Hypertension & hyperlipidaemia

Question 1

What are the associated risks with increasing systemic blood pressure?

Answer 1

Major risk factors for:

• Stroke
• MI
• Heart failure
• Chronic kidney disease
• Cognitive decline

Each 2mmHg rise in systolic BP is associated with a 7% increase in risk of mortality from IHD and 10% increase in risk of mortality from stroke

Question 2

How is hypertension classified? (by the british hypertension society)

Answer 2

• Stage 1 Hypertension:
  
  • Clinic BP > 140/90 and ABPM >135/85
• Stage 2 Hypertension:
  
  • Clinic BP >160/100 and ABPM >150/95
• Severe Hypertension:
  
  • Clinic BP SBP>180 or DBP>110

ABPM: two measurements per hour taken, average reading used. Using the average of at least 14 values will enable a diagnosis.

(At least three measurements are required to confirm hypertension)

Question 3

Compare primary hypertension to secondary hypertension

(not an objective)

Answer 3

Primary (essential) hypertension:

• 95% of cases
• Cause is not known but is likely to be multifactorial

Secondary hypertension:

• Caused by a range of pathology
• (next question is the causes)

Question 4

What are the causes of secondary hypertension?

Answer 4

• Adrenal cortical diseases:
  
  • Primary hyperaldosteronism (e.g. Conn’s): most common secondary cause
  • Cushing’s
  • Acromegaly
• Renal artery stenosis
  
  • Second most common cause
• Chronic kidney disease
• Pheochromocytoma (rare cause)
  
  • a neuroendocrine tumor of the medulla of the adrenal glands
• Coartation of the aorta
  
  • Congential narrowing of the aorta leading to increased peripheral vascular resistance
• Neurogenic causes
  
  • Raised ICP
• Pregnancy

Question 5

What is accelerated/malignant hypertension?

Describe the clinical signs and pathological features of it

How is it diagnosed?

Answer 5

• Rapid sustained increase in blood pressure
• This leads to intimal proliferation, reducing the luminal size and leading to cessation of blood flow through the small vessels
• This causes foci of tissue necrosis e.g. in the glomeruli
• Carries an untreated 1 year mortality of 20%
• Diagnosed if there is SBP>200 or DBP>120 and bilateral retinal haemorrhages/exudates
• Papillodema may be present

Question 6

What are the pathological consequences of hypertension?

(cardiovascular, cerebrovascular, renal systems and vision)

Answer 6

Heart:

• Left ventricular hypertrophy with dilation and eventual failure

Aorta:

• Predisposes to AAAs & aortic dissection

Brain:

• Intracerebral haemorrhage due to vessel rupture

Kidney:

• CKD due to progressive nephron ischaemia & glomerular destruction

Eyes:

• Hypertensive retinopathy

Question 7

How would you explain to a patient they have hypertension?

Answer 7

Your blood pressure is above “normal ranges”. A higher than normal blood pressure, which we call hypertension, is associated with increased risk of cardiovascular disease, which is disease of blood vessels and the heart – the major two diseases being stroke and heart attack. In order to reduce the risk of these diseases we need to get your blood pressure down to a lower level. We can do this using lifestyle measures and using some tablets and medicines.

Question 8

What are signs of left ventricular hypertrophy on an ECG?

Answer 8

• Tall R waves on V5 and 6
• deep S waves on V1 and 2
• inverted T waves in leads I, AvL, V5 and 6.

Question 10

What Korotkoff sounds should you hear when measuring blood pressure?

Answer 10

1. Sound 1: clear tapping sound (systolic BP)
2. Sound 2: Soft swishing murmur
3. Sound 3: Loud slapping sound
4. Sound 4: Muffling of sound
5. Sound 5: Disappearance of sound (diastolic BP – depends what book you read).

Question 11

Outline the epidiological link between cholesterol and vascular risk

Answer 11

Most men with LDL receptor defects will die before the age of 60, a majority due to coronary artery disease.

HDL protects against cardiovascular disease.

Serum cholesterol has been graphed to deaths per 1000 men; 4mM – 2, 5mM – 4.5, 6mM – 8, 7mM – 14.

Targets: Total cholesterol < 5mM, LDL < 3mM.

Question 12

How would you tell a patient they have diagnosis of hyperlipidaemia in lay terms?

Answer 12

The test results show that you have a level of lipids, which are fats, in your blood. One of these lipids that has become a bit of a household name is cholesterol. Unfortunately, having high levels of these substances in your blood increases the risk of certain adverse events to do with the circulation system, such as heart and stroke. Hopefully we can work together to reduce the amounts in the blood, and reduce the “modifiable” risk of blood vessel disease as far as possible, through lifestyle and medication measures.