Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
67 Cards in this Set
- Front
- Back
|
What is HT a risk factor for? |
Cause of CVD morbidity and mortality HT is an indépendant RF for: Myocardial infarction Chronic kidney disease Ischaemic and hemorrhagic stroke Heart failure Premature death |
|
|
What percentage of Australians are hypertensive? What BP defines HT? |
34% Australians aged >18years were hypertensive OR taking antihypertensive therapy Defined by BP >140/90 mmHg |
|
|
What percentage of ATSI adults have untreated or uncontrolled HT? |
>25% ATSI people have a greater prevalence of RF for CVD and have higher risk of premature CVD events. ATSI adults 50% more likely to die from circulatory disease compared with non-ATSI. |
|
|
What affect can modifying lifestyle factors have on HT? |
Delay or prevent onset HT Contribute to reduction of BP in treated patients Reduce or abolish the need for anti-hypertensive therapy |
|
|
What are hypertensive urgencies? |
Severe BP elevations (>180/110 mmHg) that are not immediately life threatening but are associated with either symptoms (e.g. severe headache) or moderate target organ damage. Rx - oral drugs and f/u within 24-72hrs |
|
|
What are hypertensive emergencies? |
When BP is very high (>220/140mmHg) and acute target organ damage or dysfunction is present (e.g. heart failure, APO, AMI, aortic aneurysm, ARF, major neurological changes, HT encephalopathy, papilloedema, cerebral infarction, hemorrhagic stroke). Mx - hospitalisation (usually ICU), close BP monitoring and parenteral anti-hypertensive therapy. |
|
|
What is accelerated HT and malignant HT and how are these managed? |
Accelerated HT - severe HT accompanied by presence of retinal haemorrhages and exudates Malignant HT - severe HT with retinal haemorrhages and exudates + papilloedema Both very poor prognosis without treatment Mx - urgent treatment, specialist |
|
|
By what BP are Grade 1, 2, 3 HT defined? |
Systolic Diastolic Grade 1 (mild) HT 140-159 +/ or 90-99 Grade 2 (mod) HT 160-179 +/- or 100-109 Grade 3 (severe) HT >180 +/- or >110 Isolated systolic HT >140 and <90 |
|
|
In managing a patient with HT what else needs to be considered? |
The individuals absolute CVD risk - incorporates medical history, cholesterol and diabetes status. Expressed as % this calculator estimates the individuals risk of a cardiovascular event over a 5 year period. Calculator at www.cvdcheck.org.au. Designed for primary prevention in Australians >45yrs (ATSI >35yrs) with NO known CVD. When using calculators - use clinic BP, not validated for ambulatory, automated or home BP measures. |
|
|
In which patients is calculation of CVD risk NOT appropriate? |
Persistently elevated BP >180/110mmHg (Grade3) or those with target organ damage (renal impairment, albuminuria, cardiac hypertrophy or vascular disease) - as already high absolute CVD risk. OR People with known CVD or co-morbidities - established vascular disease, prior MI, prior CVA/TIA, PVD, end stage CKD, heart failure, AF or aortic disease. |
|
|
What is the goal of absolute CVD risk assessment? |
Reduce the level of absolute CVD risk by managing multiple RFs concurrently, not BP in isolation. |
|
|
Is the absolute CVD risk calculator accurate for estimating risk in ATSI population? |
No it underestimates risk in ATSI patients. Inaccordance with the Central Australian Rural Practitioners Association Standard Treatment Manual, it isrecommended to add 5% to the calculated risk score in ATSI peoples. |
|
|
Is a one of high BP enough to diagnose HT? What device should be used to measure BP? |
A comprehensive assessment of BP should bebased on multiple measurements taken on several separateoccasions, at least twice, 1 or more weeks apart, orsooner if severe HT. BP can bemeasured in a number of ways. Clinic BP can be measured using a mercury sphygmomanometer or an automated digital device with or without the healthprofessional present. Home BP monitoring(HBPM) and 24-hour ambulatory BP monitoring (ABPM) assist in establishing an accurate B.P |
|
|
What conditions should be used when measuring a patients BP? |
A quiet, appropriate environment at room temperature. Patient should be seated (with legs not crossed) and relaxed for several minutes beforemeasurement. Patients should refrain from caffeine and smoking for at least 2 hours before measurement. |
|
|
If it is the first time measuring a patients BP which arm should be used? |
Measure both arms, particularly if there is evidence of peripheral arterial disease. Where there is variation >5 mmHg between arms, use the arm with the higher reading for allsubsequent measures. Where there is suspected postural hypotension (e.g. older patients and/or those with diabetes),measure both sitting and standing BP. Repeat measurement after patient has beenstanding for at least 2 minutes. |
|
|
How many measurements should be taken on one day in the clinic when checking a patients BP? |
Take 3 measurements and average the last two. If readings vary more than 10 mmHg systolicor 6 mmHg diastolic, have the patient rest quietly for 5 minutes then re-measure. |
|
|
What are some common errors in measuring clinic BP that cause inaccurate measurements? |
Cuff placed over thick clothing Inappropriate cuff size Worn cuff Non-validated and/or serviced sphygmomanometer Arm elevated above heart Failure to identify variance between arms Patient not rested or talking during measurement Failure to palpate radial pulse before auscultatory measurements Deflation of cuff too quickly Re-inflation to repeat measure before cuff has fully deflated Rounding off reading by >2 mmHg Taking a single measure |
|
|
What are some clinical indictors for out of clinic BP measurements with 24hour ABPM or HBPM (home BP measurements)? |
Suspicion of white-coat HT Suspicion of masked HT Identified white-coat HT Marked variability of BP measurements Autonomic, postural, post-prandial and drug-inducedhypotension Identification of true resistant HT Suspicion of nocturnal HT or absence ofnocturnal dipping e.g. in patients with OSA, CKD or diabetes. |
|
|
So is the recommendation to use clinic BP or ABPM or HBPM when diagnosing HT? |
If clinic BP is ≥140/90 mmHg, or HT is suspected,ambulatory and/or home monitoring should be offered to confirm the BP level. However, clinic BP remains the only BP measure to be used whenestimating absolute CVD risk using available risk assessmentcalculators. |
|
|
Should nighttime BP be higher or lower than daytime BP? |
Mean night-time systolic ABP should be at least 10% lower than the daytime level. Patientswho do not show night-time lowering of BP (‘non-dippers’) are at increased CVD risk. |
|
|
What are the risk factors for HT? |
Family/personal hx = CKD, HT, diabetes, dyslipidaemia, CVA, early onsetCHD (<55yrs in men and <65yrs in women), low birth weight. Modifiable lifestyle factors = smoking, diet, weight control, obesity, exercise, recreational drug use, ETOH. Personal, psychosocial and environmental factors that could influence the effectiveness of antihypertensive careincluding education, family situation, work environment, financial concerns, or associated psychological stress. Depression, social isolation and quality of social support. |
|
|
What causes of secondary HT need to be considered? What symptoms should be asked about to exclude these secondary causes? |
Pheochromocytoma = frequent headaches, sweating, palpitations. Sleep apnoea = obesity, snoring, daytime sleepiness. Complementary and/or recreational drug intake Hypokalaemia = muscle weakness, hypotonia, muscle tetany, cramps, cardiac arrhythmias. Symptoms suggestive of thyroid disease |
|
|
What over the counter medications can influence BP? |
Herbal supplements: bitter orange, Ginseng, guarana Caffeine pills and caffeine-containing products including black tea, green tea and cola nut Natural liquorice St John’s wort may reduce efficacy of prescribed cardiovascular drugs Energy drinks |
|
|
What findings should be looked for on physical examination in someone presenting with HT? |
Waist circumference, BMI HR, rhythm, character JVP and pressure Evidence cardiac enlargement Evidence cardiac failure Evidence arterial disease Palpation of enlarged kidneys - PCK Abnormalities optic fundi Endocrine abnormalities - Cushing's, thyroid |
|
|
What investigations should be preformed in the clinic for patients presenting with HT? |
Urinalysis - if abnormal send for MCS 12 lead ECG - ?AF, LVH and evidence previous IHD |
|
|
What other investigations should be ordered for patients presenting with HT? |
Urinary albumin/creatinine ratio 1st void spot urine specimens - highly recommended for all patients and mandatory for those with diabetes. Fasting glucose Fasting serum total CHO, LDL, HDL and triglycerides UEC (with eGFR) FBE - Hb and/or haematocrit |
|
|
What additional investigations can be undertaken as indicated by clinical suspicion for organ damage, CVD and CKD following a full medical history and physical examination? |
CVD: Echocardiography Carotid U/S CKD: Renal artery imaging Renal artery duplex U/S, renal nuclear medicine and/or CT angiography PAD: ABI Other: Plasma aldosterone/renin ratio - under specialist |
|
|
When giving lifestyle advice what is the recommendation for physical activity? |
Accumulate 150–300 minutes ofmoderate intensity activity or 75–150minutes of vigorous activity each week. Muscle strengthening activities on at least2 days each week. |
|
|
When giving lifestyle advice what is the recommendation for weight control in terms of WC and BMI? |
Waist circumference <94 cm males <90 cm Asian males <80 cm females BMI <25 kg/m2 |
|
|
When giving lifestyle advice what is the recommendation for diet? |
Total fat account for 20–35% of energyintake Salt to ≤6 g/day for primary preventionand 4 g/day for secondary prevention Five serves of vegetables and two serves offruit daily |
|
|
When giving lifestyle advice what is the recommendation for smoking and alcohol intake? |
Cessation smoking For healthy men and women, drinking<2 SD on anyday and <4 SD on any one occasion. |
|
|
Patients with what conditions require medical r/v and supervised physical activity? |
Unstable angina BP ≥180 mmHg systolic or ≥110 mmHg diastolic Uncontrolled heart failure or cardiomyopathy Myocardial infarction within the last 3/12 Severe aortic stenosis Resting tachycardia or arrhythmias Chest discomfort or SOB at rest or low activity Diabetes with poor glycaemic control. |
|
|
What BMI range is classified as health weight, overweight, obesity I,II,III ? |
Healthy weight 18.5 - 24.9 Overweight 25 - 29.9 Obesity I 30 - 34.9 Obesity II 35 - 39.9 Obesity III >40 |
|
|
What % of Australians are overweight or obese? In adults with BMI>35, how much weight needs to be lost to reduce systolic BP? |
63.4% (in 2014-2015) BMI>35 a weight reduction of 2kg can result in clinically meaningful reduction in systolic BP. |
|
|
When using anti-hypertensive drugs to treat HT what should the target BP be? |
HT guideline 2016 recommends that all thoserequiring antihypertensive drugs should be treated to atarget of <140/90 mmHg. In those at high risk, in whomit is deemed safe on clinical grounds and in whomdrug therapy is well tolerated, aiming for a systolicBP of target <120 mmHg is reasonable. |
|
|
What are the 1st line therapy medication classes for treating HT? |
Single drug therapy using: Thiazide diuretics Calcium channel blockers ACE inhibitors ARBs All similar in their efficacy to reduce BP. |
|
|
As well as lowering BP what additional benefits to ACE inhibitors and ARBs have? |
ACE inhibitors - prevent onset nephropathy, reduce mortality in early diabetes, prevent CHD in patient with HT. ARBs - prevent kidney failure in people with advanced diabetic nephropathy, but infer in preventing CHD in patients with HT. |
|
|
If initiating combination therapy, what combinations of medications are best? |
ACE inhibitor + CCB - presence diabetes and/or lipid abnormalities. ACE inhibitor + thiazide diuretic - heart failure or post CVA. ACE inhibitor + b-blocker - post MI or heart failure Thiazide diuretic + CCB Thiazide diuretic + b-blocker - not in diabetes, metabolic syndrome, glucose intolerance. (Note never combine ACE + ARB - increased risk renal dysfunction OR verapamil + B-blocker - increased risk heart block) |
|
|
Lifestyle advice and managing co-morbidies is recommended for treatment of all patients with HT. In which patients should antihypertensive therapy be started? |
For patients: Low absolute CVD risk (<10%) with persistent BP ≥160/100 mmHg. Moderate absolute CVD risk (10–15%) withpersistent BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, family history premature CVD or ATSI. At high absolute CVD risk (15%) start immediate drug therapy. |
|
|
When starting an antihypertensive what dose should be used? |
Start with low-moderate dose of a 1st line drug. If not well tolerated, change to a different drug class, again starting with a low-mod dose. |
|
|
At what point is it appropriate to add a second anti-hypertensive? |
If target BP not reached after 3/12 - add a second drug from a different pharmacological class at a low-mod dose, rather than increasing the dose of the first drug. This maximises anti-hypertensive efficacy, while minimising adverse effects. |
|
|
What should be done next if on 2 anti-hypertensives and BP still not at target? |
If target not reached after 3/12 - if both antihypertensives drugs have been well tolerated, increase the dose of 1 drug (excluding thiazide diuretics) incrementally to the maximal recommended dose before increasing the dose of the other drug. |
|
|
If on maximal dose of at least 2 drugs and still not reached target BP by 3/12 of this treatment, what should be done next? |
A 3rd drug class may be started at a low-mod dose. It is advisable to reassess for non-adherence, secondary HT and HT effects of other drugs, treatment resistant state due to OSA, undisclosed use of ETOH or recreational drugs or high salt intake. |
|
|
If a patient is on 3 antihypertensives and cannot achieve target BP what should be done next? |
Refer to specialist for advice |
|
|
What are the contraindications for ACE inhibitors and ARBs? |
Pregnancy Angioedema Hyperkalaemia Bilateral renal arterystenosis Possibly - women with child bearing potential |
|
|
What are the contraindications for CCBs and diuretics (low dose thiazide)? |
CCB - heart failure Thiazide diuretics: (increased risk diabetes onset) Gout Age Glucose intolerance Metabolic syndrome Hypercalcaemia Hypokalaemia |
|
|
What are the contraindications for beta-blockers? |
Asthma Bradycardia A-V block (grade 2 or 3) Uncontrolled heart failure Possibly: Type 1 or 2 diabetes Metabolic syndrome Glucose intolerance Athletes and active patients COPD (except for vasodilator beta-blockers) Depression |
|
|
Why are beta-blockers no longer recommended as 1st line therapy in uncomplicated HT? |
Due to an increased risk of developing diabetesand the trend towards worse outcomes compared to those treated with other classes of antihypertensive drugs. For patients with well-controlledHT already taking a beta-blocker, it is reasonable to continue us |
|
|
What are some of the common ACE inhibitors used to treat HT and what dose are they normally prescribed? |
Captopril 12.5–50 mg BD Enalapril 5–40 mg daily in one or two doses Fosinopril 10–40 mg once daily Lisinopril 5–40 mg once daily Perindopril arginine 5–10 mg once daily Perindopril erbumine 4–8 mg once daily Quinapril 5–40 mg daily in one or two doses Ramipril 2.5–10 mg daily in one or two doses Trandolapril 1–4 mg once daily |
|
|
What are some common side effects that we should warn patients about when starting an ACE inhibitor? |
Cough Hyperkalaemia (risk increased by renalimpairment) Renal impairment (risk increased byhypovolaemia or NSAIDs) Angioedema (infrequent; may occur after yearsof treatment) |
|
|
What are some of the ARBs used in the treatment of HT and what doses? |
Candesartan 8–32 mg once daily Eprosartan 400–600 mg once daily Irbesartan 150–300 mg once daily Losartan 50–100 mg once daily Olmesartan 20–40 mg once daily Telmisartan 40–80 mg once daily Valsartan 80–320 mg once daily |
|
|
What are some common side effects that we should warn patients about when starting an ARB? |
Hyperkalaemia (risk increased by renalimpairment) Renal impairment (risk increased byhypovolaemia or NSAIDs) Cough and angioedema are rare |
|
|
What are some of the dihydropyridine CCB medications used in the treatment of HT and at what doses? |
Amlodipine 2.5–10 mg once daily Felodipine CR, 5–20 mg once daily Lercanidipine 10–20 mg once daily Nifedipine 10–40 mg twice daily OR CR 20–120 mg once daily |
|
|
How do the dihydropyridine CCBs work? And what are some common SEs to warn patients about? |
Dihydropyridines act mainly on arteriolar smooth muscle to reduce peripheral vascular resistance and BP. They have minimal effect on myocardial cells. SEs: peripheral vasodilation (peripheral oedema, flushing, headache, dizziness), posturalhypotension, tachycardia, palpitations, chestpain, gingival hyperplasia. |
|
|
What are the 2 non-dihydropyridine CCB medications used in the treatment of HT and at what doses? |
Diltiazem CR 180–360 mg once daily Verapamil: 80–160 mg two or three times daily CR, tablet 180–480 mg daily. If>240 mg give in two doses. CR capsule 160–480mg daily |
|
|
How do the non- dihydropyridine CCBs work? And what are some common SEs to warn patients about? |
Non-dihydropyridines: diltiazem and verapamil act on cardiac and arteriolar smooth muscle. They reduce cardiac contractility, heart rate and conduction, with verapamil having the greater effect. Diltiazem has a greater effect on arteriolar smooth muscle than verapamil. SEs: Bradycardia, constipation (particularlyverapamil, may be severe), atrioventricularblock, heart failure. |
|
|
What are some of the thiazide-like diuretics used in the treatment of HT and what doses? |
Chlorthalidone = 12.5–25 mg once daily. A startingdose of 12.5 mg on alternate daysmay be appropriate in some patients. Hydrochlorothiazide = 25 mg once daily Indapamide = 1.5 mg once daily. CR, 1.5 mghas similar antihypertensive effectto 2.5 mg tablet but lower risk ofhypokalaemia |
|
|
What are some common side effects that we should warn patients about when starting a thiazide-like diuretic? |
Postural hypotension Dizziness Hypokalaemia Hyponatraemia Hyperuricaemia Hyperglycaemia |
|
|
What are some of the beta-blocker medications used in the treatment of HT and what doses? |
Atenolol 25–100 mg daily in one or two doses Carvedilol 12.5–50 mg daily in one or two doses Labetalol 100–400 mg twice daily Metoprolol 50–100 mg once or twice daily Metoprolol CR 23.75–190 mg once daily Nebivolol 5 mg once daily Oxprenolol 40–160 mg twice daily Pindolol 10–30 mg daily in two or three doses Propranolol 40–320 mg daily in two or threedoses |
|
|
What are some common side effects that we should warn patients about when starting a beta-blocker? |
Bradycardia Postural hypotension Worseningof heart failure (transient) Bronchospasm Coldextremities |
|
|
What are some of the other (non 1st line) antihypertensive drugs that can be used in treated HT? |
Amiloride (potassium sparing diuretic) Clonidine (centrally acting alpha2 and imidazoline agonist) Hydrazine (peripheral, mostly arteriolar, vasodilator) Methyldopa (centrally acting alpha2 agonist) Moxonidine (centrally acting imidazoline agonist with minor alpha2 agonist activity) Prazosin (selective alpha blocker, peripheral vasodilator) Spironolactone (aldosterone antagonist) |
|
|
For patients with a history of TIA or stroke which anti-hypertensive agent should be used and what is the BP treatment target? |
Any of the 1st line antihypertensive drugs Target BP <140/90mmHg Recommended to reduce overall CVD risk |
|
|
For patients with a chronic kidney disease which anti-hypertensive agent should be used and what is the BP treatment target? |
When treating HT in patients with CKD in thepresence of micro or macro albuminuria, an ARB or ACE inhibitor should beconsidered as first-line therapy. For patients with CKD, aiming towards a systolic BP <120 mmHg has shown benefit, where well tolerated. Close follow-up of patients is recommended to identify treatmentrelated adverse effects including hypotension, syncope, electrolyte abnormalitiesand AKI. |
|
|
In patients with diabetes when should antihypertensive therapy be started? What medication should be used? What is the target BP with treatment? |
Antihypertensive therapy is strongly recommended in patients with diabetes andsystolic BP ≥140 mmHg. Any of the 1st line antihypertensive drugs. BP target of <140/90mmHg is recommended. |
|
|
Which anti-hypertensives are recommended for: 1) patients with a history of MI 2) symptomatic patients with angina 3) patients with chronic heart failure |
1) ACE inhibitors and beta-blockers - treatment of HT and secondary prevention, for patients with a history of MI. 2) Beta-blockers or CCB if symptomatic with angina 3) ACE inhibitors and selected beta-blockers |
|
|
What is treatment resistant HT? What is its prevalence? What should be excluded when a patient has treatment resistant HT? |
Treatment-resistant HT is defined as systolicBP >140 mmHg in a patient taking 3 or more antihypertensive drugs, including a diuretic,at optimal tolerated doses. Prevalence 8-18% Poor compliance withtherapy, white-coat HT and secondary causes for HT should beconsidered. Mx: specialist review |
|
|
What f/u is needed when starting an antihypertensive agent?
|
After starting therapy, patients should be reviewed at 4–6week intervals to evaluate adherence, adverse effects,tolerability and efficacy. Electrolytes and creatinine should be measured at baselineand then 2 weeks after commencing therapy in people athigh risk of changes in kidney function. This is to ensuredetection of hyperkalaemia or dramatic changes in kidneyfunction. |
