Clinical Presentation of severe hypertension &Severe Hypertension: Understanding the Patholog Flashcards
What BMI is considered high (obese) in white and asian people
white - 25
asian- 23.9
Case: 45y/o bank executive, BMI 31.5, unfit and wants to join a gym, smokes 30/day, BP 200/120, alcohol 1 glass wine daily, nil drugs.
What would you advise his PT at the gym?
A. encourage regular exercise
B. ban him from doing any exercise at all and recommend rest adn repeat of his BP
C. advise him to see his GP beofre allowing him to exercise in the gym
D. refer him to casualty for blood pressure control
A. encourage regular exercise
if someone has hypertension what would you look for
Fundoscopy
What happens in the different grades of hypertension?
Grade 1: silver wiring
Grade 2: AV nipping
Grade 3: flame shaped haemorrhage
Grade 4: papilloedema
What could papilloedema indicate
high ICP- possibly brain tumour
hypertension
WHat are feature of long standing hypertension exist
left ventricular hypertrophy (ECG)
feel a heave
hear a bruit
hear an S4
WHat grade is this
grade 3
see flame haemorrhage
What are 6 causes of hypertension
- Conn’s
- Cushing’s
- Phaechromocytoma
- renal artery stenosis
- Acromegaly
- co arctation of the aorta
- essential
What are investigation would you like to do?
if someone presents with hypertension
- FBC
- U&E low K+ high Sodium
- ECG look for LVH
- Urinalysis (renal disease and nephritis)
- Fasting glucose
- Lipids
What percentage of people have secondary hypertension
10%
What are specific investigations to diagnose secondary causes of hypertension
renin aldosterone ration
24 hour urine for catecholamines
24 hour urine cortisol
glucose tolerance test
Someone presents with
renin 0.4 (1.1-4.5)
aldosterone 1600 (100-450)
24 hour urine catecholamine normal
What does he have
Conn
How do you treat conn’s
surgery remove it
patient presents with
renin: 7.4 (1.1-4.5)
aldosterone: 900 (100-450)
24 hour urine catecholamines is normal
What does this patient have
renal artery stenosis
What is the gold standard way of diagnosing renal artery stenosis
Digital subtraction angiogram
what does this patient have?
Renin: 2.4 (1.1 -4-5)
Aldosterone: 300(100-450)
24 hour urine for catecholamines RAISED
phaechromocytoma
how does phaechromocytoma present?
anxiety
palpitation
headache
sweating
What is the treatment for phaechromocytoma?
MEDICAL EMERGENCY
alpha blockade
How do you manage a phaechromocytoma
- alpha blockade (rehydrate if needed)
- beta blockade
- localise the lesion
- surgery (many weeks after alpha blockade)- laprascopic adrenalectomy
What does an MIBG scan show
is a radioactive scan and shows where the tumour is
the bladder always lights up
How do you treat essential hypertension?
Over 55 or afrocaribean
- CCB or thiazide
- add an ACE to either
- CCB and ACE and Thiazide
under 55
- ACE
- add a thiazide or CCB
- CCB and ACE and Thiazide
After a myocaridal infarction or angina, what anti hypertensive would give the most benefit?
beta blocker
very good for MI and angina strongly encaouraged
When do you not give a beta blocker
severe heart failure
heart block
Asthma COPD
When do you not give an ACE OR ARB?
renal impairement
Peripheral vascular disease
pregnancy
renovascular disease
When do you not give a thiazide diuretic?
Gout
What antihypertensive drugs activate and which decreases the activity of the RAAS system
decrease RAS
ACE/ARB
b blocker
increase RAS
Thiazide
CCB
A 65 year old patient with previous MI has a BP of 140/80 on atenolol
What do you do ?
add a thiazide or CCB to reach 120/80
STUDY showed it reduced their death
Especially if he had a previous MI
What is the optimal medical therapy for someone that has had an MI
- intensive lifestyle modification
- aspirin
- high atorvastatin
- optimal blood pressure
- assess for type 2
If someone has a had an MI, at what level do you want their blood pressure to be?
120/80
really strict
because improves survival
How does PCSK9 drugs work?
lowers cholesterol by binding to the LDL receptor and causes it to be destroyed by a lysossome instead of being recycled
EXAMPLE DRUG EVOLOCUMAB
does PCSK9 work
Didn’t reduce death
no effect on mortality
only use in people with familial hypercholesterolaemia
Case: 45y/o bank executive, BMI 31.5, unfit and wants to join a gym, smokes 30/day, BP 200/120, alcohol 1 glass wine daily, nil drugs.
Is this man
a) normal BMI
b) overweight
c) obese
d) severe obesity
e) morbid obesity?
Obese.
What do you see on fundoscopy of grade 1
Silver wiring
What do you see on fundoscopy of grade 2 hypertension?
Silver wiring.
AV nipping.
What do you see on fundoscopy of grade 3 hypertension?
Silver wiring.
AV nipping.
Flame haemorrhage.
What do you see on fundoscopy of grade 4 hypertension?
Silver wiring.
AV nipping.
Flame haemorrhage.
Papilloedema.
Cotton wool spots and hard exudates.
What does hypertensive retinopathy suggest?
Hypertension is severe and prolonged.
