What is Q-risk?
How likely you are to have a cardio-vascular event in the next 10 years.
What is hypertensive retinopathy? What changes would the GP expect to see on the retina with a Grade 2 hypertensive retinopathy?
What is a renal bruit? What condition might this suggest and how might it produce secondary hypertension?
Briefly outline the mechanisms that regulate arterial pressure?
Basically the baroreceptors and the renin-angiotensin-aldosterone system
Blood pressure in the arterial system is regulated by:
Cardiac output: This is increased by sympathetic activity that increases heart rate and cardiac contractility. Baroreceptors in aortic and carotid sinuses are responsible for detecting fall in BP and increasing sympathetic activity. Cardiac output is also regulated by venous return to the heart. This is increased by decreased by constriction or dilation of the venules respectively.
Peripheral resistance: Increasing this in the arterioles increases blood pressure and is regulated by a number of mechanisms, Angiotensin 2, a vasoconstrictor will act following the activation of the Reninn-Angiotensin-Aldosterone-System when BP changes are detected in the kidneys ( it will also have an effect on blood volume- see below) Sympathetic activity will also produce arteriole vasoconstriction
Blood volume: regulated by salt and water retention in the kidneys through ADH( vasopressin) and aldosterone.
When would you suspect hypertension in a patient?
- If systolic blood pressure sustained above or equal to 140 mmHg, or diastolic blood pressure sustained above or equal to 90 mmHg, or both.
- The diagnosis is then confirmed with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)
How does hypertension damage the blood vessels?
- Though process of arteriosclerosis. This is often known as 'hardening of the arteries' and refers to loss of elasticity within the tunica media. Arteries are more rigid and less able to expand with increased blood volumes. One form of arteriosclerosis is atherosclerosis which refers to atherosclerotic plaque formation which tends to occur in the larger arteries.
- Hypertension has a complex role in the development of atherosclerotic plaques, but it does damage the endothelium and acts synergistically with other risk agents to increase oxidative stress.
What is end organ damage?
How hypertension can cause damage to organs in the long run. Organs that may be damaged by hypertension:
retina – hypertensive retinopathy, test using fundoscopy (allows to see inside the eye).
heart – left ventricular hypertrophy and heart failure, test using ECG
kidneys- hypertensive nehropathy, test using urinalysis.
For this reason, all patients with newly diagnosed hypertension should be assessed for target organ damage with fundoscopy, urinalysis for blood and protein and a 12 lead ECG to assess for left ventricular hypertrophy.
How does hypertension cause left ventricular hypotrophy?
Untreated hypertension increasing peripheral arterial resistance meaning that the heart has an increased 'after load' and has to pump harder to overcome this resistance. As a result, the cardiac myocytes compensate by hypertrophy over time; the ventricular wall becomes thicker, stiffer and eventually less efficient.
What changes on an ECG would show LVH?
ECG changes in LVH may include:
- a tall R wave (greater than 25mm in V5 or V6), or R plus S greater than 35 mm (1)
- a deep S in V1 or V2
- if there is significant left ventricular 'strain' then there are also inverted T waves in V5 and V6 and possible ST depression
- left axis deviation may also be present
What is hypertensive retinopathy? What changes would you expect to see on the retina with a Grade 2 hypertensive retinopathy?
- Hypertensive retinopathy is retinal vascular damage caused by hypertension.
- Funduscopic examination shows arteriolar constriction, arteriovenous nicking (a small artery is seen crossing a small vein, which results in the compression of the vein with bulging on either side of the crossing), vascular wall changes producing 'silver wiring', flame-shaped hemorrhages, cotton-wool spots, yellow hard exudates, and optic disk edema. Treatment is directed at controlling BP and, when vision loss occurs in the severe stages of the disease, treating the retina
Grade 2 retinopathy is characterised by observing changes in the thickened arteriole walls which look like silver wiring ( copper wiring at an earlier stage), and arteriovenous nipping.
What is a renal bruit, and what does it indicate?
A 'bruit' is a sign where normally inaudible vascular flow is heard through a stethoscope. It is often produced where a vessel is thickened or narrowed.
A renal bruit can be detected by placing the stethoscope on the abdominal wall and listening for abnormal flow murmurs
Its presence suggests renal artery stenosis, narrowing of either one or both renal arteries, either by atherosclerosis or fibromuscular dysplasia (abnormal growth within the wall of an artery). Reduced renal blood flow leads to renal hypotension and compensatory over activation of the renin angiotensin system, leaving to secondary hypertension.
List three ways left ventricular hypertrophy can be diagnosed clinically?
- Displaced apex beat on cardiovascular examination
- Changes to suggest left ventricular hypertrophy on an ECG: a tall R wave (greater than 25mm in V5 or V6), or R plus S greater than 35 mm, a deep S in V1 or V2, if there is significant left ventricular 'strain' then there are also inverted T waves in V5 and V6 and possible ST depression, left axis deviation may also be present, QRS may be slightly prolonged
- An enlarged left ventricle may be seen on a Chest X-Ray.
A 55-year old man with hypertension was started on ACE inhibitor and was advised to follow up if he becomes intolerant to its side effects. Select the most common side effect of this drug:
Shortness of breath
A 57-year-old male is brought into A&E from a restaurant after developing breathing difficulties and swelling. His wife says he has an allergy to peanuts. On examination, he has swelling of his lips and around his eyes, you can hear stridor (a high-pitched, wheezing sound caused by disrupted airflow) and there is widespread wheeze on auscultation. He is tachycardic, dyspnoeic, hypotensive. Select the type of shock that best fits this scenario:
A 72- year old man with a previous diagnosis of heart failure complains of ankle swelling and is slightly more short of breath than usual. His current medications are bisoprolol, and ramipril and Indapamide, his blood tests show mild hypokalaemia.
Select the drug that should be added to his treatment:
A 72-year-old man with hypertension sees his GP for a medication review. His medicines are amlodipine, ramipril, propranolol, doxazocin and clonidine. One of these medications is an agonist, select the receptors that have been activated by this agonist.
Alpha 1 adrenoceptors
Alpha 2 adrenoceptors
Beta 1 adrenoceptors
Angiotensin converting enzyme
A new whooping cough vaccine is alleged to cause neurological damage in a number of infants. Select the most appropriate study design needed to address the research question ‘Did the vaccine cause brain damage?'.
Case control study
Cross sectional survey
Prospective cohort study
Randomised control trial
A patient has primary hypertension (essential), when taking the patients history, the healthcare provider anticipates the patient will report the following, select the best answer.
‘Every once in a while I wake up at night covered in sweat’
'I get chest pain when running for the bus'
‘I have not noticed an significant changes in my health’
‘I’m starting to get out of breath when I go up a flight of stairs’
‘Sometimes I get pain in my lower legs when I take my daily walk’
‘I have not noticed an significant changes in my health’
In normal circulation, which organ or vessel contains the largest volume of blood at any moment?
What do ACE inhibitors end with?
Recently, a freight train derailment resulted in a large chlorine spill in the town of Kluang. A random sample of town residents was selected to participate in a study that aims to investigate whether the spill has residual health effects on the community. The residents are categorized into an exposed group (within 1 mile radius of the spill) and an unexposed group (outside the 1 mile radius). They are then asked about various respiratory symptoms they may be experiencing at present. Select the study design used in this study:
Prospective cohort study
Retrospective cohort study
Select the anterior boundary of the mediastinum:
Thoracic vertebra 5 (T5) to Thoracic vertebra 12 (T12)
Sternum and transversus thoracis muscles.
Select the best description of the course of lymph drainage from the left bronchomediastinal trunk to the venous system.
Directly into the left brachiocephalic vein
Via the jugular trunk
Via the parasternal nodes
Via the tracheobronchial nodes
Via the thoracic duct
What is the correct equation for mean arterial pressure (MAP)?
Select the factor that controls blood flow in the arterial system during diastole:
Diastole is driven by continued ventricular contraction
Diastole is driven by the closing of heart valves
Diastole is driven by the elastic recoil of the major arteries
Cardiac contraction force is greater during systole
It is unimportant to maintaining capillary blood flow during this phase of the cardiac cycle
Select the layer of the aortic wall that contains concentrically arranged elastic lamellae:
External elastic lamina
Internal elastic lamina
Select the number that corresponds to the trachea in MRI taken at level T4 that is shown below.
Select the mechanism through which the kidney helps to restore homeostasis following haemorrhage.
It decreases sodium reabsorption
It decreases water reabsorption
It increases glomerular filtration rate
It increased medullary blood flow
It increases renin secretion
Select the statement that best describes the composition of an arterial blood vessel wall relating to its function:
Arterioles don’t have smooth muscle in tunica media to allow fluids containing gases, waste products, and metabolites to move through their walls.
Fenestrated capillaries are found in sites of fluid or metabolite absorption and are lined by endothelial cells characterised by the presence of numerous circular openings that provide channels across the capillary wall.
The tunica media of muscular arteries is composed almost entirely by elastic materials which play an important role to the distributing function of the blood vessel.
The endothelial cells lining the arteries only provide a physical barrier between the circulating blood and the subendothelial tissues.
Vascular smooth muscle cells in the tunica media mainly limit the distension of the elastic arteries during systole.
Select the vessels that constitute the microvascular bed of a tissue.
Capillaries and arterioles
Capillaries, arterioles, and post capillary venules
Capillaries, arterioles, post capillary venules, and veins
Capillaries, arterioles, post capillary venules, veins, and arteries