Complications of HTN Flashcards
List the cardiac complications of HTN
- Increased LV mass (hypertrophy), with or without chamber dilation
- Left atrial abnormalities
- Myocardial ischaemia
- Systolic and diastolic LV dysfunction
- Atrial and ventricular arrhythmias
- Sudden death
Describe the neurohormonal processes underlying cardiac damage from HTN
- Activation of the RAAS
- Increased ATII
- Increased aldosterone
- Enhanced adrenergic activity
- Increased production/ decreased catabolism of biologically active molecules (ATII, cytokines, growth factors)
Describe the haemodynamic processes underlying cardiac damage from HTN
- Increased peripheral resistance
- Increased wall stress
- Decreased coronary reserve
- Increased volume load
Describe the vascular processes underlying cardiac damage from HTN
- Endothelial dysfunction (from vascular wall stress)
- Vascular remodelling
- Decreased vascular compliance
- Increased vascular reactivity
- Coronary and peripheral vascular atherosclerosis
Describe the myocardial processes underlying cardiac damage from HTN
- LV remodelling
- Foetal gene expression
- Myocyte hypertrophy
- Alteration in ECM: fibroblasts replacing cardiomyocytes
List the common presenting symptoms of CHF
- Dyspnoea at rest
- Dyspnoea on exertion
- Paroxysmal nocturnal dyspnoea
- Effort intolerance
- Weakess and fatigue
- GI complaints
- Orthopnoea
List some common signs of CHF
- Resting tachycardia
- Third heart sound
- Vascular congestion
- Peripheral oedema
- Hypotension
- Organomegaly
- Pleural effusion
- Cachexia
What class of drugs should be used to manage LV systolic dysfunction in hypertensive heart disease?
ACE inhibitors or ARBs
What class of drugs should be used to manage LV diastolic dysfunction in hypertensive heart disease?
ARBs
What class of drug should be used in the presence of IHD in hypertensive heart disease?
Beta-blockers (3rd generation)
What classes of drug should be used if congestive symptoms are present in hypertensive heart disease?
Loop diuretics or anti-aldosterone
In the presence of IHD in hypertensive heart disease, what combination of drugs should be used?
- Beta blockers
- Nitrates
- ACE-I
- CCBs (not with B blockers)
What should be used if AF is present in hypertensive heart disease?
- Anticoagulation
What are the possible very early treatments for ischaemic stroke?
- Thrombolysis
- Mechanical thrombectomy
What are the possibly early treatments for ischaemic stroke?
- Aspirin
- Anticoagulants
What drugs/treatments should be used for long term prevention of ischaemic stroke?
Anti-platelets:
- Aspirin
- Clopidogrel
- Dipyridamole
Anticoagulants:
- Warfarin
- NOACs (apixaban, edoxaban, rivaroxaban)
Statins
Anti-hypertensives
Re-vascularisation: stents/angioplasty, carotid endoarterectomy
List the renal complications of HTN
Hypertensive kidney disease:
- Marked by progressive kidney dysfunction
List the non-modifiable risk factors for hypertensive kidney disease
- Increasing age
- Gender
- Ethnicity
Lost the modifiable risk factors for hypertensive kidney disease
- HTN
- Proteinuria/albuminuria
- Dyslipidaemia
- HbA1c
- Anaemia
- Ca:PO4
List the haemodynamic abnormalities in HTN and CKD
Increased cardiac output
- =Increased intravascular volume
- Decreased GFR
- Reduced Na+ excretion (therefore water excretion)
- Increased ECF
- Increased renal nerve activity
- Increased myocardial performance
- Increased adrenergic activity
Increased vasoconstriction:
- Increased adrenergic stimulation
- Increased AGII
- Increased endothelin and endothelin derived clotting factors
- Increased thromboxane
Decreased vasodilation:
- Reduced prostacyclin
- Reduced NO
- Reduced endothelin-derived hyperpolarising factors
List the stages of hypertensive retinopathy
Stage I-II (Mild) :
- Arteriolar narrowing
- Arteriolar wall opacity
- Arteriolar nicking
Stage III (Moderate):
- Mild retinopathy with:
- Retinal haemorrhage/microaneurysms
Stage IV (Malignant):
- Moderate retinopathy
- Optic disc welling
- Macular oedema
List some characteristics of hypertensive heart disease
- Altered coronary reserve
- Endothelial dysfunction
- Perivascular fibrosis
- Systolic and diastolic dysfunction
- Left ventricular hypertrophy
- Cardiac dysrhythmias
- Myocardial fibrosis- replacement of muscle cells with fibroblasts
List the clinical consequences of hypertensive heart disease
- Angina pectoris
- Asymptomatic or symptomatic HF
- ACS
- Cardiac dysrhythmias
- Myocardial infarction
- Sudden death
Describe the classification of CKD
- Kidney damage with normal GFR (GFR>90)
- Kidney damage with mildly reduced GFR (GFR 89-60)
- Kidney damage with mild to moderate GFR (GFR 59-45)
- Kidney damage with moderate GFR (GFR 45-30)
- Kidney damage with severe GFR (GFR 30-15)
- Kidney failure (GFR <15)- dialysis
What are the intrarenal effects of ACE inhibitors and ARBs on GFR compared to no treatment?
- Untreated: Efferent arteriolar tone increased causing glomerular hyperfiltration
- ACE-inhibitors: Greater increase in the diameter of the efferent arteriole due to the combined effect of increased bradykinin and decreased ATII resulting in a greater drop in GFR
- ARBs: Limited increase in efferent arteriolar tone due to ATII blockade but no effect on bradykinin resulting in reduced effect on GFR
Describe the pathology of each of these fundoscopy images
Which stage of hypertensive retinopathy does each image correspond with?
A - Generalised narrowing of the arterioles (stage I)
B - …….plus focal constriction, arteriolar sclerosis with widening of the reflex stripe (stage II)
C - …….plus haemorrhages and exudates (stage III)
D - ……..plus oedema of the disc (papilloedema) (stage IV)
