Clinical Presentation of severe hypertension &Severe Hypertension: Understanding the Patholog

Question 1

What BMI is considered high (obese) in white and asian people

Answer 1

white - 25

asian- 23.9

Question 2

Case: 45y/o bank executive, BMI 31.5, unfit and wants to join a gym, smokes 30/day, BP 200/120, alcohol 1 glass wine daily, nil drugs.
What would you advise his PT at the gym?

A. encourage regular exercise

B. ban him from doing any exercise at all and recommend rest adn repeat of his BP

C. advise him to see his GP beofre allowing him to exercise in the gym

D. refer him to casualty for blood pressure control

Answer 2

A. encourage regular exercise

Question 3

if someone has hypertension what would you look for

Answer 3

Fundoscopy

Question 4

What happens in the different grades of hypertension?

Answer 4

Grade 1: silver wiring

Grade 2: AV nipping

Grade 3: flame shaped haemorrhage

Grade 4: papilloedema

Question 5

What could papilloedema indicate

Answer 5

high ICP- possibly brain tumour

hypertension

Question 6

WHat are feature of long standing hypertension exist

Answer 6

left ventricular hypertrophy (ECG)

feel a heave

hear a bruit

hear an S4

Question 7

WHat grade is this

Answer 7

grade 3

see flame haemorrhage

Question 8

What are 6 causes of hypertension

Answer 8

1. Conn’s
2. Cushing’s
3. Phaechromocytoma
4. renal artery stenosis
5. Acromegaly
6. co arctation of the aorta
7. essential

Question 9

What are investigation would you like to do?

if someone presents with hypertension

Answer 9

• FBC
• U&E low K+ high Sodium
• ECG look for LVH
• Urinalysis (renal disease and nephritis)
• Fasting glucose
• Lipids

Question 10

What percentage of people have secondary hypertension

Answer 10

10%

Question 11

What are specific investigations to diagnose secondary causes of hypertension

Answer 11

renin aldosterone ration

24 hour urine for catecholamines

24 hour urine cortisol

glucose tolerance test

Question 12

Someone presents with

renin 0.4 (1.1-4.5)

aldosterone 1600 (100-450)

24 hour urine catecholamine normal

What does he have

Answer 12

Conn

Question 13

How do you treat conn’s

Answer 13

surgery remove it

Question 14

patient presents with

renin: 7.4 (1.1-4.5)
aldosterone: 900 (100-450)

24 hour urine catecholamines is normal

What does this patient have

Answer 14

renal artery stenosis

Question 15

What is the gold standard way of diagnosing renal artery stenosis

Answer 15

Digital subtraction angiogram

Question 16

what does this patient have?

Renin: 2.4 (1.1 -4-5)

Aldosterone: 300(100-450)

24 hour urine for catecholamines RAISED

Answer 16

phaechromocytoma

Question 17

how does phaechromocytoma present?

Answer 17

anxiety

palpitation

headache

sweating

Question 18

What is the treatment for phaechromocytoma?

Answer 18

MEDICAL EMERGENCY

alpha blockade

Question 19

How do you manage a phaechromocytoma

Answer 19

1. alpha blockade (rehydrate if needed)
2. beta blockade
3. localise the lesion
4. surgery (many weeks after alpha blockade)- laprascopic adrenalectomy

Question 20

What does an MIBG scan show

Answer 20

is a radioactive scan and shows where the tumour is

the bladder always lights up

Question 21

How do you treat essential hypertension?

Answer 21

Over 55 or afrocaribean

1. CCB or thiazide
2. add an ACE to either
3. CCB and ACE and Thiazide

under 55

1. ACE
2. add a thiazide or CCB
3. CCB and ACE and Thiazide

Question 22

After a myocaridal infarction or angina, what anti hypertensive would give the most benefit?

Answer 22

beta blocker

very good for MI and angina strongly encaouraged

Question 23

When do you not give a beta blocker

Answer 23

severe heart failure

heart block

Asthma COPD

Question 24

When do you not give an ACE OR ARB?

Answer 24

renal impairement

Peripheral vascular disease

pregnancy

renovascular disease

Question 25

When do you not give a thiazide diuretic?

Answer 25

Gout

Question 26

What antihypertensive drugs activate and which decreases the activity of the RAAS system

Answer 26

_decrease RAS_ ACE/ARB b blocker _increase RAS_ Thiazide CCB

Question 27

A 65 year old patient with previous MI has a BP of 140/80 on atenolol What do you do ?

Answer 27

add a thiazide or CCB to reach 120/80 STUDY showed it reduced their death Especially if he had a previous MI

Question 28

What is the optimal medical therapy for someone that has had an MI

Answer 28

1. **intensive lifestyle modification** 2. **aspirin** 3. **high atorvastatin** 4. **optimal blood pressure** 5. **assess for type 2**

Question 29

If someone has a had an MI, at what level do you want their blood pressure to be?

Answer 29

120/80 really strict because improves survival

Question 30

How does PCSK9 drugs work?

Answer 30

lowers cholesterol by binding to the LDL receptor and causes it to be destroyed by a lysossome instead of being recycled EXAMPLE DRUG EVOLOCUMAB

Question 31

does PCSK9 work

Answer 31

Didn't reduce death no effect on mortality only use in people with familial hypercholesterolaemia

Question 32

Case: 45y/o bank executive, BMI 31.5, unfit and wants to join a gym, smokes 30/day, BP 200/120, alcohol 1 glass wine daily, nil drugs. Is this man a) normal BMI b) overweight c) obese d) severe obesity e) morbid obesity?

Answer 32

Obese.

Question 33

What do you see on fundoscopy of grade 1

Answer 33

Silver wiring

Question 34

What do you see on fundoscopy of grade 2 hypertension?

Answer 34

Silver wiring. AV nipping.

Question 35

What do you see on fundoscopy of grade 3 hypertension?

Answer 35

Silver wiring. AV nipping. Flame haemorrhage.

Question 36

What do you see on fundoscopy of grade 4 hypertension?

Answer 36

Silver wiring. AV nipping. Flame haemorrhage. Papilloedema. Cotton wool spots and hard exudates.

Question 37

What does hypertensive retinopathy suggest?

Answer 37

Hypertension is severe and prolonged.