What is the normal cross sectional area of the mitral valve?
Correct Answer C: Mitral stenosis:
It is said that the causes of mitral stenosis are rheumatic fever, rheumatic fever and rheumatic fever. Rarer causes that may be seen in the MRCP include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis.
Features:
Features of severe MS:
Echocardiography:
The use of beta-blockers in treating hypertension has declined sharply in the past five years.
Which one of the following best describes the reasons why this has occurred?
Correct Answer A:
This was demonstrated in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).
Hypertension: diagnosis and management:
NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
Blood pressure classification:
This becomes relevant later in some of the management decisions that NICE advocate.
Diagnosing hypertension:
If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis.
Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment. Ambulatory blood pressure monitoring (ABPM):
If ABPM is not tolerated or declined HBPM should be offered.
Home blood pressure monitoring (HBPM):
Managing hypertension:
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension):
ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension):
For patients < 40 years consider specialist referral to exclude secondary causes.
Step 1 treatment:
Step 2 treatment:
Step 3 treatment:
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice.
Step 4 treatment:
If BP still not controlled seek specialist advice.
Blood pressure targets:
New drugs:
Direct renin inhibitors:
A 29-year-old woman is investigated for increasing dyspnoea and feeling generally week and lethargic. Over the past few months she has had five episodes of syncope, some of which occurred following exercise. There is no past medical history of note although her grandmother died aged 44 years after suffering increasing shortness of breath and syncope. On examination her oxygen saturations are 98% on room air and the pulse is 78 / min. The second heart sound is loud but no murmurs are heard. Auscultation of the chest is unremarkable.
What is the most likely diagnosis?
Pulmonary arterial hypertension: features and management:
Pulmonary arterial hypertension (PAH) may be defined as a sustained elevation in mean pulmonary arterial pressure of greater than 25 mmHg at rest or 30 mmHg after exercise.
Management should first involve treating any underlying conditions, for example with anticoagulants or oxygen.
Following this, it has now been shown that acute vasodilator testing is central to deciding on the appropriate management strategy. Acute vasodilator testing aims to decide which patients show a significant fall in pulmonary arterial pressure following the administration of vasodilators such as intravenous epoprostenol or inhaled nitric oxide.
If there is a positive response to acute vasodilator testing:
If there is a negative response to acute vasodilator testing:
Each one of the following may cause secondary hypertension, except:
Correct Answer A: Hypertension: secondary causes:
Renal - accounts for 80% of secondary hypertension:
Endocrine disorders:
Others:
A 29-year-old woman who is 28 weeks pregnant is reviewed. She has developed pre-eclampsia with her current blood pressure being 156/104 mmHg and the urine dipstick reported as follows:
There is no oedema and the patient is otherwise asymptomatic.
Of the following drugs, which one is least suitable to use?
Correct Answer C:
ACE inhibitors and angiotensin-2 receptor blockers should be avoided as they are teratogenic. Most clinicians would either use methyldopa or labetalol first-line in this situation.
Pre-eclampsia:
Pre-eclampsia is a condition seen after 20 weeks gestation characterized by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific.
Pre-eclampsia is important as it predisposes to the following problems:
Risk factors:
Features of severe pre-eclampsia:
Management:
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