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HYPERTENSION - Coggle Diagram
HYPERTENSION
Diagnosis
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Measure both arms first, thereafter use highest
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Pharmacotherapy
First line classes
ACE-inhibitor
- captopril 12.5-50mg BD
- enalapril 5-40mg daily
- perindopril arginine 5-10mg daily
- ramipril 2.5-10mg daily
- Useful in HFrEF and kidney disease (esp. diabetic)
- Contraindicated in RAS
- Montor for hypotension, kidney impairment and hyperkalemia
- Watch for triple whammy
ARB
- candesartan 8-32mg daily
- irbesartan 150-300mg daily
- telmisartan 40-80mg daily
- Cardioprotective + renoprotective
- Contraindicated in RAS
- Monitor for hypotension, renal impairment or hyperkalemia
- Watch for triple whammy
DHP calcium channel blocker
- amlodipine 5-10mg daily
- lercanidipine 10-20mg daily
- nifedipine MR 20-120mg daily
- Useful in stable angina
- Usually well tolerated but can cause peripheral oedema
- Redistributive rather than retentive oedema, may not respond to diuresis
Thiazide diuretics
- hydrochlorothiazide 12.5-50mg daily
- chlorthalidone 12.5-25mg daily
indapamide 1.25-2.5mg daily
- Predominantly vasodilator effects at low dose
- Not recommended first line in younger patients due to association with new-onset diabetes
- Avoid in patients with gout
Stepwise approach
- Start with single drug at low to moderate dose
- Review regularly for monitoring + adherence
- If not tolerated change class
- If not reached within 3 months, add low dose 2nd agent
- Can start dual agents in high risk or with particularly high BP
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Practice points
- Spread doses over morning and evening, preference for morning
- If DHP CCB not tolerated can swap to non-DHP but be wary of contraindications (medications, LVEF <40%, conduction blocks/AVRTs) e.g verapamil MR 120-480mg daily
- If thiazides not tolerated, can replace with MRA but be wary of hyperkalemia e.g spironolactone 12.5-50mg daily
- Do not combine ACE + ARB
- Do not combine non-DHP CCB + B-blocker
- Always wean down over weeks - sudden cessation can be fatal (e.g central antiadrenergics - clonidine)
Further work up
Red flags
Refer to hospital if
- hypertensive emergency (>180/110)
- end-organ damage (visual deficits/headache/renal failure/chest pain/LOC)
?Secondary HTN
- onset <30 with normal BMI
- new derangement in previously stable BP
- multi-drug resistant BP
- associated symptoms (palpitations, haematuria, R/F delay, epigastric bruit)
- Renal artery stenosis
- Renal parenchymal disease
- Adrenal/endocrine disorders
- Drug induced HTN
- Non-compliance
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