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WEEK 21:
Hypertension
| Question | Answer |
|---|---|
| hypertension | abnormal elevation of systolic and or diastolic blood pressure diagnosed by repeated BP of >140/90mmHg, confirmed on abulatory BP recording |
| symptom development of people with hypertension | generally asymptomatic |
| secondary hypertension | when specific cause for HTN is found (hence secondary to underlying disease process eg renal disaease) |
| primary hypertension (essential) | unknown cause and can be benign (slowly progressive) or malignant (rapid onset above 180/110) |
| risk factors for essential hypertension | advancing age, low birth weight, low socio-economic class, high salt diet, obesity, sedentary lifestyle, excessive alcohol intake, stress and anxiety, and smoking |
| what can help prevent essential hypertension | low salt diet and relaxation therapies to reduce blood pressure |
| diagnoses of HTN | if blood pressure measured in the clinic as 140/90mmHg or higher, take a second measurement during consultation (and if 2nd is different from the 1st, then take a third measurement) and record the lower of them as the clinic blood pressure |
| what do you offer if the persons BP is between 14/90 and 180/120mmHg | offer ambulatory blood pressure monitoring (ABPM) to confirm diagnosis of hypertension |
| what do you offer if ABPM is unsuitable/ person is unable to tolerate it | offer home blood pressure monitoring (HBPM) |
| ABPM | ensure that at least 2 measurements per hour are taken during the person's usual waking hours and use the average of at least 14 measurements during persons usualwake hours to confirm a diagnosis of hypertension |
| when using HBPM ensure that | each BP needs 2 consecutive measurements at least 1 minute apart with person seated, recorded twice daily (morning and evening), for at least 4 days (ideally 7 days) discarding measurements taken on first day and use average to confirm diagnosis |
| what should be done when waiting for confirmation of a diagnosis of hypertension | carry out investigations for target organ damage, followed by a formal assessment of the person's cardiovascular risk |
| clinical (ABPM) diagnosis of hypertension | 140/90mmHg or higher |
| home (HBPM) diagnosis of hypertension | 135/85mmHg or higher |
| what should be done is person's blood pressure is 180/120mmHg or higher | refer for same day specialist assessment if there are sign of retinal haemorrhage/ papilloedema, life threatening symptoms eg new onset confusion, chest pains, signs of heart failure etc) |
| treatment aims for those under 80 | clinic BP <140/90mmHg and ABPM/HBPM of <135/85mmHg |
| treatments aims for those over 80 | clinic BP of <150/90mmHg and ABPM/HBPM of <145/85mmHg |
| specific goals for those with hypertension | reduction in cardiovascular damage, preservation of renal function, limitation of reversal/ LV hypertrophy, prevention of ischaemic heart disease, and reduction in mortality due to stroke and myocardial infarction |
| CCB | calcium channel blocker |
| ARP | angiotensin II receptor blockers |
| examples of ace inhibitors | captopril, enalapril, lisinopril, and ramipril |
| mechanism of action of ACEi | block ACE (ACE is needed to convert angiotensin I to angiotensin II) |
| effects of ACEi | by inhibiting ACE they lead to reductions in angiotensin II which leads to reduction in arterial and venous vasoconstriction, reduced aldosterone production -> salt and water retention and potentially bradykinin (vasodilator) + can increase K |
| what does RAAS do | increase BP and maintain perfusion |
| RAAS simplified when there is a low BP | low BP -> kidney releases renin -> renin converts angiotensinogen into angiotensin I -> ACE converts angiotensin into angiotensin II -> angiotensin II vasoconstricts and stimulates aldosterone release -> retain Na + H2O -> increase BP |
| main role fo ANGII | vasoconstriction and stimulate aldosterone release |
| aldosterone main role | retain water and sodium to increase water intake to maintain GFR during low renal perfusion |
| ACEi should be avoided in | renovascular disease (renal artery stenosis) as renin dependent hypertension, ACEIs lead to renal underperfusion and severe hypotension |
| ACEi are effective at | prevention of nephropathy in DM and may be agents of choice in patients with diabetes |
| side effects of ACEi | angioedema, can increase potassium, and dry cough |
| AT1 receptor antagonist examples | candesartan, losartan, and valsartan (sartan drugs) |
| AT1 receptor antagonists suffix | sartan |
| ACEi suffix | pril |
| mechanism of AT1 receptor antagonists | block action of AngII at the AT1 receptor found in the heart, blood vessels, kidney, adrenal cortex, lung and brain and mediates vasoconstrictor effects |
| difference in side effects of AT1 antagonists and ACEi | ACEi gives rise to cough but AT1 antagonists do not |
| calcium channel blockers (CCB) examples | diltiazem, verapamil, dihydropyridines (eg amlodipine, felodipine, nifedipine) |
| mechanism of CCBs | inhibit voltage operated Ca2+ channels on vascular smooth muscle leading to vasodilation and a reduction in BP |
| rate limiting CCBs eg verapamil and diltiazem act more on | cardiac tissue |
| dihydropyridines act more on | vascular smooth muscle |
| diuretic examples | thiazide-like (indapamide, chlortalidone) |
| diuretics are used as | second line antihypertensives |
| diuretics mechanism | inhibit Na+/ Cl- reuptake in distal convoluted tubule (DCT) leading to reduction in circulating volume and in SV |
| MAP formula | MAP = (CO X SVR) + CVP |
| side effects of diuretics | hypokalaemia, postural hypotension, and impaired glucose control |
| examples of alpha blockers | doxazosin and prazosin |
| suffix for alpha blockers | zosin |
| alpha blocker mechanism | competitive receptor antagonists of a1 adrenoceptors reducing sympathetic drive to heart, reducing CO |
| alpha blockers as a treatment | LAST CHOICE antihypertensives |
| side effects of alpha blockers | widespread side effects which makes them poorly tolerated which is why they are the LAST CHOICE antihypertensives |
| atenolol | B1 selective beta blockers |
| propranolol | B non selective beta blockers |
| contraindication with beta blockers | may block bronchial B2 receptors and are used with caution in asthma and caution in COPD |
| what do you expect to see with people with blockade of peripheral B2 adrenoceptors | opposes vasodilation to skeletal muscle leading to cold extremities and fatigue |
| adverse effects in ACEi | cough, severe first dose hypotension, renal damage, and angioedema |
| adverse effects in CCB | peripheral oedema and postural hypotension |
| adverse effects of thiazides | hypokalaemia and postural hypotension |
| adverse effects of beta blockers | bronchospasm |
| adverse effects of alpha blockers | widespread, and postural hypotension |
Created by:
kablooey
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