Valvular and HTN Flashcards
What is clinical definition of hypertension?
What is next investigation to confirm HTN?
What values confirm HTN?
- 140/90 on 3 separate occasions. Lowest of readings 2 or 3 taken as clinical BP.
- If clinical BP higher than 140/90 offer ambulatory blood pressure monitor (ABPM) or home BP monitor (HBPM) if ABPM not appropriate.
- Confirmation of diagnosis: Clinal BP >140/90 and ABPM/ HBPM daytime average >135/85.
What are 3 stages of HTN?
What is value of malignant HTN?
- 140/90-159/99
- 160/100-179/119
3 >180/120
Outline the 4 steps in choosing anti-HTN medication.
- ACEi/ ARB or CCB
- ACEi/ ARB + CCB (or Thiazide diuretic)
- ACEi/ ARB + CCB + thiazide-like diuretic.
- Confirm resistant hypertension. ?add Spironolactone or Alpha/ Beta blocker.
Give side effects of the following:
- ACEi (3)
- CCB (2)
- BB (1)
- AB(1)
- Diuretics (2)
- ACEi: cough, high potassium, raised Cr.
- CCB: swelling, angioedema
- BB: dizziness
- AB: dizziness
- Diuretics: dry mouth, low potassium levels.
Give 3 categories of patient to measure standing and sitting BP in.
What is upper limit of BP maintenance in >80yr olds.
- T2DM, symptoms of postural hypotension, people aged >80.
- Clinic BP <150/90, ABPM <145/85
What needs to be urgently assessed in stage 3 HTN?
Give 3 reasons to refer to a same-day specialist review.
- Assess target organ damage ASAP.
Refer to specialist: - Retinal haemorrhage/ papilloedema
- Life threatening Sx; confusion, chest pain, AKI, signs of HF.
- Suspected phaeochromocytoma- e.g. labile/postural hypotension, headache, palpitations, pallor, abdominal pain, diaphoresis).
How may physiological splitting of S2 occur?
What may cause paradoxical splitting.
What may cause persistent splitting?
What may cause fixed splitting?
- Inspiration, decreased intrathoracic pressure, increased compliance of pulmonary vascular bed, augmented right heart filling. Right ventricle filling increased as result- later valve closure.
- Paradoxical splitting- results from prolonged LV systole (Prolonged emptying, AS, LBBB).
- Persistent splitting: prolonged RV systole/ shorter duration of LV systole. PS, RBBB
- Fixed: Atrial septal defect
What causes the sound of S3.
What patients can it be heard in?
- Produced during passive ventricular flilling, blood strikes compliant LV
- Healthy young people with well functioning heart.
Older people with heart failure.
What produces the S4 sound?
Give 3 cardio conditions it can be heard in.
- Forceful atrial contraction ejecting blood into hypertrophied ventricle which cannot expand further. Indicates stiff ventricle, caused by turbulent flow.
- HTN, aortic stenosis, hypertrophic cardiomyopathy.
Which manoeuvre amplifies mitral stenosis?
Which manoeuvre amplifies aortic regurgitation?
- Lean patient of left hand side
- Lean patient forward.
Describe murmur heard in aortic stenosis.
Give 3 other clinical signs of aortic stenosis
Give 3 non-cardio symptoms.
- Ejection systolic high pitched murmur.
- Crescendo decrescendo character- flow is fastest mid-systole.
- Radiates to carotids
- Slow rising pulse and narrow pulse pressure
- Patients may complain of exertional syncope.
- Worsening SOB
- Leg swelling
Describe mitral regurgitation murmur and radiation.
Give 3 possible causes.
- Pan-systolic high pitched whistling murmur
- Radiates to left axilla.
- IHD, Idiopathic with age, connective tissue disorder.
Describe mitral stenosis murmur. How is it accentuated?
Give 2 associated conditions and 1 symptom.
- Mid-diastolic low pitched rumbling with loud S1.
- Accentuated by lying on LHS
- Atrial fibrillation, rheumatic fever
- Malar flush: red cheeks.
Describe aortic regurgitation murmur.
What location and position is it amplified in?
Give 5 clinic signs of aortic regurgitation.
Describe the pulse pressure.
- Early diastolic, soft murmur
- heard better at Erb’s point: left sternal edge, 3rd intercostal space, holding breath after expiration and sitting forward.
- Collapsing pulse- Corrigan’s pulse
- Corrigan’s sign: pulsation of neck.
- Quincke’s sign: pulsation of nail bed.
- De Musset’s sign: nodding of head with pulse
- Becker’s sign: pupil and retinal artery pulsation
- Muller’s sign: uvula pulsation
Wide pulse pressure
What other type of murmur can be caused by aortic regurgitation?
- Austin flint murmur- aortic incompetence.
Noise of turbulent blood flow hitting anterior leaflets of mitral valve.
Causes mid-diastolic murmur: physiological mitral stenosis.
Describe murmur in tricuspid regurgitation, where it is heard best and how it is amplified.
Give two associated conditions.
What clinical sign can be seen.
- Pansystolic murmur- heard better at lower left sternal edge- louder on inspiration- carvallo’s sign.
- Infective endocarditis, congenital defects.
- Raised JVP: giant V waves.
Define rheumatic fever.
Give 3 general symptoms
Give 3 cardio symptoms.
Give 3 joint symptoms.
- Inflammatory multisystem disorder. Follows Group A Beta-haemolytic Stretococci (GAS) pharyngeal infection.
- Fever, malaise, anorexia
- SOB, palpitations, chest pain
- Swollen, painful, reduced movement.
What is the Jones criteria for rheumatic fever?
What other feature is present.
- Joints- polyarthritis
- Nodules- painless
- Erythema marginatum
- Sydenham chorea- involuntary movements with slurred speech
Also pericarditis/ endocarditis: pericardial effusion, myocardial thickening, valvular dysfunction.
What throat culture is taken for rheumatic fever?
What ECG changes are seen?
- Throat culture for growing GAS or anti-Streptolysin O titres.
- Saddle-shaped ST elevation, PR depression.
Give the cause of the following buzzwords:
- Narrow PP, soft S2, ES murmur radiating to carotids
- Blowing PS murmur at apex radiating to axilla
- Wide PP, displaced, EDM at LSE- best heard leaning forward on expiration
- Tapping apex beat + malar flush. Loud S1, rumbling MDM at apex.
- PSM LLSE, best heard on inspiration. L parasternal heave, pulsatile liver, raised JVP, IVDU.
- Aortic stenosis
- Mitral regurgitation
- Aortic regurgitation
- Mitral stenosis
- Tricuspid regurgitation.
