Pharmacological Management of Hypertension Flashcards Preview

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Flashcards in Pharmacological Management of Hypertension Deck (49)
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What is the difference between primary and secondary hypertension?

  • Primary hypertension
    • Idiopathic; unknown origin; >90% of cases. 
  • Secondary hypertension
    • Known cause; <10% of cases.
    • Examples: renal disease, phaeochromocytoma, diabetes, Cushing's, some drugs.


Differentiate between 'low' BP, normal BP, stage 1 and stage 2 hypertension. 


What are the chances of harm due to hypertension?

  • Depends on:
    • How high the BP is 
    • How long the person has had high BP
    • Whether any relevant concurrent health problems (such as high cholesterol or diabetes)
    • Concordance with medication / lifestyle changes


What is hypertension a major risk factor for?

  • Stroke
  • MI
  • Heart failure
  • CKD
  • Cognitive decline
  • Premature death
  • Untreated hypertension can cause cascular and renal damage leading to a treatment-resistance state. 


What are the goals of hypertension treatment?

  • Reduce arterial BP to recommended targets.
  • Reduce risk of end organ damage (CV, renal, cerebrovascular). 
  • Reduce risk of mortality due to CV disease. 


Describe the care pathway for hypertension.


What are the indications to prescribe for management of hypertension?

  • Patients of any age with stage 2 or 3 hypertension. 
  • Patients with stage 1 hypertension who have one or more of the following:
    • Target organ damage
    • Established CV disease (CHD, CVA)
    • Renal disease
    • Diabetes
    • 10-year CV risk equivalent to 20% or greater


What are the risk score calculators for estimating CV risk?

  • Qrisk
  • JBS3
  • Based on:
    • BP
    • Age
    • Weight/height
    • Gender
    • Smoking
    • Cholestrol
    • Ethnicity
    • Social class
    • Family history
    • Diabetes, rheumatoid arthritis, renal function


What are the BP treatment targets?

  • Standard patients
    • <140/90mmHg
  • Over 80 years of age
    • <150/90mmHg
    • More important than controlling BP is preventing falls. Do not drop BP too fast or too low. 
  • Cardiac / renal disease or diabetes
    • <130/80mmHg
  • BUT, make it patient centres:
    • Individualised targets based on appropriateness, tolerability and frailty. 


Before prescribing anti-hypertensive medication, you must review the patient's drugs.

Which drugs cause a possible increase in BP?

  • NSAIDs (e.g. ibuprofen, diclofenac)
  • Oral steroids (e.g. Prednisolone)
  • Venlafaxine (anti-depressant)
  • Oral sympathomimetic decongestants (e.g. Pseudoephedrine - "Sudafed")
  • Soluble or dispersible drugs - contains SALT
  • Illicit drug use. 


What are the factors which regulate arterial BP?

  • Cardiac output (CO) - HR, SV
  • Total peripheral resistance (TPR) - or systemic vascular resistance.
  • TPR x CO = MAP


Give a summary of the stepwise anti-hypertensive drug treatment. 


What are the major classes of anti-hypertensive drugs?

  • Renin-Angiotensin system inhibitors
  • ​Calcium channel blockers
  • Diuretics


Give examples of the Renin-Angiotensin system inhibitors.

  • ​Angiotensin converting enzyme inhibitors (ACE inhibitors)
    • Ramipril, lisinopril, captopril
  • Angiotensin AT1 receptor antagonists (ARBs)
    • Losartan, candesartan, irbesartan


Give examples of calcium channel blockers.

  • Amlodipine
  • Felodipine
  • Lercanidipine


Give examples of the diuretics used in management of hypertension.

  • Thiazide-like diuretics - often essential at step 2 or 3, but not effective in moderate-severe renal impairment.
    • Indapamide, bendroflumethiazide
  • High dose loop diuretics (e.g. Furosemide) may be used for raised BP in renal failure.


What are the additional treatments for resistant hypertension?

  • Sympathetic nervous system antagonists
    • β-blockers 
      • E.g. atenolol
    • α1 adrenoceptor blockers
      • E.g. doxazosin
  • Kidney function modifiers
    • Potassium sparing diuretics and aldosterone antagonists
      • E.g. amiloride, spironolactone


Describe the parts of the pathway which ACE-Inhibitors and ARBs act upon to produce their anti-hypertensive effects.


What are the contraindications for prescribing ACE-I or ARBs?

  • Allergy, hypersensitivity.
  • History of angioneurotic oedema (hereditary, idiopathic or due to previous angioedema with ACE-I or ARBs). 
  • Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney. 
  • Pregnancy. 


What are the common side effects of ACE Inhibitors?

  • Persistent dry cough (15%) which is untreatable (patients need to switch to ARB); dizziness; tiredness; headaches.
  • Slight increased risk of angioedema in African/Carribean ethnicity. 
  • Risk of hyperkalaemia (care with drug interactions).
  • Renal impairment. 


What are the common side-effects of ARBs?

  • Dizziess; headaches; back / leg pain.
  • Risk of hyperkalaemia, renal impairment. 


Describe the mechanism of action of calcium channel blockers.

  • Block entry of calcium through slow channels in cardiac and smooth muscle.
  • Reduce cardiac output (class 4 anti-arrhythmics - verapamil, diltiazem). 
  • Peripheral vasodilation, reduced TPR. 


Which kind of calcium channel blockers should be used as anti-hypertensives and why?

  • In hypertension, use dihydropyridine-like CCBs:
    • E.g. amlodipine, felodipine, lercanidipine. 
  • Used because they have less effect on cardiac muscle cells, greater impact on vascular smooth muscle, reduces PR. 


What are the contraindications of dihydropyridine-like calcium channel blockers?

  • Uncontrolled heart failure
  • Cardiogenic shock (MI) (recent)
  • Significant aortic stenosis
  • Unstable angina
  • Pregnancy (but consider risk / benefit)


What are the common side-effects of dihydropyridine-like calcium channel blockers?

  • Flushes
  • Headaches
  • Ankle oedema
  • Dizziness


Which classes of drugs are kidney function modifiers?

Where in the kidney do they act?

  • Thiazide-like diuretics
  • Aldosterone antagonists


Give examples of thiazide-like diuretics.

  • Indapamide
  • Bendroflumethiazide


Give an example of an aldosterone antagonist.

  • Spironolactone


What is the mechanism of action of thiazide diuretics?

  • Inhibits the NaCl co-transporter in the distal tubule
    • so less NaCl is reabsorbed
    • so causing moderate diuresis, reducing oedema and BP.
  • Direct relaxant effect on vascular smooth muscle (reduces BP).


What are the indications for prescribing thiazide?

  • Hypertension (not if also have moderate-severe renal impairment). 
  • Mild heart failure.
  • Severe resistant oedema (plus loop diuretic).
  • Nephrogenic diabetes insipidus.