Heart 1

oelomar's version from 2016-03-06 14:50


Question Answer
What is hypertension?A resting blood pressure persistently at 140/90 or above. Note that a single measurement of elevated blood pressure is not adequate to make a diagnosis of hypertension.
What are the risk factors for developing hypertension?Increase in age, obesity, diabetes, smoking, genetics, black>white.
What can hypertension predispose one to?Atherosclerosis, left ventricular hypertrophy, stroke, CHF, renal failure, retinopathy, and aortic dissection.
What should be done if the blood pressure measured in clinic is 140/90mmHg or higher?Take a second measurement during the consultation. If the second measurement is substantially different from the first, take a third measurement. Record the lower of the last two measurements as the clinic blood pressure. To confirm the diagnosis: If the clinic blood pressure is 140/90 mmHg or higher, offer ABPM to confirm the diagnosis of hypertension. If a person is unable to tolerate ABPM (ambulatory blood pressure monitoring), HBPM (home blood pressure monitoring) is a suitable alternative to confirm the diagnosis of hypertension.
What percentage of hypertension is essential (primary) and what percentage is secondary?90% and 10% respectively.
What is malignant hypertension?Malignant hypertension is extremely high blood pressure that develops rapidly and causes some type of organ damage. A person with malignant hypertension has a blood pressure that's typically above 180/120.
What routine investigations are carried out in people with hypertension, and why are they carried out?ECG, urine stix test for protein and blood, fasting blood for lipids (total and HDL cholesterol) and glucose, serum U&E. These tests are performed to rule out secondary hypertension from conditions such as renal artery stenosis, phaeochromocytoma, Conn’s syndrome, and Cushing’s syndrome.
When is treatment for hypertension initiated in a non-diabetic?Initiate treatment when systolic BP ≥ 160 mmHg, or sustained diastolic BP ≥ 100 mmHg. Decide on treatment in subjects with sustained systolic BP between 140 and 159 mmHg, or sustained diastolic BP between 90 and 99 mmHg, according to the presence or absence of target organ damage or a 10-year cardiovascular disease risk > 20%.
When is hypertension treatment initiated in a diabetic?If systolic BP is sustained ≥ 140 mmHg, or diastolic BP is sustained ≥ 90 mmHg.
What is the target blood pressure for patients with diabetes, renal impairment or established cardiovascular disease?130/80mmHg.
How do ambulatory blood pressure readings differ from clinic blood pressure readings?Ambulatory blood pressure readings are approximately 10/5mmHg lower, and this applies to both the threshold and target.


Question Answer
What is step 1 in the management of hypertension in over 55s or blacks?1st choice is a Ca2+ channel blocker (or a thiazide like diuretic if intolerant or heart failure or a risk of heart failure is present.
What is step 1 in the management of hypertension in non-black under 55s?1st choice is an ACE inhibitor (or an ARB if intolerant).
What is step 2 in the management of hypertension?Ca2+ channel blocker in combination with an ACE inhibitor.
What is step 3 in the management of hypertension?Ace inhibitor/Ca2+ channel blocker/thiazide like diuretic.
What is step 4 in the management of hypertension?25 mg once daily spironolactone if blood potassium level is 4.5 mmol/l or lower. A higher-dose thiazide-like diuretic if blood potassium level is higher than 4.5 mmol/l. If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker.
How do calcium channel blockers work?They block the voltage-dependent L-type calcium channels of cardiac and smooth muscle and thereby reduce muscle contractility.
Name a calcium channel blocker.Amlodipine.
What are the side-effects of amlodipine?Flushing and headache caused by vasodilation. More severely ankle oedema.
How do ACE inhibitors work?They inhibit the angiotensin-converting enzymes, thereby reducing the levels of angiotensin II. Angiotensin II inactivates bradykinin, which is a potent vasodilator. Therefore, with decreased levels of angiotensin II, there will be more bradykinin to lower blood pressure with its vasodilator effect.
Name an ACE inhibitor.Ramipril.
What are the side-effects of Ramipril?Dry cough, first-dose hypotension, teratogenicity, reversible renal dysfunction (in presence of renal artery stenosis), angioedema. Patients on ACE inhibitors should have their U&E checked after starting therapy.
How do patients avoid the “first-dose hypotension” side-effect of Ramipril?Take the ACE inhibitors at night.
What is losartan?An angiotensin II receptor antagonist. Note that it is not an ACE inhibitor and does not cause a dry cough.
What are the effects of thiazide diuretic toxicity?Hypokalaemic metabolic alkalosis, hyponatraemia, hyperglycaemia, hyperlipidaemia, hyperuricaemia, and hypercalcaemia.
Patients with gout should not take thiazide diuretics. True or false?True.


Question Answer
With regards to hypertensive retinopathy, as seen on fundoscopy, what is grade I?Tortuosity of the retinal arteries with increased reflectiveness (“silver wiring”).
With regards to hypertensive retinopathy, as seen on fundoscopy, what is grade II?As grade I + the appearance of what is called “arteriovenous nipping” produced when thickened retinal arteries pass over the retinal veins.
With regards to hypertensive retinopathy, as seen on fundoscopy, what is grade III, and what is it diagnostic of?As grade II + flame-shaped haemorrhages and soft (“cotton wool”) exudates due to small infarcts. This is diagnostic of malignant hypertension.
With regards to hypertensive retinopathy, as seen on fundoscopy, what is grade IV, and what is it diagnostic of?Grade III + papilloedema (blurring of the margins of the optic disc). This is diagnostic of malignant hypertension.
Many antihypertensive agents are contraindicated in pregnancy. In that case, how is hypertension managed in pregnancy?With methyldopa or labetalol.
What is labetalol?A mixed alpha/beta adrenergic antagonist used to treat hypertension.
In women of childbearing potential, what is the recommended hypertension treatment to start with?A beta-blocker.
When and how is severe acute hypertension treated?Only treat if the blood pressure is causing end organ dysfunction (e.g. acute MI/ acute pulmonary oedema, acute renal failure, acute aortic stenosis, hypertensive encephalopathy). Treatment is with IV labetalol.


Question Answer
Which vessels are most likely to be affected by atherosclerosis?Atherosclerosis is a disease of elastic arteries and large and medium-sized muscular arteries. Abdominal aorta>coronary arteries>popliteal artery>carotid artery.
Name some of the signs of hyperlipidaemia.Atheromas, xanthomas, tendinous xanthomas, arcus senilis (corneal arcus).
What is a xanthoma?Plaques or nodules composed of lipid-laden histocytes in the skin, especially the eyes (xanthelasma).
What is a tendinous xanthoma?Lipid deposits in the tendons which appear as hard, non-tender nodular enlargement of tendons. They are most commonly found on the knuckles and the Achilles tendon
How do statins work?Inhibition of HMG CoA reductase which is a cholesterol precursor, thereby preventing the formation of mevalonate.
Name some of the mild side-effects of statins.Muscle pain (myalgia), GI disturbances, raised concentrations of LFTs, insomnia, rash.
Name some of the more serious side-effects of statins.Hepatotoxicity, myositis (inflammation and degeneration of muscle tissue), rhabdomyolysis.
In what are statins contraindicated?Pregnancy, lactation, clarithromycin.
When is lipid modification therapy started and what does it involve?Offer 40 mg simvastatin as part of the management strategy for adults over 40 who have a 20% or greater 10-year risk of developing CVD.

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