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Pharmsoc hypertension tutorial SBAs & SAQ 1. Marianne is newly diagnosed with hypertension. She contacted her GP as she was concerned that she had headaches. Her GP took her blood pressure in clinic, which was 146/82mmHg, and offered her ambulatory blood pressure monitoring. Marianne has a blood pressure machine at home so instead opted to take her own blood pressure in the morning and evening for a week. It was 141/84mmHg on average over the week. Based on which of these findings did her GP diagnose hypertension? a. Systolic blood pressure of >140mmHg in clinic b. Patient experiencing headaches c. Overall diastolic blood pressure of >80mmHg at home and in clinic d. Diastolic blood pressure of >80mmHg in clinic e. Systolic blood pressure of >135mmHg on average over the week 2. Which of the following is not a physiological consequence of hypertension? a. Decreased vascular resistance in small vessels b. Thickened left ventricular wall muscle c. Decreased cardiac stroke volume d. Increased clotting factor activation e. Blockage of vessels in the brain 3. Which of the following happens first when a calcium channel blocking medication acts on vascular smooth muscle? a. Drug binds to DHP-type voltage gated calcium channel b. Increased calcium efflux from smooth muscle cell c. Decreased release of calcium ions from sarcoplasmic reticulum d. Drug breakdown by macrophage enzymes e. Drug binding to calcium ions 4. Which of the following statements is most correct based on the data above? a. Amlodipine is best taken once a day as it will last for the whole day, but felodipine should be taken twice daily b. Felodipine is a better choice for those who have renal disease as it is cleared faster than amlodipine c. Missing a daily dose of felodipine is much more likely to lead to increased blood pressure than missing a dose of amlodipine d. Felodipine is a better choice for someone with lifethreatening hypertension than amlodipine as it acts faster e. Amlodipine remains in the body for around twice as long after felodipine is completely excreted 5. Mahamoud is a 65 year old man of mixed Black Caribbean and Chinese ethnicity working as a nurse. He is fit and well, with no medical history of note and no medications. A routine health check at the GP suggested hypertension, which was then confirmed using ambulatory blood pressure monitoring. What should the GP do next? a. Offer lifestyle advice and re-measure BP in six months b. Offer an ACE inhibitor c. Offer an angiotensin II receptor blocker d. Calculate his QRISK score and prescribe medication if >10% e. Offer a calcium channel blocker 6. Which of the following medications will NOT be less effective in a patient with liver failure? a. Ramipril b. Lisinopril c. Benazepril d. Enalapril e. Captropril 7. Why can thiazide diuretics cause hypokalemia? a. Increased Na+ in urine activates Na+/K+ATPase in the collecting duct, increasing K+ excretion b. Inhibit Na+/K+ co-transporter, decreasing K+ reabsorption along with Na+ c. Blocks action of Na+/Cl- co-transporter, preventing K+ reabsorption down its electrostatic gradient d. Inhibits Na+/K+ATPase in the collecting duct, preventing K+ reabsorption e. Can also act on and block K+ channels in the distal convoluted tubule 8. What step in blood pressure regulation is inhibited by ACE inhibitors? a. Renin production b. Conversion of angiotensinogen to angiotensin I c. Conversion of angiotensin I to angiotensin II d. Aldosterone production e. Vasoconstriction of vascular smooth muscle 9. Which of the following statements about blood pressure medications is correct? a. Ramipril is a safe medication to give in renal failure b. Losartan is a better first choice of antihypertensive in a patient with diabetes than ramipril c. Amlodipine’s side effects include leg swelling d. Thiazide diuretics act in the collecting duct e. No antihypertensive should be started if lifestyle modification has not been attempted 10. Which of the following statements about pharmacokinetics is correct? a. Clearance is the measure of the body’s ability to eliminate a drug b. Elimination half-life is the time taken for the kidneys to remove half of a specific drug from the circulation c. The faster a drug’s absorption rate, the greater its time to peak plasma levels d. Pro-drugs are medications that work best when combined with anti-drugs e. Drug clearance is usually lower when the kidneys are working well compared to in renal impairment SAQ: (8 marks) Part 1 of 4 Kai has been told by their GP that they need to start ‘blood pressure tablets.’ Kai is worried as they have seen lots of different tablets online. What are two factors the GP should consider when deciding what to prescribe for Kai? (1) Part 2 of 4 The GP prescribes Kai an ACE inhibitor. Explain the mechanism of action of this medication. (3.5) Part 3 of 4 Kai has been taking their ACE inhibitor for six months, but their blood pressure is still high. The GP offers Kai a calcium channel blocker as well. Kai is unsure as they have heard about many side effects of this medication. State and explain a side effect of a calcium channel blocker. (1.5) Part 4 of 4 Kai goes on to develop liver failure. How would this impact on the clearance and time to peak plasma levels of their ACE inhibitor, assuming it is mainly metabolized in the liver? (2) Answers 1. Marianne is newly diagnosed with hypertension. She contacted her GP as she was concerned that she had headaches. Her GP took her blood pressure in clinic, which was 146/82mmHg, and offered her ambulatory blood pressure monitoring. Marianne has a blood pressure machine at home so instead opted to take her own blood pressure in the morning and evening for a week. It was 141/84mmHg on average over the week. Based on which of these findings did her GP diagnose hypertension? 1. Systolic blood pressure of >140mmHg in clinic 2. Patient experiencing headaches 3. Overall diastolic blood pressure of >80mmHg at home and in clinic 4. Diastolic blood pressure of >80mmHg in clinic 5. Systolic blood pressure of >135mmHg on average over the week2. Which of the following is not a physiological consequence of hypertension? 1. Decreased vascular resistance in small vessels 2. Thickened left ventricular wall muscle 3. Decreased cardiac stroke volume 4. Increased clotting factor activation 5. Blockage of vessels in the brain 3. Which of the following happens first when a calcium channel blocking medication acts on vascular smooth muscle? 1. Drug binds to DHP-type voltage gated calcium channel 2. Increased calcium efflux from smooth muscle cell 3. Decreased release of calcium ions from sarcoplasmic reticulum 4. Drug breakdown by macrophage enzymes 5. Drug binding to calcium ions 4. Which of the following statements is most correct based on the data above? 1. Amlodipine is best taken once a day as it will last for the whole day, but felodipine should be taken twice daily 2. Felodipine is a better choice for those who have renal disease as it is cleared faster than amlodipine 3. Missing a daily dose of felodipine is much more likely to lead to increased blood pressure than missing a dose of amlodipine 4. Felodipine is a better choice for someone with lifethreatening hypertension than amlodipine as it acts faster 5. Amlodipine remains in the body for around twice as long after felodipine is completely excreted 5. Mahamoud is a 65 year old man of mixed Black Caribbean and Chinese ethnicity working as a nurse. He is fit and well, with no medical history of note and no medications. A routine health check at the GP suggested hypertension, which was then confirmed using ambulatory blood pressure monitoring. What should the GP do next? 1. Offer lifestyle advice and re-measure BP in six months 2. Offer an ACE inhibitor 3. Offer an angiotensin II receptor blocker 4. Calculate his QRISK score and prescribe medication if >10% 5. Offer a calcium channel blocker6. Which of the following medications will NOT be less effective in a patient with liver failure? 1. Ramipril 2. Lisinopril 3. Benazepril 4. Enalapril 5. Captropril 7. Why can thiazide diuretics cause hypokalemia? 1. Increased Na+ in urine activates Na+/K+ATPase in the collecting duct, increasing K+ excretion 2. Inhibit Na+/K+ co-transporter, decreasing K+ reabsorption along with Na+ 3. Blocks action of Na+/Cl- co-transporter, preventing K+ reabsorption down its electrostatic gradient 4. Inhibits Na+/K+ATPase in the collecting duct, preventing K+ reabsorption 5. Can also act on and block K+ channels in the distal convoluted tubule 8. What step in blood pressure regulation is inhibited by ACE inhibitors? 1. Renin production 2. Conversion of angiotensinogen to angiotensin I 3. Conversion of angiotensin I to angiotensin II 4. Aldosterone production 5. Vasoconstriction of vascular smooth muscle 9. Which of the following statements about blood pressure medications is correct? 1. Ramipril is a safe medication to give in renal failure 2. Losartan is a better first choice of antihypertensive in a patient with diabetes than ramipril 3. Amlodipine’s side effects include leg swelling 4. Thiazide diuretics act in the collecting duct 5. No antihypertensive should be started if lifestyle modification has not been attempted 10. Which of the following statements about pharmacokinetics is correct? 1. Clearance is the measure of the body’s ability to eliminate a drug 2. Elimination half-life is the time taken for the kidneys to remove half of a specific drug from the circulation 3. The faster a drug’s absorption rate, the greater its time to peak plasma levels 4. Pro-drugs are medications that work best when combined with anti-drugs 5. Drug clearance is usually lower when the kidneys are working well compared to in renal impairmentSAQ: Part 1 of 4 Kai has been told by their GP that they need to start ‘blood pressure tablets.’ Kai is worried as they have seen lots of different tablets online. What are two factors the GP should consider when deciding what to prescribe for Kai? (1) Answer: - Ethnicity (0.5) - Type 2 diabetes mellitus (0.5) - Age >55 (0.5) - Any other sensible answer e.g. blood potassium, frailty, postural hypotension, other medications used, allergies (0.5) Part 2 of 4 The GP prescribes Kai an ACE inhibitor. Explain the mechanism of action of this medication. (3.5) Answer: - Inhibits angiotensin converting enzyme (0.5) to prevent conversion of Angiotensin I to Angiotensin II (0.5) in the lungs (0.5) - Angiotensin II cannot act on vascular smooth muscle (0.5) to cause vasoconstriction (0.5) - Angiotensin II cannot trigger aldosterone production (0.5) preventing sodium and water retention - Lowers blood pressure (0.5) Part 3 of 4 Kai has been taking their ACE inhibitor for six months, but their blood pressure is still high. The GP offers Kai a calcium channel blocker as well. Kai is unsure as they have heard about many side effects of this medication. State and explain a side effect of a calcium channel blocker. (1.5) Answer: - Leg swelling (0.5) because vasodilation causes redistribution of fluid from the intravascular space to the interstitium (1) - Light-headedness (0.5) as blood pressure is low and less blood reaches the brain (1) - Constipation (0.5) as calcium channels causing gut motility are also blocked (1) - Bradycardia (0.5) as cardiac muscle is also affected (1) - Any other sensible answer Part 4 of 4 Kai goes on to develop liver failure. How would this impact on the clearance and time to peak plasma levels of their ramipril, assuming it is mainly metabolized in the liver? (2) Answer: - Clearance would decrease (0.5) as it measures the ability of the bod to excrete the drug and the liver is unable to metabolise and excrete the drug (0.5) - Time to peak plasma levels would stay the same (0.5) as ramipril is not a pro-drug (0.5)