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Flashcards in Hypertension + HF Deck (68):
1

What are mechanisms of physiological control of blood pressure

RAAS:
vasoconstriction
NA + water reabsorption
Aldosterone release

Autonomic nervous system: HR, TPR

2

What is definition of hypertension

Chronically raised blood pressure:
Clinic BP >140/90
ABPM >135/85

Most important risk factor for CVD (stroke,ihd)

3

What is white coat hypertension

Raised clinic BP but normal ABPM
Do not treat

4

What is malignant hypertension

Rapid increase in BP, leading to severe hypertension and vascular damage
>200/130
Treat immediately

5

What is primary hypertension

Without underlying cause
95%

6

What is secondary hypertension

Underlying cause
5%

7

What are secondary causes of Hypertension

Renal: renal artery stenosis, pyelonephritis, glomerulonephritis, PCKD
Endocrine: Conns Syndrome, Cushing’s syndrome, pheochromocytoma, hyperparathyroidism
Drugs: steroids, oral contraceptives, NSAIDs

8

What are clinical features of hypertension

Asymptomatic
Signs of End organ damage
Malignant: headaches, visual disturbance, seizures

9

What investigations are required to diagnose hypertension

Clinic BP
ABPM or Home BP monitoring
Assess CV risk: glucose, cholesterol
Assess end organ damage: fundoscopy, urine dipstick, ECG

10

What are the stages of hypertension

Stage 1: cBP >140/90 And ABPM >135/85
Stage 2: cBP >160/100 and ABPM >150/95
Stage 3: cBP >180 systolic or >110 diastolic

11

What are treatment goals for hypertension

<140/90
<135/85 for DM
<150/90 for >80yo

12

What are lifestyle management of hypertension

Low Na diet
Stop smoking
Low caffeine intake
Low alcohol intake
Low fat diet
Exercise
Weight loss

13

How do you manage clinic BP <140/90

No treatment
Normotensive

14

How do you manage clinic BP >140/90

ABPM or Home BP monitoring
Assess CV risk
Assess end organ damage

15

How do you manage clinic BP >180/110

Treat immediately
Referral if: retinal haemorrhage, papilloedema, suspected phaeochromocytoma

16

How do you manage ABPM <135/85

No treatment
Normotensive

17

How do you manage ABPM >135/85

Treat if <80yo AND:
10yr CV risk >20%
End organ damage
Diabetes
Reno-vascular disease
CV disease

18

How do you manage ABPM >150/95

Treat

19

What is first step of management

<55yo: ACE-I or ARB
>55yo or Afro-carribean: CCB or Thiazide-like diuretic

20

What is second step of management

Ace-I + CCB or
ACE-I + Thiazide

21

What is third step of management

ACE-I + CCB + Thiazide

22

What is fourth step of management

Add on a fourth drug:
Spironolactone if K <4.5 mmol/L
Higher dose thiazide if K >4.5 mmol/L
Alpha or beta blocker if diuretic not tolerated
Renin inhibitor If non above tolerated

23

Why are thiazide-like diuretics preferred over traditional thiazide

Lower risk of hyponatraemia and falls

24

Give examples of ACE inhibitors

Ramipril
Lisinopril

25

What is mechanism of action of ACE inhibitors

Reduce Angiotensin II synthesis
Reduce vasoconstriction
Reduce Na and water reabsorption
Reduce aldosterone release
Enhance bradykinin activity (vasodilator)

26

What are side effects of ace inhibitors

Dry cough
Angio-oedema
Renal failure
Hyperkalaemia
First dose hypotension

27

What are contra indications of ace inhibitors

High dose diuretics
Severe aortic stenosis (sudden cardiac death)
Renovascular disease
Pregnancy + breastfeeding

28

What monitoring is required with ace inhibitors

U+Es
Baseline
After increasing dose

29

Give examples of ARB

Losartan
Candesartan

30

When is ARB indicated

When ACE-I not tolerated (dry cough)

31

What is mechanism of action of ARB

Inhibit Angiotensin AT1 receptor
Inhibit AII activity

32

What are side effects of ARB

Hyperkalaemia
Renal failure
Urticaria
Pruritus

33

Give examples of CCB

Dihydropyridines: amlodipine
Phenylalkylamines: verapamil
Benzothiazepenes: Diltiazem

34

What is mechanism of action of CCB

Inhibit L type calcium channels
Inhibit Ca influx
Smooth muscle relaxation of peripheral, coronary and pulmonary arterioles

35

What are pk properties of amlodipine

Good oral bioavailability
Long T1/2
Few active metabolites - safer in renal disease

36

What are side effects of amlodipine

Ankle Oedema
Flushing
sweating
tachycardia
palpitations

37

What is mechanism of action of verapamil

Inhibit Ca channels in SAN/AVN, cardiac myocytes, vascular SM
Slow HR
Reduce contractility
Vasodilation

38

What are side effects of verapamil

Bradycardia
Constipation
Worsen HF

39

What are contraindications of verapamil

Heart failure

40

Give examples of thiazide diuretics

Bendroflumethiazide

Thiazide-like diuretic:
Metolazone
Chlortalidone

41

What are contra indications of thiazide diuretic

Gout

42

Give examples of alpha blockers

Doxazocin

43

What is mechanism of action of alpha blockers

Inhibit alpha 1 adrenoceptor of Vascular SM
Inhibit Ca influx
Vascular SM relaxation
Reduce TPR

44

What are side effects of alpha blockers

Postural hypotension
Ankle oedema
Dizziness

45

Give examples of beta blockers

Atenolol, bisoprolol

46

What is mechanism of action of beta blockers

Inhibit beta 2 adrenoceptor of Heart
reduce HR and contractility
Inhibit renin release

47

What are side effects of beta blockers

Bronchospasm
Bradycardia
Lethargy
Impaired glucose tolerance
Impaired exercise tolerance
Impotence

48

What are contraindications of beta blockers

Asthma

49

Give examples of renin inhibitors

Aliskiren

50

What is mechanism of action of renin inhibitors

Inhibit conversion of angiotensinogen to Angiotensin I
Reduce AII levels

51

What are side effects and contra indications of aliskiren

Diarrhoea
Pregnancy

52

Give examples of direct acting vasodilator

Hydralazine
Miroxidil

53

When is direct acting vasodilator indicated

Severe hypertension

54

How do you manage malignant hypertension

Treat immediately
Controlled reduction over days
Oral admin

55

How do you manage hypertensive encephalopathy

IV sodium nitroprusside
BP reduction to 110 diastolic over 4 hrs

56

What are cautions of sodium nitroprusside

Metabolised to cyanide
Caution in liver disease
Avoided repeated use

57

What are side effects of hydralazine

Flushing
Tachycardia
Drug-induced Lupus

58

What drugs are used in pharmacological management of heart failure

Beta blocker
Ace inhibitor
Spironolactone
Hydralazine combined with nitrate
Digoxin
Diuretics: loop, thiazide

59

Which medications improve long term mortality in heart failure

Beta blockers
Ace inhibitors
Spironolactone
Hydralazine with nitrates

60

What is the role of diuretics in heart failure management

Symptom relief
No improvement in mortality

61

What is first step of management of heart failure

Beta blocker
Ace inhibitor

62

What is second step of management of HF

Addition of spironolactone or
ARB or
Hydralazine with nitrates

63

What is third line of management of HF

Addition of Digoxin

64

Which diuretics are used in HF management

Loop: furosemide
Add Spironolactone: If hypokalaemic
Add thiazide: if refractory oedema

65

What are indications of ACE I

All HF patients

66

What are indications of Beta blockers
What caution is required

All HF patients
Start at low dose, titrate slowly

67

When is spironolactone indicated

Symptomatic despite optimal therapy
Post-MI with LVSD

68

When is Digoxin indicated

Symptomatic despite optimal therapy
AF