1 LOBS Flashcards
Define blood pressure. How would you describe what blood pressure is to patients
(avoiding medical jargon).
High blood pressure (hypertension) means that your blood is pumping with more force than normal through your arteries. The added stress on the arteries can speed up the clogging of arteries with fatty plaques (atherosclerosis). Atherosclerosis contributes to many illnesses, such as heart attack and stroke.
What happens when blood pressure is too low? Too high? Review how blood
pressure is regulated.
Blood pressure which is too high or too low can lead to a wide range of pathology (e.g. ruptured blood vessels, reduced perfusion to organs).
Define essential hypertension
persistently elevated arterial blood pressure that has no underlying (secondary) cause
Define Iatrogenic hypertension
high blood pressure caused by a chemical substance or medicine.
Define Secondary Hypertension
It is high blood pressure that’s caused by another medical condition. It can be caused by conditions that affect the kidneys, arteries, heart or endocrine system.
What are the 5 common causes of secondary hypertension?
- Obesity
- Pregnancy
- Kidney disease - Glomerulonephritis, Diabetic nephropathy and Renal cell carcinoma
- Vascular disease - Diabetic nephropathy and Renal cell carcinoma
- Endocrine disease - Hyper/hypothyroidism and Cushing’s syndrome
- Drugs - Alcohol, Illicit drugs (e.g. cocaine), Corticosteroids, Non-steroidal anti-inflammatories (NSAIDs) and Venlafaxine
- AND other causes like Connective tissue disorders (e.g systemic sclerosis, systemic lupus erythematosus and polyarteritis nodosa) and Obstructive sleep apnoea
Define Malignant/Accelerated hypotension
Clinic BP is usually higher than 180/120 mmHg with signs of papilloedema and/or retinal haemorrhage.
Can be fatal due to heart failure, cerebral haemorrhage, or renal failure.
Define masked hypertension
Masked hypertension is defined as a normal blood pressure (BP) in the clinic or office (<140/90 mmHg), but an elevated BP out of the clinic (ambulatory daytime BP or home BP>135/85 mmHg)- within the hypertensive range
Define white-coat hypertension
This condition occurs when blood pressure readings at a health care provider’s office are higher than they are in other settings, such as at home. Home or ambulatory blood pressure monitoring readings are lower, with a discrepancy of > 20/10 mmHg.
They may also exhibit signs in clinic such as tachycardia, sweating, or palpitations.
Review the types of antihypertensive medications in common practice
- Patients aged <55 years who are not of Black African or African-Caribbean descent: offer an ACE inhibitor such as ramipril.
-If an ACE inhibitor is not tolerated offer an angiotensin-II receptor blocker such as losartan.
OR - Patients aged ≥55 years and patients of Black African or African-Caribbean descent: offer a calcium channel blocker such as amlodipine.
- Patients already taking an ACE inhibitor or angiotensin-II receptor blocker: offer a calcium channel blocker such as amlodipine or a thiazide-type diuretic such as indapamide.
- Patients already taking a calcium channel blocker: offer an ACE Inhibitor such as ramipril or a thiazide-type diuretic such as indapamide.
If an ACE Inhibitor is not tolerated offer an angiotensin-II receptor blocker such as losartan.
Angiotensin-II receptor blockers preferred in patients Black African or African-Caribbean descent.
- Offer a combination of an ACE inhibitor or angiotensin-II receptor blocker plus a calcium channel blocker and thiazide-type diuretic.
What are the long-term implications of uncontrolled hypertension?
Please focus on
end-organ disease, specifically the brain, heart, kidneys and eyes (hypertensive
retinopathy).
Heart: left ventricular hypertrophy, angina/previous myocardial infarction, previous coronary revascularization, and heart failure
Brain: stroke or transient ischemic attack, dementia
Chronic kidney disease
Peripheral arterial disease
Retinopathy
List the modifiable and non-modifiable risk factors that predispose a patient to
coronary artery disease.
Smoking. (M)
Lack of exercise. (M)
Diet. (M)
Obesity. (M)
High blood pressure. (M and NM)
High LDL or low HDL cholesterol levels. (M and NM)
Family history of heart disease or other cardiovascular disease. (NM)
Age (NM)
What is metabolic syndrome and why is it important?
Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension) and obesity. or
The metabolic syndrome is the name of a cluster of risk factors that, when they appear together, dramatically raise your risk of heart disease, heart failure, stroke and diabetes, as well as other non-cardiovascular conditions.
What is dyslipidaemia and how can we measure and treat it?
Dyslipidemia is the imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, (LDL-C), triglycerides, and high-density lipoprotein (HDL).
Dyslipidaemia is a broad term describing a number of conditions, including hypercholesterolaemia, hyperlipidaemia and mixed dyslipidaemia, in which disturbances in fat metabolism lead to changes in the concentrations of lipids in the blood.
The most commonly used options for pharmacologic treatment of dyslipidemia include bile acid–binding resins, HMG-CoA reductase inhibitors, nicotinic acid and fibric acid derivatives.
What lifestyle advice is customary to give to individuals with cardiovascular risk
factors?
What are some techniques clinicians can use to successfully encourage
individuals to change their behaviours?
What are some strategies available to medical providers to encourage smoking
cessation?
- Nicotine replacement therapy
- Counselling
- Acupuncture
- Physical activity
- Relaxation techniques like yoga
Develop a differential diagnosis for palpitations.
Arrhythmias:
Atrial fibrillation/flutter
Bradycardia caused by advanced arteriovenous
block or sinus node dysfunction
Bradycardia-tachycardia syndrome (sick sinus syndrome)
Multifocal atrial tachycardia
Premature supraventricular or ventricular contractions
Sinus tachycardia or arrhythmia
Supraventricular tachycardia
Ventricular tachycardia
Wolff-Parkinson-White syndrome
Psychiatric causes:
Anxiety disorder
Panic attacks
Drugs and medications:
Alcohol
Caffeine
Certain prescription and over-the-counter agents (e.g., digitalis, phenothiazine, theophylline, beta agonists)
Street drugs (e.g., cocaine)
Tobacco
Nonarrhythmic cardiac causes:
Atrial or ventricular septal defect
Cardiomyopathy
Congenital heart disease
Congestive heart failure
Mitral valve prolapse
Pacemaker-mediated tachycardia
Pericarditis
Valvular disease (e.g., aortic insufficiency, stenosis)
Extracardiac causes:
Anemia
Electrolyte imbalance
Fever
Hyperthyroidism
Hypoglycemia
Hypovolemia
Pheochromocytoma
Pulmonary disease
Vasovagal syndrome
Describe the pathophysiology of atrial fibrillation and link it to the typical ECG
findings.
Atrial fibrillation (AF) is a cardiac arrhythmia characterised by disorganised electrical activity within the atria resulting in ineffective atrial contraction and irregular ventricular contraction.
AF is a type of supraventricular cardiac arrhythmia meaning the origin of the arrhythmia arises from above the ventricles.
What are the risk factors for essential hypertension?
- Sex - up to 65 M>W, 65-74 W>M
- Ethnicity: people of Black African and Black Caribbean origin are at a higher risk of developing HTN.
- Age: blood pressure rises with increasing age.
- Lifestyle factors: cigarette smoking, excess alcohol consumption, excess dietary salt intake, obesity and lack of physical activity.
- Genetic factors
- Social deprivation
- Stress and anxiety
What are the risk factors for essential hypotension?
Sex: up to 65 years women tend to have lower blood pressures than men, however, between the ages of 65-74 years women tend to have higher blood pressures.
Ethnicity: people of Black African and Black Caribbean origin are at a higher risk of developing HTN.
Age: blood pressure rises with increasing age.
Lifestyle factors: cigarette smoking, excess alcohol consumption, excess dietary salt intake, obesity and lack of physical activity.
What are the risk factors for cardiovascular disease, including social History and family history?
High blood pressure
Smoking
High cholesterol
Diabetes
Lack of physical activity
Being overweight or obese
Family history of CVD
Ethnic background
Age
Gender
Diet
Alcohol
What is meant by the term pack year?
A pack-year is used to describe how many cigarettes you have smoked in your lifetime, with a pack equal to 20 cigarettes.
Is gender considered a CVS risk factor?
YES.
What is the management for essential hypertension? Including blood tests.
Management of essential hypertension:
- Take BP: offer ABMP or HBMP to rule out white coat
- Blood Tests: Glucose, eGFR, Lipid profile, Electrolytes, Plasma renin, Thyroid function, Plasma Aldosterone, ACR
- Urine dipstick
- CXR: Might show Cardiomegaly
- ECG: Might show left ventricular hypertrophy
- Lifestyle modification: Diet, exercise, stress, smoking, alcohol
What is end-organ damage?
Damage occurring in major organs fed by the circulatory system.
What sort of end-organ damage can blood pressure cause?
stroke, chronic heart disease, heart failure, renal failure, peripheral vascular disease, or retinopathy
What are the categories of BMI?
- <18.5 = underweight
- 18.5 – 25 = healthy
- 25 – 30 = overweight
- > 30 = obese
What are the health implications of a raised BMI?
The higher your BMI, the higher your risk for certain diseases such as heart disease, high blood pressure, type 2 diabetes, gallstones, breathing problems, and certain cancers.
What are the reasons that someone could have a raised BP?
- are overweight.
- eat too much salt and do not eat enough fruit and vegetables.
- do not do enough exercise.
- drink too much alcohol or coffee (or other caffeine-based drinks)
- smoke.
- do not get much sleep or have disturbed sleep.
are over 65. - pregnancy
Understand the terms atherosclerosis and arteriosclerosis
Atherosclerosis – build-up of fats, cholesterol, and other constituents in and on artery walls. The build-up forms a plaque that causes arteries to narrow and harden therefore constricting blood flow. It can cause arteriosclerosis.
Arteriosclerosis – the hardening of the arteries. Blood vessels that carry oxygen and nutrients from heart to rest of body become hard and stiff as a result restricting blood flow to organs and tissues.
Can urine dip rule out altered kidney function? What is urine ACR?
No because …
Urine albumin to creatinine ratio helps identify kidney disease that occur as a complication of diabetes. The higher the ACR level, the higher the indication of severe kidney disease
What is an ECG and what is it used for?
ECG is used to look for signs of cardiac arrhythmias and heart failure. (check answer)
What does a normal ECG look like?
What is HBa1c?
indicates average blood glucose concentration over the previous 3 months; high levels may suggest diabetes.
What is meant by metabolic syndrome?
Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension), unhealthy cholesterol levels and obesity. It puts you at greater risk of getting coronary heart disease, stroke and other conditions that affect the blood vessels.
What does cholesterol/HDL ratio mean?
the level of good cholesterol in your blood compared to your overall cholesterol level. Higher ratios mean high risk of heart disease.
What are the stages of hypertension?
stage 1: Clinic BP 140/90mmHg up to 159/99mmHg and ABPM and HBPM 135-80mmHg - 149/94mmHg
stage 2: Clinic BP 160/100mmHg - up to 180/120mmHg and ABPM and HBPM BP of 150/95mmHg or higher
stage 3: clinic systolic BP of 180mmHg or higher OR clinic diastolic BP of 120mmHg or higher
What are anti-hypertensive categories?
- ACE Inhibitors
- ARBs
- Alpha Blockers
- Beta-blockers
- Calcium channels blockers (CCBs)
- Diuretics
What are the NICE guidelines for treatments for hypertension?
look at the NICE guidelines
What are the common and important arrythmias?
- Atrial fibrillation – heart beats irregularly
- Bradycardia – heart beats more slowly than normal
- Supraventricular tachycardia – episodes of abnormally fast heart rate at rest
? anymore
What are the causes of palpitations?
- Emotional responses such as stress, anxiety, or panic attacks
- Stimulants including caffeine, cocaine, or amphetamines
- Hormonal changes such as menstruation, pregnancy, or menopause
- Vigorous exercise
pheochromocytoma
hyperthyroidism.
fever
check answer.
What is atrial fibrillation? (and read the CKS guidance)
Atrial fibrillation is an arrhythmia that results from an irregular/disorganised electrical activity in the atria leading to an ineffective atrial contraction and an irregular ventricular rhythm/contraction.
In atrial fibrillation, the heart rate is irregular and can sometimes be very fast. In some cases, it can be considerably higher than 100 beats a minute.
What are some causes of atrial fibrillation?
Cardiac or valve conditions, such as:
- Congestive heart failure.
- Rheumatic valvular disease.
- Atrial or ventricular dilation or hypertrophy.
- Pre-excitation syndromes (such as Wolff–Parkinson–White syndrome).
- Sick sinus syndrome.
- Congenital heart disease.
- Inflammatory or infiltrative disease (such as pericarditis, amyloidosis, or myocarditis).
Non-cardiac conditions, such as:
- Acute infection.
- Autonomic neuronal dysfunction (such as vagally induced AF).
- Electrolyte depletion (such as hypokalemia and hyponatremia).
- Cancer (such as primary lung cancer involving the pleura and pericardium, and cancers such as breast cancer and malignant melanoma metastasising to the pericardium).
- Pulmonary embolism.
- Thyrotoxicosis
- Diabetes mellitus
Dietary and lifestyle factors, such as:
- Excessive caffeine intake.
- Alcohol abuse (especially in susceptible individuals such as those with structural heart disease)
- Obesity
- Smoking.
- Medication exposure (such as thyroxine or bronchodilators).
What is a CHA2DS2-VASc score?
A clinical prediction for estimating risk of stroke in AF patients.
It comprises eight components which when added together guide the decision of whether to offer a patient anticoagulation therapy.
What is an ORBIT score?
Bleeding risk score for AF patients predicting bleeding risk in patients on anticoagulation (medicine that help prevent blood clot)
What is rivaroxaban and propranolol and why is it used?
Rivaroxaban – an anticoagulant - helps prevent blood clot, reduce risk of heart attack and stroke
Propranolol – type of beta blocker - used to treat heart attack problems, help with anxiety, and prevent migraines
Explain, and give the rationale behind the investigations, acute and long-term
management for atrial fibrillation, including anticoagulation to prevent thrombus
formation (immediate with heparin and longer term with DOAC or warfarin). Please
include side effects + contraindications.
What is Isolated systolic HTN and who does it happen to?
It should be suspected in a person (especially > 60 years) with systolic pressure of at least 160 mmHg and a diastolic pressure below 90 mm Hg. NO DIFFERENCE IN MANAGEMENT.
Investigation for essential hypertension:
- Under 40 with stage 1 HTN and no evidence of end-organ damage —> refer for secondary HTN investigations
- Consider Rx if under 60 with stage 1 HTN & QRISK3 < 10%
- Consider Rx in people >80 with Stage 1 HTN if clinic BP is > 150/90
- Any age with stage 2 HTN = Treat
- Start Rx if under 80 with stage 1 HTN and one or more of the following
- Target organ damage
- Established CVD
- Renal disease
- Diabetes
- QRISK3 ≥10%
- Use QRISK3 if cardiovascular risk >10% offer lipid modification therapy with atorvastatin ??
Secondary HTN – History, examination and investigation findings
Renal:
- Haematuria, polyuria, proteinuria and elevated creatinine
Phaeochromocytoma:
- Rare tumour of the adrenal glands, specifically from the chromaffin cells
- Dysregulated release of adrenaline and noradrenaline
- Paroxysmal symptoms. Anxiety or panic attacks, palpitations, tremor, sweating, headache, flushing, nausea. Labile hypertension, tachycardia, bradycardia, orthostatic hypotension
Aortic coarctation:
- Radio-femoral delay, systolic ejection murmur, diminished lower extremity pulses, differential upper and lower extremity BP
Renal artery stenosis:
Abdominal or flank bruits, or a significant rise in serum creatinine when starting an ACE-inhibitor may indicate renovascular hypertension
Conn’s syndrome/ primary hyperaldosteronism:
Hypokalemia
Cushing’s syndrome:
Osteoporosis, truncal obesity, round face, purple striae, muscle weakness, easy bruising, hirsutism, hyperglycemia, hypokalemia and hyperlipidemia
Complications of HTN
Increases the risk of:
Heart:
- Coronary artery disease
- LVH
- Heart failure
- Arrhythmias –> Infarcts
Stroke:
- Infarction. Big vs small.
Small –> cognitive decline, vascular dementia
Tiny aneurysms –> Haemorrhage
Chronic kidney disease
Peripheral artery disease
Single biggest risk factor for CVD. Half of all heart attacks and strokes are associated with HTN
Define ABPM and HBPM and what it involves:
Ambulatory blood pressure monitoring (ABPM) - monitor blood pressure over a 24-hour period of at least two measurements per hour
Use the average value of at least 14 measurements to confirm a diagnosis of HTN.
Home blood pressure monitoring (HBPM) – monitor blood pressure twice daily ideally in the morning and evening.
For each blood pressure measurement, advise the patient to record two consecutive measurements taken at least one minute apart whilst seated.
The patient should record their blood pressure recording for at least four days but ideally for seven days.
After 7-14 days discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of HTN.
Diagnosis of HTN
3 THINGS:
Target organ damage:
12-lead electrocardiogram (ECG) for left-ventricular hypertrophy (LVH)
Renal function tests (U&Es) and urine tests (proteinuria or albuminuria, haematuria) for renal impairment.
Eye screening/ fundoscopy for hypertensive retinopathy
Assess cardiovascular risk:
Hba1C, cholesterol
Calculate person’s 10-year risk of developing cardiovascular disease (CVD) using QRISK3 assessment tool (age, sex, ethnicity, smoking status, diabetes? FHx of heart issues, renal impairment, bp Rx, RA, cholesterol)
Management for HTN - targets
Use clinic blood pressure to monitor BP unless they have white coat HTN in which case you would also use ABPM or HBPM
Measure standing and seated BP in people with T2DM/ symptoms of postural hypotension/ aged ≥80
Aim for <140/90 in people <80 (<135/85 if using ABPM or HBPM)
Aim for <150/90 in people >80 (<145/85 if using ABPM or HBPM)
Use clinical judgement for people with frailty or multimorbidity
Management – Targets - Exceptions
Type 1 Diabetes:
- <135/85
- <130/80 if there is albuminuria, or 2 or more features of the metabolic syndrome
Chronic Kidney Disease (CKD) not diabetic
- Urinary ACR <70 mg/mmol: clinic bp <140/90
- Urinary ACR ≥70 mg/mmol: clinic bp <130/80
CKD with diabetes
- < 130/80
Management - Lifestyle
Diet
– low calorie diets, reduced saturated fat intake
- Aim for ≤ 6g/day salt
Exercise
– aerobic exercise (brisk walking, jogging or cycling) for 30-60 minutes, 3-5 times a week.
Weight loss – achieve ideal body weight
Alcohol – 14 units/week spread over 3 days or more
Relaxation therapies
Coffee
Smoking cessation
Red flag symptoms of accelerated or malignant HTN
Headache
Visual disturbances
Seizures
Nausea and vomiting
Chest pain
History- Symptoms suggestive of kidney disease as a secondary cause of HTN include:
Haematuria
‘Frothy’ urine suggestive of proteinuria
Dyspnoea (pulmonary oedema)
Lower limb swelling (peripheral oedema)
Flank tenderness and pain
Weight loss is suggestive of renal cell carcinoma
History- Symptoms suggestive of coarctation of the aorta as a secondary cause of HTN include:
Headache
Epistaxis
Intermittent claudication
Lower limb weakness
Cold legs and feet
History- Symptoms suggestive of endocrine disease as a secondary cause of HTN include:
Muscle weakness, muscle spasms and paraesthesia are suggestive of hyperaldosteronism.
Severe headache, palpitations and sweating are suggestive of pheochromocytoma.
Weight gain particularly abdominal, facial and on the back of the neck and shoulders is suggestive of Cushing’s syndrome.
Tall statures, swelling of the hands and feet and deepening of the voice are suggestive of acromegaly.
Weight gain, cold intolerance and low mood are suggestive of hypothyroidism.
Weight loss, heat intolerance and palpitations are suggestive of hyperthyroidism.
What is Coarctation of the aorta?
it is a birth defect in which a part of the aorta, the tube that carries oxygen-rich blood to the body, is narrower than usual.
What clinical examination should patients undergo to see if they suffer from hypertensive retinopathy
fundoscopy
