Hypertension And Heart Failure | Flashcards
Hypertension
Persistent elevation of BP in the systemic arterial circulation to a level higher than expected for the age, sex, and race of the individual
Primary hypertension
Hypertension with no singular identifiable cause
Risk factors
- old
- smoking
- family history
- obesity
- alcohol intake
- salt intake
Secondary hypertension
Caused by identifiable singular cause, removal or reversal of this would normalise BP
Causes of secondary hypertension
Renal disease
Obesity
Pregnancy associated hypertension (eclampsia)
Endocrine - adrenal gland hyper function, tumours, hyperaldosteronism, Cushings
Drugs e.g. corticosteroids
Coarction of aorta
Benign hypertension - what it is and consequences
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
Malignant hypertension
Acute, severe elevation of BP - diastolic pressure >130-140
Needs urgent treatment to prevent death
Consequences:
Cerebral oedema
Acute renal and heart failure
Haemorrhage
White coat hypertension
Hypertension that only exists when BP is measured during medical consultations
Discrepancy of more than 10/20 mmHg
Masked hypertension
Hypertension that exists when not being measured during clinical consultations so can go unnoticed
Stage 1 hypertension
Clinic BP is >140/90 mmHg
ABPM or HBPM daytime average is >135/85
Stage 2 hypertension
Clinic BP is >160/100 mmHg or higher
ABPM or HBPM daytime average is >150/95
Severe hypertension
Clinic systolic BP >180 mmHg
Clinic diastolic BP >110 mmHg
Symptoms of hypertension
Usually asymptomatic
Malignant hypertension will present acutely
- headache
- blurred vision
- chest pain
- altered mental status
Signs of hypertension
Pulses bruits
- sound of blood flowing through narrow part of artery
Examine Fundi
- hypertensive retinopathy
Complication of hypertension
Ischaemic heart disease
Cerebrovascular disease
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure
Investigations of hypertension
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
Monitoring hypertension - check how bad it is
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
Intervention for stage 1 hypertension
Lifestyle interventions alone
- exercise
- smoking cessation
- diet modification
Unless there is organ damage or 10-year risk >10%
Medical management of hypertension
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%
Heart failure
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
Main causes of heart failure
Ischaemic heart disease
Dilated cardiomyopathy
Hypertension
Ejection fraction
The percentage of blood that is pumped out of the heart during each beat (SV/EDV x 100)
2 types of heart failure
Heart Failure with Reduced Ejection Fraction - HFrEF
Heart Failure with Preserved Ejection Fraction - HFpEF
Heart failure with reduced ejection fraction
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
Heart failure with preserved ejection fraction
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)
Left sided heart failure - 2 types
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
Right-sided heart failure - 2 types
Reduced EF
- Increased right ventricular afterload due to increase in pulmonary artery pressure
Preserved EF
- Increased right ventricular preload caused by tricuspid valve regurgitation
Compensatory mechanisms to heart failure - 3 ways
Increased adrenergic activity
Increase of RAAS
Secretion of BNP
What does increased adrenergic activity do to compensate for heat failure
Increases heart rate, blood pressure, and ventricular contractility
How is increase of RAAS actived to compensate for heart failure
Activated following decrease in renal perfusion which occurs after reduced SV and CO
What does increase of RAAS do to compensate for heart failure
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
What does secretion of BNP do to compensate for heart failure - why + how
Predominantly secreted in ventricles in response to increased myocardial wall stress
works to decrease blood pressure
2 consequences of decompensated heart failure
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
Symptoms of heart failure
Exertional dyspnoea - difficult breathing
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue
Signs of Heart failure -6
Tachycardia
Elevated JVP
Cardiomegaly - enlarged heart
3rd + 4th heart sounds
Ankle oedema
Ascites - fluid collects in abdomen
Classification of heart failure - Class 1 to 4
- 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
Investigation of heart failure
ECG
Chest X-ray
BNP test
Followed by echocardiogram
Management of heart failure - general
Education
Diet
Smoking cessation
Low intensity exercise
Consider antiplatelet or statin
Management of HFpEF
Loop diuretic - furosemide to relieve fluid overload
Management of HFrEF
ABAL
ACE inhibitor
B blocker
Aldosterone antagonist - (MA) - if not controlled with A+B
Loop diuretic for fluid
Complications of heart failure - 5
- Arrythmias - most commonly AF and ventricular arrhythmias
- Depression
- Cachexia - weakness + wasting of body
- Chronic kidney disease
- Sudden cardiac death
Acute presentation of Heart failure: drugs to use
LMNOP
Loop diuretic - furosemide
Morphine - IV
Nitrates
Oxygen
Position - sit patient up
B blockers make it worse
