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Cardiovascular > Hypertension And Heart Failure | > Flashcards

Hypertension And Heart Failure | Flashcards

1
Q

Hypertension

A

Persistent elevation of BP in the systemic arterial circulation to a level higher than expected for the age, sex, and race of the individual

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2
Q

Primary hypertension

A

Hypertension with no singular identifiable cause

Risk factors
- old
- smoking
- family history
- obesity
- alcohol intake
- salt intake

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3
Q

Secondary hypertension

A

Caused by identifiable singular cause, removal or reversal of this would normalise BP

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4
Q

Causes of secondary hypertension

A

Renal disease
Obesity
Pregnancy associated hypertension (eclampsia)
Endocrine - adrenal gland hyper function, tumours, hyperaldosteronism, Cushings
Drugs e.g. corticosteroids
Coarction of aorta

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5
Q

Benign hypertension - what it is and consequences

A

Stable elevation of blood pressure over many years
Asymptomatic

Consequences:
LV hypertrophy
Congestive cardiac failure
Increased atheroma
Thickening of tunica media
Increased aneurysm rupture
Renal disease

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6
Q

Malignant hypertension

A

Acute, severe elevation of BP - diastolic pressure >130-140
Needs urgent treatment to prevent death

Consequences:
Cerebral oedema
Acute renal and heart failure
Haemorrhage

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7
Q

White coat hypertension

A

Hypertension that only exists when BP is measured during medical consultations
Discrepancy of more than 10/20 mmHg

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8
Q

Masked hypertension

A

Hypertension that exists when not being measured during clinical consultations so can go unnoticed

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9
Q

Stage 1 hypertension

A

Clinic BP is >140/90 mmHg
ABPM or HBPM daytime average is >135/85

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10
Q

Stage 2 hypertension

A

Clinic BP is >160/100 mmHg or higher
ABPM or HBPM daytime average is >150/95

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11
Q

Severe hypertension

A

Clinic systolic BP >180 mmHg
Clinic diastolic BP >110 mmHg

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12
Q

Symptoms of hypertension

A

Usually asymptomatic

Malignant hypertension will present acutely
- headache
- blurred vision
- chest pain
- altered mental status

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13
Q

Signs of hypertension

A

Pulses bruits
- sound of blood flowing through narrow part of artery

Examine Fundi
- hypertensive retinopathy

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14
Q

Complication of hypertension

A

Ischaemic heart disease
Cerebrovascular disease
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure

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15
Q

Investigations of hypertension

A

ABPM - ambulatory BP monitoring - over 24 hours

HBPM - home BP monitoring - over a week at random times throughout day

Normally ABPM fist then HBPM if ABPM doesn’t work

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16
Q

Monitoring hypertension - check how bad it is

A

To asses for end organ damage

Urine
- Albumin:creatinine ratio for proteinuria
- Dipstick for haematuria

Bloods
To test renal function and lipids

Fundoscopy
- hypertensive retinopathy

12 lead ECG

Calculate 10 year risk - ASSIGN or QRISK3

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17
Q

Intervention for stage 1 hypertension

A

Lifestyle interventions alone
- exercise
- smoking cessation
- diet modification

Unless there is organ damage or 10-year risk >10%

18
Q

Medical management of hypertension

A

Step 1

  • ACE-inhibitor(e.g. ramipril) if <= 55 years old
    • If unable to tolerate ACE-inhibitor then switch toARB(e.g. candesartan, losartan(also reduces plasma urate))
  • DHP-Calcium Channel Blocker(e.g. nefedipine) if >55 years old OR African or Caribbean ethnicity

Step 2

If maximal dose of Step 1 has failed or not tolerated:

  • Combine CCB and ACE-i/ARB

Step 3

If maximal doses of Step 2 has failed or not tolerated:

  • Add thiazide-like diuretic(e.g. indapamide)

Step 4

  • If blood potassium <4.5mmol/L then add spironolactone
    • Blocks action of aldosterone resulting in sodium excretion and potassium reabsorption
    • Increases risk of Hyperkalaemia
  • If >4.5mmol/Lincrease thiazide-like diuretic dose
  • Other options at this point if the potassium is >4.5mmol/L include:
    • Alpha blocker (e.g. doxacosin)
    • Beta blocker (e.g. atenolol)
    • Referral to cardiology for further advice

CV risk management

  • Statins for primary prevention if 10-year CV risk is >20%
19
Q

Heart failure

A

Complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation

20
Q

Main causes of heart failure

A

Ischaemic heart disease
Dilated cardiomyopathy
Hypertension

21
Q

Ejection fraction

A

The percentage of blood that is pumped out of the heart during each beat (SV/EDV x 100)

22
Q

2 types of heart failure

A

Heart Failure with Reduced Ejection Fraction - HFrEF

Heart Failure with Preserved Ejection Fraction - HFpEF

23
Q

Heart failure with reduced ejection fraction

A

Ejection fraction <40%

Unable to eject adequate amount during systole

Reduced contractility -> reduced CO

Commonly caused by
ischaemic heart disease, valvular heart disease and hypertension

24
Q

Heart failure with preserved ejection fraction

A

Ejection fraction >50%

Filled with less blood

Decreased ventricular compliance -> less decreased CO

Caused by increased stiffness of the ventricle (ventricular wall hypertrophy) and impaired relaxation of the ventricle (constrictive pericarditis)

25
Q

Left sided heart failure - 2 types

A

Reduced EF
- Increased left ventricular afterload due to increased aortic pressure or by outflow obstruction

Preserved EF
- Increased left ventricular preload due to back-flow into left ventricle caused by aortic insufficiency

26
Q

Right-sided heart failure - 2 types

A

Reduced EF
- Increased right ventricular afterload due to increase in pulmonary artery pressure

Preserved EF
- Increased right ventricular preload caused by tricuspid valve regurgitation

27
Q

Compensatory mechanisms to heart failure - 3 ways

A

Increased adrenergic activity
Increase of RAAS
Secretion of BNP

28
Q

What does increased adrenergic activity do to compensate for heat failure

A

Increases heart rate, blood pressure, and ventricular contractility

29
Q

How is increase of RAAS actived to compensate for heart failure

A

Activated following decrease in renal perfusion which occurs after reduced SV and CO

30
Q

What does increase of RAAS do to compensate for heart failure

A

Increase of Angiotensin 2 causes:

Peripheral vasoconstriction - increasing BP :. Afterload
Vasoconstriction of the efferent arterioles increasing intraglomerular pressure :. Maintaining glomerular filtration rate

Increase aldosterone causes:
Increased renal Na+ and H2O reabsorption
Increases preload

31
Q

What does secretion of BNP do to compensate for heart failure - why + how

A

Predominantly secreted in ventricles in response to increased myocardial wall stress

works to decrease blood pressure

32
Q

2 consequences of decompensated heart failure

A

Forward failure
Reduced cardiac output leading to organ dysfunction

Backward failure
Causes backup of blood in vessels going into heart
- LV -> pulmonary oedema
- RV -> systemic venous congestion producing peripheral organ oedema and congestion of internal organs
Caused by LV failure
Biventricular failure is most common

33
Q

Symptoms of heart failure

A

Exertional dyspnoea - difficult breathing
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue

34
Q

Signs of Heart failure -6

A

Tachycardia
Elevated JVP
Cardiomegaly - enlarged heart
3rd + 4th heart sounds
Ankle oedema
Ascites - fluid collects in abdomen

35
Q

Classification of heart failure - Class 1 to 4

A
  • Class I - no limitation of physical activity, activity doesn’t cause SOB
  • Class II - slight limitation of physical activity, comfortable at rest but normal activity causes SOB
  • Class III - marked limitation of physical activity, comfortable at rest but less than normal activity causes SOB
  • Class IV - unable to carry out any activity without symptoms, can be symptomatic at rest
36
Q

Investigation of heart failure

A

ECG
Chest X-ray
BNP test

Followed by echocardiogram

37
Q

Management of heart failure - general

A

Education
Diet
Smoking cessation
Low intensity exercise
Consider antiplatelet or statin

38
Q

Management of HFpEF

A

Loop diuretic - furosemide to relieve fluid overload

39
Q

Management of HFrEF

A

ABAL

ACE inhibitor
B blocker
Aldosterone antagonist - (MA) - if not controlled with A+B
Loop diuretic for fluid

40
Q

Complications of heart failure - 5

A
  • Arrythmias - most commonly AF and ventricular arrhythmias
  • Depression
  • Cachexia - weakness + wasting of body
  • Chronic kidney disease
  • Sudden cardiac death
41
Q

Acute presentation of Heart failure: drugs to use

A

LMNOP

Loop diuretic - furosemide
Morphine - IV
Nitrates
Oxygen
Position - sit patient up

B blockers make it worse

Cardiovascular (9 decks)

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