1 - ACS and Hypertension Flashcards
What are the different stages of hypertension?
Stage 1: 140/90 or 135/85 HBPM/ABPM
Stage 2: 160/100 or 150/95 HBPM/ABPM
Severe/Stage 3: Sys>180 or Dia>120
How is hypertension diagnosed?
If >140/90 then offer ambulatory BP or home BP to check it is true before treating
If severe treat immediately with no ABPM/HBPM
What is malignant hypertension?
Rapid rise in blood pressure to over 200/130, leading to vascular and organ damage
Can causes bilateral retinal haemorrhages, headache, visual disturbances
Needs urgent treatment (BB or CCB)
Hypertension can be primary (90%) or secondary (10%). What are some secondary causes of hypertension?
- Renal disease: renal artery stenosis, polycystic kidneys
- Cushing’s
- Phaeochromocytoma
- Pregnancy
- Drugs
- COCP
- Cocaine
What are some symptoms of hypertension?
- Usually asymptomatic
- Sweating, headache, palpitations and anxiety if phaeochromocytoma
- Muscle weakness or tetany in hyperaldosteronism
What are some signs on examination of a patient with hypertension?
- Retinopathy
- Palpable kidneys/renal bruits
- Radiofemoral delay in coarctation
- Signs of Cushing’s
What other tests apart from BP are performed when a patient is newly diagnosed with hypertension?
- Urine dip
- Bloods
- Retinopathy
- ECG
- ECHO
- Q Risk score
How do you test for end organ damage in hypertension?
- Check for proteinuria or haematuria
- Check for retinopathy
- Do ECHO for LV hypertrophy
When should hypertension be pharmacologically managed?
Stage 1: if under 80 and end organ damage
Stage 2 and above: everyone should be offered
What are target blood pressures to bear in mind when treating hypertension?
- Low-moderate risk: <140/90
- Diabetic/Previous Stroke: <130/80 (keep below 85)
- Elderly >80: <150/90
Reduce slowly, can be fatal if lower too rapidly!
How is hypertension treated non-pharmacologically?
- Weight loss
- Stop smoking
- Reduce alcohol
- Reduce salt intake
- Aerobic exercise
How is hypertension treated pharmacologically?
ACD rule!
What are some side effects of the following antihypertensive drugs?
- Thiazides
- CCBs
- ACEi
- ARB
- BB
Thiazides: impotence, hypoK, hypoNa, cannot use in gout
CCB: ankle oedema, flushing, gum hyperplasia
ACEi: cough, hyper K, renal failure, angio-oedma
ARB: vertigo, urticaria, be careful in valve disease
BB: bronchospasm, cold peripheries, impotence
Why should you drop hypertension slowly?
Any sudden drops in BP increases stroke risk as cerebral autoregulation is poor
What is the definition of a hypertensive emergency?
Increase in BP which if sustained over the next few hours will cause irreversible end organ damage (encephalopathy, LV failure, aortic dissection, unstable angina, renal failure)
What is the difference between a hypertensive emergency and urgency?
Emergency - High BP with critical illness (AKI,MI, Encephalopathy). Will cause damage over hours
Urgency - High BP without critical illness at the moment, often accompanied by retinal damage. Will cause damage over days
How is a hypertensive emergency managed?
Aim to reduce diastolic BP to 110 in 3-12 hours (if emergency) or 24 hours (if urgency)
How is hypertensive urgency managed?
Reduce diastolic gradually to <100 over 48-72 hours using PO drugs
Usually a combination of ACEi and CCB or Nifedipine AND Amlodipine for 3 days and then continue Amlodipine alone
- Amlodopine
- Diltiazem
- Lisinopril
What is the classic triad of symptoms for patients with a phaeochromocytoma?
- Episodic headache
- Sweating
- Tachycardia
with sustained/paroxysmal hypertension
How is phaeochromoctyoma diagnosed?
24h urine collection: measure urinary and plasma metanephrines and catecholamines
Can do MRI or CT abdo/pelvis to detect adrenal tumours
How is a phaeochromocytoma managed after diagnosis?
- Surgical resection
- Whilst awaiting surgery hypertension control: combined alpha and beta blockade. Start alpha blocker first (phenoxybenzamine) then add beta blocker when alpha blockade achieved. Never BB first
How do you diagnose Cushing’s syndrome as the underlying cause of hypertension?
- Physical appearance
- Hyperglycaemia
- Elevated 24h urine cortisol
- Diagnosis: low dose dexamethasone suppression test
- Need to do adrenal CT
When should you suspect primary hyperaldosteronism as the cause of hypertension and how do you diagnose this?
Suspect:
- Low K+ and high/normal Na+
- FHx of premature hypertension
- Resistant hypertension
Diagnose:
- Aldosterone:renin ratio measured in the morning. Will be very high
- Adrenal CT
How does the RAAS system work?
What are some causes of postural hypotension?
- Hypovolemia
- Drugs e.g diuretics, nitrates, antipsychotics
- Autonimic neuropathy
- Hypopituatirism
How do you treat postural hypotension?
What are some signs of hyperlipidaemia?
- Xanthoma
- Xanthelasma
- Corneal arcus
What are the causes of the following pulses:
- Bounding pulse
- Collapsing waterhammer pulse
- Slow rising anacrotic pulse
- Jerky pulse
- Pulsus paradoxus
Bounding: sepsis, CO2 retention, liver failure
Collapsing pulse: aortic regurgitation, AV malformation, PDA
Slow rising: aortic stenosis
Jerky pulse: HCM
Pulsus paradoxus: severe asthma, pericardial constriction, cardiac tamponade
What does each part of the JVP wave form represent?
S1 is the closure of the mitral and tricuspid valve. S2 is closure of the pulmonary and aortic valve. What makes a loud S1, soft S1, loud A2 and loud P2?
Loud S1: Mitral stenosis
Soft S1: Mitral regurg
Loud A2: tachycardia, hypertension
Loud P2: pulmonary hypertension
When do you hear an opening snap?
Mid diastolic murmur of mitral stenosis usually due to calcification
What do the following murmurs indicate:
- Ejection-systolic
- Pansystolic
- Early diastolic
- Mid diastolic
Ejection Systolic: (Crescendo-Decresendo) aortic stenosis, pulmonary stenosis
Pansystolic: mitral regurgitation, tricuspid regurgitation
Early diastolic: aortic regurgitation
Mid diastolic: mitral stenosis, rheumatic fever, Carey Coombs
Which murmurs radiate and to where?
Aortic stenosis: carotids
Mitral regurgitation: axilla
Which murmurs can be heard best when leaning forward, left lateral positioned, expiring?
- Leaning forward: aortic regurg
- Left lateral: mitral stenosis
- Expiring: left sided murmurs as expiring increases blood follow to left side of heart
What are the following signs:
- De Mussets
- Corrigan’s
- Muller’s
- Quincke’s
- Traubes’
All signs of aortic regurgitation
Lookat Quinke and demussets
Why are transoesophageal echos better than transthoracic and what are they used for?
Closer to the heart so more sensitive
- Cardiac emboli
- Aortic dissections
- Assessing prosthetic valves
What is cardiac catheterisation used for and what are some complications of this procedure?
- Angioplasty
- Valvuloplasty
- Intravascular ultrasound or ECHO
What is used second line to treat hypertension for an Afro-Carribbean patient?
ARB e.g Valsartan
Which valve is the most commonly affected in infective endocarditis?
Mitral valve
What medication do you need to give a patient before PCI?
Dual antiplatelet therapy with aspirin and a P2Y12 antagonist(-grel)
PLUS
Unfractionated Heparin
What is the difference between a STEMI and an NSTEMI?
STEMI is complete occlusion of the coronary artery but NSTEMI is only partial
Both result in tissue necrosis
How is hypertensive retinopathy graded?
1 - Tortuous arterterues with thick shiny walls
2 - AV nipping where arteries cross veins
3 - Flame haemorraghes and cotton wool spots
4 - Papilloedema
How should cocaine induced MI be managed?
Benzodiazepine plus GTN
