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OD3 (S1&2) > DIS - Diseases of the Vasculature III: Hypertension - Week 11 > Flashcards

DIS - Diseases of the Vasculature III: Hypertension - Week 11 Flashcards

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1
Q

Define the following:
Essential/primary hypertension
Borderline
Normotensive
How many readings are required?

A

Essential
-BP >160/95mmHg
Borderline
-BP 140/90 to 160/95
Normotensive
-BP <140/90
3 readings on separate occasions

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2
Q

What diastolic BP is considered too high and worthy of reducing?

A

Anything over 100mmHg (in general)

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3
Q

List four things BP is considered in relation to.

A

Serum cholesterol
Race
Age
Family history

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4
Q

Define malignant hypertension. What is it associated with and in what two organs?

A

> 120mmHg diastole
Associated with exudative vasculopathy in the retina and kidney

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5
Q

What percentage of hypertension cases are secondary?

A

5%

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6
Q

What two types of conditions cause secondary hypertension? Give some examples for each.

A

Renal conditions
-nephritis, renal failure, tumour
Endocrine conditions
-diabetes, hyperthyroidism, parathyroidism

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7
Q

What five things is the degree of BP an accurate predictor of?

A

Coronary artery occlusion
Stroke
Renal failure
Heart failure
Peripheral vascular disease

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8
Q

Is there some risk of pathology even at normal blood pressures?

A

Yes

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9
Q

List three things that can happen to the brain due to hypertension.

A

Atherosclerotic/endarteritic damage to cerebral vessels
TIA
Stroke

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10
Q

List two things that can happen to the kidney due to hypertension.

A

Enarteritic changes in the renal bed
Ultimate renal failure from sclerosis

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11
Q

List two things that can happen to the heart due to hypertension.

A

Left ventricular hypertrophy - cardiac failure
BP damage to cardiac vessels - myocardial infarction

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12
Q

Do patients with similar blood pressure have similar or different ocular signs?

A

Different - variable relatinoship between measured blood pressure and retinopathy

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13
Q

What percentage of hypertension patients have a normal fundus?

A

~1/3

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14
Q

Why does constriction of arterioles occur with hypertension and what is it in response to exactly (2)?

A

Lumen narrows to maintain blood flow as perfusion pressure drops
-autoregulation to decreased peripheral resistance

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15
Q

What are two consequences of constricted arterioles on the retina (fundus appearances)?

A

Attenuation
Focal constriction

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16
Q

How does arteriolar sclerosis affect vessel wall transparency? What fundus appearance does this give?

A

Loss of transparency
-increased reflex and copper wiring

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17
Q

Does arteriolar sclerosis cause lumen narrowing? What fundus appearance does this give?

A

Yes
-nicking

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18
Q

What happens to veins at AV crossings due to arteriolar sclerosis? What fundus appearance does this give?

A

Deflection
-right angle Xing

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19
Q

How is the lumen of veins affected by arteriolar sclerosis? What fundus appearance does this give?

A

Compression
-banking

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20
Q

List three signs of first degree hypertension. Describe its clinical significance.

A

Focal arteriolar constriction
Banking (a form of crossing change)
Isolated flame haemorrhage
Lower clinical significance

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21
Q

Is first degree hypeltension related to accelerated or non-accelerated blood pressure?

A

Non-accelerated

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22
Q

List five signs of second degree hypertension. Describe its clinical significance.

A

Numerous flame haemorrhage
Retinal lipid/exudate
Cotton wool patches
Retinal vessel occlusion
Papilloedema

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23
Q

Is second degree hypertension related to accelerated or non-accelerated blood pressure?

A

Accelerated

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24
Q

List the four grades of hypertension according to the wong and mitchell grading system for hypertensive retinopathy.

A

No retinopathy
Mild retinopathy
Moderate retinopathy
Malignant retinopathy

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25
List four signs suggestive of mild hypertensive retinopathy.
One or more of the following Generalised arterial narrowing Focal arterial narrowing AV nicking Silver wire
26
List four signs suggestive of moderate hypertensive retinopathy.
One or more of the following Haemorrhage (dot/blot/flame) Microaneurysm Cotton wool spots Hard exudates
27
List two requirements for malignant hypertensive retinopathy.
Moderate retinopathy signs plus optic disc oedema
28
Within how many disc diameters are focal arteriolar constrictions most readily seen? How does it appear on funduscopy?
1-2DD of the disc Alternating zones of passive dilation and spasm
29
Does the presence of focal arteriolar constriction have good or poor sensitivity and specificity for systemic hypertension?
Good for both
30
Comment on the presence of banking in terms of hypertension possibility.
A reliable guide to possibility of hypertension
31
Where is banking commonly seen?
AV crossings
32
Describe how banking appears and what it means.
Restriction of venous return Upstream dilation of the vein -distal vein calibre > proximal side
33
What does banking indicate?
Significant interruption to venous blood flow
34
What does banking increase the risk of (3)?
Thrombus formation (eventual venous occlusion) Vein's endothelium may become sticky Risk of platelet adhesion to walls
35
What may bypass banking?
Shunt vessels
36
Is hypertension a common cause of flame haemorrhage?
Yes
37
What is a flame haemorrhage? Where does blood run along?
Leakage of superficial capillaries into the NFL -seepage along axon bundles
38
What three things are flame haemorrhages indicative of?
Vascular occlusive disease Diseases specifically affecting blood viscosity Diseases affecting integrity of vessel wall
39
List 6 differential diagnoses for flame haemorrhages.
Glaucoma Papillitis Papilloedema Following acute PVD Diabetic retinopathy Retinal vein occlusion
40
What type of glaucoma are flame haemorrhages especially likely?
Low tension
41
What causes cotton wool patches? Is it ischaemic
Occlusion of minor arterioles/capillaries supplying NFL -ischaemia with resultant cloudy swelling of axons
42
Within what timeframe do cotton wool spots appear of infarction?
Within 24h of infarct
43
List 7 diseases aside from hypertensive retinopathy where cotton wool spots can be found.
AIDS Diabetes Carotid artery stenosis Systemic diseases with ischaemic manifestations SLE CVO/BVO Anaemia
44
How long do cotton wool spots often persist for?
6 weeks
45
Can cotton wool spots cause vison loss?
Often not, but will if axons rupture from oedema
46
Is papilloedema inflammatory?
No
47
What causes papilloedema with hyerptension?
Stasis/blockage of axoplasmic transport
48
Describe how papillodema appears in hypertensive retinopathy.
Visible disc swelling and indistinct margins
49
What four other things are you likely to see if papillodema is present in hypertensive retinopathy?
Venous engorgement Exudates Flame haemorrhages Cotton wool spots
50
What is blood pressure probably like if papilloedema is present in hypertensive retinopathy?
Very high
51
What two things should papilloedema be differentiated from if you suspect hypertensive retinopathy?
Retinal/optic nerve disease (RVO/RAO/AION, papillitis etc) Intracranial masses/pseudotumour
52
Does papilloedema require urgent referral if it is secondary to hypertension?
Yes
53
Which of the following may be seen with hypertensive retinopathy: Vein occlusion (CRVO/BRVO) Retinal arteriolar aneurysm Non-arteritic AION
All three are possible
54
Which of the following have high sensitivity for blood pressure? Dot/blot haemorrhages Microaneurysms Sub-retinal haemorrhages Pre-retinal/sub-hyaloid haemorrhages Arterial atheromatous plaques/emboli Vein Sheathing Tortuous veins/venules Shunts/collaterals Arteriolar straightening/attenuation Arteriovenous nicking (Gunn's sign) Right angle AV crossing
All have poor sensitivity
55
What is arteriolar attenuation? What changes occur to bifurcations?
Arterioles are straight over extended portions -bifurcations are acute-angled
56
What two things aside from hypertensive retinopathy can arteriolar attenuation occur secondary to?
Retinal arterial occlusion Toxic states
57
What is gunns sign?
AV nicking
58
Describe the appearance of AV nicking.
Blood column in veins appears narrowed just upstream and downstream of the crossing
59
Is AV nicking the same as banking?
No
60
What is sallus' sign?
A right angle AV crossing
61
What two choroidal changes may be present with hypertension?
Elschnig's spots Siegrist's streaks
62
What are elschnigs spots? What is it mainly seen in? Does it have any visual significance?
Mainly in toxaemia Numerous, small RPE detachments (1/4DD) Little visual significance
63
What are siegrist's streaks? What do they follow?
Fine pigment lines following choroidal vessels which have sclerosed and occluded
64
List the following in order of probably importance in detecting early hypertension: Banking Vascular occlusions evidenced by flame haemorrhages, lipid exudates, vein sheathing, and CWP Atherosclerosis in other signs Focal arteriolar constrictions
Focal arteriolar constrictions Vascular occlusions evidenced by flame haemorrhages, lipid exudates, vein sheathing, and CWP Banking Atherosclerosis in other signs
65
You should refer to a GP when you see what four signs of recent origin?
Haemorrhages Cotton wool spots Papilloedema CRVO/BRVO
66
You should refer to an ophthalmologist when you see what three recent vascular occlusions?
CVO/BVO AION Macroaneurysm
67
List the types of stroke and their percentages. Also note their cause.
Ischaemic - from thrombosis/embolus (80%) Haemorrhagic - vascular rupture (20%)
68
For stroke and CVA, describe the proportion of cases with recovery, severe residual handicap, and death.
1/3rd recover 1/3rd suffer severe residual handicap 1/3rd die
69
What is a TIA?
Transient ischaemic attack -stroke symptoms lasting <1h
70
What is the timeframe for a TIA.
Must be <24h
71
What damage occurs with TIA (2)?
Often no damaage -any damage that occurs is less severe than stroke
72
List 8 general symptoms of stroke. Do they occur slowly or suddenly?
Numbness Parasthaesia Weakness Paralysis of contralateral limb/face Aphasia Confusion Visual disturbance in one or both eyes Headache
73
What do neurological deficits seen during a stroke reflect?
The area of the brain involved
74
Would you expect to see unilateral or bilateral symptoms if there is an anterior circulation stroke? What about posterior? Which of the two is more likely to affect consciousness? What artery is often involved?
Anteiror - unilateral Posterior - can be both Posterior more likely to affect consciousness -especially if basilar artery affected
75
What three things are the visual signs of a completed stroke dependent on?
Location/blood vessels affected Type of stroke Effect on cranial nerves
76
List 8 predisposing factors to stroke.
Age Atherosclerosis Hypertension (uncontrolled) Diabetes Smoking High HDL/LDL levels Sedentary lifestyle Blood viscosity disorders
77
What four things does occlusion of the internal carotid artery often prodrome with?
TIA Amaurosis Speech Tingling/sensations
78
Does occlusion of the internal carotid artery often produce symptoms initially?
Often not
79
What is a transient ischaemic attack exactly? What three neurological dysfunctions can it cause
Episodes of cerebral ischaemia Somatosensory Motor Vision (amaurosis fugax)
80
What three things is a transient ischaemic attack characterised by?
Abrupt onset Short duration Complete recovery -no residual defects
81
How long do transient ischaemic attacks often last for (2)? What is the limit?
1-2 minutes mainly 5 minutes is common Up to 24h
82
When do major stroke events tend to occur relative to transient ischaemic attacks?
Commonly occurs within 1st weeks after 1st transient ischaemic attack
83
What is there a high risk of following a transient ischaemic attack and for how long?
high risk of stroke within the next 2 years
84
What is visual transient ischaemic attack? What side does it occur on?
Amaurosis fugax -same side as carotid stenosis
85
What side to motor/sensory deficits occur on with transient ischaemic attacks?
Opposite side
86
Describe the manner in which vision loss occurs and returns with transient ischaemic attacks. What can occasionally occur instead?
Loss - like a blind coming down Recovery - like a blind going up -occasionally photopsia instead
87
What five things should you ask a patient if you suspect transient ischaemic attacks?
Pins/needles Tingling in fingers Loss of power in hands Lip/tongue numbness Episodes of slurred speech
88
List 5 unilateral signs of carotid insufficiency (i.e. ipsilateral to the carotid insufficiency).
Venous stasis retinopathy Ocular ischameic syndrome Pain Cataract - asymmetrical Dilated conjunctival/scleral vessels
89
List 3 atherosclerotic signs of carotid insufficiency.
BRAO (old or recent) Hollenhurst plaque (cholesterol) Fisher plug (fibrin)
90
List and describe three tests for assessing carotid artery integrity.
Stethoscope bell -listen for heart sound - normal -wooshing/blowing sound - anomaly Ultrasound Ophthalmodynamometry -measure ophthalmic artery pressure
91
What is a positive measurement for ophthalmodynamometry?
20% difference between eye is positive
92
List two treatment options for carotid insufficiency.
Anticoagulant therapy (aspirin or similar) Surgery - carotid endartectomy
93
What does carotid enartectomy increase the risk of and when? What patients is this normally indicated for?
Risk of inducing stroke during the surgery -normally indicated for younger patients in good health

OD3 (S1&2) (114 decks)

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