Hypertension and scoring systems Flashcards
Cut offs for hypertension
Hypertension stage 1- 140/90 mmHg
Over 80- 150/90
Type 1 diabetes 135/85
Type 2 diabetes 140/80
Risks of high blood pressure
- Heart disease
-Heart attacks - Strokes
- Heart failure
- Peripheral arterial disease
- Aortic aneurysm
- Kidney disease
- Vascular dementia
- Major cause of premature death worldwide
Risk factors for hypertension
- Overweight
- Too much salt
- Not enough fruit/veg
- Sedentary lifestyle
- Excess alcohol or caffeine
- Over 65
- Family history
- Black African or caribbean descent
- Low socioeconomic status
Annual health checks
Offered to people over the age of 80
Do screening for diabetes (HBA1C)
Check BP for hypertension
Might do FBC and LFT- fatty liver disease
U&E- CKD
Lipid profile
Address lifestyle risk factors
HBA1c levels in annual health check
- <42 normal
- 42-48 - pre-diabetes, non-diabetic hyperglycaemia (NDH)
- > 48 diabetes
Stage 1 hypertension
140-159/90-99
Manage lifestyle factors first and try to reduce blood pressure
Only treat if QRISK >10%
Stage 2 hypertension
> 160/>100
Pharmacological treatment
QRISK
The chance of having a cardiovascular event in the next 10 years, anything over 10% is significant
If high QRISK, important to start treatment
Statins are a good drug to reduce QRISK
Statins- when to use/not use
Before starting statins, do LFT to assess liver function and do it after 3 months
If hepatic impairment, statins are not suitable as they are metabolised in the liver by CYP450 enzymes
Offer a statin to anyone with a QRISK >10% even if their cholesterol isn’t particularly raised
Continue using statin unless ALT is more than 3x normal
Disadvantages of statins and what to use if contraindicated
Disadvantages- liver inflammation, muscle side effects, myalgia, rhadomyolysis
What to use if contraindicated- Zetamide
Types of prevention
Primary prevention- aims to prevent a disease before it even occurs. Done in GP and community
Secondary prevention- treating the disease ASAP to minimise complications, secondary care and hospital
Secondary causes of hypertension
- Secondary problems include adrenal gland problems, renal problems, renal artery stenosis, endocrine disorders (primary hyperaldosteronism, hyperthyroidism, hypothyroidism), pheochromocytoma (neuroendocrine tumour)
- If secondary to another disease, tend to be showing systemic symptoms as well as hypertension
- Also, more likely to be young (<40) with no family history of HTN
Key NICE guideline message for Hypertension
- Stepwise approach to treatment
- Treatment threshold
- Looking at overall CHD risk
- Differences with different ethnic groups
Issues with concordance with anti-hypertensive medication
• Most people with hypertension feel well
• Anti-hypertensives can make people feel unwell or give unwanted side-effects [e.g., erectile dysfunction]
• Treating because of long term risks of events - this can be a hard concept to explain to patients
Treatment for adults with hypertension without type 2 diabetes
Under 55
1. ACE inhibitor or ARB
2. calcium channel blocker of thiazide diuretic
If black African or African-Caribbean
1. calcium channel blocker
2. ACE inhibitor, ARB or thiazide diuretic
Anyone over 55
1. calcium channel blocker
2. ACE inhibitor, ARB or thiazide diuretic
- ACEI/ARB AND calcium channel blocker AND thiazide like diuretic
Monitor and review annually
Treatment for adults with T2 diabetes with hypertension
- step 1 is ACE inhibitor or ARB
- step 2 is calcium channel blocker or thiazide like diuretic
ACE inhibitors
Lisinopril, ramipril, imidapril
Angiotensin converting enzyme inhibitors
Relax veins and arteries and causes more water excretion
Prevent angiotensin converting enzyme in body from producing angiotensin II-substance which narrows blood vessels
Most common side effect is a dry cough
Contraindications for ace inhibitors
- Dont use on patients with angioedema, pregnant/breastfeeding women
- Use with caution in people of black african or caribbean origin, those with renal impairement, taking diuretics and some cardiomyopathies
ARBS
Candesartan, irbesartan, valsartan, losartan
Angiotensin receptor blockers
Reduce action of angiotensin II
Contraindications of ARBS
- Contraindicated in people with diabetes, pregnant women and those planning pregnancy, breastfeeding women
- Used with caution in people of black African or Caribbean origin, with renal impairment or renal artery stenosis or aortic/mitral valve stenosis, history of angioedema
Side effects- renal impairement, hyperkalaemia, angiodema, dizziness
Calcium channel blockers
amlodipine, felodipine, nifedipine
Lower BP by preventing calcium entering cells, calcium contracts muscular linings of blood vessels
Without calcium, blood vessels relax and heart muscles receive more blood
Contraindications and side effects of calcium channel blockers
Contraindications= Heart failure, cardiac outflow obstruction, Hepatic/renal impairement
Side effects= Abdominal pain, AV block, constipation, dizziness
Thiazide diuretics
Indapamide, Bendroflumethiazide
Relieve oedema due to chronic heart failure and lower BP
Inhibit sodium reabsorption. Affects distal renal tubule, blocks Na+/Cl- transporter
Contraindications and side effects of thiazide diuretics
Contraindications- - Avoided in people with refractory hypokalaemia, hyponatraemia, hypercalcaemia, Addison’s disease, asymptomatic hyperuricaemia, severe liver disease, reduced eGFR and pregnant women.
Side effects- postural hypotension, electrolyte imbalance, arrhythmias, dizziness and headache
What are the parameters for the early warning scores
- Respiration rate
- Oxygen saturation
- Systolic blood pressure
- Pulse rate
- Level of consciousness or new confusion
- Temperature
Threshold for the early warning score
Score 0-4 - low risk - ward-based response
Score of 3 in any parameter - low/medium risk - urgent ward-based response
Score of 5-6 - medium risk - key threshold for urgent response
Score of 7 or more - high risk - urgent or emergency response
Mini mental state exam
30 point questionnaire to check for cognitive impairment
27 or higher is considered normal, 24-27 is mild cognitive impairment, 18-23 is mild dementia, 10-18 is moderate dementia, 10 or less is severe dementia
MoCA test
30 question test to assess for dementia
Scores range from 0-30, 26 or higher is considered normal, 18-25 mild cognitive impairment, 10-17 moderate cognitive impairment, less than 10 severe cognitive impairment
GCS- E
1= No opening of the eye
2= Eyes opening in response to pain
3= Eyes opening in response to speech
4= Eyes opening spontaneously
GCS- V
1= no verbal response
2= Incomprehensible sounds
3= single words
4= Confused
5= Orientated
GCS- M
1= No response
2= Abnormal extension ‘decerebrate’
3= Abnormal flexion ‘decorticate’
4= Normal flexion
5= Localises to pain
6= Obeys command
Total anterior circulation stroke (TACS)
All 3 of the following
- Unilateral weakness (and/or sensory) defecit of the face, arm and leg
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia)
Partial anterior circulation stroke (PACS)
Two of the following:
- Unilateral weakness (and/or sensory deficit) of the face, arm and leg
- Homonymous hemianopia
- Higher cerebral dysfunction (dysphasia, visuospatial)
Lacunar syndrome
One of the following
- Pure sensory stroke
- Pure motor stroke
- Sensory and motor stroke
- Ataxic hemiparesis
Posterior circulation stroke (POCs)
One of the following
- Cranial nerve palsy and a contralateral motor/sensory defecit
- Bilateral motor/sensory defecit
- Conjugate eye movement disorder
- Cerebellar dysfunction (DANISH)
- Isolated homonymous hemianopia
Carotid dissection symptoms
-Ipsilateral headache, neck and facial pain
- Transient blindness
- Ptosis with miosis (partial Horner’s syndrome)
- Neck swelling
- Pulsatile tinnitus
- Decreased taste sensation
- Focal weakness
CVST symptoms
- Sharp pain behind the eye
- Symptoms begin a few days after an infection like a boil or sinusitis
- Swelling and bulging of the eye
- Red eye and eye pain
- Difficulty moving the eye, drooping of the eye
- High temperature, vomiting, changes in mental states and seizures
Re-entrant tachycardia
- Not a sinus rhythm because there is no P wave, narrow complex, tachycardic
- Treatment: vagal manoeuvres, beta-blockers, calcium channel antagonist
ECG: 3rd degree heart block
- Narrow complex, bradycardic sinus rhythm. Not conducting to the ventricles
- The ventricles and atrium are unrelated
- Definitive treatment: pacemaker
ECG: Left ventricular hypertrophy and cardiomegaly
- High QRS complex
- Left axis deviation causes a negative lead II (QRS complex upside down), right axis deviation causes a negative lead I. Axis deviation is often due to cardiomegaly
ECG: Atrial fibrilation
Wobbly base line
Irregularly irregular
ECG: Unstable angina
Sinus bradycardia with T wave inversion
Breathlessness score
MRC score
1- Not troubled by breathlessness except on strenuous exercise
2- Short of breath when hurrying on the level or walking up a slight hill
3- Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
4- Stops for breath after walking about 100 yards or after a few minutes on level ground
5- Too breathless to leave the house, or breathless when undressing
DECAF score
Measures mortality for acute exacerbations of COPD
-MRC score
-Eosinophilia score
-Consolidation on chest x-ray
-Acidaemia
-Atrial fibrilation
Decubits x-ray
Done with the patient lying side on, done for the acutely unwell patient
Difference between cholangitis, choleystitis and pancreatitis
Cholecystitis: in the gallbladder
Cholangitis: in the common bile duct
Pancreatitis: gallstone in the ampullar vater, blocks the enzymes from leaving the pancreas, causes autolyses of the pancreas
Painless jaundice, portal hypertension and splenomegaly
Painless jaundice: pamcreatic cause
Splenomegaly: caused by cirrhosis
Portal hypertension: cuases ascites, varices and splenomegaly
Pneumoperitoneum
Air beneath the diaphragm, visible bilaterally. Suggests intestinal perforation or recent intra-abdominal surgery
Addisons disease
- Adrenal insufficiency causing a lack of cortisol and aldosterone
- Symptoms: fatigue, low mood, postural dizziness, muscle cramps and dark pigmentation in the gums
Different scoring systems
Glasgow blatchford score- risk stratifies upper GI bleeds
Forrest- stratifies severity of UGI bleeding according to endoscopic findings
Oakland- predicts risk of readmission for lower GI bleeds
Manning- used for the diagnosis of IBS
