Severe HTN and the investigations to perform

Question 1

Categorise BMI

Answer 1

18.5 Underweight
18.5-24.9 Healthy weight
25–29.9 Overweight
30-34.9 Obese (class 1 obesity)
35-39.9 Severe obesity (class 2 obesity)
40-50 Morbid obesity (class 3 obesity)
50-60 Super obesity
>60 Super-morbid obesity

Question 2

What happens to usual circadian BP rhythm if you have essential HTN

Answer 2

It is lost

Question 3

What would you look for if the BP is high

Answer 3

Fundoscopy

Question 4

What is seen on fundoscopy at each of the 4 grades of HTN

Answer 4

Grade 1: silver wiring (white bit in the artery)… shows it’s chronic

Grade 2: av nipping… the artery compresses the vein so vein narrows

Grade 3: Flame haemorrhae

Grade 4: Papilloedema

Question 5

When is papillodema seen

Answer 5

Can be seen when high ICP due to brain tumour, as well as in HTN

Question 6

Other signs in a patient with longstanding HTN

Answer 6

1. LVH cannot be detected on clinical examination
2. Heave
3. S4
4. Bruits

Question 7

What happens to make S4 sound

Answer 7

S4 is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle

Question 8

T/F in HTN you might feel a displaced apex beat

Answer 8

F.

Remember that in HTN you might get LVH over long term. This is not detectable on examination

Contrastingly, in HF you get dilated left ventricle which causes the shift apex beat

Question 9

How can you tell if papilloema

Answer 9

Cannot see outline of optic disc

Question 10

What does hypertensive retinopathy suggest

Answer 10

That the hypertension is severe and prolonged…

Question 11

Causes of HTN

Answer 11

Conn's disease 
Phaeochromocytoma 
Cushings 
Renal artery stenosis 
Cushings 
Acromegaly 
Coarctation of the aorta 
Essential

Question 12

What investigations for HTN and why

Answer 12

FBC (polycythaemia)

U + E (potassium might be low, renal function might be affected).. MOST USEFUL because a low potassium makes endocrine more likely

ECG (LVH)

Urinalysis (nephritis or renal disease)

Fasting glucose (risk of diabetes)

Lipids

Question 13

What percentage of hypertensive patients have secondary hypertension

Answer 13

Under 30 (probably 30%)
In older people (probably under 5%)

Question 14

What is the renin and aldosterone in conns and why

Answer 14

Aldosterone high and the renin is low because it s suppressed by the high BP

Question 15

When is the renin and aldosterone high

Answer 15

RAS

Question 16

What is the presentation of phaeochromocytoma

Answer 16

Nervousness
Sweat pouring down face
Racing heartbeat (palpitations)
Episodic severe hypertension

It’s sudden episodes because it’s neural tissue degranulating, not like conns’s where it’s a constant tumour

Question 17

What can happen to the bowel in phaeo

Answer 17

severe vasoconstriction could cause necrotic bowel

Question 18

First therapeutic step with a phaeo

what is the other management

Answer 18

(Rehydrate if dehydrated)
FIRST: Alpha blockade
Beta blockade
Localise the lesion
surgery

Question 19

What test could we do for a patient with a phaeo

Answer 19

MIBG

Question 20

65 yo patient with a previous MI has a BP of 140/80 on atenolol.

Would you add a thiazide

Answer 20

Yes….. intensive control is better than standard control and it prevents deaths

“AGGRESSIVE” management of BLOOD PRESSURE and LIPIDS improves SURVIVAL

Using thiazides in 100 people with CAD will save 2 lives over 5 years.

Question 21

Optimum medical therapy for those with previous CAD

Answer 21

Intensive lifestyle modification

Aspirin

High dose statin (Atorvastatin 40-80mg od)

Optimal blood pressure control to 120/80

Assessment for probable T2D

Question 22

Outline the physiology of PCSK9

Answer 22

It controls the digestion of the LDLR.

Normally, PCSK9 will bind to the LDLR and, when the LDLR is recycled, causes it to be digested in the lysozyme so it can no longer bind cholesterol in the blood

Question 23

How do PCSK9i work

Answer 23

It is a monoclonal antibody, it prevents PCKS9 binding to LDLR and thus prevents the digestion of this protein in the lysozome.

So it can stay and continue to remove cholesterol from the bloodstream and thus is lipid lowering

Question 24

Is PCSK9 useful

Answer 24

No, wasn’t shown to