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Pharmacological Management of Hypertension Flashcards

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1
Q

What is the difference between primary and secondary hypertension?

A
  • Primary hypertension
    • ​Idiopathic; unknown origin; >90% of cases.
  • Secondary hypertension
    • ​Known cause; <10% of cases.
    • Examples: renal disease, phaeochromocytoma, diabetes, Cushing’s, some drugs.
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2
Q

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

A
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3
Q

What are the chances of harm due to hypertension?

A
  • 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
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4
Q

What is hypertension a major risk factor for?

A
  • Stroke
  • MI
  • Heart failure
  • CKD
  • Cognitive decline
  • Premature death
  • Untreated hypertension can cause cascular and renal damage leading to a treatment-resistance state.
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5
Q

What are the goals of hypertension treatment?

A
  • Reduce arterial BP to recommended targets.
  • Reduce risk of end organ damage (CV, renal, cerebrovascular).
  • Reduce risk of mortality due to CV disease.
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6
Q

Describe the care pathway for hypertension.

A
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7
Q

What are the indications to prescribe for management of hypertension?

A
  • 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
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8
Q

What are the risk score calculators for estimating CV risk?

A
  • ASSIGN
  • Qrisk
  • JBS3
  • Based on:
    • BP
    • Age
    • Weight/height
    • Gender
    • Smoking
    • Cholestrol
    • Ethnicity
    • Social class
    • Family history
    • Diabetes, rheumatoid arthritis, renal function
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9
Q

What are the BP treatment targets?

A
  • 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.
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10
Q

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

Which drugs cause a possible increase in BP?

A
  • 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.
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11
Q

What are the factors which regulate arterial BP?

A
  • Cardiac output (CO) - HR, SV
  • Total peripheral resistance (TPR) - or systemic vascular resistance.
  • TPR x CO = MAP
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12
Q

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

A
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13
Q

What are the major classes of anti-hypertensive drugs?

A
  • Renin-Angiotensin system inhibitors
  • ​Calcium channel blockers
  • Diuretics
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14
Q

Give examples of the Renin-Angiotensin system inhibitors.

A
  • ​Angiotensin converting enzyme inhibitors (ACE inhibitors)
    • Ramipril, lisinopril, captopril
  • Angiotensin AT1 receptor antagonists (ARBs)
    • Losartan, candesartan, irbesartan
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15
Q

Give examples of calcium channel blockers.

A
  • Amlodipine
  • Felodipine
  • Lercanidipine
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16
Q

Give examples of the diuretics used in management of hypertension.

A
  • 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.
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17
Q

What are the additional treatments for resistant hypertension?

A
  • 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
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18
Q

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

A
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19
Q

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

A
  • 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.
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20
Q

What are the common side effects of ACE Inhibitors?

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A
  • 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.
21
Q

What are the common side-effects of ARBs?

Study These Flashcards
A
  • Dizziess; headaches; back / leg pain.
  • Risk of hyperkalaemia, renal impairment.
22
Q

Describe the mechanism of action of calcium channel blockers.

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A
  • 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.
23
Q

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

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A
  • 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.
24
Q

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

Study These Flashcards
A
  • Uncontrolled heart failure
  • Cardiogenic shock (MI) (recent)
  • Significant aortic stenosis
  • Unstable angina
  • Pregnancy (but consider risk / benefit)
25
What are the common side-effects of dihydropyridine-like calcium channel blockers?
* Flushes * Headaches * Ankle oedema * Dizziness
26
Which classes of drugs are kidney function modifiers? Where in the kidney do they act?
* Thiazide-like diuretics * Aldosterone antagonists
27
Give examples of thiazide-like diuretics.
* Indapamide * Bendroflumethiazide
28
Give an example of an aldosterone antagonist.
* Spironolactone
29
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).
30
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.
31
Give examples of the contraindications for prescribing thiazides.
* Hypercalcaemia * Hyponatraemia * Hypokalaemia * Symptomatic hyperuricaemia * Addison's disease
32
What are the common side-effects of thiazides?
* Low K, Na, Mg * Promotion of calcium retention / hypocalciuria * Metabolic alkalosis * Gout * Erectile dysfunction * Hyperglycaemia, hyperlipidaemia
33
What are the indications for aldosterone antagonists?
* Hypertension * Oedema (heart, liver, nephrotic syndrome) * Conn's syndrome (primary hyperaldosteronism)
34
From which class of drugs are aldosterone antagonists?
Mineralocorticoid receptor antagonists (MRAs).
35
What are the contraindications for prescribing mineralocorticoid receptor antagonists?
* Addison's disease * Anuria / kidney failure +++ * Hyperkalaemia
36
What are the side-effects of mineralocorticoid receptor antagonists?
* Hypotension * Renal impairment * High potassium (care if renal impairment!) * Hyponatraemia * GI upset * Metabolic acidosis * Gynaecomastia with spironolactone
37
What is amiloride? Describe its mechanism of action.
* Potassium-sparing weak diuretic. * Acts by directly blocking epithelial sodium channels in the collecting tubule so less sodium is reabsorbed, causing diuresis. * Usually synergistically combined with thiazide or loop diuretics.
38
What are the indications for amiloride?
* Hypertension * Oedema including ascites
39
What are the contraindications for amiloride?
* Addison's disease * Anuria * Hyperkalaemia
40
What are the side-effects of amiloride?
* High potassium (care if renal impairment) * GI upset * Metabolic acidosis * Renal impairment
41
What are β-blockers? Give examples.
* Sympathetic nervous system antagonist * **Atenolol, Bisoprolol, Carvedilol** * β1 receptor blockers (cardioselective) * Act centrally, reducing sympathetic activity, reduce CO, and also reduces renin release. * **No longer first choice** * Less effective at reducing cardiac events and stroke than ACE-I / ARB, CCB and thiazides.
42
What are the contraindications for β-blockers?
* Asthma * Cardiogenic shock / uncompensated heart failure * Hypotension * Marked bradycardia * Severe peripheral arterial disease
43
What are the β1-blocker side effects?
* Fatigue * Cold extremities * Peripheral vascular disease * Bradycardia * Bronchospasm * GI upset * Erectile dysfunction * Heart failure * Sleep disorders
44
Describe the mechanism of action of α1 antagonists. Give an example.
* **Example: doxazosin** * Sympathetic NS antagonist, blocking alpha 1 receptors. * Block vasoconstriction, resulting in vasodilation.
45
What are the side-effects of α1 antagonists?
* Postural hypotension * Dizziness * Lethargy * GI upset * Headache * Peripheral oedema
46
What are the contraindications for α1​ antagonists?
* History of micturition syncope (in patients with benign prostatic hypertrophy)
47
Summarise antihypertensive drug treatment.
48
What are the pros of multi-drug treatment of hypertension?
* Reduced mortality / morbidity. * Each drug class working at different sites on the body - can achieve BP targets more quickly. * Reduces dose burden of individual drugs, thereby minimising side-effects.
49
What are the cons of multi-drug treatment of hypertension?
* Concordance a problem: * "I felt fine before I started these drugs!" * "I keep forgetting to take all these drugs!" * Side-effects may be more frequent * Increased drug costs to the NHS

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