Hypertension

Question 1

why is HTN a problem

Answer 1

high pressure damages the walls of arteries = blocked

risk of stroke, heart attack, heart and renal failure increases with BP

Question 2

definition and classificiations of HTN

Answer 2

Question 3

Mx of HTN

Answer 3

• 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

Question 4

mx of HTN in people who already have heart disease

Answer 4

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

Question 5

S3 heart sound

Answer 5

• 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

Question 6

s4 heart sound

Answer 6

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

Question 7

what is galloping heart sounds

Answer 7

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

Question 8

cardiac risk factors

Answer 8

BMI – obese

RF

• HTN
• Smoker
• Lack of exercise
• Weight
• Male
• Sedentary lifestyle

Question 9

BMI cut offs

Answer 9

U shaped curve shape of survival – underweight = more at risk of infectious disease

Asian health risk start to raise >23

Question 10

immediate approach to long standing HTN

Answer 10

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 1^st

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

Question 11

signs of chronic HTN

Answer 11

seen on fundoscopy - hypertensive retinopathy

S4

heaves - R side of heart push through lungs

bruits

LVH cant be seen o/e

Question 12

grade 1 hypertensive retinopathy

Answer 12

silver wiring in middle of the artery, around the disk

Question 13

grade 2 hypertensive retinopathy

Answer 13

AV nipping

Artery crossing the vein – vein is nipped ie vein narrows where artery is because pressure in artery compresses the vein

Question 14

grade 3 hypertensive retinopathy

Answer 14

Flame shaped haemorrhages

Patches of ischemia and cotton wool spots

Ischemia – blood not reaching retina = cotton wool (fluffy)

Question 15

grade 4 hypertensive retinopathy

Answer 15

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

Question 16

sx of retinopathy

Answer 16

none until suddenly blind

Question 17

what grade of HTN

Answer 17

Grade 3 HTN because cotton wool and flame shaped haemorrhages

Question 18

secondary causes of HTN

Answer 18

phaeochromocytoma

cushings

conns

acromegaly

renal artery stenosis

co-arctation of aorta

drugs - cocaine

Question 19

co-arctation of the aorta

Answer 19

aorta gets narrowed below arch = poor blood flow to legs and kidneys – act like renal artery stenosis

Question 20

basic Ix for HTN

Answer 20

• 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

Question 21

summarise RAAs

Answer 21

ACE is in lungs

Question 22

Answer 22

CONN’S SYNDROME

If conns = high alsosterone – increase pressure because retain salt – HTN will suppress the renin

Answer 23

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

Question 24

Answer 24

angiogram with renal artery stenosis that has since been fixed

Question 25

how does salt cause HTN

Answer 25

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.

Question 26

dx test for renal artery stenosis

Answer 26

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

Question 27

Answer 27

PHAEOCHROMOCYTOMA Some drugs that give false positive – run on assay in same place – anti-depressants.

Question 28

sx/signs of phaeo

Answer 28

* 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

Question 29

Mx of phaeochromocytoma

Answer 29

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 – 2^nd step. B2 receptor that cause peripheral dilation – if block = vasoconstriction = increase BP* Can get sudden cardiac death – sudden vasoconstriction.

Question 30

why do you get episodic HTN in phaeochromocytoma

Answer 30

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)*

Question 31

indications and CI for a blocker for HTN

Answer 31

indication - BPH caution - postural Hypotension, HF CI - urinary incontinence

Question 32

indications and CI of ACEi

Answer 32

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

Question 33

indications and CI of ARB

Answer 33

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

Question 34

indications and CI of B blocker for HTN

Answer 34

indication - MI, angina possible indication - HF caution - HF if severe, PVD, dm (except with CHD) CI - asthma/copd, heart block

Question 35

indications of CCB and CI for HTN

Answer 35

indication - elderly, ISH (isolated systolic HTN), angina potential indications - elderly, angina, MU caution - combination with B blockade CI - heart block, heart failure

Question 36

indications and CI of thiazide/thiazide-like diuretics

Answer 36

indications - elderly, ISH, heart failure, secondary stroke prevention CI - gout

Question 37

HTN med if dm

Answer 37

ACEi ## Footnote ARB in pt who are ACE intolerant – have ACEi cough – leukotrienes.

Question 39

Mx of HTN if microalbuminuria

Answer 39

ACEi unless CI

Question 40

what do you do if there is a statin intolerance

Answer 40

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

Question 41

mechanism of proprotein convertase subtilisin kexin 9 (PCSK9) Ab (evolocumab)

Answer 41

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.**

Question 42

statin intolerance

Answer 42

SE are imaginary nociceptive effect about muscle aches. Need to push them more