CVASC3 Flashcards by M G

How well did you know this?

Not at all

Perfectly

What key lifestyle factors should be addressed in patients with hypertension?

Smoking, nutrition, Alcohol and Physical activity according to guidelines.
Ask and advice about stress/workplace stress.
Diagnose and treat OSA
Review progress regulary.
Refer to other health professionals for ongoing follow up and support where appropriate

How well did you know this?

Not at all

Perfectly

Which patient perspectives are important to understand when managing hypertension?

Be aware of the factors affecting their adherence to management
Address patient understanding of the cause.
Explain the lack of symptoms in HTN
Address any concerns about adverse effects of therapy

How well did you know this?

Not at all

Perfectly

What are the treatment targets for hypertension?

Normal population and CVD high risk - 140/90 or less if tolerable

Diabetes with normal kidneys - 140/90

Secondary prevention of coronary artery disease - 130/80 (less than 120 if possible)

CKD - 130/80

Diabetes with albuminuria, proteinuria, or CKD - 130/80

How well did you know this?

Not at all

Perfectly

Starting ACE inhibitor dosage?

Ramipril 2.5mg to 10 mg orally daily.

Commence at low dose

Then increase gradually every 2 weeks after checking Potassium, Serum Creatinine level and HB (anaemia).

How well did you know this?

Not at all

Perfectly

Protocol for increasing ACE Inhibitor/ARB dosage - what would you do if there is a change in UEC?

Commence at low dose

Then increase gradually every 2 weeks after checking Potassium, Serum Creatinine level and HB (anaemia).

CHECK UEC 5-7 DAYS AFTER COMMENCEMENT

IF THERE IS A RISE IN SERUM CREATININE or Potassium :

IF S.Cr is GREATER THAN 25% of baseline OR if K is greater than 6 - STOP Ace/Arb - Suggests the patient may have bilateral renal artery stenosis

IF S.Cr is less than 25% baseline and K less than 6 - continue same dose and repeat UEC in 2 weeks time

Restrict dietary potassium for mild increases

How well did you know this?

Not at all

Perfectly

What is the triple whammy? Why is it dangerous?

ACEI or ARB

NSAID (including cox2)

Diuretic

Can Cause ACUTE KIDNEY INJURY

How well did you know this?

Not at all

Perfectly

What is the mechanism by which ACEI/ARB, NSAID and Diuretic can cause kidney damage?

ACEI ARB are usually renoprotective BUT can caused vasodilatation of the efferent renal arteriole - increases risk of AKI

Diuretic causes hypovolaemia

NSAID blocks prostacyclin synthesis which causes vasoconstriction of affernt arteriole.

Together they can cause significant damage

How well did you know this?

Not at all

Perfectly

Contraindications for ACE/ARB

Bilateral renal artery stenosis

Pregnancy

Allergy

How well did you know this?

Not at all

Perfectly

What are the adverse reactions of ACEI/ARB

Transient taste disturbance

ACE - Cough - usually transient - 15% can be long term - CHANGE OVER TO ARB

Hyperkalaemia

Hypotension (first dose - esp. in heart failure patients)

Pemphigus Vulgaris

How well did you know this?

Not at all

Perfectly

What do you know about metabolism of ACE and ARBs

ACE - renally excreted

ARB - liver metab

NSAIDS counteract action of both

How well did you know this?

Not at all

Perfectly

Starting dose of ARB?

Valsartan 80mg orally daily

Check uec in 5-7 days

if K is over 6 or S.Cr increases by 25% - STOP

if less than 25% - continue same dose for two weeks then recheck UEC

How well did you know this?

Not at all

Perfectly

Whats the mechnism of action of The Dihydropyridine CCB’s vs the NON dihydropydridine CCBs?

Dihydros - act on peripheral vascular smooth muscle (eg amlod, felod)

NON dihydros - act on the heart itself (Eg verap)

Dilt - acts on both

Thats why these are CI’d with BB’s and in pt’s with HF or HBlock

How well did you know this?

Not at all

Perfectly

ADR of Dihydropyridine CCBs?

Flushing

headaches

gum hypertrophy

nocturia

Ankle swelling in some

These can be used with BB

These can be used in HTN with ashtma

These can be used in HTN with Asthma

How well did you know this?

Not at all

Perfectly

If someone wants to commence a patient on a NON Dihydropyridine CCB - what would you suggest?

What are the ADR of NON dihydropyridine CCBs?

Make sure patient is not taking a Beta blocker.
Ensure patient does not have heart failure or heart Block.
PERFORM ECG prior to commencement to look specifically for HB

ADR - Constipation and Heart Block

How well did you know this?

Not at all

Perfectly

Whats the mechanism of action of a thiazide diuretic? Starting dose/regime?

Acts on Potassium/Sodium Cotransporter

12.5mg HCTz orally daily

CHECK Calcium Magnesium Sodium Potassium after 4 weeks

Advise patient to eat diet high in these elements - lentils, fibre, nuts

IF potassium drops - add amiloride OR change to ACE/ARB

How well did you know this?

Not at all

Perfectly

ADR of thiazides?

Hyperlipidaemia

Hyperglycaemia/DM

Gout

Impotence

Cramps/Muscle Weakness

Liver failure in pt with cirhossis

Pancreatitis

May aggravate BPH

How well did you know this?

Not at all

Perfectly

Patient on Thiazide diuretic - EGFR drops below 30 - what would you do?

Stop thiazide.

Commence on Loop or other alternate BP med.

How well did you know this?

Not at all

Perfectly

In which patients is thiazide diuretic appropriate?

Usu. elderly with good kidneys/prostate

If have kidney disease (GFR less than 50 or serum Cr over 150) or prostate issues - dont commence

How well did you know this?

Not at all

Perfectly

ADR of Loop diuretics?

Study These Flashcards

Deafness - ototoxicity

Reduces Sodium, Potassium, Calcium , Magnesium and Acid levels

Metabolic Alkalosis

GOUT

Mechanism of action of loop diuretics?

Study These Flashcards

Acts on Na/K ATPase

causes profound diuresis and vasodilation

Indications for use of Aldosterone antagonists?

Study These Flashcards

2nd line in HTN

Conns Syndrome (primary hyperaldosteronism)

Cirrhosis

Heart Failure

ADR of sprionolactone and aldosterone antagonists?

Study These Flashcards

Converts testosterone to oestrogen

THEREFORE ADR:

Testicular atrophy and gynaecomastia in males

In females - menstruation abnormality

Increases K and H - therefore Gastric ulcers/Dyspepsia/GORD

Initial dosage of Aldosterone antagonist?

Study These Flashcards

Spironolactone 12.5mg daily orally

OR Amiloride 2.5mg daily

_{increases K and H also}

_{REDUCES uric acid}

Amiloride

When could an alpha blocker be considered for HTN

Only case really is BPH and HTN Start with prazosin 0.5mg orally twice daily These drugs can increase the rates of CV events c/f with other drugs. especially in HFailure patients. CAN CAUSE POSTURAL HYPOTENSION (warn patients)

Under what circumstances would you prescribe a betablocker in HTN?

Heartfailure with reduced ejection fraction Also can be useful where HTN is combined with stable angina or after an MI. Start with 25mg metoprolol bd

Beta blockers are prohibited in which sports?

Billiards, Archery, Diuretics and Bblockers used to mask the performance enhancing drug

When is minoxidil indicated in hypertensive therapy? What are the precautions?

Only when not controlled by other drugs or are not tolerated. Always give with a) Loop diuretic (prevent overload) and b) another drug usually a BB (prevent tachycardia

What is treatment resistant hypertension?

Which centrally acting anti adrenergic agents are used in Hypertensive therapy? What's the main indication?

Methyldopa Monoxidine Clonidine PREGNANCY

When is monoxidine contraindicated?

In patients with heart failure. Associated with INCREASED MORTALITY

What happens if clonidine is stopped suddenly?

Its associated with severe REBOUND hypertension 12 to 36 hours later instead - halve dose every 2 to 3 days until 75mcg then stop Usual starting dose is 50mcg twice daily

Starting dose of methyldopa?

125mg orally twice daily

BASIC Initial investigations in a patient with HTN

**Fasting lipids** **Fasting Glucose** **Urea, Electrolytes and Creatinine** **Urine Albumin: Creatinine Ratio**

In which grade of hypertensive retinopathy would you see AV Nipping

Grade 2 Keith wagner staging 1 - silver wiring 2 - av nipping 3- Flame haemorrhages, Cotton wool spots, Hard exudates 4 - Pappiloedema SAFE CHAP

What is the Keith Wagner staging of hypertensive retinopathy?

Keith wagner staging 1 - silver wiring 2 - av nipping 3- Flame haemorrhages, Cotton wool spots, Hard exudates 4 - Pappiloedema

what symptoms are associated with cardiac tamponade

ELEVATED JVP MUFFLED HEART SOUNDS LOW BP Urgent transfer to hospital

What are the criteria for diagnosis of an inflammatory pericarditis?

**2 of the following 4 criteria:** pericarditic chest pain pericardial rub New widespread ST Elevation or PR depression on ECG pericardial effusion (new or worsening)

Symptoms of pericarditis?

Sharp, Pleuritic chest pain eased by sitting up or leaning forward worse when supine

Additional supportive findings in an inflammatory pericarditis

Elevated CRP, ESR. White cell count or evidence of pericardial inflammation on CT or CMRI

What is coronary artery calcium scoring

Its another form of cardiac risk stratification. Used in patients who are at intermediate risk to give them an individualised risk score. This test is not subsidised so patients need to weigh up the benefits relative to the financial outlay.

What are the major causes of sudden cardiac death? Screening of first degree relatives?

1. Structural Heart disease a) Hypertrophic cardiomyopathy (young) b) Congenital HD (young) c) arrhythmogenic right ventricular cardiomyopathy d) myocarditis e) CAD (mainly older) 2. Non structural Heart disease a) long qt syndrome b) brugada syndrome Genetic testing can be performed on tissue extracted from the dead person at autopsy. HYPERTROPHIC cardiomyopathy is AUTOSOMAL DOMINANT First degree relatives have 50% chance of carrying gene mutation All first degree relatives of SCD - 1. Echo, 2. ECG 3. REfer to cardiologist for genetic test

How is a true aneurysm defined?

Full thickness dilatation of blood vessel having at least 50% increase in diameter compared with expected

How do Thoracic aortic aneurysms present?

Usually silent - unless a complication occurs - Dissection or rupture. _{Symptoms in the chronic setting are usually due to compression of adjacent structures leading to flank, back, chest or abdo pain. if pressing on pulmonary nerves can get hoarseness, diaphragmatic compression.} Investigation of choice **CT angio or MRI** Most serious Cx - Dissection and Rupture **Rupture - severe pain, hypotension and shock** Thoracic aortic aneurysm or thoracoabdominal aortic aneurysm - **REFER vasc or cardiothoracic surg** - _repair usually at 6cm._

Risk factors for Aortic Dissection

1. Hypertension 2. Genetically mediated collagen disorders eg Marfans 3. Pre-existing aortic aneurysm 4. Bicuspid aortic valve 5. Aortic instrumentation or surgery 6. Aortic coarctation 7. Turners syndrome 8. Pregnancy and Delivery 9. Inflammatory diseases that cause vaculitis eg rheumatoid, takayasus arteritis,

Clinical features of aortic dissection

Can also get dyspnoea, and neuro symptoms like - horners syndrome, hemiparesis

What is the grading system for aortic aneurysms? For aortic dissections?

aneurysms - Crawford - 1 - 4 (starting proximally and going further down dissections - Stanford A - proximal Stanford B - Distal (Also Debakey 1-3)

CVASC3 Flashcards

(48 cards)