Test: Hypertension - NEET PG MCQ

Verapamil influences the AV node and reduces the heart rate. When combined with a beta blocker, it will further decrease the heart rate.

• The associated urinary loss of potassium and hydrogen accounts for hypokalemic alkalosis.

Supravalvular aortic stenosis is defined by an external hourglass shape of the aorta, accompanied by a corresponding luminal narrowing just distal to the coronary artery ostia. The typical clinical findings in SVAS (Supravalvular aortic stenosis) include:

• Discrepancies between carotid pulsations and pulses, as well as blood pressure in the upper extremities.

These discrepancies arise because the blood flow jet from SVAS preferentially directs into the brachiocephalic (innominate) artery (i.e. Coanda effect). In SVAS, the characteristic systolic murmur has a crescendo-decrescendo pattern, is low pitched, and is best detected at the heart's base, positioned higher than in valvular aortic stenosis. (Chapter 51e-2, Harrison 19). The patient exhibited an early diastolic murmur, confirming that SVAS is the correct diagnosis.

In cases of unequal blood pressure between the left and right arms, the defect should exist between the right brachiocephalic trunk and the left common carotid artery. In Takayasu's arteritis, narrowing at the ostia of the left and right subclavian arteries can result in differential blood pressure. Pre-ductal coarctation of the aorta affects the arch of the aorta and leads to unequal blood pressure between the arms. Similarly, aortic dissection can cause differences in blood pressure between the arms and a dusky appearance of the toes, which is crucial for early diagnosis.

The blood pressure difference between both arms should remain under 10 mmHg. A difference exceeding this threshold may be linked to:

• Atherosclerosis or inflammatory disease of the subclavian artery
• Supravalvular aortic stenosis
• Coarctation of the aorta
• Aortic dissection

The patient is experiencing resistant hypertension, with the primary reason being non-compliance on their part. Resistant hypertension is characterised by blood pressure that stays elevated despite the simultaneous administration of three antihypertensive medications from different classes.

• Ideally, one of these three medications should be a diuretic.
• All medications should be prescribed at optimal dosages.

Lowering diastolic blood pressure to under 60-80 mm Hg does not enhance survival rates and could result in negative cardiovascular outcomes. This is referred to as the J-curve phenomenon. Given her positive family history, dietary strategies aimed at halting hypertension represent the most effective intervention.
The factors contributing to isolated diastolic hypertension include:

• Essential hypertension
• Hypothyroidism
• Conn syndrome
• Cushing syndrome

• Seventy per cent of aortic dissections result from hypertension.
• The tear happens in the tunica media, leading to a tearing sensation in the chest, peaking in intensity around the interscapular region.
• The investigation of choice for aortic dissection is transoesophageal echocardiography.
• Marfan syndrome can also manifest with aortic dissection, which is, in fact, the primary cause of mortality in these individuals.
• Syphilis affects the aortic arch and can lead to an aneurysm that may rupture at any time.

Secondary hypertension is significantly less prevalent, representing only 5-10% of all hypertension cases. The primary cause of secondary hypertension is renal disease, which can arise from:

• Both renal parenchymal and reno-vascular conditions.

Renal parenchymal damage accounts for approximately 2-5% of all hypertension cases and is the leading cause of secondary hypertension. As chronic glomerulonephritis has declined in frequency, hypertensive nephrosclerosis and, even more so, diabetic nephropathy have emerged as the most prevalent causes of chronic renal disease. In elderly patients, reno-vascular disease is the most frequent origin of secondary hypertension. Atherosclerosis is the predominant renovascular contributor to secondary hypertension in older individuals, whereas fibromuscular dysplasia is the leading cause in younger patients.

Patients with atrial fibrillation present an irregularly irregular pulse, which causes standard oscillometric devices to struggle with blood pressure measurement. Therefore, the N.I.C.E (British hypertension guidelines) recommends using the auscultatory method exclusively.

In cases of complete heart block, while bradycardia is present, the rhythm remains regular, allowing blood pressure to be measured using both oscillometric and auscultatory methods.

Evidence-based recommendations from the American Association of Clinical Endocrinologists identify methyldopa or Labetalol as the more suitable anti-hypertensive treatments during pregnancy. For women with preeclampsia who are at a heightened risk of seizures, magnesium sulfate is recommended.

• ACE inhibitors should be avoided in pregnancy.
• They are linked to fetal renal dysgenesis or death when taken during the second and third trimesters.
• Additionally, they pose an increased risk of cardiovascular and central nervous system malformations if used in the first trimester.

ADULT Essential hypertension
CHILDREN: Chronic glomerulonephritis
Depending on the techniques used for patient identification, 80-95% of individuals with hypertension are classified as having 'essential' hypertension (also known as primary or idiopathic hypertension). In the other 5-20% of hypertensive patients, a particular underlying condition that leads to increased blood pressure can be determined.