Postural hypotension, dyslipidaemia and valvular heart disease

Question 1

Define Postural hypotension

Answer 1

A fall in systolic BP of >20mmHg and/or a fall in diastolic BP of >10mmHg within 3 minutes of standing

In HTN patients the fall in systolic BP must be >30mmHg

Question 2

what is aetiology of OH?

Answer 2

older age 
Alpha blockers
Diuretics 
TCA's and anti-hypertensives 
volume depletion 

Peripheral neuropathy
Pakinsons
Lewy body dementia
Pure autonomic failure

Question 3

What are the S&S of OH?

Answer 3

postural lightheadedness
Syncope
cerebral hypoperfusion signs like visual changes, weakness

Question 4

What are the investigations for OH?

Answer 4

Serial BPs from sitting to standing for 3 mins
Tilt table testing
Plasma noradrenaline - decreased compared to normal on standing
Deep breathing - diminished beat to beat variation on ECG during inspirationa and expiration
Nerve conduction studies

Question 5

What are the treatment options for OH?

Answer 5

Stop causative Meds

Education

• lie down when diizzy
• valsalva like manoeuvres should be avoided
• frequent small meals to reduce post prandial hypotension
• avoid hot environments
• raise head of bed

mineralocorticoid therapy e.g fludrocortisone

Question 6

what is dyslipidaemia?

Answer 6

it is defined as serum total cholesterol (TC), LDL-C, triglycerides, apolipoprotein B, or lipoprotein (a) concentrations above the 90th percentile or HDL-C or apolipoprotein A-1 concentrations below the 10th percentile for the general population

Question 7

what is the aetiology of dyslipidaemia?

Answer 7

primary = familial hypercholesterolaemia

secondary = high fat diet, sendentary lifestyle, chronic renal insufficiency, obesity, DM, hypothyroidism

Question 8

what drugs can cause dyslipidaemia?

Answer 8

thiazides, oral oestrogens, glucocorticoids, anabolic steroids.

Question 9

whats are the S&S of dyslipidaemia?

Answer 9

presence of RF's and family hx 
high fat diet 
obesity 
xanthelomas 
tedninous xanthomas 
corneal arcus <45

Question 10

What investigations highlight dyslipidaemia?

Answer 10

lipid profile

• TC >5.18mmol/l
• LDL-C >2.58mmol/l
• HDL-C <1.04mmol/l
• Triglycerides >1.7mmol/l

Serum TSH
- in hypothyroidism there is increases in TC, LDL and apolipoprotein B, so this must be ruled out

Lipoprotein (a)
- >50mg/dl

Question 11

what are the treatement options for dyslipidaemia?

Answer 11

Lifestyle change
Statins
Ezetimibe - inhibits intestinal absorption of cholesterol
PCSK9 inhibitor such as alirocumab

Question 12

outline the pathology of mitral stenosis

Answer 12

reduction in size of the mitral orifice. This leads to impeded flow between LA and LV, meaning the pressure in the LA remains higher than LV.

The increased LA pressure is referred to the lungs leading to congestion and the LV filling is reduced, leading to reduced CO

The effects of mitral stenosis produces a syndrome mimicking left HF

Question 13

what are the S&S of mitral stenosis?

Answer 13

Dyspnoea and orthopnoea
Diastolic murmur with loud S1 (opening snap)

Neck vein distension
Malar flush on cheeks
Haemoptysis (bronchial vein anastomoses rupture due to PH)
peripheral oedema

Question 14

How is mitral stenosis diagnosed and treated?

Answer 14

Diagnosed via echo and treated with diuretics, balloon valvulplasty and B-blocker + anticoagulant if arrhythmia risk

Question 15

What are the signs and symptoms of mitral regurg?

Answer 15

exertional dyspnoea 
peripheral oedema 
pansystolic murmur at apex radiating to axilla 
Diminished S1 and presence of S3 
palpitations

Question 16

how is mitral regurg diagnosed and treated?

Answer 16

diagnosed via echo and treated with annuloplasty, mechanical valve insertion and diuretics, B-blockers, ACEi

Question 17

whats is the aetiology of aortic stenosis?

Answer 17

Calcification (80%)
Bicuspid valve
Coarctation of the aorta
Rheumatic heart disease

Question 18

what are the S&S of aortic stenosis?

Answer 18

dyspnoea
chest pain (exertional)
Syncope (postural hypotension)

Ejection systolic murmur with crescendo-decresendo pattern that peaks in mid systole and radiates to carotid

Narrow pulse pressure

Paradoxically split S2. In severe disease the aortic valve closure becomes so delayed it comes after the pulmonary valve closure

Question 19

How is AS diagnosed and treated?

Answer 19

diagnosed via echo. ECG may show LVH, absent Q waves, LBBB or AV block

Treated with balloon valvuloplasty or replacement. Transcatheter aortic valve replacement (TAVR) used.

Question 20

What is the aetiology of acute and chronic aortic regurg?

Answer 20

acute = IE, ascending aortic root dissection, chest trauma

chronic = rheumatic heart disease, biscuspid valve, aortic root dilation, CT disordered (SLE, RA, Marfans)

Question 21

What are the S&S of AR?

Answer 21

high pitched early diastolic murmur

dynspnoea 
fatigue 
pulmonary oedema 
JVP distension 
Collapsing pulse + weak pulse pressure

Question 22

How is AR diagnosed and treated?

Answer 22

Echo
ECG may show LVH, LAD and ST-T wave changes

Acute AR = inotropes, vasodilators and urgent repair

Chronic = mild to moderate needs no treatment. Severe needs valve repair or replacement with vasodilator and ACEi therapy