Hypertension And Heart Failure | Flashcards by Adam Kane

Hypertension

Persistent elevation of BP in the systemic arterial circulation to a level higher than expected for the age, sex, and race of the individual

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Primary hypertension

Hypertension with no singular identifiable cause

Risk factors
- old
- smoking
- family history
- obesity
- alcohol intake
- salt intake

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Secondary hypertension

Caused by identifiable singular cause, removal or reversal of this would normalise BP

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Causes of secondary hypertension

Renal disease
Obesity
Pregnancy associated hypertension (eclampsia)
Endocrine - adrenal gland hyper function, tumours, hyperaldosteronism, Cushings
Drugs e.g. corticosteroids
Coarction of aorta

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Benign hypertension - what it is and consequences

Stable elevation of blood pressure over many years
Asymptomatic

Consequences:
LV hypertrophy
Congestive cardiac failure
Increased atheroma
Thickening of tunica media
Increased aneurysm rupture
Renal disease

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Malignant hypertension

Acute, severe elevation of BP - diastolic pressure >130-140
Needs urgent treatment to prevent death

Consequences:
Cerebral oedema
Acute renal and heart failure
Haemorrhage

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White coat hypertension

Hypertension that only exists when BP is measured during medical consultations
Discrepancy of more than 10/20 mmHg

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Masked hypertension

Hypertension that exists when not being measured during clinical consultations so can go unnoticed

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Stage 1 hypertension

Clinic BP is >140/90 mmHg
ABPM or HBPM daytime average is >135/85

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Stage 2 hypertension

Clinic BP is >160/100 mmHg or higher
ABPM or HBPM daytime average is >150/95

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Severe hypertension

Clinic systolic BP >180 mmHg
Clinic diastolic BP >110 mmHg

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Symptoms of hypertension

Usually asymptomatic

Malignant hypertension will present acutely
- headache
- blurred vision
- chest pain
- altered mental status

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Signs of hypertension

Pulses bruits
- sound of blood flowing through narrow part of artery

Examine Fundi
- hypertensive retinopathy

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Complication of hypertension

Ischaemic heart disease
Cerebrovascular disease
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure

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Investigations of hypertension

ABPM - ambulatory BP monitoring - over 24 hours

HBPM - home BP monitoring - over a week at random times throughout day

Normally ABPM fist then HBPM if ABPM doesn’t work

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Monitoring hypertension - check how bad it is

To asses for end organ damage

Urine
- Albumin:creatinine ratio for proteinuria
- Dipstick for haematuria

Bloods
To test renal function and lipids

Fundoscopy
- hypertensive retinopathy

12 lead ECG

Calculate 10 year risk - ASSIGN or QRISK3

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Intervention for stage 1 hypertension

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Lifestyle interventions alone
- exercise
- smoking cessation
- diet modification

Unless there is organ damage or 10-year risk >10%

Medical management of hypertension

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Step 1

ACE-inhibitor(e.g. ramipril) if <= 55 years old
- If unable to tolerate ACE-inhibitor then switch toARB(e.g. candesartan, losartan(also reduces plasma urate))
DHP-Calcium Channel Blocker(e.g. nefedipine) if >55 years old OR African or Caribbean ethnicity

Step 2

If maximal dose of Step 1 has failed or not tolerated:

Combine CCB and ACE-i/ARB

Step 3

If maximal doses of Step 2 has failed or not tolerated:

Add thiazide-like diuretic(e.g. indapamide)

Step 4

If blood potassium <4.5mmol/L then add spironolactone
- Blocks action of aldosterone resulting in sodium excretion and potassium reabsorption
- Increases risk of Hyperkalaemia
If >4.5mmol/Lincrease thiazide-like diuretic dose
Other options at this point if the potassium is >4.5mmol/L include:
- Alpha blocker (e.g. doxacosin)
- Beta blocker (e.g. atenolol)
- Referral to cardiology for further advice

CV risk management

Statins for primary prevention if 10-year CV risk is >20%

Heart failure

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Complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation

Main causes of heart failure

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Ischaemic heart disease
Dilated cardiomyopathy
Hypertension

Ejection fraction

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The percentage of blood that is pumped out of the heart during each beat (SV/EDV x 100)

2 types of heart failure

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Heart Failure with Reduced Ejection Fraction - HFrEF

Heart Failure with Preserved Ejection Fraction - HFpEF

Heart failure with reduced ejection fraction

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Ejection fraction <40%

Unable to eject adequate amount during systole

Reduced contractility -> reduced CO

Commonly caused by
ischaemic heart disease, valvular heart disease and hypertension

Heart failure with preserved ejection fraction

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Ejection fraction >50%

Filled with less blood

Decreased ventricular compliance -> less decreased CO

Caused by increased stiffness of the ventricle (ventricular wall hypertrophy) and impaired relaxation of the ventricle (constrictive pericarditis)

Left sided heart failure - 2 types

Reduced EF - Increased left ventricular afterload due to increased aortic pressure or by outflow obstruction Preserved EF - Increased left ventricular preload due to back-flow into left ventricle caused by aortic insufficiency

Right-sided heart failure - 2 types

Reduced EF - Increased right ventricular afterload due to increase in pulmonary artery pressure Preserved EF - Increased right ventricular preload caused by tricuspid valve regurgitation

Compensatory mechanisms to heart failure - 3 ways

Increased adrenergic activity Increase of RAAS Secretion of BNP

What does increased adrenergic activity do to compensate for heat failure

Increases heart rate, blood pressure, and ventricular contractility

How is increase of RAAS actived to compensate for heart failure

Activated following decrease in renal perfusion which occurs after reduced SV and CO

What does increase of RAAS do to compensate for heart failure

Increase of Angiotensin 2 causes: Peripheral vasoconstriction - increasing BP :. Afterload Vasoconstriction of the efferent arterioles increasing intraglomerular pressure :. Maintaining glomerular filtration rate Increase aldosterone causes: Increased renal Na+ and H2O reabsorption Increases preload

What does secretion of BNP do to compensate for heart failure - why + how

Predominantly secreted in ventricles in response to increased myocardial wall stress works to decrease blood pressure

2 consequences of decompensated heart failure

Forward failure Reduced cardiac output leading to organ dysfunction Backward failure Causes backup of blood in vessels going into heart - LV -> pulmonary oedema - RV -> systemic venous congestion producing peripheral organ oedema and congestion of internal organs Caused by LV failure Biventricular failure is most common

Symptoms of heart failure

Exertional dyspnoea - difficult breathing Orthopnoea Paroxysmal nocturnal dyspnoea Fatigue

Signs of Heart failure -6

Tachycardia Elevated JVP Cardiomegaly - enlarged heart 3rd + 4th heart sounds Ankle oedema Ascites - fluid collects in abdomen

Classification of heart failure - Class 1 to 4

- Class I - no limitation of physical activity, activity doesn’t cause SOB - Class II - slight limitation of physical activity, comfortable at rest but normal activity causes SOB - Class III - marked limitation of physical activity, comfortable at rest but less than normal activity causes SOB - Class IV - unable to carry out any activity without symptoms, can be symptomatic at rest

Investigation of heart failure

ECG Chest X-ray BNP test Followed by echocardiogram

Management of heart failure - general

Education Diet Smoking cessation Low intensity exercise Consider antiplatelet or statin

Management of HFpEF

Loop diuretic - furosemide to relieve fluid overload

Management of HFrEF

ABAL ACE inhibitor B blocker Aldosterone antagonist - (MA) - if not controlled with A+B Loop diuretic for fluid

Complications of heart failure - 5

- Arrythmias - most commonly AF and ventricular arrhythmias - Depression - Cachexia - weakness + wasting of body - Chronic kidney disease - Sudden cardiac death

Acute presentation of Heart failure: drugs to use

LMNOP Loop diuretic - furosemide Morphine - IV Nitrates Oxygen Position - sit patient up B blockers make it worse

Hypertension And Heart Failure | Flashcards

(41 cards)