Case of the GP under Pressure Flashcards
high blood pressure affects people in UK?
1 in 4
hypertension is?
3 rd biggest risk factor
every 10mmHg reduction in BP reduces?
CAd- 17%
Stroke- 27%
HF-28%
all cause mortality- 13%
Blood pressure equation
BP=CO x PR
cardiac output equation?
CO= HR x SV
pathogenesis of HTN?
increased sympathetic tone
increased peripheral vascular resistance
RAAS activation
Increased cardiac output
causes of HTN?
primary-90%
secondary- 10% underlying disease
younger patients, hypertensive crises, abnormal blood results, signs and symptoms
Causes of HTN?
PKD, glomerulonephritis, renal artery stenosis
High aldosterone, cushings, phaechromocytoma, hypo/hyperthyroidism, hyperparathyroidism, acromegaly
Steroids, COCP, NSAIDs, cocaine, antidepressant, EPO,
obstructive sleep apnoea
pregnancy
congenital-coarction of the aorta
risk factors of HTN?
male, age, FH, ethnicity (south asian, black african), smoke, high lipids, diabetes, socioeconomic status
RAAS?
Renin from juxtaglomerular apparatus released and will act on angiontensinogen released from liver. this will produce angiotensun 1, which is converted angiotensin II by ACE enzyme.
angiotensin II increases sympathetic activity, aldosterone secretion, tubular Na/Cl absorption and K excretion, H20 retention, arteriolar vasoconstriction, ADH secretion-H2O reabsorption
hyperaldosteronism?
low plasma renin
40%- Conns
bilateral adrenal hyperplasia- 60%
key investigation for hyperaldosteronism?
high plasma aldosterone/ renin ratio
pH in hyperaldosteronism?
metabolic alkalosis
how to check for what type of hyperaldosteronism?
CT/MRI adrenals
Adrenal vein sampling- lesion is functional
how to treat hyperaldosteronism?
laparoscopic adrenalectomy
radiofrequency ablation
mineralocorticoid receptor antagonist- spironolactone/eplerinone
causes of hyperaldosteronism with high plasma renin?
secondary hyperaldosteronism- kidneys detect low kidney blood flow
renal artery stenosis
coarction of the aorta
reninoma
hereditary disorders
diagnosis of high plasma renin hyperaldosteronism?
HTN
low plasma aldosterone: renin ratio
high creatinine
MR renal angiogram
CT renal angiogram/ renal dopplers
gold standard of high renin aldosterinism?
renal angiogram
10% of renal artery stenosis?
fibromuscular dysplasia- beading
treatment high renin hyperaldosteronism?
medical- control BP
renal angioplasty
stent insertion
surgical repaire
ateriosclerosis?
blood vessels become thicker
atherosclerosis?
inflammatory process and high cholesterol leading to plaque, which could narrow the artery
how to diagnose target organ damage?
fundoscopy for retinopathy
ECG- LVH, AF
Urinalysis- proteinuria
Bloods- U/Es
acute target organ damage due to hypertensive crisis?
eyes- retinal haemorrhage/ papilloedema
brain-encephalopathy, stroke
heart- pulmonary oedema, MI
Kidneys- AKI
aortic dissection
pre-eclampsia
causes of secondary hypertension CHAPS?
Cushings
Hyperaldosteronism
Aortic Coarctation
Pheochromocytoma
Stenosis of renal arteries
phaechromocytoma?
adrenal medullary tumour that secretes excess catecholamines from chromaffin cells
paraganglioma?
neuroendocrine tumours that arise from sympathetic and parasympathetic ganglia
common signs and symmptoms of phaechromocytoma/paraganglioma?
headache
sweating
high blood pressure
tachycardia
anxiety
palpitation
abdominal pain
dizziness
blurry vision
diabetes symptoms
Heart failure
phaechromocytoma affects
0.01 to 0.1%
investigate phaechromocytoma if?
signs/ symptoms
severe HTN, HTN crisis
refractory HTN>3 drugs
HTN at young age
adrenal lesion
FH
phaechromocytoma 5 Ps?
pain
pressure
palpitation
perspiration
pallor
paroxysms spells
mechanism of hypotension in phaechromocytoma?
loss of postural reflexes due to prolonged catecholamine stimulation
release of adrenomedullin (vasodilatory neuropeptide)
catecholamines cause?
dilated cardiomyopathy so affect systolic dysfunction
HTN causes?
hypertrophic cardiomyopathy so affects systolic function
other features of phaechromocytoma?
lipolysis
mild glucose intolerance
hypercalcaemia- MEN2, PTHrP secreted by pheo
adrenaline is produced in?
only adrenals because phenyethanolamine n-methyltransferase is present only there
if clinical suspicion of PPGL first check?
urine metanephrines then imaging
why might you get a false positive for high metanephrines in urine?
extreme stress, critical illness, non supine position, sympathoadrenergic activity, renal insufficiency, diet (coffee, tea, bananas, chocolate), medication
what is a really good scan for phaechromocytoma?
galium dotatate
preoperative treatment?
7-14 days
alpha adrenergic receptor blocker- phenoxybenzamine, doxazocin
propanolo- if tachycardic
calcium channel blocker
metyrosine- sympathtic
familial phaechomoctoma?
40%- bilateral, paragnaglioma, unilateral with FH, uinlateral and young age of onset, metastasis
familial phaechromocytoma could be due to?
MEN 2a, MEN 2b, Von Hippel-landau, NF1, familial paraganglioma, familial pheo and islet cell tumout
men 2 a?
pheochromocytoma, medullary thyroid carcinoma, parathyroid hyperplasia
men 2b?
pheochromocytoma, medullary throid carcinoma, marfanoid habitus, mucosal neuroma
NF1?
cafe au lait spots, neurofibroma and optic glioma
von hipple landau?
pheochromocytoma, retinoblastoma, cerebellar hemangioma, nephroma, renal/pancreas cysts
familial pheochromocytoma gene
succinate dehydrogenase mutation
WHO healthcare quality dimensions?
effective- adherent to an evidence base and results in improved health outcomes
efficient- maximises resource use and avoids waste
accessible
acceptable- takes into account preferences and aspirations of individual service users/ cultures of their community
equitable-
safe
sustainability?
outcome for patients and populations divided by environmental social and financial impacts
components of healthcare (donabedian model)?
structure- facilities, equipment, human resources,
process- care seeking behaviour, diagnosis, treatment
outcome- patient knowledge, behaviour, health status and satisfaction
audit?
way to find out if healthcare is being provided in line with standards and let care providers and patients know where their service is doing well and where there could be improvements
stimulus for quality improvement?
reflective case, large scale data, feedback, learning event analysis
research?
creating new knowledge that can be generalised beyond the participant sample or setting
difference in clinical audit vs quality improvement?
audit- evaluating service against a benchmark
QI- find out something about that service which can be used to improve that service
which cycle is pertinent to improvent?
plan do study act
