DIS - Diseases of the Vasculature III: Hypertension - Week 11 Flashcards
Define the following:
Essential/primary hypertension
Borderline
Normotensive
How many readings are required?
Essential
-BP >160/95mmHg
Borderline
-BP 140/90 to 160/95
Normotensive
-BP <140/90
3 readings on separate occasions
What diastolic BP is considered too high and worthy of reducing?
Anything over 100mmHg (in general)
List four things BP is considered in relation to.
Serum cholesterol
Race
Age
Family history
Define malignant hypertension. What is it associated with and in what two organs?
> 120mmHg diastole
Associated with exudative vasculopathy in the retina and kidney
What percentage of hypertension cases are secondary?
5%
What two types of conditions cause secondary hypertension? Give some examples for each.
Renal conditions
-nephritis, renal failure, tumour
Endocrine conditions
-diabetes, hyperthyroidism, parathyroidism
What five things is the degree of BP an accurate predictor of?
Coronary artery occlusion
Stroke
Renal failure
Heart failure
Peripheral vascular disease
Is there some risk of pathology even at normal blood pressures?
Yes
List three things that can happen to the brain due to hypertension.
Atherosclerotic/endarteritic damage to cerebral vessels
TIA
Stroke
List two things that can happen to the kidney due to hypertension.
Enarteritic changes in the renal bed
Ultimate renal failure from sclerosis
List two things that can happen to the heart due to hypertension.
Left ventricular hypertrophy - cardiac failure
BP damage to cardiac vessels - myocardial infarction
Do patients with similar blood pressure have similar or different ocular signs?
Different - variable relatinoship between measured blood pressure and retinopathy
What percentage of hypertension patients have a normal fundus?
~1/3
Why does constriction of arterioles occur with hypertension and what is it in response to exactly (2)?
Lumen narrows to maintain blood flow as perfusion pressure drops
-autoregulation to decreased peripheral resistance
What are two consequences of constricted arterioles on the retina (fundus appearances)?
Attenuation
Focal constriction
How does arteriolar sclerosis affect vessel wall transparency? What fundus appearance does this give?
Loss of transparency
-increased reflex and copper wiring
Does arteriolar sclerosis cause lumen narrowing? What fundus appearance does this give?
Yes
-nicking
What happens to veins at AV crossings due to arteriolar sclerosis? What fundus appearance does this give?
Deflection
-right angle Xing
How is the lumen of veins affected by arteriolar sclerosis? What fundus appearance does this give?
Compression
-banking
List three signs of first degree hypertension. Describe its clinical significance.
Focal arteriolar constriction
Banking (a form of crossing change)
Isolated flame haemorrhage
Lower clinical significance
Is first degree hypeltension related to accelerated or non-accelerated blood pressure?
Non-accelerated
List five signs of second degree hypertension. Describe its clinical significance.
Numerous flame haemorrhage
Retinal lipid/exudate
Cotton wool patches
Retinal vessel occlusion
Papilloedema
Is second degree hypertension related to accelerated or non-accelerated blood pressure?
Accelerated
List the four grades of hypertension according to the wong and mitchell grading system for hypertensive retinopathy.
No retinopathy
Mild retinopathy
Moderate retinopathy
Malignant retinopathy
List four signs suggestive of mild hypertensive retinopathy.
One or more of the following
Generalised arterial narrowing
Focal arterial narrowing
AV nicking
Silver wire
List four signs suggestive of moderate hypertensive retinopathy.
One or more of the following
Haemorrhage (dot/blot/flame)
Microaneurysm
Cotton wool spots
Hard exudates
List two requirements for malignant hypertensive retinopathy.
Moderate retinopathy signs plus optic disc oedema
Within how many disc diameters are focal arteriolar constrictions most readily seen? How does it appear on funduscopy?
1-2DD of the disc
Alternating zones of passive dilation and spasm
Does the presence of focal arteriolar constriction have good or poor sensitivity and specificity for systemic hypertension?
Good for both
Comment on the presence of banking in terms of hypertension possibility.
A reliable guide to possibility of hypertension
Where is banking commonly seen?
AV crossings
Describe how banking appears and what it means.
Restriction of venous return
Upstream dilation of the vein
-distal vein calibre > proximal side
What does banking indicate?
Significant interruption to venous blood flow
What does banking increase the risk of (3)?
Thrombus formation (eventual venous occlusion)
Vein’s endothelium may become sticky
Risk of platelet adhesion to walls
What may bypass banking?
Shunt vessels
Is hypertension a common cause of flame haemorrhage?
Yes
What is a flame haemorrhage? Where does blood run along?
Leakage of superficial capillaries into the NFL
-seepage along axon bundles
What three things are flame haemorrhages indicative of?
Vascular occlusive disease
Diseases specifically affecting blood viscosity
Diseases affecting integrity of vessel wall
List 6 differential diagnoses for flame haemorrhages.
Glaucoma
Papillitis
Papilloedema
Following acute PVD
Diabetic retinopathy
Retinal vein occlusion
What type of glaucoma are flame haemorrhages especially likely?
Low tension
What causes cotton wool patches? Is it ischaemic
Occlusion of minor arterioles/capillaries supplying NFL
-ischaemia with resultant cloudy swelling of axons
Within what timeframe do cotton wool spots appear of infarction?
Within 24h of infarct
List 7 diseases aside from hypertensive retinopathy where cotton wool spots can be found.
AIDS
Diabetes
Carotid artery stenosis
Systemic diseases with ischaemic manifestations
SLE
CVO/BVO
Anaemia
How long do cotton wool spots often persist for?
6 weeks
Can cotton wool spots cause vison loss?
Often not, but will if axons rupture from oedema
Is papilloedema inflammatory?
No
What causes papilloedema with hyerptension?
Stasis/blockage of axoplasmic transport
Describe how papillodema appears in hypertensive retinopathy.
Visible disc swelling and indistinct margins
What four other things are you likely to see if papillodema is present in hypertensive retinopathy?
Venous engorgement
Exudates
Flame haemorrhages
Cotton wool spots
What is blood pressure probably like if papilloedema is present in hypertensive retinopathy?
Very high
What two things should papilloedema be differentiated from if you suspect hypertensive retinopathy?
Retinal/optic nerve disease (RVO/RAO/AION, papillitis etc)
Intracranial masses/pseudotumour
Does papilloedema require urgent referral if it is secondary to hypertension?
Yes
Which of the following may be seen with hypertensive retinopathy:
Vein occlusion (CRVO/BRVO)
Retinal arteriolar aneurysm
Non-arteritic AION
All three are possible
Which of the following have high sensitivity for blood pressure?
Dot/blot haemorrhages
Microaneurysms
Sub-retinal haemorrhages
Pre-retinal/sub-hyaloid haemorrhages
Arterial atheromatous plaques/emboli
Vein Sheathing
Tortuous veins/venules
Shunts/collaterals
Arteriolar straightening/attenuation
Arteriovenous nicking (Gunn’s sign)
Right angle AV crossing
All have poor sensitivity
What is arteriolar attenuation? What changes occur to bifurcations?
Arterioles are straight over extended portions
-bifurcations are acute-angled
What two things aside from hypertensive retinopathy can arteriolar attenuation occur secondary to?
Retinal arterial occlusion
Toxic states
What is gunns sign?
AV nicking
Describe the appearance of AV nicking.
Blood column in veins appears narrowed just upstream and downstream of the crossing
Is AV nicking the same as banking?
No
What is sallus’ sign?
A right angle AV crossing
What two choroidal changes may be present with hypertension?
Elschnig’s spots
Siegrist’s streaks
What are elschnigs spots? What is it mainly seen in? Does it have any visual significance?
Mainly in toxaemia
Numerous, small RPE detachments (1/4DD)
Little visual significance
What are siegrist’s streaks? What do they follow?
Fine pigment lines following choroidal vessels which have sclerosed and occluded
List the following in order of probably importance in detecting early hypertension:
Banking
Vascular occlusions evidenced by flame haemorrhages, lipid exudates, vein sheathing, and CWP
Atherosclerosis in other signs
Focal arteriolar constrictions
Focal arteriolar constrictions
Vascular occlusions evidenced by flame haemorrhages, lipid exudates, vein sheathing, and CWP
Banking
Atherosclerosis in other signs
You should refer to a GP when you see what four signs of recent origin?
Haemorrhages
Cotton wool spots
Papilloedema
CRVO/BRVO
You should refer to an ophthalmologist when you see what three recent vascular occlusions?
CVO/BVO
AION
Macroaneurysm
List the types of stroke and their percentages. Also note their cause.
Ischaemic - from thrombosis/embolus (80%)
Haemorrhagic - vascular rupture (20%)
For stroke and CVA, describe the proportion of cases with recovery, severe residual handicap, and death.
1/3rd recover
1/3rd suffer severe residual handicap
1/3rd die
What is a TIA?
Transient ischaemic attack
-stroke symptoms lasting <1h
What is the timeframe for a TIA.
Must be <24h
What damage occurs with TIA (2)?
Often no damaage
-any damage that occurs is less severe than stroke
List 8 general symptoms of stroke. Do they occur slowly or suddenly?
Numbness
Parasthaesia
Weakness
Paralysis of contralateral limb/face
Aphasia
Confusion
Visual disturbance in one or both eyes
Headache
What do neurological deficits seen during a stroke reflect?
The area of the brain involved
Would you expect to see unilateral or bilateral symptoms if there is an anterior circulation stroke? What about posterior? Which of the two is more likely to affect consciousness? What artery is often involved?
Anteiror - unilateral
Posterior - can be both
Posterior more likely to affect consciousness
-especially if basilar artery affected
What three things are the visual signs of a completed stroke dependent on?
Location/blood vessels affected
Type of stroke
Effect on cranial nerves
List 8 predisposing factors to stroke.
Age
Atherosclerosis
Hypertension (uncontrolled)
Diabetes
Smoking
High HDL/LDL levels
Sedentary lifestyle
Blood viscosity disorders
What four things does occlusion of the internal carotid artery often prodrome with?
TIA
Amaurosis
Speech
Tingling/sensations
Does occlusion of the internal carotid artery often produce symptoms initially?
Often not
What is a transient ischaemic attack exactly? What three neurological dysfunctions can it cause
Episodes of cerebral ischaemia
Somatosensory
Motor
Vision (amaurosis fugax)
What three things is a transient ischaemic attack characterised by?
Abrupt onset
Short duration
Complete recovery
-no residual defects
How long do transient ischaemic attacks often last for (2)? What is the limit?
1-2 minutes mainly
5 minutes is common
Up to 24h
When do major stroke events tend to occur relative to transient ischaemic attacks?
Commonly occurs within 1st weeks after 1st transient ischaemic attack
What is there a high risk of following a transient ischaemic attack and for how long?
high risk of stroke within the next 2 years
What is visual transient ischaemic attack? What side does it occur on?
Amaurosis fugax
-same side as carotid stenosis
What side to motor/sensory deficits occur on with transient ischaemic attacks?
Opposite side
Describe the manner in which vision loss occurs and returns with transient ischaemic attacks. What can occasionally occur instead?
Loss - like a blind coming down
Recovery - like a blind going up
-occasionally photopsia instead
What five things should you ask a patient if you suspect transient ischaemic attacks?
Pins/needles
Tingling in fingers
Loss of power in hands
Lip/tongue numbness
Episodes of slurred speech
List 5 unilateral signs of carotid insufficiency (i.e. ipsilateral to the carotid insufficiency).
Venous stasis retinopathy
Ocular ischameic syndrome
Pain
Cataract - asymmetrical
Dilated conjunctival/scleral vessels
List 3 atherosclerotic signs of carotid insufficiency.
BRAO (old or recent)
Hollenhurst plaque (cholesterol)
Fisher plug (fibrin)
List and describe three tests for assessing carotid artery integrity.
Stethoscope bell
-listen for heart sound - normal
-wooshing/blowing sound - anomaly
Ultrasound
Ophthalmodynamometry
-measure ophthalmic artery pressure
What is a positive measurement for ophthalmodynamometry?
20% difference between eye is positive
List two treatment options for carotid insufficiency.
Anticoagulant therapy (aspirin or similar)
Surgery - carotid endartectomy
What does carotid enartectomy increase the risk of and when? What patients is this normally indicated for?
Risk of inducing stroke during the surgery
-normally indicated for younger patients in good health
