GP - Primary Prevention of CVD Flashcards

Question

Which 4 organs in the body are common sites of damage/modification as a result of Hypertension?

Answer 1

1. **Eyes** * Retinopathy/maculopathy 2. **Brain** * Strokes * Microaneurysms 3. **Heart** * Compensative/adaptive cardiomegaly * Ischaemic heart disease * CCF (followed by pulmonary HTN) * Aortic aneurysms * Peripheral vascular disease (not actually related to the heart) * PE * Sudden death 4. **Kidneys** * Hypertensive nephropathy (HTN causing kidney pathology) * Nephron arteriosclerosis --\> ischaemia --\> kidney atrophy (small kidneys) * Glomerular ischaemia due to renal artery stenosis caused by plaques or stiffening * Glomerular HTN can result in glomerular damage --\> causing blood and protein leakage into urine

Answer 2

1. **Papilloedema** - optic disc swelling **due to ↑ ICP** ( which can be caused by malignant hypertension) * Venous engorgement (often 1st sign) * Blurring of optic disc margin * **Paton's lines** - concentric/radial lines cascading from optic disc 2. **Flame Haemorrhage** - intraretinal haemorrhage (looks like bruise) * Feather/flame shape indicates bleed occurs at level of nerve fibre layers 3. **Hard exudates** - small white/yellowish lipid deposits with sharp margins, which form due to capillary leakage (i.e. ↑ retinal vascular permeability) * Often appear waxy / shiny / glistening 4. **Cotton wool spots** - white spots which represent swelling of retinal nerve fibres due to microinfarctions * Usually near optic disc

Answer 3

Two causes of Primary Hyperaldosteronism: 1. **Conn's Syndrome** = Unilateral Aldosterone producing adenoma (~30% of cases) --\> adrenalectomy 2. **Bilateral adrenal hyperplasia** (~70% of cases) --\> spironolactone Metabolic disturbance due to Hyperaldosteronism: 1. **↓ K⁺** and **↓ H⁺** --\> **Hypokalaemic Alkalosis** 2. **↑ Na⁺** and **↑ BP**

Answer 4

Addison's Disease = autoimmune destruction of adrenal glands causing --\> hypoadrenalism (↓ cortisol + ↓ aldosterone) Causes of Primary Hypoadrenalism: * 80% of primary hypoadrenalism = Addison's Disease * TB, metastases, meningococcal septicaemia, HIV, antiphospholipid syndrome Treatment: * Ongoing: **hydrocortisone** (glucocorticoid) + **fludrocortisone** (mineralocorticoid) * Mineralocorticoid dose is impacted by mineralocorticoid activity of glucocorticoid given * Adrenal **Crisis**: **50-100mg IV every 6 hours** for 1-3 days Features: * **Lethargy** + weakness * **Anorexia** * **Weight loss** * **Hyperpigmentation** (especially palmar creases) * ↓ BP * 'Salt-craving' due to hyponatraemia * Nausea / vomiting * Hyperkalaemia + acidosis * Hypoglycaemia * Vitiligo

Answer 5

**Short** Syn**ACTH**en Test 1. Administer tetracosactide (synacthen) 250 micrograms IV/IM 2. Check blood cortisol at time 0 and +30 mins 3. Cortisol at +30min should be **\> 600 nmol/L** = in normal person 4. If cortisol **\< 600 nmol/L** --\> **Addison's Disease**

Answer 6

* Essential/primary hypertension = 90-95% * Cause unknown * Secondary hypertension = 5-10% * This is hypertension due to an underlying pathology

Answer 7

Causes + some signs: * **Renal** diseases: - ↑ creatinine + abnormal urinalysis * Polycystic kidney disease (PKD) * Chronic glomerulonephritis * Pyelonephritis * Renovascular disease e.g. renal artery stenosis * Presence of atherosclerotic disease elsewhere * Asymmetry in renal size of \> 1.5cm (without other cause) * Renal artery bruit * **Endocrine** diseases: * Cushing's Syndrome - moon face, striae, central obesity, proximal muscle weakness, facial plethora, thin skin, bruising, ↓ libido * **Primary hyperaldosteronism**: (**most common** cause of secondary hypertension) * Conn's syndrome * Bilateral idipathic adrenal hyperplasia * Pheochromocytoma * **Neurological** disease: * Brainstem lesion * Space occupying lesion --\> ↑ ICP --\> ↑ resistance to cranial bloodflow --\> heart ↑ BP to compensate * **Drugs**: * Steroids * MAO inhibitors (antidepressants) * COCP * NSAIDs * **Pregnancy**: * Pre-eclampsia * **Aorta coarctation** * ****Diminished femoral or left brachial pulse with high BP in right arm (subject to location of coarctation) * **Obesity** * **Sleep apnoea** - ↓ oxygen supply to body --\> heart tries to compensate by ↑ BP (noctural ↑BP) * Obese men, loud snoring, daytime somnolence, fatigue, morning confusion * **Licorice** (excessive consumption)

Answer 8

A **neuroendocrine tumour** of the **chromaffin** cells of the **adrenal medulla** * **↑ BP** (HTN) + **Hyperglycaemia** are common * 10% present without hypertension * **90% unilateral** vs 10% bilateral * **FHx** of such tumours is suggestive of --\> **Multiple endocrine neoplasia syndromes** (MENs)

Answer 9

Features: * Hypertension (↑ BP) * Alkalosis * Hypokalaemia: * Muscle weakness & ↓ tone * Palpitations * Hypokalaemia induced nephrogenic DI --\> polyuria + polydipsia

Answer 10

ECG: * **Prolonged PR interval** * **ST depression** * **T-wave flattening** or **inversion** * **Apparent Long QT** * it only appears to show long QT, but due to fusion of the T+U waves it is actually the **QU segement** not QT being viewed * **U-waves** (best seen in precordial leads i.e. V1-V6)

Answer 11

**Hypokalaemia** * ST depression * T wave inversion * Prominent U waves * Long QU interval

Answer 12

Causes of Primary Hypoadrenalism: 1. **80%** of primary hypoadrenalism = **Addison's Disease** 2. 20% is due to congenital adrenal hyperplasia, TB, metastases, meningococcal septicaemia, CMV infection (HIV pts), antiphospholipid syndrome

Answer 13

Features of Addison's disease: * Female * **Tiredness /** weakness * **↓ BP** * **Anorexia** * **Weight loss** * **Hyperpigmentation** (especially palmar creases) * Nausea / **vomiting** * **'Salt-craving'** (rare but occurs if hyponatremia features) * Loss of axillary + pubic hair (women) * Hypoglycaemia * Hyponatremia & Hyperkalaemia (may be seen) * Other **signs of autoimmunity** e.g. vitiligo, Hashimoto's thyroiditis, pernicious anaemia * **Adrenal Crisis**: * Collapse * Shock * Fever

Answer 14

Lifetime: 1. **Hydrocortisone** (glucocorticoid) usually **15-30 mg daily** in **divided doses** - depends on body weight & metabolism 2. **Fludrocortisone** (mineralocorticoid) usually **50-300 mg daily** - depends on metabolism & exercise * Mineralocorticoid dose is impacted by mineralocorticoid activity of glucocorticoid given Adrenal **Crisis**: * **Hydrocortisone 50-100mg IV** every **6 hours** for **1-3 days**

Answer 15

1. Offer antihypertensive in pts **\< 80yrs** + **stage 1 HTN** who have **1 or more** of the following: * Target organ damage * Established CVD * Renal disease * Diabetes * 10-year cardiovascular risk \> 10% 2. Offer antihypertensive in **everyone** with **stage 2 HTN**

Answer 16

1. **55yrs** is the cut-off for guiding drug choice 2. **ACE-inhibitor** or ARB 3. **Afro-carribbean** origin influence drug choice 4. **Thiazide** 5. **Angiotension II receptor blocker** (ARB)

Answer 17

**ACE-inhibitors** (end in -pril): e.g. lisinopril, perindopril, captopril, enalapril etc. * **Cough** * **Angioedema** - swelling of lower layer of skin; face, tongue, larynx, abdomen, arms, legs * **Hyperkalaemia** * Agranulocytosis (rare) * Notes: * **Avoid in pregnancy** * **Monitoring -** renal function check at **initiation** + 2-3 weeks later + **dose changes** due to risk of ↓ renal function in renal artery stenosis * ↑ in creatinine + K⁺ may be expected but shouldn't be \> 30% of baseline (creatinine) or \> 5.5 mmol/L K⁺ **Ca²⁺ channel blockers:** - side effects for dihydropyridines (end in -pine) 1. **Ankle oedema** 2. **Headache** 3. **Flushing** **Thiazide-diuretics:** e.g. Indapamide, chlorthialidone, chlorothiazide, metolazone * **Dehydration** * **Hyponatraemia** (↓ Na⁺) * **Hypokalaemia** (↓ K⁺) * **Hypercalcaemia** (↑ Ca²⁺) * **Postural hypotension** * ↑ Urea reabsorption --\> ↑ Uric acid --\> can worsen **gout** * Impotence * Rare: Agranulocytosis, thrombocytopenia, photosensitve rash, pancreatitis * Notes: * Thiazides actually have very weak diuretic action **ARBs** (end in -sartan) e.g. candesartan, losartan * Hypotension (↓ BP) * Hyperkalaemia * Note: avoid in pregnancy

Answer 18

**\< 80yrs**: * \< 140/90 via clinic BP * \< 135/85 mmHg via ABPM or HBPM **\> 80yrs:** * \< 150/90 via clinic BP * \< 145/85 mmHg via ABPM or HBPM

Answer 19

In **Pregnant** Women * Methyl-dopa = **compeititve inhibitor of DOPA decarboxylase** (which converts L-DOPA --\> dopamine) * Dopamine is a precursor for noradrenaline + adrenaline * Methyl-dopa ↓ dopaminergic + adrenergic neurotransmission --\> vasodilation + ↓ BP

Answer 20

1. **Urine** tests: - check for renal disease * Urine sample for albumin:creatinine ratio (tests for proteinuria) * Urine dipstick for haematuria 2. **Blood** tests: * Serum glucose + HbA1c * U+Es - looking for electrolyte disturbance * Creatinine * eGFR * Serum cholesterol, HDL and LDL 3. **Fundoscopy**: * Hypertensive retinopathy 4. 12-lead **ECG** * ****Check for left ventricular hypertrophy or ischaemic heart disease

Answer 21

Between **90/60 - 140/90** mmHg * Some sources describe being between 120/80 and 140/90 as 'pre-hypertensive' * BP varies depending on; **Age**, **gender** and **physiology**

Answer 22

**Black Afro-carribean** and **Elderly** (BP rises with age, up to the 7th decade)

Answer 23

**Refer to specialist** If no evidence of target organ damage, CVD, renal disease or diabetes

Answer 24

**ACE-inhibitors** (end in -pril): e.g. **lisinopril**, perindopril, captopril, **enalapril** etc. * **Cough** * **Angioedema** - swelling of lower layer of skin; face, tongue, larynx, abdomen, arms, legs * **Hyperkalaemia** * Agranulocytosis (rare) * Notes: * Avoid in pregnancy * **Renal function check** at initiation + dose changes + 2-3 weeks after initiation due to risk of ↓ renal function in renal artery stenosis * ↑ creatinine + ↑ K⁺ may be expected but shouldn't be \> 30% of baseline (creatinine) or \> 5.5 mmol/L K⁺

Answer 25

**Ca²⁺ channel blockers**: - side effects for dihydropyridines (end in -pine) 1. **Ankle oedema** 2. **Headache** 3. **Flushing**

Answer 26

Patient's **absolute risk** of suffering a; **cardiac event** or **stroke** over the **next 10-years** Takes into account: * Age * Sex * Ethnicity * BP * BMI * Cholesterol results * Smoking + Diabetes * FHx * Other existing conditions e.g. RA, migraines, SLE, AF, CKD etc.

Answer 27

**Inhibit HMG-CoA reductase** thus ↓ coversion of saturated fat --\> cholesterol

Answer 28

1. **Macrolide Abx** (e.g. erythromycin, clarithromycin) * Stop statins until Abx course is completed 2. **Pregnancy**

Answer 29

* **Muscle aches** / cramps (common) - consult GP * **Liver impairment** * Monitoring - **LFTs** at **baseline**, **3-months** and **12-months** * Discontinue statin if serum transaminase (**ALT** & **AST**) concentrations **↑ + persist** at **3 x upper limit of reference range** * Muscle **pain**, tenderness or weakness --\> STOP statin now! * Can be due to **rhabdomyolysis** (muscle breakdown) * Blood test for **↑↑↑ creatinine kinase** Advise: * **Avoid Grapefruit juice** * If starting new medication or OTC - ensure your statin is known about

Answer 30

1. **All pts** with **established CVD** e.g. stroke, TIA, ischaemic heart disease, peripheral arterial disease 2. **QRISK 3 \> 10** **%** (i.e. 10-year CVD risk \> 10%) AND lifestyle modification is ineffective 3. **T1DM** pts if: * diagnosed \> 10-years ago * \> 40-yrs old * have established nephropathy * have other CVD risk factors

Answer 31

Myopathy is **more common** in: * **Simvastatin** * **Atorvastatin** Myopathy is less common in: * Rosuvastatin * Pravastatin * Fluvastatin

Answer 32

Primary prevention: * **Atorvastatin 20 mg BD** Secondary prevention: * **Atorvastatin 80 mg OD**

GP - Primary Prevention of CVD Flashcards

(57 cards)