue, oedema

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7
Q

What causes chronic heart failure?

A
  • Cardiomyopathy
  • Cor pulmonale
  • Hypertension
  • Diabetes
  • Valvular disease
  • Coronary artery disease
  • Inherited conditions
  • Pericarditis
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8
Q

How is chronic heart failure treated?

A

1st - ACEi/ARB and B blocker and diuretics
2nd - Spironolactone, hydralazine + nitrate
3rd - Digoxin

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9
Q

Which drugs give prognostic benefit?

A

ACEi/ARB and beta blockers, particularly to those with HF due to LVSD

Spironolactone - need to monitor U&E

Hydralazine/nitrates for those intolerant to ACEi/ARB

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10
Q

Which patients should be given digoxin for chronic heart failure?

A

Treatment resistant or AF (elderly, sedentary)

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11
Q

Which drugs give symptomatic benefit?

A

Loop diuretics - furosemide

Digoxin

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12
Q

What are the aims of treatment in patients with heart failure?

A 
Symptom relief
•	reduce SOB, fluid retention
•	diuretics, ACEI
•	digoxin if still symptomatic on optimal dose ACEI/diuretics
Survival benefit
•	ACEI
•	Beta Blocker
•	Spironolactone (post MI)
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13
Q

What comorbidities do you need to be aware of when treating HF?

A

BP – high or low
• If hypotensive – cant use GTN as nitrates make you hypotensive

Asthma – avoid β blockers

Renal - Toxicity of ACEi and ARB

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14
Q

Do you use beta blockers in acute HF?

A

NO!!! - If used in acute heart failure you could patient into cardiogenic shock and kill them. Need to wait until HF has stabilized.

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15
Q

What drugs do we use in acute HF?

A

Inotropes - e.g dobutamine (acute/cardiogenic shock)
Opiates - Diamorphine
Nitrates - e.g GTN
Loop diuretics - furosemide

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16
Q

What drugs do we use in chronic HF?

A 
Loop diruetics - furosemide
K sparing diuretics - spironolactone
ACEis - lisinopril, ramipril
ARBs - losartan
Beta blockers - atenolol
Cardiac glycosides - digoxin
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17
Q

What is the use of furosemide in HF?

A

Acutely used IV in combo with oxygen therapy, used to shift fluid (put in a catheter)

Chronic – figure out what dose ~40mg

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18
Q

What is the use of diarmorphine in HF?

A

Acute phase breathlessness

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19
Q

What is the use of GTN in HF?

A

Offload the preload of the heart (careful of hypotension)

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20
Q

What is the use of inotropes in HF?

A

Help to continue kidney perfusion, but can cause arrhtymias

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21
Q

What is the use of K+ sparing diuretics in HF?

A

Spironolactone - often used in combo with loop diuretics to fine tune treatment in chronic.
Can cause hyperkalaemia.

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22
Q

What is the use of ACEis in HF?

A

Chronic - Start with a low dose and titrate up, checking kidney function as you go. Common side effect is the dry cough.

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23
Q

What is the use of ARBs in HF?

A

Chronic - Start with a low dose and titrate up, checking kidney function as you go. Alternate if ACE cause bad side effects.

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24
Q

What is the use of loop diuretics in HF?

A

Symptomatic benefit - loss of oedema and work on the heart

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25
What is the use of digoxin in HF?
Use in treatment resistant or AF, very narrow therapeutic range → can cause digoxin toxicity.
26
What is the ACD rule when managing hypertension?
1. Acei/ARB or CCB 2. Add thiazide like Diuretic 3. Add further Diuretic of a/b blocker
27
Which ACEis are used in HTN?
Lisinopril, ramipril, enalapril
28
What are the indications for using ACEis in HTN?
First line for <55, non-afrocarribbean
29
What are the contraindications to using ACEis in HTN?
- Pregnancy - Peripheral vascular disease - Renal disease - Hyperkalemia
30
What are the side effects of ACEis?
Dry cough, hypotension, fatigue, headache, renotoxic (must monitor U&E)
31
How do ACEis work?
Stop the action of ACE and therefore prevent conversion of angiotensin 1 to angiotensin 2, thus inhibiting the RAAS
32
Which CCBs are used in HTN?
Nifedipine, amlodipine, verapamil
33
What are the indications for using CCBs in HTN?
First line for >55 or black afrocaribbean (as they have a more salt sensitive HTN)
34
What are the contraindications for using CCBs in HTN?
Right sided heart failure
35
What are the side effects of CCBs?
Dizziness, constipation, facial redness (no metabolic effects)
36
How do CCBs work?
Stop calcium influx into vascular smooth muscle therefore stopping vasoconstriction
37
Which ARBs are used in HTN?
Losartan
38
What are the indications for using ARBs in HTN?
Cant tolerate ACEis
39
What are the side effects of ARBs?
Headache, dizziness, myalgia
40
How do ARBs work?
Stop angiotensin binding to receptor, thus inhibiting the RAAS system
41
Which b blockers are used in HTN?
Atenolol (sometimes combined with an alpha blocker such as doxazosin)
42
What are the indications for b blockers in HTN?
Use of unable to tolerate other drugs or women of child bearing age
43
What are the contraindications for b blockers in HTN?
- Asthma - COPD - Heart block
44
What are the side effects of beta blockers?
Dizziness, SOB
45
How do b blockers work?
Antagnose B1 receptors in the heart to reduce HR
46
Which a blockers are used in HTN?
Doxazosin (use in combo with b blocker)
47
What are the indications and contraindications for a blockers?
I - prostatism | CI - urinary incontinence
48
Which diuretics are used in HTN?
Thiazide like - sulphonamide, indapamide Potassium-sparing - spironolactone Thiazides - bendroflumathiazide
49
What are the indications for diuretics in HTN?
Varied, usually when people haven't responded well to ACEis/ARB/CCB
50
What are the contraindications for diuretics in HTN?
Gout, renal failure
51
How do diuretics work?
Thiazide-like - net loss of Na and H20 Spironolactone - act on DCT and collecting duct Thiazides - net loss of Na and H20
52
What are the side effects of diuretics?
Hyperglycaemia, hyperlipidemia
53
Which drugs are best used in pregnancy ?
Methyldopa Nifedipine Labetolol
54
Which drugs can't you use in pregnancy?
Beta blockers (excpet labetolol) • Unsafe in pregnancy before 28weeks gestation (growth retardation) Thiazides • Unsafe in pregnancy (oligohydramnios) ACE Inhibitors • Unsafe throughout pregnancy (congenital malformations (1st trimester exposure) and ACEI fetopathy (2nd trimester exposure). A2 Antagonists also contraindicated.
55
What is stage 1 hypertension?
Clinic BP >140/90 AND ABPM>135/85
56
What is stage 2 hypertension?
Clinic BP>160/100 AND ABPM>150/95
57
What is stage 3 hypertension?
Clinic BP>180 systolic or 110 diastolic
58
When do you start initiating treatment in a pt with hypertension?
``` Offer to stage 1 if they also have: - target organ damage - renal disease - established cardiovascular disease - diabetes - 10yr cardiovascular risk >20% using the QRISK score Offer to all in stage 2 or above ```
59
What is white coat hypertension?
A discrepancy of over 20/10 mmhg between clinic and home readings
60
Aside from medication, what should be offered to all people with HTN?
Urine dip - proteinuria, albumin:creatinine ratio, haematuria Bloods - glucose, electrolytes, creatinine, eGFR, cholesterol Fundi exam - hypertensive retinopathy ECG - cardiovascular, K Lifestyle advice - smoking, diet, exercise
61
What is the target BP if under 80yo with HTN?
140/90
62
What is the target BP if over 80yo with HTN?
150/100
63
What are the causes of secondary HTN?
* Renal disease, renal artery stenosis (fibromuscular hyperplasia in this age group), pre-eclampsia, * Conn’s syndrome (primary hyperaldosteronism causes sodium retention and low potassium), * Cushing’s syndrome, Coarctation, Phaeochromocytoma, Acromegaly
64
What are the complications of HTN?
• MI • Left ventricular hypertension → very tall QRS • Stroke → Cerebral infarction, brain haemorrhage, Lacunar syndromes, Multi-infarct disease • Hypertensive nephrosclerosis → monitor protein urea. Also monitor urine for Albumin-creatinine ratio (ACR). ACR<2 is normal. Haematuria if a bad sign, especially in men, of kidney damage. • Eyes → Earliest HTN sign is silver wiring – silver look to the arteries. Severe = papilloedema. • Dissecting aortic aneurysm → severe tearing pain… measure BP in both arms, it will be significantly lower in the left arm than the right arm. • Peripheral Vascular disease → especially in combination with smoking and diabetes • Accelerated (malignant) Hypertension – Medical emergency (SBP >200) o Headache, Visual impairment, Renal impairment, Cardiac failure, Neurological signs, Microangiopathic haemolytic anaemia, Fundal changes

4TH YEAR - CPTP (19 decks)

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