HTN and Valves

Question 1

Renal causes of HTN?

Answer 1

Renal artery stenosis, chronic glomerulonephritis, pyelonephritis, polycystic kidney diseases, renal failure

Question 2

Endocrine causes of HTN?

Answer 2

DM, hyperthyroidism, cushings, conns, hyperPTH, phaeochromocytoma, CAH, acromegaly

Question 3

Drugs, cardio and pregnancy HTN causes?

Answer 3

Symphamomietics, corticosteroids and contraceptives

Coarctation of the aorta, increased intravascular volume
Pre-eclampsia

Question 4

What counts as stage 1 HTN?

Answer 4

> 135/85
Treat if > 8- and any folloiwng CORD10

CVD
Target Organ damage
Renal disease
Diabetes
10 year CV risk 10% or greater

Question 5

What is stage 2 HTN?

Answer 5

> 150/95

Treat everyone regardless of age`

Question 6

Describe first steps of HTN management?

Answer 6

<55 years old or T2DM = ACEi or ARB

Then A + CCB or A + Thiazide Diuretic

> 55 and no T2DM/black carribea n CCB

Then CCB + A or Ccb + diuretic

Joint pathway = A + C + D

Question 7

What is the management after A + C + D?

Answer 7

If K+ <4.5mmol/L add spiromolactone
if >4.5mmol/L add alpha or beta blocker
Specialist review if not controlled on 4 drugs

Question 8

What lifestyle changes to reduce HTN?

Answer 8

Diet with low salt and fruit/veg rich.
Stop smoking
Less alcohol and exercise/lose weight

Question 9

SE of HTN drugs?

Answer 9

ACEi = COUGH, angioedema, hyperkalaemia

ARB = hyperkalaemia

CCB = Flushing, anfle oedema, headache and gum hyperplasia

Thiazide = Hyponatraemia, hypokalaemia, dehydration and ECG changes

Spironolactone = HYPERKALAEMIA AND GYNOACOMASTIA

Beta blockers = BRONCHOSPASM AND HEART FAILURE, lethargy

Question 10

Contraindicators for ACEi?

Answer 10

Pregnant women and check renal function 2-3 weeks after starting to not worsen renal function

Question 11

What is hypertensive emergency a nd examples?

Answer 11

BP>180/120mmHg

Target organ damage e.g. brain, eyes, heart and kidneys

e.g. CCF or encephalopathy (headache, CNS signs, seizures and coma)

Accelerated HTN: severe increase in BP with signs or retinal haemorrhage r pappiloedema associated with target organ damage

RFS: uncontrolled HTN< CKD< RAS, renal transplant, pregnancy, phaechromocytoma

MX: IV labetolol and specilaist review. Aim to reduce MABP by no more than 25% in 1st hour and ischaemia

Question 12

Phaechromocytoma sx?

Answer 12

HTN, headaches, palpitations, tremors

Mx: alpha blockade then beta blockade

Question 13

Grades of hypertensive retinopathy?

Answer 13

1 = tortosity with increased reflectiveness of retinal arteries (Siver wiring)

2= 1 + arteriovenous napping

3= 2+ Flames shape haemoorhage and cotton wool exudates

4 = 3 + pappiloedema

Question 14

WHat is heard in diastole?

Answer 14

Mid-diastolic : mitral or tricuspid stenosis

Early (regurgitation) : aortic or pulmonary regurgitation

Question 15

What is heard in systole>

Answer 15

Pan-systolic (regurgitation): tricuspid, MITRAL and ventricular septal defect

Mid-systolic = aortic stenosis

Late-systolic = valve prolapses

Question 16

When left or right heard loudest?

Answer 16

lEft = Expiration

rIght = Inspiration

Question 17

Symptoms of Aortic stenosis?

Answer 17

Exertional chest pain, SYNCOPE 40%, arrhythmia or postural hypotension

Asx

Question 18

Symptoms of mitral regurgitation?

Answer 18

Decreased exercise tolerance, lower extremitry oedema

Asx

Question 19

Tricuspid regurgitation symptoms?

Answer 19

Palpitations, irregular heart rhythm

Exertional or Asx

Question 20

Aortic regurgation symptoms?

Answer 20

Dyspnoea (pulmonary oedema or progressive LV dysfunction) and weakness

?fatigue orthopnoea, palpitations, Asx

Question 21

Mitral stenosis symptoms>

Answer 21

Dyspnoea (increased LA pressure -> pulmonary congestion)

?fatigue orthopnoea, palpitations, Asx

Question 22

Causes of aortic stenosis?

Answer 22

Degenerative age-related calcification
Bicuspid aortic valve
Williams = congenital

Question 23

Signs of aortic stenosis?

Answer 23

Slow-rising pulse, narrow pulse pressure
Heaving palpation, no apex displacement

Absent S2 and maybe reverse splitting S2

EJECTION SYSTOLIC MURMUR radiation to carotids and apex

Sit forward and hold breath on expiration to accentuate

Question 24

Mitral regurgiation causes?

Answer 24

Degenerative age-related calcification
LV dilatation
Rupture of chordae tendinae
PAPPILARY MUSCLE RUPTURE

Question 25

Signs of mitral regurgitation?

Answer 25

Normal/irreegularly irregular pulse

Lateral displaced apex beat

Pan-systolic murmur louest over mitral area radiating to axilla.

Listen in left lateral position with bell for low rumblling

Question 26

Causes of tricuspid regurgitation?

Answer 26

RV dilatation, rheumatic fever, INFECTIVE ENDOCARDITIS. carcinoid syndtome and Ebstein anomaly

Question 27

Signs of tricuspid regurgiation?

Answer 27

Raised JVP, parasternal heave

RHF signs: pleural effusion, hepatomegaly, ascites, pitting oedema, RV heave and visible/hepatic pulsations

Pan-systolic murmur heard over tricuspid region and on inspiration for loudest

Question 28

What is Ebsteins anomaly?

Answer 28

Abnormal attachment of tricupid valve leaflets causes it to displace downwards into the RV

Question 29

Causes of aortic regurgitation?

Answer 29

Ascending aorti arch dissection

Connective tissue disease e.g. Marfans/ehlers-dahlos

Question 30

Signs of aortic regurgitation?

Answer 30

Quinckes sign (hands)
Wide pulse pressure
Collapsing/water hammer/corrigans pulse
Displaced apex beat

Early diastolic murmur heard best over LSE and aortic area (severe radiates to apex)
Sit forward and hold breath on expiration

Question 31

What is an austin flint murmur?

Answer 31

Sign of severe aortic regurgitation

LSE radiates to apex
Low pitched rumbling mid-diastoli murmur

Question 32

Aortic regurgitation emponymous sings?

Answer 32

Quinckes
Water hammer pulse
Corrigans (visible distention and collapse of carotid arteries)
De Mussets - head bobbing with heart beat
Beckers - visible retinal artery pulsations through fundoscope

Question 33

Mitral stenosis causes?

Answer 33

RHEUMATIC HEART DISEASE
Congenital
left atrial myxoma
Connective tissue disorder
Mucopolysaccharidosis

Question 34

Signs of mitral stenosis?

Answer 34

Malar flush
Thready pulse or irregularly irregular AF
Tapping apex and parasternal heave on palpation

Mid-diastolic murmur = loud 1st HS with opening snap
Listen in left lateral position with bell for low rumbling murmur