Ward 13

Question 1

What is the most risk factor for premature death and CVD? How much of it is it responsible for?

Answer 1

Hypertension, causing 50% of all vascular death

Question 2

At which blood pressure should we decide to treat?

Answer 2

• All with BP ≥160/100 mmHg (or ABPM (ambulatory blood pressure monitoring) ≥150/95 mmHg).
• For those ≥140/90, the decision depends on the risk of coronary events, presence of diabetes,
  or end-organ damage

Question 3

BP in younger individuals

Answer 3

People—BP is on average lower in young people (eg 100–110/60–70 in 18-year olds)

Question 4

What is white coat hypertension

Answer 4

Refers to an elevated clinic pressure, but normal ABPM (day average <135/85)

Question 5

What is masked hypertension? Do you treat?

Answer 5

• Opposite of white coat hypertension
• NICE says don’t treat; but more likely to develop hypertension in future, and may have risk of CVD.

Question 6

What is malignant hypertension also known as?

Answer 6

accelerated phase hypertension

Question 7

What is malignant hypertension? What are things we observe in that situation?

Answer 7

• A rapid rise in BP leading to vascular
  damage (pathological hallmark is fibrinoid necrosis)
• Usually there is severe
  hypertension (eg systolic >200, diastolic>130mmHg) + bilateral retinal haemorrhages
  and exudates; papilloedema may or may not be present. Symptoms are common,
  eg headache ± visual disturbance

Question 8

Does malignant hypertension require treatment? Why?

Answer 8

• It requires urgent treatment, and may also precipitate acute kidney injury, heart failure, or encephalopathy, which are hypertensive
  emergencies.
• Untreated, 90% die in 1yr; treated, 70% survive 5yrs.

Question 9

What is primary hypertension also known as?

Answer 9

Essential hypertension

Question 10

What is the cause of primary hypertension and how many cases of hypertension are caused by it?

Answer 10

Cause unknown, thought to be due to mutations in several genes.
- It is responsible for 95% of cases of hypertension

Question 11

What is hypertension divided into?

Answer 11

Primary and secondary

Question 12

What can the causes of secondary hypertension be divided into and which is most common?

Answer 12

• Renal disease: Most common
• Endocrine disorders: Most commonly treatable cause
• Others

Question 13

Renal diseases leading to hypertension

Answer 13

• 75% are from intrinsic renal
  disease: glomerulonephritis, polyarteritis nodosa (PAN), systemic sclerosis, chronic
  pyelonephritis, or polycystic kidneys.
  -25% are due to renovascular disease, most frequently atheromatous (elderly male cigarette smokers, eg with peripheral vascular
  disease) or rarely fibromuscular dysplasia (young females).

Question 14

Endocrine causes leading to hypertension

Answer 14

Cushing’s and Conn’s syndromes, phaeochromocytoma, acromegaly, hyperparathyroidism

Question 15

What is crushing’s syndrome?

Answer 15

A syndrome caused caused by prolonged exposure to high circulating levels of cortisol

Question 16

Causes of cushing’s syndrome

Answer 16

• The most common cause of cushingoid features is iatrogenic corticosteroid use, while some herbal preparations can also increase circulating corticosteroid levels leading to Cushing syndrome.
• ACTH-dependent cortisol excess due to a pituitary adenoma is called Cushing disease, and it is responsible for 80% of endogenous Cushing syndrome

Question 17

What is conn’s syndrome?

Answer 17

Primary hyperaldosteronism

Question 18

Causes of COnn’s syndrome

Answer 18

The syndrome may be secondary to adrenal hyperplasia, adrenal adenoma, aldosterone-secreting adrenal carcinoma (1%), or familial hyperaldosteronism

Question 19

What is glomerulonephritis?

Answer 19

The term “glomerulonephritis” encompasses a subset of renal diseases characterized by immune-mediated damage to the basement membrane, the mesangium, or the capillary endothelium, resulting in hematuria, proteinuria, and azotemia

Question 20

Symptoms of hypertension

Answer 20

• Most cases of hypertension are asymptomatic and are diagnosed incidentally on blood pressure recording or measurement.
• Some cases present directly with symptoms of end-organ damage as stroke-like symptoms or hypertensive encephalopathy, chest pain, shortness of breath, and acute pulmonary edema
• Headache is no more common than in the general population

Question 21

Signs of hypertension

Answer 21

Physical examination may be unyielding other than occasional pedal edema or raised blood pressure, but one needs to look for signs of precipitating disease:
- Coarctation of the aorta (radio-radial delay, radio-femoral delay, differences in left and right arm BP or upper and lower limb BP more than 20 mm Hg)
- Central obesity
- Aortic valve disease (systolic ejection murmur, 4th heart sound)
- Renovascular disease or fibromuscular dysplasia (FMD) - (renal bruit, carotid bruit)
- Polycystic kidneys (enlarged kidneys bilaterally)
- Endocrine disorders [hypercortisolism(thin skin, easy bruising, hyperglycemia), acromegaly)
- Thyroid disorders(palpable/ painful or enlarged thyroid, exopthalamus] make up the common treatable causes of secondary hypertension
- The presence of a 4th heart sound, which represents a stiff and non-compliant left ventricle, hints towards left ventricular hypertrophy and diastolic dysfunction.
- Tremors
- The presence of lung rales and/or peripheral edema suggests cardiac dysfunction and gives a clue to the chronicity of hypertension.

Question 22

Difference between cholecystitis vs cholelithiasis vs cholidocolithiasis vs cholangitis

Answer 22

1- Inflammation of the gallbladder
2- Stones in the gallbladder
3- Stones in the bile duct
4- Inflammation of the biliary tree

Question 23

Diagnosis of hypertension

Answer 23

The ACC recommends at least two office measurements on at least two separate occasions to diagnose hypertension.

The ESC/ESH recommends three office BP measurements at least 1 to 2 minutes apart and additional measurements only if the initial two readings differ by greater than or equal to 10 mm Hg. BP is then recorded as the average of the last two readings.

Both societies endorse the use of higher BP readings and putting patients into higher stages/grades for adequate medical therapy.

The patient should remain seated quietly for at least 5 minutes before taking the blood pressure, and proper technique is necessary. The blood pressure cuff should cover 80% of the arm circumference because larger or smaller pressure cuffs can falsely underestimate or overestimate blood pressure readings.

Ambulatory blood pressure measurement is the most accurate method to diagnose hypertension and also aids in identifying individuals with masked hypertension as well as the white coat effect.

Question 24

Evaluation of patients

Answer 24

The evaluation consists of looking for signs of end-organ damage and consists of the following,
- 12 lead ECG (to document left ventricular hypertrophy, cardiac rate, and rhythm)
- Fundoscopy to look for retinopathy/ maculopathy
- Blood workup
- Urine albumin to creatinine ratio
- Ankle-brachial pressure index - ABI (if symptoms suggestive of peripheral arterial disease)
- Imaging: including carotid Doppler ultrasound, echocardiography, and brain imaging (where clinically deemed feasible)
- Special tests: Renal ultrasound/arteriography (renal artery stenosis); 24h urinary meta-adrenaline; urinary free cortisol; renin; aldosterone; MR aorta (coarctation)

Question 25

Tests in a patient with hypertension

Answer 25

• Including complete blood count, ESR, creatinine, eGFR, electrolytes, HbA1c, thyroid profile, blood cholesterol levels, and serum uric acid
• To help quantify overall
  risk: Fasting glucose; cholesterol. To look for end-organ damage: ECG or echo (any
  LV hypertrophy? past MI?); urine analysis (protein, blood). To ‘exclude’ secondary
  causes: U&E (eg K+ in Conn’s); Ca2+ ( in hyperparathyroidism)

Question 26

Grading retinopathy and what is used

Answer 26

Fundoscopy
1 Tortuous arteries with thick shiny walls (silver or copper wiring).
2 AV nipping (narrowing where arteries cross veins, p560, fi g 12.19).
3 Flame haemorrhages and cotton-wool spots.
4 Papilloedema,

Question 27

Management of hypertension

Answer 27

• Look for and treat underlying causes (eg renal disease, Increased alcohol)
• The management of hypertension subdivides into pharmacological and nonpharmacological management.

Question 28

Non pharmacological management of hypertension

Answer 28

Reduce or control concomitant risk factors: stop smoking; low-fat diet. Reduce alcohol and salt intake and caffeine; increase exercise; reduce weight if obese, manage OSA.
- - Weight reduction alone can result in decreases of up to 5 to 20 mm Hg in systolic blood pressure
- Smoking may not have a direct effect on blood pressure but will help in reducing long-term sequelae if the patient quits smoking.
- Lifestyle changes alone can account for up to a 15% reduction in all cardiovascular-related events

Question 29

Should blood pressure be dropped rapidly?

Answer 29

Reduce blood pressure slowly; rapid reduction can be fatal, especially in the context of an acute stroke

Question 30

What is more important, adequate BP reduction or specific drug used?

Answer 30

= The ALLHAT study suggests that adequate BP reduction is more important than
the specific drug used
- However, beta-blockers seem to be less effective than other drugs at reducing major cardiovascular events, particularly stroke.
- Beta-blockers and thiazides may increase the risk of new-onset diabetes, Ca2+-channel blockers appear
neutral, and ACE-i or ARB may reduce the risk.

Question 31

What is a hypertensive crisis?

Answer 31

BP >180 systolic or diastolic 120

Question 32

What are symptoms of cushing’s syndrome?

Answer 32

Centripetal obesity (a condition where fat accumulates in the abdomen and around the center of the body, particularly in the form of visceral fat), skin thinning, weakness, weight gain, fatigue, weakness, round moon face, delayed wound healing, easy bruising, back pain, bone pain, loss of height, depression, mood swings, emotional reactivity, loss of libido, erectile dysfunction in males, irregular menstrual cycles in females, infertility, hyperhidrosis, hirsutism, biparietal visual loss if there is a large pituitary adenoma, recurrent fungal and bacterial infections due to impaired immunity, and difficulty in combing hair or rising from a sitting position

Question 33

What shoud be asked to a patient with hypertension?

Answer 33

FH- hypertension, endocrine disease, polycystic kideny disease, heart disease
DH- Cardiac and antihypertensive medications, steroids, contraceptive pill, levothyroxine/carbimazole, MAOI, antipsychotics, recreational drugs (cocaine, amphetamines)
SH- Exercise tolerance, smoking

Question 34

Worrying features of a patient with hypertension

Answer 34

Altered mentation, seizures, retinal hemorrhages, AKI, chest pain, arterial aneurysms

Question 35

Complications of hypertension

Answer 35

End organ damage, malignant HTN, CV disease

Question 36

Pharmacological therapy for hypertension

Answer 36

• Monotherapy (1st line): If ≥55yrs, and in black patients of any age, 1st choice is a Ca2+-channel antagonist or thiazide. If <55, 1st choice is ACE-i (or ARB if ACE-i intolerant, eg cough).
  beta-blockers are not 1st line for hypertension, but consider in younger people, particularly
  if: intolerance or contraindication to ACE-i/ARB, she is a woman of child-bearing
  potential, or there is increased sympathetic drive.
• Combination : ACE-i + Ca2+-channel antagonist or diuretic is logical, and has been commonly used in trials. There is little evidence on using 3 drugs but current recommendation
  is ACE-i, Ca2+-channel antagonist, and thiazide.
• If BP still uncontrolled
  on adequate doses of 3 drugs, add a 4th—consider: spironolactone 25–50mg/24h or higher-dose thiazide, but monitor U&E. Alternatively, beta-blocker, or selective beta-blocker
  and get help.

Question 37

1st Choice of antihypertensive in patient with LVF

Answer 37

ACE inhibitor

Question 38

Hypertension crisis causese threatening causes of hypertensive crisis

Answer 38

Question 39

1st Choice of antihypertensive in patient with diabetes and why?

Answer 39

ACE inhibitor, beta blockers can aggravate or increase diabetes

Question 40

Management of hypertension crisis

Answer 40

• Acute treatment: In the absence of end- organ damage, oral therapy with
  a calcium channel blocker or ACEi should be instigated.
  If end- organ damage is present, admit patient to a monitored area (HDU/ ICU), with close monitoring of BP (Box 7.7), ECG, neurological state, and fluid
  balance (consider arterial line, central line, catheterization).
  Rapid reduction in BP can be dangerous, resulting in cerebral hypoperfusion and
  is only necessary in an acute MI or aortic dissection. Otherwise, aim to
  reduce diastolic BP to 100mmHg or by 25% (whichever value is higher)
  over 24h
  Patients with early features of end- organ damage may be commenced on oral therapy, though more severe organ damage may require treatment with
  IV agents.
• Chronic treatment BP needs checking regularly once discharged from hospital.
  Ensure GP knows what investigations have been undertaken, their
  results, and what the therapeutic plan/ target BP is

Question 41

Signs of end organ damage in hypertension

Answer 41

Question 42

Oral Pharmacotherapy for acute management of hypertensive crisis

Answer 42

If no evidence of LVF use labetalol; if LVF present commence
furosemide (20– 50mg IV) ±hydralazine.
- Consider ACEi to counteract
high circulating levels of renin.
- Nitroprusside and hydralazine are still used as adjuncts in severe crises under expert guidance

Question 43

IV pharmacotherapy for acute management of hypertensive crisis

Answer 43

Question 44

What is the drug in isoket

Answer 44

Isosorbide dinitrate

Question 45

When should senior help/ arrest team be called in bradycardia patient?

Answer 45

Drop in GCS or BP less than 90 systolic