Author: Dr.Mehnaz

INFECTIVE ENDOCARDITIS

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Zoom in🔎/Tap for more!👆🏻
Indications for cardiac surgery in Infective Endocarditis:

🔅 Heart Failure due to valve damage
🔅 Failure of antibiotic therapy
🔅 Large vegetations 
🔅 Abscess formation

Dr. Mehnaz Memon🖊

References: Davidson’s Principles and Practice of Medicine Textbook

MANAGEMENT OF HYPERTENSION

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(A)

  1. Quantification of cardiovascular risk(CVR)
  2. Threshold for intervention
  3. Treatment targets
  4. Non-drug therapy
  5. Drug therapy – Antihypertensive drugs & their choice
  6. Emergency treatment of accelerated phase/Malignant hypertension
  7. Refractory HT
  8. Adjuvant drug therapy

(B)

🔅General Measures(Lifestyle Modification):
  1. Relief of stress
  2. Salt restriction – NaCl upto 5g/day help reduce BP. Diet rich in potassium & calcium should be employed
  3. Weight reduction
  4. Control of risk factors:
  • Restriction of cholesterol & saturated fat in diet reduces the atherosclerotic complications
  • Alcohol, smoking – ❌🚭
  • Control of blood sugar level in diabetics

5. Regular exercise: Jogging & swimming – ⬇️ Arterial pressure

(1) Quantification of Cardiovascular Risk:

• Objectives

🔅 To reduce the incidence of adverse cardiovascular events viz coronary heart disease, stroke & heart failure

• Benefits:

🔅Diuretics or β blockers have shown to reduce the risk of

  • CAD by 16%
  • Stroke – 13%
  • Cardiovascular death – 21%
  • Mortality – 13%

🔅Most of the excess Morbidity & Mortality associated with HT is attributable to CAD. Total CVR = CAD risk x 4/3

(2) Threshold for intervention:

  • Systolic & Diastolic BP – predictors of CVR (≥ 140/90 mm Hg)
  • The threshold for initiating AHT is lower in diabetics/cardiovascular disease as they are at a higher risk
  • The threshold for treatment of HT in elderly is same as in younger patient.

🔅 Hypertension in old age:

  1. Prevalence – half of the population over the age of 60
  2. Risks – MI, heart failure, stroke
  3. Benefit – from Anti-hypertensives is greatest in older people
  4. Target BP – similar to that for younger patient
  5. Tolerance – Well tolerated
  6. Drug of choice – low dose thiazides

Target BP during AHT

(3) Treatment Targets:

  • Optimum BP (130/83) for reduction of major cardiovascular events
  • improve screening
  • Follow up every 3 months

(4) Non-drug therapy ~ General measures

(5) Drug Therapy:

remember – ABCD👇🏻

NOTE: 🔎

A. ACE Inhibitors:

👉🏻Patients with renal artery stenosis/impaired Renal function (given with utmost care)

⬇️

Reduction of filteration pressure in the glomeruli

⬇️

Renal failure

Hence contraindicated! ❌☝🏻

👉🏻These agents also reduce the progression of Nephropathy in type II diabetes

👉🏻Level of electrolytes & creatinine should be checked before & after 1-2 weeks.

B. ARB’s

👉🏻Have lesser side effects of cough & angioedema than ACE inhibitors

C. Beta-blockers:

👉🏻These drugs are not used now as first line AHT; except in patient with Angina

👉🏻Labetalol & Carvedilol: Have better effect when combined. Labetalol is used as infusion in malignant phase HT.

D. CCB’s

👉🏻The dihydropyridines are effective, well-tolerated particularly in older people

👉🏻Rate–limiting CCB’s: HT with angina. Bradycardia may occur

  • S/E – Constipation(Verapamil)
  • Tachycardia(Nifedipine)

E. Thiazides & other Diuretics:

👉🏻The loop diuretics have few A/D over thiazides unless there’s renal impairment.

Chart showing Mode of Action & Side effects of AHT’s☝🏻

The influence of comorbidity on the choice of antihypertensive drug therapy

Management of hypertension: British hypertension society guidelines

🔅Choice of AHT drug:

Criteria:

  • Age & ethnic background
  • Cost, convenience
  • Response to initial therapy
  • S/E

A = ACE inhibitor (consider AT-II receptor antagonist if ACE-intolerant); C = Calcium channel blocker; D = thiazide-type diuretic)

(6) Emergency treatment of accelerated phase/Malignant hypertension

🔅 In accelerated phase HT, lowering BP too quickly may compromise tissue perfusion & can cause –

  • Cerebral damage
  • Occipital blindness
  • Coronary/Renal insufficiency

🔅150/90 mm Hg within 48 hours is ideal along with cardiac failure/hypertensive encephalopathy

🔅Avoid parenteral therapy

  • iv/im: Labetalol (2mg/min)
  • iv: Glyceryl trinitrate(0.6-1.2mg/hour)
  • im: Hydralazine(5-10 mg aliquots repeated at 1/2 hourly interval)
  • iv: Na Nitroprusside(0.3 – 1 μg/kg body wt/min)

(7) Refractory HT:

🔅Causes of treatment failure include:

  1. Non-adherence to drug therapy
  2. Inadequate therapy
  3. Renal artery stenosis

(8) Adjuvant Drug Therapy:

📌Aspirin – Antiplatelet

  • ⬇️ Cardiovascular risk
  • S/E: Bleeding

📌Statins – Reduced risk by treating hyperlipidaemia

Dr. Mehnaz Memon🖊

References: Davidson’s Principles and Practice of Medicine Textbook

10 Steps to Accurate Manual Blood Pressure Measurement

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Image Via: medical.docs

Step 1 – Choose the right equipment: 
What you will need: 
1. A quality stethoscope 
2. An appropriately sized blood pressure cuff 
3. A blood pressure measurement instrument such as an aneroid or mercury column sphygmomanometer or an automated device with a manual inflate mode.

Step 2 – Prepare the patient:Make sure the patient is relaxed by allowing 5 minutes to relax before the first reading. The patient should sit upright with their upper arm positioned so it is level with their heart and feet flat on the floor. Remove excess clothing that might interfere with the BP cuff or constrict blood flow in the arm. Be sure you and the patient refrain from talking during the reading.

Step 3 – Choose the proper BP cuff size: Most measurement errors occur by not taking the time to choose the proper cuff size. Wrap the cuff around the patient’s arm and use the INDEX line to determine if the patient’s arm circumference falls within the RANGE area. Otherwise, choose the appropriate smaller or larger cuff.

Step 4 – Place the BP cuff on the patient’s arm: Palpate/locate the brachial artery and position the BP cuff so that the ARTERY marker points to the brachial artery.  Wrap the BP cuff snugly around the arm.

Step 5 – Position the stethoscope: On the same arm that you placed the BP cuff, palpate the arm at the antecubical fossa (crease of the arm) to locate the strongest pulse sounds and place the bell of the stethoscope over the brachial artery at this location.

Step 6 – Inflate the BP cuff:Begin pumping the cuff bulb as you listen to the pulse sounds. When the BP cuff has inflated enough to stop blood flow you should hear no sounds through the stethoscope. The gauge should read 30 to 40 mmHg above the person’s normal BP reading. If this value is unknown you can inflate the cuff to 160 – 180 mmHg. (If pulse sounds are heard right away, inflate to a higher pressure.)

Step 7 – Slowly Deflate the BP cuff: Begin deflation. The AHA recommends that the pressure should fall at 2 – 3 mmHg per second, anything faster may likely result in an inaccurate measurement.

Step 8 – Listen for the Systolic Reading: The first occurence of rhythmic sounds heard as blood begins to flow through the artery is the patient’s systolic pressure. This may resemble a tapping noise at first.

Step 9 – Listen for the Diastolic Reading: Continue to listen as the BP cuff pressure drops and the sounds fade. Note the gauge reading when the rhythmic sounds stop. This will be the diastolic reading.

Step 10 – Double Check for Accuracy: The AHA recommends taking a reading with both arms and averaging the readings. To check the pressure again for accuracy wait about five minutes between readings. Typically, blood pressure is higher in the mornings and lower in the evenings. If the blood pressure reading is a concern or masked or white coat hypertension is suspected, a 24 hour blood pressure study may be required to assess the patient’s overall blood pressure profile.

Further Reading/References:

https://www.suntechmed.com/support/product-training-tutorials/1692-how-to-measure-blood-pressure