Cardiovascular

• Direct - Acting oral anticoagulants (DOACs)

  • Summary
  • Dabigatran, Edoxaban, Apixaban and Rivaroxaban
  • Dabigatran functions as a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation.
  • Apixaban, Edoxaban and Rivaroxaban act as reversible inhibitors of activated factor X (factor Xa), preventing thrombin generation and the formation of blood clots.
• Hypertension in Pregnancy


  Hypertension may pre-exist or be diagnosed in the first 20 weeks (chronic hypertension) or as new-onset after 20 weeks (gestational hypertension)
• Pre-eclampsia


  New onset after 20 weeks with multi-organ involvement
• Symptoms


  • Severe headache
  • Problems with vision
  • Severe pain below ribs
  • Vomiting and sudden swelling of hands, feet or face accompanied with proteinuria and BP >140/90
• Labetalol


  • Adult dose: initially 100 mg twice daily, dose to be increased at intervals of 14 days
  • Usual dose 200 mg Twice daily: increased if necessary to up to 800mg daily in 2 divided doses
  • To be taken with food
  • Higher doses to be given in 3 - 4 divided doses
  • Maximum 2.4g per day
• Target BP


  < 135/85
• Second line treatment


  MR nifedipine
• Third line treatment


  Methyldopa - stop methyldopa 2 days after birth and continue regular hypertension treatment
• IV magnesium sulfate


  In critical care for severe hypertension or pre-eclampsia
• After Birth


  ACEi (Enalapril) and monitor renal function
• First line treatment for women of black African or African-Caribbean family origin


  • MR Nifedipine or amlodipine
• Second line treatment for women of black African or African-Caribbean family origin


  • MR Nifedipine or amlodipine + Enalapril
• Third line treatment for women of black African or African-Caribbean family origin


  • Addition of labetalol or atenolol
• Target threshold to initiate treatment (Important)

  1. Age < 80 years
  2. Clinic: <140/90 mmHg
  3. HBPM/ABPM: <135/85 mmHg
  4. Age ≥ 80 years or above
  5. Clinic: 150/90 mmHg
  6. HBPM/ABPM: 145/85 mmHg
  7. CKD + Diabetes Mellitus
  8. <130/80 mmHg
  9. Target range systolic (120 - 129)
  10. CKD + ACR <70
  11. <140/90 mmHg
  12. Target range systolic: (120 - 139)
  13. CKD + ACR >70
  14. <130/80 mmHg
  15. Target range systolic: (120 - 129)
• Hypertension without type 2 diabetes:

  • Age < 55 and not of black African or African Caribbean family origin - same as with type 2 diabetes
  • Stage 1: ACEi or ARBs
  • Stage 2: ACEi or ARBs + CCB or thiazide like diuretic
  • Age 55 or over or all ages of African-Caribbean family origin
  • Stage 1: CCB
  • Stage 2: CCB + ACEi or ARBs or thiazide like diuretics
• Hypertension with type 2 diabetes (in all patients)

  • Stage 1: ACEi or ARBs
  • Stage 2: ACEi or ARBs + CCB or thiazide like diuretic
• Hypertension with type 1 diabetes

  • In adults < 80 years old
  • Target BP is:
  • If the urine albumin:creatinine ratio (ACR) is less than 70 then < 140/90
  • If the ACR is 70 or more than < 130/80
  • In adults 80 years old or more:
  • Aim for target < 150/90
  • Stage 1: ACEi or ARBs start with low dose then titrate
  • Stage 2 can be any of the options below:
  • Beta Blockers
  • CCB only long acting preparation e.g. MR nifedipine or amlodipine
  • Diuretics (low dose thiazide) in combination with Beta blockers
• Hypertension with type 1 diabetes

  • In adults < 80 years old
  • Target BP is:
  • If the urine albumin:creatinine ratio (ACR) is less than 70 then < 140/90
  • If the ACR is 70 or more than < 130/80
  • In adults 80 years old or more:
  • Aim for target < 150/90
  • Stage 1: ACEi or ARBs start with low dose then titrate
  • Stage 2 can be any of the options below:
  • Beta Blockers
  • CCB only long acting preparation e.g. MR nifedipine or amlodipine
  • Diuretics (low dose thiazide) in combination with Beta blockers
• There are TWO types of hypertension:

  1. Primary hypertension: No identifiable cause, affecting 90% of individuals
  2. Secondary hypertension: which is in 10% of people and has a known underlying cause such as renal, endocrine, or vascular disorder and use of certain drugs.

  Factors contributing to secondary hypertension include:

  • Alcohol - misuse of alcohol may be the most common individual secondary cause of hypertension.
  • Combined oral contraceptive
  • Corticosteroids
  • Erythropoietin
  • NSAIDs
  • Cyclosporin
• Hypertension

  • Hypertension, characterised by persistent high blood pressure, stands as one of the most treatable contributors to premature morbidity and mortality.
  • Systolic or diastolic pressure is above the normal pressure of 120/80 mmHg.
  • Diastolic is the maximal aortic pressure when the left ventricle ejects blood into the aorta.
  • Systolic is the lowest pressure which occurs as the left Ventricle is relaxing and filling just before the left ventricle ejects blood into the aorta.
• Risk factors of hypertension

  • Age
  • Genetic factors
  • Ethnicity
  • Sex
  • Established cardiovascular diseases
  • Anxiety and emotional stress
  • Target Organ damage
  • Social Deprivation
  • Lifestyle
• Age


  Blood pressure tends to rise with advancing age
• Genetic factors


  Research on twins suggests that up to 40% of blood pressure variability may be attributed to genetic factors
• Ethnicity


  Individuals of Black African and Black Caribbean origin are more prone to hypertension diagnosis
• Sex


  Up to 65 years, women tend to have a lower blood pressure than men, between 65 to 74 years of age, women tend to exhibit a higher blood pressure
• Established cardiovascular diseases


  • Medical history of stroke
  • T.I.A
  • Angina and MI
  • Narrow arteries
• Anxiety and emotional stress

  Can elevate blood pressure due to increased adrenaline and cortisol levels
• Target Organ damage


  • Heart
  • Brain
  • Kidney e.g. CKD
  • Eye (e.g Retinopathy)
• Social Deprivation

  Individuals from the most deprived areas in England are 30% more likely to have hypertension than those from the least deprived areas
• Lifestyle factors


  • Smoking
  • Excessive alcohol consumption
  • Excess dietary salt
  • Obesity
  • Lack of physical activity
• These lifestyle factors are associated with hypertension
• Hypertension Classes


  Stage 1

  • Clinic Blood Pressure - 140/90 mmHg to 159/99
  • ABPM and HBPM - 135/85 mmHg to 149/94

  Stage 2

  • Clinic Blood Pressure - 160/100 but less than 180/120 mmHg
  • ABPM and HBPM - 150/95 or higher

  Stage 3 or severe hypertension

  • Systolic blood pressure of more than 180 mmHg or higher and the clinic diastolic blood pressure of 120 mmHg or higher

  For stage 1 and 2 it must be both readings in that range but for stage 3 urgent referral is required if either the systolic or diastolic reading falls within the hypertensive range.
• Lifestyle advice


  • Always offer
• Consider treatment if applicable

  1. If age is > 80 with a clinic blood pressure of > 150 / 90 mmHg

  2. Use clinical judgment regarding frailty and multi-morbidity

  3. Consider antihypertensive treatment
• Consider antihypertensive drug treatment

  1. If age is < 80 years with 1 or more of the following:

  2. Target organ damage

  3. Established CVD

  4. Renal disease

  5. Diabetes

  6. 10 year risk of cardiovascular disease ≥ 10%
• Consider antihypertensive drug treatment

  For adults aged < 60 years and an estimated 10 year CVD risk below 10%
• For adults with age < 40 years


  1. Investigate for secondary causes of hypertension

  2. More detailed assessment required for evaluation of long term benefits vs risks
• Hypertension Stage 1


  Condition requiring lifestyle advice
• Diet and exercise advice


  1. Emphasise healthy diet

  2. Offer weight loss advice for overweight or obese individuals
• Caffeine


  Discourage excessive consumption of coffee and other caffeine rich products