Endocrinology - Lipids and Hypertension Flashcards
1
Q
Discuss screening for dyslipidemia
A
- men >40 and women >50 or post-menopausal Regardless of Age Conditions - evidence of arthersclerosis - AAA - diabetes - hypertension - cigarette smoking - stigmata of dyslipidemia (arcus cornea, xanthelasma or xanthoma) - Family history of cardiovascular disease or dysplipidemia - Chronic kidney disease - Obesity - IBD - HIV - Erectile dysfunction - COPD - hypertension in pregnancy
2
Q
Discuss screening risk using Framingham Risk Score, LDL, Non-HDL and Apo-B screening
A
No Pharmacology - low risk: FRS <10% Primary Prevention - Intermediate risk: FRS 10-19% and LDL >=3.5 or Non-HDL >=4.3 or Apo-B >=1.2 or men >50, women >60 with one component of metabolic syndrome - High risk: FRS: >20% Statin-Indicated Condition - Clinical artherosclerosis - AAA - Diabetes: age >40, Age >30 with type 1 for >15 years, microvascular disease - Chronic kidney disease LDL >=5 (genetic)
3
Q
Discuss dyslipidemia therapy and targets
A
Targets following Initiation of Statin - LDL <2.0 or >50% reduction or ApoB <0.8 or non-HDL <2.6 - Every doubling of dose of statin result in 6% decrease in LDL Target Not Achieved Add on - Ezetimibe 1st line - PCSK9 inhibitor as 2nd line Non Pharmacological Therapy - Smoking cessation - Diet - Exercise
4
Q
Discuss valid blood pressure check in clinic
A
Patient - back and arm supported - seated comfortably with legs uncrossed, feet on ground shoulder width apart - no talking - sitting for 5 minutes Cuff - 3cm above elbow crease - width 40% of arm circumference - length 80-100% of arm circumference Measurement - inflate to 30 mmHg above radial pulse obliteration - deflate slowly for average of 2 readings 60 seconds apart
5
Q
Discuss criteria for diagnosis of hypertension
A
First Visit
- BP >180/110 then hypertension
- BP automatic >135/85 or office >140/90 then move to second visit
At Home Automatic Blood Pressure
- daytime automatic is >135/85 then hypertension
- if no home monitoring available and BP >140/90 then hypertension
6
Q
List the target blood pressures
A
- <140/90
- <130/80 for diabetes
- <150/90 for elderly
7
Q
Discuss lifestyle modifications for hypertension
A
Diet - DASH diet - limit sodium to 1.5-2.3g Exercise - 30-60min 4-7x/week Smoking Cessation Relaxation and Stress Management Healthy BMI and Waist Circumference
8
Q
Discuss the indications to begin medication for hypertensions
A
- diastolic >90 with target organ damage or cardiovascular risk factors
- diastolic >100 or systolic >160
- systolic >140 with end organ damage
9
Q
Discuss the medications used for hypertension
A
1st Line - Thiazide diuretics - ACE inhibitors - ARB - Long acting calcium channel blockers - Beta blockers Add-On - caution CCB and BB - caution ACEi and ARB - caution hypokalemia with thiazides
10
Q
Discuss secondary causes of hypertension and potential investigations
A
Hyperthyroidism - TSH Aortic Coartation - CXR - CT angiogram Cushing Syndrome - 24-hr urine cortisol Obstructive Sleep Apnea - Overnight polysomnogram Renal Disease - Renal ultrasound Pheochromocytoma - 24hr urine fractionated metanephrines and catecholamines Medications - NSAIDs - OCP - Steroids - Cocaine
11
Q
Discuss the Framingham risk score
A
- completed every 3-5 years in those 40-75 Components - Gender - Age - HDL-C - total cholesterol - SBP - Smoking - Diabetes Double - Family with cardiovascular disease in male <55 or female <55
12
Q
Differentiate between hypertensive crisis and malignant hypertension
A
Crisis
- asymptomatic hypertension >=210/130
Malignant Hypertension
- BP >180/110 with acute target ongoing organ damage
- hypertensive encephalopathy with papilledema
- acute ischemic stroke
- intracranial hemorrhage
- acute LV failure
- ACS
- Acute aortic dissection
- Acute Kidney Injury
- Eclampsia
13
Q
Discuss the causes of malignant hypertension
A
Essential Hypertension Secondary Hypertension - renovascular - endocrine: hypo/hyperthyroid, hyperaldosteronism, pheochromocytoma - chronic kidney disease CNS - stroke - mass - epilepsy Vascular - aortic dissection Medication - MAOI - beta blocker withdrawal Substance - alcohol withdrawal - cocaine/amphetamine intoxication - pregnancy
14
Q
Discuss the presentation and management of hypertensive crisis
A
Presentation
- blurred vision
- headache
- nausea/vomiting
- focal neurological deficit
- dyspnea
- angina
Investigations
- CBC, electrolytes, creatinine, BUN, glucose
- CXR
- ECG
- Urinalysis
- possible troponin or CT head if concerned
Management
- ABC
- Treat underlying cause
- Reduce blood pressure
- reduce MAP by 10-20% in first hour then by 25% gradually over next 23hr, target <170/110
- IV labetalol bolus 20mg followed by 20-80mg every 10 min for total dose of 300mg
- IV nitroprusside 0.25-0.5mcg/kg per minute increased to 8-10mcg/kg if needed
- Address target organ damage
- hypokalemia then PO KCl
15
Q
Discuss signs of secondary hypertension
A
- age of onset before puberty
- age <30 in non-obese and non-black with negative family history
- severe or resistant hypertension
- acute rise in BP in previously stable individual
- malignant or accelerated hypertension
