HTN

Question 1

What are the cardiovascular risks associated with HTN

Answer 1

age, sex, familial history, weight, excersice, serum cholesterol, DM, Pre existing vascular Ds

Question 2

Define hypertension according to biritish HTN society classification.

Answer 2

1_optimal <120\80
2_normal<130\85
3_high normal 130_139\85-89
4_grade 1 140_159\9099
5 grade 2160_179\100_109
6_grade 3> 180\110
isolated: diastole< 90

Question 3

Mention the causes of secondary HTN

Answer 3

1-renal ds: renal paranchymal ds (glomerulonephritis), renovascular ds, polycystic kidney.
2-obesity
3-pregnancy
4-endocrine: acromegaly, hypothyroidism, thyrotoxicosis, hyperparathyrodism, cushing syn, conns syn, glucocorticoid suppressible hyperaldosteronism, pheochromocytoma, congenital adrenal hyperplasia(11 b hydroxylase or 17 a hydroxylasedeficiency), liddles syn, 11 b hydroxysteroid dehydrogenase deficiency
5-drugs
6-alchohol
7_coarcotation of the aorta

Question 4

what are factors contribute in regulating Bp and development of hypertension?

Answer 4

renal dysfunction
peripheral resistance
vessle tone
endothelial dysfunction
autonomic tone, insulin resistance, neurohumoral factors

Question 5

what are environmental factors associated with increase risk of HTN?

Answer 5

high salt intake, alchohol, obesity, lack of exersice , impaired intrautrine growth, low birth weight.

Question 6

what are the adverse effects of hypertension on cardiovascular system?

Answer 6

1_in large artries: internal elastic lamina is thickend, muscles are hypertrophied, deposition of fibrous tissue.. vessel dilated and turtuous, less compliant.
2_small vessels: hyaline arteriolosclerosis in wall, lumen narrow, aneurysm develop
3_atheroma develop, may lead to CAD, CVA,
those factors increase vascular resistance and dec renal blood flow so activation of SNS, RAAS

Question 7

describe the clinical features of a pat with hypertension.

Answer 7

1-usually asymptomatic dicoverd on routine examination or when complications arise.
2_signs of risk factors or clinical features of underlying cause.
3_signs of complications (LV hypertrophy, loud A2, S4,AF.

Question 8

describe the grades of hypertensive retinopathy.

Answer 8

1_arteriolar thickinig, turtousity, increase reflectivness (silver wire)
2_1+constriction of veins at arterial crossing(arteriovenous nipping).
32+evidence of retinal ischemia (flame shape or plot hemorrhage, cotton wool exudate)
4 3+ papilloedema.
hypertension can cause also central retinal vein thrombosis.

Question 9

differntiate between diabetic and hypertensive retinpoathy

Answer 9

diabetic: dot hemorrhage (microaneurysm), hard exudate, small dense white deposit of fat)
HTN: plot hemorrhage, cotton wool exudate.

Question 10

what are ABPM or hbpm useful for?

Answer 10

1_white coat hypertension
2_labile bp
3_refractory bp
5_symptomatic hypotension

Question 11

What are the general investigations for all pat with hypertension?

Answer 11

1_blood urea, creatinine, electrolyte.
2_urinanalysis for pn glu blood
3_blood glucose
4_serum total and HDL cholesterol
5_thyroid function test
6_ECG

Question 12

Mention the specialised investigation for hypertension.

Answer 12

1_CXR
2_ABPM
3_ECHO
4_renal US
5_renal angiography
6_urinary catecholamines
7_urinary cortisol and dexamethasone suppression test
8_plasma renin activity and aldosterone.

Question 13

what is the optimum pb for major reduction of cardiovascular events?

Answer 13

139/83 mmhg

Question 14

what is the managment for pat with hypertension according to biritish HTN society?

Answer 14

1_clinical bp <140/90: normotensive, check bp every 5 years, more often if bp is close to 140/90
2clinical bp> 140/90:
A- ABPM < 135/85:normotensive.
B ABPM> 135/85 : stage 1 HTN:
*offer life style intervention
*if <40 yo: onsider specialist referral
*if end organ damage present or Cv risk> 20%: offer antihypertensive drugs. then life style intervention.
C_ABPM> 150/95: antihypertensive drugs.
3_clinical bp> 180/110:if accelerated hypertension or pheochromocytoma suspected refer same day for specialist care and start drugs immediately. then monitor with ABPM.

Question 15

what are the drugs given in hypertension?

Answer 15

1_diuertics
2_ca C B
3_ACE, ARBS
4_B Blockers
5_vasodilators
6_aspirin
7_statins

Question 16

what are diuertics used, dose, preferation.

Answer 16

1_thiazide, may take a month for max effect to be observed.
bendroflumethiazide 2.5 mg daily
or cyclopenthiazide 0.5 mg d
2_loop, more potent, more advantage with renal impairment or conjugated with ACE I
furosamide 40 mg d or bumetanide 1mg d

Question 17

what are ACE I , ARBS used in hypertension, doses, side effects.

Answer 17

ACE
1_enalapril 20 mg d
2_ramipril 5-10 mg d
3_lisinopril 10-40 mg d.
SE: fist dose hypotension, cough rash, hylerkalemia, renal dysfunction.
ARBS.
1irbesartan 150-300 mg d
2 valsartan 40-160 mg d
don’t cause cough and better tolerated.

Question 18

Mention ca c antagonist used in hypertension, dose, uses, side effect

Answer 18

1_amlodipine 5-10 mg d
2Nifedipine 30-90 mg d
used in old age, SE: flush, palpitation, fluid retention.
3 rate limiting: diltiazem 200-300 mg
verapamil 240 mg d.
SE: constipation.
useful in hypertension with angina but may cause bradycardia.

Question 19

what are sympatholytic drugs used in hypertension, indication, dose,

Answer 19

A_B. blockers: indication: angina
1_bisoprolol 5-10 mg d(block B1)
2_metoprolol 100-200 mg d
3atenolol 50-100 mg d
B combined a and b blockers.
1_labetalol 200 mg -2.4 g d
2_carvedilol 6.25-25 mg twice aday.
sometimes more effective than pure b blockers, labetalol use in infusion in malignant hypertension.

Question 20

mention some vasodilators used in hypertension, dose, SE

Answer 20

1_a1 antagonist: prazosin 0.5-20 mg d, indoramin 25-100 mg twice d.
doxazosin 1-16 mg d.
2_hydralazine 25-100 mg twice d
3_minoxidil 10-50 mg d.
SE: first dose postural hypotension, headache, tachycardia, fluid retention, hirustism.

Question 21

why do we use aspirin and statins in hypertension?

Answer 21

1_aspirin: antiplatlete therapy, powerful reduction in cardiovascular risk. for pat aged 50 or more with controlled bp and either target organ damage or DM or 10 years CAD risk of at least 15%
2_statins: treat hyperlipidemia.
reduce cardiovascular risk.
indicated in pat with established vascular diseases or high risk of developing Cardiovascular dis 10%

Question 22

Mention the factors affecting the choice of antihypertensive drugs.

Answer 22

age, ethenic group, cost, side effects, response to intial therapy, comorbidities.

Question 23

What is accelerated hypertension?
and how to diagnose it?

Answer 23

it is a rare condition characterized by accelerated microvascular damage, with necrosis in the walls of small artries (fibrinoid necrosis) and intravaccular thrombosis.
diagnosis is based on evidence of high bp and rapidly progressive end organ damage: retinopathy, renal dysfunction, hypertensive encephalopathy.

Question 24

How to manage malignant hypertension?

Answer 24

controlled reduction to a level of 150-90 mmHg over a period of 24-48 hour is ideal.
with most pat bed rest and oral therapy is enough.
IV, IM labetalol, IV GTN , IM hydralazine, IV NA nitroprusside all effective.

Question 25

compare between the following drugs according to compelling indications, possible indications, caution, compelling contraindications.
1_a blocker
2_b blocker
3_ACE
4_ARBs
5_dihydropyridine
6_rate limitting ca c blockers
7_thiazide
8_spironolactone

Answer 25

1_a blocker: BPH__,postural hypotension and heart failure,* urinary incontinence.
2_b blocker: MI. angina.Stable HF,__, acute HF. PAD. DM except withCADAstham. COPD. Heart block
3_ACE: HF, LV dysfunction, post MI,established CAD, 2 strok prevention, type1D nephropathy type 2 nephropathy, CRD *renal impairment, PAD *pregnancy, renovascular disease.
4_ARBs: ACE intolerance, post MI, HTN with LV dysfunction, HF,type 2 nephropathy *intolerance to other antihypertensive drugs, CRD, HFrenal impairment, PADpregnancy.
5_dihydropyridine: old, isolated sys HTNangina________.
6_rate limitting ca c blockers: anginaoldcombination with B blockers AV block, HF.
7_thiazide: old, isolated sys HTN, HF, Secodary stroke prevention *______ gout.
8_spironolactone: used in resistance HTN