Cardiovascular Risk Factors - HTN, Lipids and Medications

Question 1

Hypertension
-presentation
-investigation
-diagnosis

Answer 1

Asymptomatic - may initially present as stroke, MI
Severe - headache, nosebleed, chest pain, SOB

GP BP 2x - 140/90+
-if 2 clinic readings are very different, take 3rd and take lower of last 2
=> ABPM/HBPM to confirm - 135/85+

GP BP - 180/120+ => no home check

HTN in U40 => investigate 2ndary cause?

Question 2

Hypertension management
-Stage 1

Answer 2

ABPM/HBPM - 135/85+

Lifestyle
-diet, exercise => lower BMI, salt
-smoking cessation
-reduce alcohol

If U80 and any of
-target organ damage
-established CVD
-renal disease
-DM
-QRISK 10%+
=> drug treatment

Question 3

Hypertension management
-Stage 2
-U55, DM
-55+, black

Answer 3

Lifestyle advice + drug

U55, DM
1st line - A, swap if needed
2nd line - A+C
3rd line - A+C+D

55+, black
1st line - C (D if CI)
2nd line - add ARB/ACEi/D
3rd line - A+C+D

4th line =>
-spirololactone if K U4.5
-Ab/Bb if K 4.5+

5th line => specialist advice

Question 4

Hypertension management
-Stage 3

Answer 4

Refer - same day assessment if
-retinal bleed, papillodema
-life threatening symptoms (new confusion, chest signs, heart failure, AKI)
-pheochromocytoma?

If no same day referral needed => target organ damage check
Yes => drug treatment
No => repeat CBPM in 1wk

Question 5

How to assess for target organ damage
When would you do this

Answer 5

If Stage 3 HTN => kidney and eye

Urine dip => hematuria
Fundoscopy => HTN retinopathy
ECG

Bloods
-urine albumin:creatinine => proteinuria
-HbA1C
-U&E, eGFR => CKD

Question 6

BP targets
-U80
-80+

Answer 6

U80
CBPM - U140/90
ABPM/HBPM - U135/85

80+
CBPM - U150/90
ABPM/HBPM - U145/85

ABPM/HBPM if significant white-coat effect

Question 7

QRISK
-when to use
-results interpretation

Answer 7

CVD risk for primary prevention up to 84 y/o

U10% - lifestyle + comorbidity optimisation
10%+ - +atorvastatin 20mg

Question 8

Lipid modification therapy
-investigations
-when to suspect familial hypercholesterolemia
-management of high cholesterol 9+if homozygous FH)
-statin, ezetimibe MOA

Answer 8

Investigations
-lipids - current lipid control
-LFT - poor liver function CI
-U&Es, eGFR, HbA1c

Familial hypercholesterolemia - AD
-FHx of CHD
-Total 7.5mmol/L+
-LDL 4.9mmol/L+
-tendon xanthomata
=> refer to lipid clinic

Management
Primary - atorvastatin 20mg
Secondary - atorvastatin 80mg
2nd line - ezetimibe
If homozygous FH
-LDL apheresis
-liver transplant

Statins - inh HMG CoA reductase
Ezetimibe - inh dietary uptake

Question 9

Statin counselling
-what are statins for
-how to take it
-monitoring
-SE
-lifestyle changes

Answer 9

2 types of cholesterol
-good (HDL)
-bad (LDL) => increased risk of heart attacks and strokes
Statins aim to reduce the amount of LDL

Tablet - OD
-time of day depends on statin used
-take missed doses ASAP but no DD

Before - lipids, LFTs
3, 12months - lipids

CI - liver problems, pregnancy

SE
Common - GI upset
Key - generalised muscle pain => GP

Lifestyle changes
-no grapefruit
-ABx interactions
-CV risk optimisation

Question 10

Anti-hypertensive counselling
-what are anti-HTNs for
-how to take it
-monitoring
-SE for ACEi, ARB, CCB
-lifestyle changes

Answer 10

High BP => increased risk of heart attacks, strokes
Aim to reduce HTN

Tablet
-slowly increase dose until BP controlled

Before - BP, kidneys
12months - kidney
Home BP monitoring

CI - kidney problems, pregnancy

SE
ACEi - dry cough => GP if a bother
-Hypotension => GP
-Angiodema, anaphylaxis => A&E
CCB
-Headache, swollen ankles, constipation

Lifestyle changes
-avoid NSAIDs
-CV risk optimisation

Question 11

Diuretic counselling
-what are diuretics for
-how to take it
-monitoring
-CI
-SE
-lifestyle changes

Answer 11

Kidneys filter out water, salts, waste from blood
By using diuretics to remove more water and salt => lower BP

Tablet
-early morning => less disruption to sleep

Before - U&E, kidneys
Initial frequent monitoring until stable

CI - kidney problems

SE
Hypotension, dehydration, dizzy => GP

Lifestyle changes
-CV risk optimisation

Question 12

Bb counselling
-what are Bb for
-how to take it
-monitoring
-CI
-SE
-lifestyle changes

Answer 12

Bb reduce BP by slowing down HR and reducing force of pulse

Tablet

CI
-COPD, asthma, poor peripheral circulation

SE
-cold peripheries, fatigue
SOB, dizzy, chest pain => GP

Lifestyle changes
-CV risk optimisation

Question 13

Causes of HTN

Answer 13

Primary - lifestyle factors (CV risk)
Secondary - underlying cause

Renal
-renal artery stenosis
-PKD

Endocrine
-pheochromocytoma
-Hyperaldosteronism
-Cushing

Other
-coarctation of aorta
-pre-eclampsia