Session 9 - Hypertension and Heart Failure

Question 1

Is blood pressure a disease?

Answer 1

No, it’s a risk factor for future vascular disease

Question 2

How does higher blood pressure cause organ damage?

Answer 2

Higher Blood Pressure -> Increased arterial thickening -> Smooth muscle cell hypertrophy and accumulation of vascular matrix -> Loss of arterial compliance -> end organ damage

Question 3

What are the five organ systems affected by sustained hypertension?

Answer 3

Brain
Heart
Arterial System
Kidney
Eye

Question 4

What two conditions is blood pressure a good indicator of?

Answer 4

Ischaemic heart disease and stroke

Question 5

What are the two types of hypertension and which is more common?

Answer 5

Primary and secondary
Primary high BP with unkown cause - 90% pop
Secondary - Known cause
10% pop

Question 6

What two factors determine whether drug therapy is offered to a patient or not?

Answer 6

The sustained level of blood pressure

The overall cardiovascular risk profile

Question 7

What is hypertension defined as?

Answer 7

BP over 140/90

Question 8

What is the effect of lowering diastolic BP by 10mmHg?

Answer 8

58% reduction in strokes

37% reduction in coronary artery disease

Question 9

What level of hypertension justifies drug treatment

Answer 9

 ≥ 160mmHg Systolic and ≥100mmHg diastolic justifies drug treatment

Question 10

What is the overall cardiovasc risk profile?

Answer 10

 Is there > 15% risk of a cardiovascular event in the next 10 years?
 Presence of end organ damage?
 In the presence of diabetes the treatment threshold is 140/90mmHg

Question 11

What are the four non-pharmocological factors that will modify decision to insitute a drug regime

Answer 11

o Optimum body weight (BMI 20-25 kg/m2)
o Regular physical activity (>30 mins a day)
o Moderation of alcohol and salt. (< 2 units for women. < 6g salt)
o Smoking cessation should be strongly advised, and supported as necessary (e.g. nicotine replacement therapy)

Question 12

What is severe hypertension?

Answer 12

> 180/>110

Question 13

What is mild hypertension?

Answer 13

140-159/90-99

Question 14

Name three ace inhibitors

Answer 14

 Ramipril
 Lisinopril
 Captopril

Question 15

What is the mech of action of ACE inhibitors in lowering blood pressure

Answer 15

 ACE inhibitors cause inhibition of Angiotensin Converting Enzyme, consequently reducing Angiotensin II and Aldosterone levels. This causes vasodilation and consequent reduction in peripheral resistance and reduced sodium retention.
 Reduce breakdown of the vasodilator Bradykinin

Question 16

Give three indications for ACE inhibitors?

Answer 16

 Hypertension
 Heart failure
 Renal dysfunction

Question 17

Give three contraindications for ACE inhibitors

Answer 17

 Pregnancy, renovascular disease, aortic stenosis

Question 18

Give five adverse drug reactions of ACE inhibitors

Answer 18

 Characteristic dry cough
 Angio-oedema (rare, but more common in black population)
 Renal Failure
 Hyperkalaemia
 Hypotension, dizziness and headache, diarrhoea and muscle cramps

Question 19

Give two angiotensin blockers

Answer 19

 Losartan

 Valsartan

Question 20

Give an indication for an angiotensin blocker

Answer 20

 Hypertension

Question 21

When would you not use an angiotensin blocker?

Answer 21

 Pregnancy, breastfeeding

 Caution in renal artery stenosis and aortic stenosis

Question 22

Give a mechanism of action of an angiotensin blocker?

Answer 22

 Bind to and antagonise the receptor for Angiotensin II – Angiotensin 1 Receptor (AT1 R).
 Inhibits vasoconstriction and aldosterone stimulation by angiotensin II.

Question 23

Give the main diuretic used in control of BP

Answer 23

Thiazide diuretics

Question 24

Give a short list of drugs involved in BP management

Answer 24

ACE inhibitors
Angiotensin blocker
Beta blocker
Calcium Channel Blockers

Question 25

Give four beta blockers

Answer 25

 Propranolol  Atenolol  Bisoprolol  Metoprolol

Question 26

Give the mechanism of action of beta blockers

Answer 26

 Antagonise β-adrenoreceptors. β1-receptors are found in the heart, when they are activated they cause increased Chronotropy and Inotropy.  Inhibit renin release

Question 27

Give four indications for beta blockers

Answer 27

 Angina  Post myocardial infarction  Hypertension  Arrhythmias

Question 28

Give a couple of contraindications for beta blockers

Answer 28

 Non-selective β-blockers (e.g. Propranolol) must not be given to asthmatic patients.  Bradycardia, hypotension, AV block, Congestive Cardiac Failure

Question 29

Give some adverse drug reactions to B blockes

Answer 29

 Bronchospasm, fatigue and insomnia, dizziness, cold extremities, hypotension, bradycardia and decreased glucose tolerance in diabetic patients

Question 30

Give two drug-drug interactions of beta blockers

Answer 30

 Prevents Salbutamol working (β2-adrenoagonist) |  Verapamil – Both have –‘ve inotropic action

Question 31

Give three types of calcium channel blockers

Answer 31

Dihydropyridine Phenylalkylamine Benzothiazepine

Question 32

What is the mechanism of action of calcium channel blockers?

Answer 32

o Calcium channel blockers bind to specific alpha subunit of L-type calcium channel, reducing cellular calcium entry o Vasodilates peripheral, coronary and pulmonary arteries o No significant effect on veins o Verapamil depresses SA node and slows A-V conduction

Question 33

Give two examples of dihydropyridine calcium channel blockers

Answer 33

Nifedipine | Amlodipine

Question 34

Give three properties of 1. Dihydropyridine Ca2+ blockers

Answer 34

 Good oral absorption  Protein bound > 90%  Metabolised by the liver

Question 35

Give three adverse effects of dihydropyridine

Answer 35

 Sympathetic nervous system activation – tachycardia and palpitations  Flushing, sweating, throbbing headache  Oedema

Question 36

What is a phenylalkylamine calcium channl blocker?

Answer 36

Verapamil

Question 37

Give three properties of verapamil (phelyalkylamine calcium channel blocker)

Answer 37

 Impedes calcium transport across myocardial and vascular smooth muscle cell membrane  Class IV anti-arrhythmic agent (prolongs action potential/effective refractory period)  Peripheral vasodilation and a reduction in cardiac preload and myocardial contractility

Question 38

Give three adverse effects of verapamil

Answer 38

 Impedes calcium transport across myocardial and vascular smooth muscle cell membrane  Class IV anti-arrhythmic agent (prolongs action potential/effective refractory period)  Peripheral vasodilation and a reduction in cardiac preload and myocardial contractility

Question 39

Give an example of a benzothazepine calcium channel bloceker

Answer 39

 Diltiazem

Question 40

Give three properties of a benzothazepine calcium channel bloceker

Answer 40

 Impedes Calcium transport across the myocardial and vascular smooth muscle cell membrane  Prolongs the action potential/effective refractory period  Peripheral vasodilation and reduction in cardiac preload and myocardial contractility

Question 41

Give two adverse effects of 3. Benzothiazepine Calcium Channel Blockers

Answer 41

 Risk of bradycardia |  Negative inotropic effect (less than Verapamil) can worsen heart failure

Question 42

Name a direct renin inhibitor

Answer 42

Aliskiren

Question 43

Give an indication for a direct renin inhibitor

Answer 43

Hyperension

Question 44

Give to contraindicator

Answer 44

 Pregnancy  Caution in patients at risk of hyperkalaemia, Na+ and volume depleted patients, severe renal impairment and renal stenosis

Question 45

Give a mechanism of action a direct renin inhibitor

Answer 45

 Antagonises Renin, preventing the conversion of Angiotensinogen  Angiotensin I.  Reduces plasma renin activity by 50-80%

Question 46

Give an adverse drug reaction of angio-oedema

Answer 46

 Angio-oedema, hyperkalaemia, hypotension, GI disturbances

Question 47

Give a therapeutic note for direct renin inhibitors

Answer 47

 t½ of ~40 hours, supporting once daily doses  Mainly eliminated as an unchanged compound in faeces (78%)  Not metabolised via CYP450

Question 48

What are two common combinations of blood pressure control?

Answer 48

o Diuretic and ACE inhibitor | o Diuretic and Beta Blocker

Question 49

What is treatment patter in people under 55?

Answer 49

Primary is Ace inhibitor (A) Secondary A+C or A+D Third is A+C_D Four is more diuretic, alpha blocker or beta blocker

Question 50

What treatment pattern in people over 55 or black patients?

Answer 50

Primary is C or D Secondary A+C or A+D Third is A+C_D Four is more diuretic, alpha blocker or beta blocker