Hypertension Flashcards
why is HTN a problem
high pressure damages the walls of arteries = blocked
risk of stroke, heart attack, heart and renal failure increases with BP
definition and classificiations of HTN
Mx of HTN
- Lower the bp = better risk reduction
- Target between 85-80 is a good target
- in dm - All risks were reduced in tight control gp
drug options
- ACEi
- ARB
- B blocker
- CCB
- diuretic
- (a blocker)
Evidence that 3 drugs at half standard dose better than 1 drug at normal dose
- less SE
- better compliance, fixed-dose combinations
- heterogenous pts
- additive/complementary pharmacology
mx of HTN in people who already have heart disease
in tightly controlled group risk of heart attack by 2%
and risk of all death by 2%
therefore aggressive mx of BP in people with heart disease improves survival
add thiazide diuretic - in 100 people witj CAD will save 2 lives oevr 5yrs
intensive lifestyle modification
aspirin
high dose statin - atorvastatin 40-80mg od
aspirin and statin prevent secondary MI
optimal BP control
assessment for t2dm
S3 heart sound
- After s2
- Suggest rapid ventricular filling
- Happens when have large ventricle – HF/really fit people
- LV dilatation – failing heart – heart dilates and CXR >50% thorax – feature of failing heart on PA film. – S3 – Kentucky – rapid ventricular filling
- As blood hits the ventricular wall
- During passive filling
s4 heart sound
Sound of atrial contraction – to overcome LV in ventricular hypertrophy or stiff ventrivle
Long standing HTN – muscle wall thicker and exercise hard against high pressure – grow thick inwards – v tall R waves. CXR normal – ie heart not bigger. S4 1 2 – Tennessee
what is galloping heart sounds
4 heart sounds – long standing HTN and then go into ischemia – have all 4 sounds – sound like a horse gallop – summation gallop of 3rd and 4th heart sound together
cardiac risk factors
BMI – obese
RF
- HTN
- Smoker
- Lack of exercise
- Weight
- Male
- Sedentary lifestyle
BMI cut offs
U shaped curve shape of survival – underweight = more at risk of infectious disease
Asian health risk start to raise >23
immediate approach to long standing HTN
encourage regular exercise
If a pt with long standing stable HTN and sent to casualty –diet and exercise and BP fall. Give drugs – but SE so use non-drug methods 1st
If diastolic >140 – accelerated HTN if have other clinical signs – casualty, check few times, see if S4, ECG – tall R waves, examine eyes. If chronic want to bring just down below 140.
If bring down too quickly = stroke. Need to drop slowly – reduce salt and then start on treatment if persistently high
signs of chronic HTN
seen on fundoscopy - hypertensive retinopathy
S4
heaves - R side of heart push through lungs
bruits
LVH cant be seen o/e
grade 1 hypertensive retinopathy
silver wiring in middle of the artery, around the disk
grade 2 hypertensive retinopathy
AV nipping
Artery crossing the vein – vein is nipped ie vein narrows where artery is because pressure in artery compresses the vein
grade 3 hypertensive retinopathy
Flame shaped haemorrhages
Patches of ischemia and cotton wool spots
Ischemia – blood not reaching retina = cotton wool (fluffy)
grade 4 hypertensive retinopathy
When really severe
Papilloedema – cant see the disk – edge is not visible
Also in obstructive hydrocephalus
- When see papilloedema in casualty with headache and blurred vision – likely tumour blocking 3 or 4 ventricle = hydrocephalus so CT or MRI
- If other features of HTN might be grade 4
Hard exudates are for diabetic not for HTN - deposits of cholesterol
sx of retinopathy
none until suddenly blind
what grade of HTN
Grade 3 HTN because cotton wool and flame shaped haemorrhages
secondary causes of HTN
phaeochromocytoma
cushings
conns
acromegaly
renal artery stenosis
co-arctation of aorta
drugs - cocaine
co-arctation of the aorta
aorta gets narrowed below arch = poor blood flow to legs and kidneys – act like renal artery stenosis
basic Ix for HTN
- FBC – polycythaemia
- UE – K low because conns – a lot of endo causes. Renal func affected
- ECG – LVH (tall R waves – deep 2 wave in V2 and tall R in V5. If add s and r – 40 or 45mm)
- Urinalysis – nephritis or renal disease – haematuria. Nephritis is treatable
- Fasting glucose – DM
- Lipids – if also high it is an added RF
So start with the K – if K not low it wont be conns, cushings, phaeo
summarise RAAs
ACE is in lungs
CONN’S SYNDROME
If conns = high alsosterone – increase pressure because retain salt – HTN will suppress the renin
RENAL ARTERY STENSOSIS
If K low – renal artery stenosis
Not conn’s because primary hyperaldosteronism,
This is secondary renal artery stenosis
Need ACE to vasoconstrict to maintain the eGFR
angiogram with renal artery stenosis that has since been fixed
how does salt cause HTN
System retains salt in form of RAAS
Kidney will excrete salt slowly but designed to retain salt – so have higher BP. Push out salt with thiazide diuretics.
dx test for renal artery stenosis
On US can see the stenosis. MRI w/o contrast ie MR angiography is the dx test. Look at coarctation, renal artery and adrenal tumour -do one MR angio
PHAEOCHROMOCYTOMA
Some drugs that give false positive – run on assay in same place – anti-depressants.
sx/signs of phaeo
- Tachy
- Palpitations
- Panic attacks
- HTN that shoots up suddenly and then down again – episodes of sudden HTn
- nervousness
- sweat
- Alpha receptor vasoconstrict = bowel infarction
- Pul oedema
Mx of phaeochromocytoma
A BLOCKADE
rehydrate - may need saline
B blcokade
localise lesion
surgery
- Adrenaline has a and b receptor. If block a – prevent the severe HTN from vasoconstriction = safe*
- B blocker – 2nd step. B2 receptor that cause peripheral dilation – if block = vasoconstriction = increase BP*
Can get sudden cardiac death – sudden vasoconstriction.
why do you get episodic HTN in phaeochromocytoma
Adrenal medulla is neural tissue – whole tumour act like syncytium – wave spread through tumour and cells degranulate randomly or when stimulated.
When scare instead of getting normal blast get 10x normal amount – pulse of HTN. Then come down again.
in conns get constant aldosterone = constant HTN (also smaller on imaging than phaeo)
indications and CI for a blocker for HTN
indication - BPH
caution - postural Hypotension, HF
CI - urinary incontinence
indications and CI of ACEi
indications - HF, LV dysfunction, post MI or established CHD, t1dm nephropathy, secondary stroke prevention
possible indications - chronic renal disease, t2dm nephropathy, proteinuric renal disease
caution - renal impairment, PVD
CI - preg, renovascular disease
indications and CI of ARB
indication - ACEi, t2dm nephropathy, HTN with LVH, HF in ACE intolerant, post-MI
possible indications - LV dysfunction post-MI, intolerance of otehr antihypertensive drugs, proteinuric renal disease, chronic renal disease, HF
caution - renal impairment, PVD
CI - pregnancy, renal vascular disease
indications and CI of B blocker for HTN
indication - MI, angina
possible indication - HF
caution - HF if severe, PVD, dm (except with CHD)
CI - asthma/copd, heart block
indications of CCB and CI for HTN
indication - elderly, ISH (isolated systolic HTN), angina
potential indications - elderly, angina, MU
caution - combination with B blockade
CI - heart block, heart failure
indications and CI of thiazide/thiazide-like diuretics
indications - elderly, ISH, heart failure, secondary stroke prevention
CI - gout
HTN med if dm
ACEi
ARB in pt who are ACE intolerant – have ACEi cough – leukotrienes.
Mx of HTN if microalbuminuria
ACEi unless CI
what do you do if there is a statin intolerance
Problem with statins is that the SE are imaginary – nociceptive effect about muscle aches. Need to push them more
ezetemibe - drops lipids but not as well as statins
evolocumab - PCSK9 monoclonal Ab
mechanism of proprotein convertase subtilisin kexin 9 (PCSK9) Ab (evolocumab)
Protein that sits on the LDL receptor – involved in the recycling of receptor – PC9SK9 tell cell to destroy the receptor.
gain of function mutations of PCSK9 reduce LDL receptors = high LDL in plasma and increased susceptibility of CHD
If don’t have it – LDL receptor recycled and more LDL is removed = low LDL cholesterol = protecton from CHD
evoculomab is an injection every 2wks - cholesterol falls to a low level
No difference in death – small difference in non-fatal heart attacks.
high NNT, absolute risk reduction small
so use if have statin intolerance, familial hypercholosteramia.
statin intolerance
SE are imaginary
nociceptive effect about muscle aches.
Need to push them more
