1. What is blood pressure? Pressure exerted by blood on arterial wall
2. What is hypertension? Hypertension (HTN) is defined as a systolic blood pressure (SBP) >140 mmHg, a diastolic blood pressure (DBP) >90 mmHg, or any patient requiring antihypertensive therapy.
3. What are the different types of hypertension?
4. Systolic BP: heart muscles contract causing ↑BP since blood is pumped out of the heart.
5. Diastolic BP: heart muscles relaxes, ↓BP as blood fills the heart.
6. Isolated systolic HTN: SBP > 140, DBP < 90mmHg. Isolated systolic hypertension (ISH) is present when the patient’s systolic blood pressure is >140 mmHg and diastolic blood pressure is <90 mmHg. ISH is more prevalent in the elderly because the systolic pressure rises and the diastolic pressure falls after age 60.
7. White coat HTN: occurs only in clinical settings
8. Masked HTN: normal BP in clinical settings, but elevated in non-clinical settings
9. Hypertensive urgency: BP >180/120 mmHg but no organ damage
10. Hypertensive emergency: BP >180/120 mmHg + organ damage
11. What is essential hypertension? Essential hypertension also called primary HT is high blood pressure that doesn't have a known cause. It's also referred to as primary hypertension.
12. What are different stages of hypertension?

1. What are the complications of persistent high blood pressure?

1. What does it mean when a patient is ambulatory? This means the patient is able to walk around. After surgery or medical treatment, a patient may be unable to walk unassisted. Once the patient is able to do so, he is noted to be ambulatory.

1. What are the main reasons for essential hypertension?

1. What are the drugs that cause HTN?

1. What is baroreceptor and how does baroreceptor work? Baroreceptors are mechanoreceptors located in the carotid sinus and in the aortic arch. Their function is to sense pressure changes by responding to change in the tension of the arterial wall. The baroreflex mechanism is a fast response to changes in blood pressure. If the blood pressure within the aorta or carotid sinus increases, the walls of the arteries stretch and stimulate increased activity within the baroreceptors.
2. What is natriuretic and what is its function? Natriuretic peptides (ANP, BNP, and CNP) are a family of hormone/paracrine which induces natriuresis- the excretion of sodium by the kidneys. Known natriuretic peptides include: 

• Atrial natriuretic peptide, also known as ANP. 
• Brain natriuretic peptide, also known as BNP. 
• C-type natriuretic peptide, also known as CNP.

1. What is aldosterone’s function in the body?  Aldosterone is a hormone produced in the outer section (cortex) of the adrenal glands, which sit above the kidneys. Aldosterone causes:
2. salt & water to be reabsorbed which will increases blood volume and therefore increases blood pressure.
3. K+ to be excreted

1. What are different types of blood pressure measurement?

1. What is the gold standard in blood pressure diagnosis? 
2. Ambulatory (continuous) monitoring is preferred  and is considered the gold standard of BP measurement. 
3. The home BP series comprises 2 readings taken each morning and evening for 7 days (28 total readings); discard the first-day readings and use  the mean of the remaining 24 readings
4. How to get an accurate blood pressure reading in office? The patient should not talk

1. Do you start monotherapy or dual therapy?
2. If diastolic more than 10> of target then start dual
3. If systolic is more than 20> of target then start dual

1. What is the pathway of diagnosis HTN recommended by Canadian guidelines?
2. Ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), both out-of-the-office blood pressure measurement (OBPM) methods, have better predictive ability compared to the office blood pressure measurement methods because they easily identify the white coat hypertension.
3. White coat hypertension is defined as elevated OBPM (≥140/90 mm Hg) with normal out-of-office readings (<135/85 mm Hg daytime ABPM or HBPM and/or <130/80 mm Hg 24-hr ABPM). 
4. In the office, oscillometric (electronic) devices used on the upper arm are preferred accurate method.
5. What are goals of therapy in HTN patients?
6. Control/eliminate modifiable risk factors
7. Prevent complications and morbidity associated with HTN
8. Provide convenient and cost-effective therapy to improve adherence
9. Maximize patient adherence to reach target BP in an adequate time frame

1. What are BP targets for patients with HTN?

1. What are non-pharmacological measures in controlling blood pressure? non-pharm. measures can cause ↓5 mmHg improvements in systolic BP which means non-pharm measures can be as effective as medications!
2. Weight control: Weight loss of 4 kg or more if overweight.
3. Target body mass index: 18.5 – 24.9 kg/m2

1. Target waist circumference men <102 cm & women <88 c

1. Smoking cessation
2. DASH diet (fruits, vegetables, low-fat dairy, reduced fat and alcohol)
3. Physical activity
4. Reduce alcohol consumption
5. Reduction in sodium intake. <2000 mg (88 mmol) per day
6. Increased dietary potassium if not at risk for hyperkalemia
7. What is resistance hypertension? Resistant hypertension is defined as a blood pressure that is above target despite treatment with 3 drugs, optimally dosed, one of which is a diuretic.
8. What is albuminuria? Albuminuria is defined as an albumin to creatinine ratio (ACR) >2 mg/mmol in urine.
9. What is the difference between heart attack (MI) and heart failure? 
10. Heart attack means, the blood flow to a part of heart is lost which has caused some of heart muscles to die. It is most often caused by CAD (a blockage or clot in one of the coronary arteries). It is also called MI and happens suddenly.
11. Heart failure means that the heart has been working too hard and suddenly stops. It develops slowly over a period of time until the failure happens.
12. What are aldosterone antagonists? An antimineralocorticoid, MCRA, or an aldosterone antagonist, is a diuretic drug which antagonizes the action of aldosterone at mineralocorticoid receptors. This group of drugs is often used as adjunctive therapy, in combination with other drugs, for the management of chronic heart failure and hypokalemia caused by other diuretics.
13. Name aldosterone antagonists? Spironolactone, eplerenone
14. What is transient ischemic attack (TIA)? A transient ischemic attack (TIA) is a brief interruption of blood flow to part of the brain that causes temporary stroke-like symptoms. The risks for TIA are the same as for heart attack, stroke, and peripheral artery disease, and include smoking, high blood pressure, high cholesterol, diabetes, and family history.
15. How do calcium channel blockers control HTN? body sometimes uses calcium to narrow blood vessels and this can raise blood pressure. Calcium channel blockers block voltage-gated calcium channels and therefore inhibit the influx of intracellular calcium that is required for smooth muscle contraction. This leads to vasodilation of the smooth muscles (in the arteries), which reduces systemic vascular resistance. When systemic vascular resistance is reduced, BP is lowered. If these channels were kept open, the smooth muscle would contract, leading to vasoconstriction and higher blood pressure.
16. How does grapefruit affect CCBs? CCBs are metabolized by CYP450, Grapefruit juice causes inhibition of CYP 3A4 and thus serves to increase CCBs in blood causing hypotension.
17. How do diuretics work in controlling HTN?

In the treatment of primary hypertension, diuretics have been shown to lower blood pressure by inhibiting the reabsorption of sodium at different sites of a nephron, leading to an increase in sodium and fluid loss.

1. Loop diuretics (e.g. furosemide and torsemide) target their mechanism of action at the ascending Loop of Henle. in patients who have a creatinine clearance <30 mL/min, loop diuretics are preferred as initial therapy.
2. thiazide-type diuretics 
3. (e.g. chlorthalidone and indapamide) target their mechanism of action at distal convoluted tubule.
4. Thiazide diuretics are less effective than loop diuretics when creatinine clearance is <30 mL/min. 
5. There is strong evidence to indicate that thiazide diuretics at low doses (defined as < 50 mg/day hydrochlorothiazide) reduce stroke, myocardial infarction (MI), heart failure, and cardiovascular and all-cause mortality in patients with hypertension. 
6. Other diuretics, such as potassium-sparing agents (e.g. amiloride) and mineralocorticoid receptor antagonists (e.g. spironolactone and eplerenone) are not preferred in patients with primary hypertension but may show more efficacy in resistant hypertension.

In order for both thiazide-type and loop diuretics to be effective, these drugs must be able to be transported into the lumen of the renal tubule in the nephron through organic acid transporters in the proximal tubule. As clearance decreases with decreasing renal function, organic acid levels start to increase. As acids increase, these molecules start competing with diuretics for transport into the tubular lumen, making thiazide-type and loop diuretics less effective.

1. What are different classes of diuretics?
2. Thiazide Diuretics: Hydrochlorothiazide, indapamide, Chlorthalidone, Metolazone
3. Loop Diuretics: Frusemide (Lasix), Bumetanide, Torsemide and Ethacrynic Acid
4. Potassium Sparing Diuretics: Spironolactone, Triamterene and Amiloride
5. For which diseases are diuretics used for? Only for HP & CHF
6. What is the 1st choice for young patient with HP? Beta blocker is the 1st choice not diuretics
7. Can you give diuretics to pregnant lady? Diuretic cannot be given to the pregnant which might decrease body fluid and harm baby

1. What are common side effects of diuretics? 
2. All diuretics cause sulfa allergy
3. All diuretics in long term cause ototoxicity and lead to hearing loss.
4. Diuretic cannot be given to the pregnant which might decrease body fluid and harm baby
5. You cannot give diuretics to gout disease because of hyperuricemia side effect of diuretics.
6. You cannot give diuretics to diabetic patient
7. You better not give diuretics to elderly who have diabetics
8. Which diuretic might cause gynecomastia and why? Spironolactone SE, Gynecomastia, impotence and BPH have all been reported with the use of spironolactone because it also affects other steroid receptors (in addition to blocking the mineralocorticoid receptor to blunt the effects of aldosterone). Such effects have not been reported with eplerenone because it is more selective for the mineralocorticoid receptor, and is virtually inactive on androgen & progesterone receptors.
9. Which diuretic blocks epithelial Na channel in collecting duct? Triamterene & amiloride which are K-sparing diuretics.
10. What is the main difference between Spironolactone with amiloride and triamterene? Spironolactone works in the presence of aldosterone, while amiloride and triamterene work on epithelial sodium channel.
11. Why it’s not a good idea to take ACEi with K+ sparing diuretics? ACE inhibitors inhibit aldosterone secretion and increase potassium in the body. So, if ACE inhibitors are taken with potassium sparing diuretics it will cause excessive hyperkalemia.
12. Which diuretic acts on the proximal tubule? CA inhibitors – Carbonic Anhydrase inhibitors
13. What are the main indications of loop diuretics(furosemide)? Loop diuretics are used to treat:
    1. Severe edema (e.g. Associated with CHF), 
    2. Hyperkalemia, 
    3. Acute renal failure (to increase urine flow)
    4. Hypercalcemia.
14. How do you treat hyponatremia? Conivaptan is used for treatment of hyponatremia by preventing ADH. Conivaptan improves urine flow without causing the body to lose too much sodium as you urinate.
15. Which diuretic causes hypercalcemia? Thiazide diuretics reabsorb Ca+ and causes hypercalcemia
16. Which diuretic can be used for treatment of diabetes insipidus? Thiazide diuretics
17. Which diuretic crosses placental barrier? Loop diuretics (Furosemide) crosses placental barrier
18. Which diuretic can be used to treat aspirin toxicity? Carbonic anhydrase inhibitors can be used for treatment of acidic drugs’ overdose toxicity. For example, if a child is overdosed with aspirin, s/he can be given Acetazolamide, this promotes HCO3 and Na excretion and alkalinizes urine that traps aspirin for excretion
19. Why thiazide diuretic should not be used together with digoxin? One of the most important side effects of thiazides is “digoxin” toxicity due to hypokalemia.
20. Why furosemide should not be used together with gentamycin? Furosemide should not be used with gentamycin because they both cause ototoxicity
21. Can you use thiazide diuretics together with loop diuretics? Yes, if indicated, Loop diuretics can be used with thiazide diuretics
22. What will be the side effect of concomitant use of thiazide & furosemide? Using of thiazides together with loop diuretics causes kidney stone
23. How do you put diuretics in correct order of sodium blocking strength? 

Furosemide < Hydrochlorothiazide < Spironolactone

1. Spironolactone is K+ sparing diuretic which is an aldosterone antagonist that has been shown to significantly reduce mortality & morbidity in CHF and after a myocardial infarction.
2. Mannitol can cause heart failure
3. Mannitol can pull water out of the cell of the whole body
4. Furosemide leads to dissipation of the medullary interstitial gradient
5. Sedatives of NSAID, morphine etc., should not be taken with diuretics

1. What are two ANS drug used for pregnancy hypertension? labetalol, methyldopa
2. What are some common points about beta-blockers?
3. A2 is the brake of sympathetic, when you administer alpha 2 agonist the sympathetic will slow down.
4. Beta-blockers are given to younger patients and diuretics are given to older patients for BP purposes.
5. avoid grape fruit juice because it will cause excessive hypotension
6. avoid exposure to sun due to photosensitivity caused by B-blockers
7. avoid in asthma since B-blockers cause bronchospasm
8. Beta-blockers are a first-line medication for hypertension during pregnancy - labetalol
9. In patients with stable angina caused by CAD, selective b-blockers are 1st-line therapy
10. Beta-adrenergic blockers have been contraindicated in peripheral arterial disease because of the perceived risk that these drugs could worsen intermittent claudication. The concern is that interventions which might lower systemic arterial blood pressure could potentially adversely affect limbs with impaired blood flow.
11. Beta Blockers can cause depression
12. all afterload reducing agents (angiotensin-converting enzyme inhibitors, calcium channel blockers, blockers) are contraindicated in AORTIC STENOSIS. It is contraindicated due to their potential to cause profound hypotension in aortic stenosis. Simply imagine that the heart can’t pump a lot of blood and at the same time the tubes are dilated We will end up with dangerous low blood pressure
13. Propranolol & Metoprolol are best absorbed with food but consistency is the most important factor
14. Beta blockers that have first pass metabolism; propranolol, timolol
15. Beta blockers that act as membrane stabilizer; propranolol
16. Beta blockers that have no biotransformation; atenolol
17. Beta blockers that have a blockade effect: labetalol, carvedilol
18. Central a2-sympathomimetics cause negative sympathetic outflow and lowering peripheral
    resistance.
19. The following beta-blockers are used in treatment of angina:
20. Beta-blockers with intrinsic sympathomimetics activity (ISA): Acebutolol, pindolol
21. Beta-blockers with selective ISA: Acebutolol
22. Beta blockers with nonselective, ISA: Pindolol
23. Beta blockers with non-ISA: metoprolol & atenolol can be used
24. Beta blockers with nonselective, non-ISA: Propranolol, Nadolol, Timolol.
25. What are the different kinds of hypertension based on the causes?
26. Primary or Essential Hypertension: because of unknown causes
27. Secondary hypertension:
    1. Pheochromocytoma (tumor of the adrenal medulla) – this causes excess NE secretion and HP
    2. Cushing's syndrome (excessive production of cortisone) – adrenal cortex causes this syndrome
    3. Renal diseases or renal artery stenosis à when there is less blood flow to kidneys, they think there is less fluid in the body and secret renin which results in angiotensin II and high blood pressure, kidney also causes blood pressure by reabsorbing water and Na+ retention to increase blood volume and blood pressure. 
    4. Toxemia of pregnancy: A condition during pregnancy characterized by high blood pressure, protein in the urine, and fluid retention. If untreated, it can lead to eclampsia and convulsions that can be life-threatening to the mother and baby (the exact reason is not clear)
    5. Some drugs such as oral contraceptives and cortisone
28. What are the different kinds of hypertension based on the physiology?
29. Systolic BP is affected by heart and peripheral resistance, 
30. Diastolic BP is affected only by peripheral resistance. 

So peripheral resistance affects both diastolic and systolic BP. If hypertension happens due to heart rate rather than peripheral resistance it is considered as arrhythmia rather than hypertension

1. Pentoxifylline and cilostazol are available for the symptomatic treatment of intermittent claudication. Calcium channel blockers remain the treatment of choice for Raynaud's phenomenon.
2. The only vasodilator that is used for angina is nitrate
3. In hospital when the patient has severe tachycardia, they give the patient diltiazem injection to decrease heart rate.

• Direct vasodilators are the fastest medicines to reduce blood pressure; so, in case of emergency vasodilation we use direct vasodilation injection
• Why do we use Na nitroprusside always as an injection? Because when it is taken orally, it is metabolized in the liver and gives cyanide which is very toxic substance. It is given for a short time to avoid cyanide accumulation.
• Why are direct vasodilators recommended to be used together with B-blockers? To avoid reflex tachycardia.
• Arteries à After-Load
• Veins à Pre-Load
• In case of emergency hypertension in hypertension crisis, direct vasodilators are the first choice
• Indirect Vasodilators are: ACE inhibitors & Calcium channel blockers

1. HP + Diabetic à ACEi / ARB/ CCB – avoid beta blockers
2. HP + cholesterol à ACEi / ARB / CCB – avoid diuretics
3. HP + gout à ACEi / ARB / B-blocker – avoid diuretics
4. HP + Asthma à Diuretics / CCB – avoid b-blockers
5. HP + angina à diltiazem (CCB) / b-blocker