CVASC5

Question 1

Can Beta blockers affect mental health?

Answer 1

They can precipitate or exacerbate depression in certain individuals

Question 2

In most adults what is the diameter of the Abdominal aorta?

Answer 2

90% is less than 3.0cm

IN most adults greater than 3 cm is considered aneurysmal.

Question 3

Whats the natural history of AAA

Answer 3

Progressive expansion.

Depends on a) aneurysm diameter and b) other factors most important of which is SMOKING

Question 4

Risk factors associated with Aneurysmal disease?

Answer 4

Male

Older age

Cigarette smoking

Caucasian race

Atherosclerosis

FHx of AAA

HTN

Hypercholesterolaemia

other large artery aneurysm (illiac, femoral, popliteal)

Question 5

Rare causes of AAA

Answer 5

Marfans syndrome, Ehlers Danlos syndrome, collagen vascular disease, mycotic aneurysm

Question 6

How are Asymptomatic AAAs found?

Answer 6

INcidentally on imaging.

Majority of cases are asymptomatic

Question 7

HOw would a symptomatic, non ruptured AAA present?

Answer 7

Abdominal pain,

Back pain

Flank Pain

Also acute or chronic limb ischaemia

Systemic symptoms - fever, malaise

Question 8

How does a ruptured AAA present?

Answer 8

Hypotension, severe pain and pulsatile abdominal mass.

Rupture into peritoneal cavity is rapidly fatal.

Retroperitoneal rupture can transiently stabalise providing a window for lifesaving intervention.

Question 9

Imaging choice for asymptomatic AAA?

Answer 9

Abdominal ultrasound

Question 10

Imaging choice for symptomatic AAA?

Answer 10

Abdominal CT

Question 11

What are the appropriate surveillance intervals for AAA?

Answer 11

3-3.9cm - 24 months

4-4.5 - 12 months

4.6-5cm - 6 months

Greater than 5 - 3 months

Question 12

Indications for AAA repair?

Answer 12

Male with AAA greater than 5.5 cm

Female with AAA greater than 5 cm

Rapid growth greater than 1cm a year

Symptomatic AAA (abdominal/back pain/Distal embolization)

Question 13

Tenderness in multiple areas over the costosternal or costochondral junctions; Palpation reproduces the pain; No associated swelling; Mostly affects 2nd to 5th ribs

Answer 13

Costochondritis

Question 14

Pain in the lower chest or upper abdomen, with a tender spot on the costal margin, pain reproduced by pressing on the spot.

Answer 14

Lower rib pain syndrome.

Question 15

Localised tenderness over the body of the sternum or sternalis muscle; palpation often causes radiation of pain bilaterally

Answer 15

Sternalis syndrome

Question 16

Localised pain possibly 3-4 cm from the midline, and possibly referred pain ranging from the posterior midline to the lateral chest wall and anterior chest pain

Movement of the rib provokes pain at the costovertebral joint and reproduces referred pain

Answer 16

Thoracic costovertebral joint dysfunction

Question 17

Widespread muskuloskelatal pain and tenderness, poor quality unrefreshing sleep, fatigue, cognitive disturbance (not accounted for by other condition)

Answer 17

Fibromyalgia

Question 18

Swelling and/or tenderness of multiple large and/or small synovial joints, positive for RF and Anti Citrullinated Protein antibodies, abnormal C Reactive protein and erythrocyte sedimentation rate

Answer 18

Rheumatoid arthritis

Question 19

Back pain for 3 months or longer, with onset under 45 years of age, together with either:

Imaging features of sacroillitis on MRI or XRay and one other feature of SpA

HLA B27 and two other features of SpA

Answer 19

Axial Spondyloarthropathy (including ankylosing spondylitis)

Question 20

Inflammatory articular disease (Joint, spine or entheseal) with three out of five of the following:

1. Evidence of current psoriasis, past history or family history of psoriasis
2. Current psoriatic nail changes
3. Negative for rheumatoid factor
4. Current or a history of dactylitis
5. Radiographic evidence of juxto-articular new bone formation on plain radiographs of the hand or foot

Answer 20

Psoriatic arthritis

Question 21

Acute back pain, loss of height or kyphosis for thoracic spine fractures, acute localised pain for rib fractures, Corticosteroid use and other Osteoporosis risk factors for both.

Answer 21

Osteoporotic fracture

Question 22

Severe and/or night pain, and associated non musculoskeletal symptoms

Answer 22

Neoplasm with pathological fracture or bone pain

Question 23

What are the common causes of musculoskeletal chest wall pain?

Answer 23

1. Isolated musculoskeletal chest wall pain
   - Costochondritis

Sternalis syndrome

Lower rib pain syndrome

Thoracic costoverterbral joint dysfunction

2. Rheumatic causes

fibromyalgia

psoriatic arthritis

rheumatoid arthritis

axial spondyloarthropathy (including ankylosing spondylitis)

3. Non rheumatic systemic causes

Osteoporotic fracture

Neoplasm with pathological fracture or bone pain

Question 24

How would you treat isolated muculoskeletal chest wall pain?

Answer 24

Reassurance and explanation for all patients

Temporarily avoiding aggravating activities

Stretching

Application of heat for muscle spasm or ice for swelling

Simple analgesia

Consider formal physiotherapy if symptoms persist for biomechanical assessment and graduated activity/mobilisation

Injection of local anaesthetic/corticosteroid may be indicated in severe cases (esp for night pain or morning stiffness).

Question 25

How do we determine whether to start BP lowering meds?

Answer 25

Absolute CVD _{(if Sustained BP's over 160/100 - commence regardless of risk)}

Question 26

How do you treat A patient with subclinical end organ damage and hypertension

Answer 26

Needs drugs as well as non pharm Mx

Question 27

Diastolic BP is more commonly elevated in which group?

Answer 27

Younger than 50 With age - systolic becomes the issue

Question 28

What are the risks of uncontrolled HTN

Answer 28

CVA, cognitive decline, MI, HF, CKD and premature death

Question 29

Reno-vascular damage from HTN can lead to?

Answer 29

A treatment resistant state

Question 30

Epidemiology of HTN?

Answer 30

6 million Aussies 4 million with uncontrolled or untreated 25% of ATSI adults have untreated HTN Higher rates of HTN with lower socioeconomic status

Question 31

Trouble shooting home BP cuffs?

Answer 31

- Ensure **appropriate sized** cuff for patients arm. - Ensure meausring devices are appropriately maintained, validated and regularly **recalibrated to manufacturers** standards - If patient has **irregular heart rate** - needs manual BP

Question 32

A patient presents with postural dizziness - how would you measure their BP?

Answer 32

1. Initial measurement with patient supine or seated. 2. Repeat the measurement after patient stands for ONE MINUTE - If **systolic** BP falls by **20mmHg** then: 1. Review meds 2. Do future BPs with patient standing 3. Consider specialist review if symptoms of Postural Hypotension persist

Question 33

What methods are available for measuring Bp?

Answer 33

1. Automated clinic measurement. 2. Non automated clinic measurement 3. Home BP monitoring. 4. Ambulatory BP monitoring. ATYPICAL BP presentations such as: a) white coat b) masked HTN c)nocturnal non dipping CAN BE DETECTED BY: _Taking multiple measurements on separate occasions_

Question 34

Advantages of ambulatory BP monitoring?

Answer 34

Most accurate and comprehensive information Reveals variations in daily life Particularly useful if atypical presentations are suspected, but not practical for routine use.

Question 35

How should home BP's be measured

Answer 35

Home BP should be measured using * A **validated, automatic BP device (preferably with memory storage), using an appropriately sized upper arm cuff.** * **Measurements should be taken after five minutes of seated rest and before medication, food or vigorous exercise.** * BP should be **recorded for seven days (five days minimum) in the morning and evening (two readings each).** * Overall, **home BP is the average systolic and diastolic BP over seven days (excluding the first day);** an **average of ≥135/85 mmHg is indicative of hypertension.**

Question 36

NICE guideline for diagnosing HTN?

Answer 36

1. If clinic BP reading is over 140/90 take a second durin consult If that is also higher Take a third. RECORD lower of the last two measurements as the clinic BP. 2. If BP is 140/90 offer ambulatory BP recording to confirm the diagnosis. 3. If Person has severe hypertension consider commencement of medications immediately without awaiting results of ABPM or HBPM

Question 37

What should be done whilst waiting for a confirmation of hypertension?

Answer 37

1. Investigations to exclude end organ damage. 2. Absolute cardiovascular risk assessment

Question 38

How would you use ABPM to confirm a diagnosis of HTN?

Answer 38

- Ensure 2 measurements per hour during patients normal waking hours. - Take average of at least 14 measurements to calculate BP.

Question 39

What are the indications for Ambulatory Blood pressure monitoring?

Answer 39

Suspected white-coat hypertension (including in pregnancy) • Suspected masked hypertension (untreated subject with normal clinic BP and elevated ABP) Suspected nocturnal hypertension or no night time reduction in BP (dipping) * Hypertension despite appropriate treatment * Patients with a high risk of future cardiovascular events (even if clinic BP is normal) • Suspected episodic hypertension.

Question 40

When is ABPM not appropriate?

Answer 40

No specific contraindications. If HTN is severe - Greater than or equal to 180/110 shouldnt delay commencement of meds In Arrhythmia or AF may be inaccurate

Question 41

What advice do you give patient about ABPM?

Answer 41

* the device will automatically inflate the cuff and measure BP periodically over a 24 hour period * book to have the monitor fitted * cannot get the device wet - attend after bathing * Patients should continue with their normal daily activities, preferably including a work day rather than a rest day * Take all their usual meds * the cuff starts to inflate the patient should stop moving and talking, keep the arm still and relaxed, and breathe normally * avoid activities that may interfere with the device such as vigorous exercise * Keep diary of activities is important to record timing of activities, sleep, taking of medicines, posture and symptoms (eg. dizziness) that may be related to BP. * No medicare rebate at the moment

Question 42

What is the grading of ABPM and HBPM for diagnosing severity of HTN?

Answer 42

Average BP during the DAY is greater than or equal to **135/85** (**stage 1)** _Stage 2: 150/95_

Question 43

Clinic BP staging of HTN?

Answer 43

Stage 1 greater than or equal to 140/90 Stage 2 greater than or equal to 160/100 Stage 3 greater than or equal to 180/110

Question 44

Patient presents with hypertension and increasing jaw size during adulthood, with increasing glove size and need to increase size of finger rings. What cause should be considered? How would you test for it?

Answer 44

**Acromegaly** Insulin like Growth Factor 1 **IGF 1**