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I thought we did this meeting is being recorded. Oh, excuse me, it's unwise course. Um So I thought what what we do is we would take a look at the basics of cardiology and from a family medicine perspective, um there are a couple of conditions that are really important and they include hypertension, heart failure, ischemic heart disease. We don't do a lot of acute cardiology. But at my end, what I'll try to do in these cardiology presentations is to go through the basics. Um And to do it from a family medicine perspective. Um Are there any questions? Yeah. Are there any questions so far? No ma'am? Okay. So um cardiovascular disease is a, is a very common cause of death and uh it also results in a lot of uh disability and um the lower income countries have much higher incidences of cardiovascular disease. Um and partly that might be related to ill health, it might be related to diet, it might be related to genetics. Um but it is, it is becoming an emerging uh public health problem for developing countries. Uh But we see a lot of cardiovascular disease in primary care also because the burden of preventative medicine, early detection and management of patient's and secondary prevention pretty much comes down to the GPS. Uh um So how would you take a cardiovascular history? So, in the first uh talk, we talked about how to take a basic history. And, and the only reason I'm doing this, this might seem very, very basic is, I don't really know when I'm teaching you what your level is. So whether everybody is a final year or some people are third year and some people are fourth year. So rather uh leave that uh as a as a question mark, I thought I just go through the basics of what you do. If you're taking a cardiovascular history. Obviously, if somebody comes to you with any kind of cardiac symptoms, the first thing you want to do is you want to rule out any red flags. So people can present with a symptom of breathlessness or palpitations, dizziness collapse. Um And sometimes they come with chest pain, obviously, if they come with chest pain, that makes it a bit easier. But cardiac chest pain can often mimic gastroesophageal reflux, it can mimic other conditions. So, what you're really looking for is you're looking to rule out somebody who has um acute Coronary syndrome and it's developing acute coronary syndrome. So you wouldn't want to take any of the symptoms that a patient describes um lightly. Um obviously, acute coronary syndrome bond or sudden onset dull squeezing chest pain, radiating to the shoulder, the jaw with shortness of breath, you know, that's fairly easy. But sometimes in women, um, women can, uh, develop uh atypical symptoms. Diabetics can have uh silent heart attacks. So when you're taking the history, you need to do a risk assessment. So you need to look in your history for previous cardiovascular disease, their smoking status. What was their last lipid profile? And family history is really important. So if somebody has had a history of premature cardiovascular family history, premature cardiovascular disease, and that is significant and some recreational drugs like cocaine can put you at an increased risk. Um Previous cardiovascular disease is also easy because then they are more in keeping with secondary prevention. Um and when you take a history, especially if you're looking at somebody who's elderly, you want to look at their functional baseline. So you also want to, you need to find out where they live, what's their physical activity, how much disability this has caused what their care arrangements are. So we will do elderly medicine and care of elderly as a separate module altogether. But just to be careful when you're taking history from an older patient. If you have already done a relative, you if you know about the patient, it's important to just document their um uh whether they have capacity and what the uh memory status is. And of course, physical examination is pretty uh simple. You do a general physical examination, you'll see the breathlessness, you'll have them sitting up, you look at their color, whether they are fail or they've got a mala flush. You see that in mitral stenosis, um whether they're obese and other features of cardiovascular disease, you know, and whether there's evidence of heart failure. Obviously, when you're looking at somebody with any kind of chest pain, you have to be cognizant of not all chest pain is um acute coronary syndrome. Sometimes um A pneumothorax, A P E, an aortic dissection is official rupture. They all present in pretty much the same way. If people have really bad hyper lipidemia, you can see xanthomas on the tendon. Some people have features of Marfan's syndrome. And obviously, when you are doing their examination, you'd be looking for murmurs. Um Now if somebody has decompensation and it got heart failure, then the G D P is raised. So in the subsequent slide, we will look at that, we also examine the carotid pulse and we want to listen for a carotid bruit because cardiovascular disease is present in all the arteries. So there's no artery that is spared. So if you're resuming somebody has cardiovascular disease, then it's a good idea to just check the carotid pulse because you may have atherosclerosis and you get buoy, then they need carotid dopplers. Um You need to check the pulse and the BP and look for clubbing splintered hemorrhage is, does anybody know in what condition you get splintered hemorrhage is. Mhm. Bridgeman. Sorry, I can barely hear you. Sorry, what condition? Um, would you be? So you get splinted hemorrhage is, it's as effective and look, our diet is. Um, and then there is, you also look at the mouth, sorry. You also look at the mouth and oral hygiene. Um, and then you come to the clinical examination. So, um, you look for scars, obviously, if somebody has had bypass surgery, you'll be able to see that and then you need to be able to examine the GDP. Now, the jugular venous bells reflects the central venous pressure and that's the right atrial pressure and it's normally about nine centimeters of water. So if a patient is sitting at a 45 degree angle, yeah, approximately, if the sternal angle is say five centimeters above the right atrium, you should be able to see the JVP up to about four centimeters. So if it is distended beyond that, then you would say that the JVP is raised as you can see in this picture. And then you do a pal patient palpate the heart, feel, feel, feel the apex beat. And if you get any thrills, thrills are usually sort of a vibratory sensation. If you've got valvular disease, you can actually put your hand and you'll be able to feel the thrill, sorry, that shouldn't be there. Uh And um then of course, you listen to the heart sounds, whether there's a normal 1st and 2nd heart sound that there are any added sounds, whether they're split, whether there are any murmurs. And um you can listen to the chest for basic crackers. Um You see that in heart failure, if somebody has a chest infection, they have diffused crackers, you can examine the abdomen for enlarged liver, enlarged spleen, uh fluid in the abdomen, societies and sometimes you can get a pulse, it'll mass. So I'm doing this at a very basic level because this is the first lecture in cardiology. So we may as well just cover all the basics. So that if later on something comes up, you know what we're talking about. Um You also want to look at the legs and the feet and that's because um you can see evidence of heart failure. Um sometimes when people have beta blockers, their hands and feet can be very cold. Um You can get a Dema and heart failure and peripheral vascular disease often runs with the scheme ick heart disease, you need to feel their peripheral pulses. But if there's any rash cellulitis and obviously, you'll do A E C G. Um The most basic cardiac investigations is office based 12 lead E C G. Um You can also order a chest X ray that can show some um cardiac enlargement. If there's a very cardio diffusion or left atrial enlargement, you can see a prominent atrial appendage. Um I think you've already had a lecture on chest X rays, but it's not a bad investigation, certainly in, uh, as an admitting officer and in a, any, it's a good investigation to, to, to be able to do. And if the patient is, um, um, sometimes you can actually see aortic enlargement, especially if it's calcified. And if there's pulmonary edema, you can see that on the chest X ray. Um, there are other cardiac investigations that we can do. Uh, they include a CT coronary angiography. You can do an MRI these are more secondary care based investigations. If you're thinking of a thoracic aortic aneurysm than you want uh a thoracic ct of the chest and you can request that. Um And last time when we spoke about history taking, I didn't get a chance to discuss um something called the S bar. So um the BuSpar is a communicating tool uh that we use in the UK when two clinicians will be speaking to each other. So sometimes medical students would um take a history and when you ask them about the patient, they will tell you the history again. But a better way to communicate is too frame the history in uh the framework of an S bar. And esper stands for situation background, your assessment and recommendation. So, whereas you might take a really good history of two or three pages and done your assessment and espe are, is a very, very short uh sort of brief uh uh communicating uh tool so that when you're speaking, clinician to clinician, when you're speaking, say medical student to doctor, you are giving them the most important information. So you would say something like Mr S is a 60 year old gentleman. He's happy is the schema cart disease. He lives alone or you could say he, he lives with his wife. He's self getting. He's presented with new onset chest pain. I have examined him. This is my assessment. This is what I think we ought to do. So I just thought I'd drop this in because we didn't do it the last time. And some of this will be repetitive as we go through the lectures, we can practice this when we are doing your communication module. Um So today we're going to talk about hypertension. So um can I is that uh are you on, are you on uh the can you uh are you able to speak to me? Yes, ma'am. Yeah. So, so can anybody define hypertension? Any ideas anybody define hypertension? No. Okay. So usually what happens is that there is a range of normal BP and we're going to see it as uh as the next few slides come. But the BP that is sustained over 1 40 by 80 would be somebody who has hypertension. Now, there are patient's that we recognize that have pre hypertension. So these are people who have borderline BP. So BP say 1 20 by 70 would be considered normal and somebody that is hovering between that and getting to about 100 and 40 would be pre hypertension. Do we know uh why we use the number 1 40 by 80? Does it matter? So if I said to you, I don't know, pick a number 1 30 by 70. Why is 1 30 by 70? Okay? And 1 40 by 80? Not okay or above 1 40 by 80? Not okay. What happens with people with high BP? All cases their body vascular risks? Sorry, I can't hear you. Does it increase the cardiovascular? So the risk of like secondary cardiovascular problems, uh, just candiate. Is there anything in the chat? I think doctor, I think doctor. Uh, so how does, how does the BP of 1 30 by 70 affect a patient versus a BP? 1 50 by 90. So what if I had a patient of 50 years old and he had a BP of 1 50 by 90? And I decided I wouldn't treat him or the patient refuses. How would you counsel him? Should we just leave such people alone? Should we be treating them? Does it matter? Should be treating them because higher chance of give them giving them on my cardio function at night as hyper tended of me the value to us. Yeah, I suppose we don't treat them. So before we just leave them alone, what do you think might happen to them? What do you think might happen to them? Literally, I potential is to end organ like uncontrolled. The one needs to end organ damage like the retina, the brain, the kidneys, if not well controlled my my damage, the hogan's you to um impaired and perfusion of refuge diameters or uh can you just um yeah, somebody side, right. Everyone has said there's a higher chance to get violent reaction, increase vascular resistance. So that is partially true. Thank you for that, sira. So what happens with people when they have high BP? Essentially, it damages the blood vessels, putting it in very, very simple terms, it will damage the blood vessels of the, of the heart. It will damage the blood vessels of the kidneys and it damages the blood vessels of the eyes. Um And it's a, it's a major modifiable risk factor and uh it's estimated about a third of our population is hovering with prehypertension, hypertension and that there are a lot, many more people out there who have undiagnosed hypertension. And uh when we're looking at hypertension, really speaking, it is only the one factor in overall cardiovascular risk reduction. So it doesn't mean that uh on its own, if you manage somebody's high BP, but then you don't reduce the other risks, which is their diet, their lifestyle, their body weight, the lipid profile that you will get the total benefit. So what's really important is to make sure that you do a holistic assessment. So it's part. So managing BP is a part of a comprehensive cardiovascular risk reduction strategy. So, when somebody presents to you with the hypertension, we look at the whole person, we don't just look at uh we don't just look at uh just, just isolated BP control. Um No, when somebody gets hypertension, it's a very big risk factor for atrial fibrillation. Um And there is a belief that if we treat our hypertensive patient's better, they won't get cardiac hypertrophy, they won't get um left ventricular hypertrophy and they won't get atrial damage and that we will be able to reduce the incidents of atrial fibrillation. So, if somebody develops atrial fibrillation because of hypertension, what is the main risk with atrial fibrillation? Any ideas? Okay. Okay. The atrial fibrillation risk of stroke, doesn't it hypertension increases the risk of myocardial infarction and end stage renal disease. So, these people get more and more kidney disease. So, if you want to control the BP down to those levels below which it has been shown in studies not to cause um cardiovascular um consequences. So some patient's majority of them are a is symptomatic, but some patient's will present to you with dizziness and visual disturbances and they could have some little bleeding from their nose and the incidents of hypertension will obviously rise as they grow older. Um in the younger patient, they are unique. Uh You have to see patient's who you pick up with hypertension before the age of 30 as not primary or essential hypertension. You're looking at people that have some under uh some other underlying pathology and women generally have less hypertension than men. And once they undergo the menopause, the BP levels will rise to the same trend as men. And we know that certain ethnicities have higher hypertension uh incidences and these are the Africa Ribhi in people, they have more hypertension. So certainly does anybody know which other condition is more common in people who are Africa Ribhi in if you were doing a male health clinic. So, so prostate cancer is more common, isn't it? Um, because I, I don't think we can communicate. You can't, um I can't hear you. Um So when you're taking a history, you want to look for any other factors. So mostly this is essential hypertension or which there's no cause there's a very strong genetic link. So we always ask them about their family history, but you need to ask them about their diet, their lifestyle, their weight, the alcohol intake, whether they are doing any drugs, how much cigarettes they're smoking stressors and what are the medications are they taking? So if they're hypertensive and you're seeing them for a review, sometimes the BP is high and the communist cause is that they have not taken their medication or they run out of the medication or they've developed side effects and they've not told you, um, you need to go back into the patient record and see how long they've been hypertensive and then you do a risk assessment. So you want to look for other co morbidities, diabetes, chronic kidney disease, um, whether they've had a previous stroke and gout is an independent risk factors. Uh, hyperuricemia is an independent risk factor for um, ischemic heart disease and certain medications like anti inflammatories, cortical steroids, SSRI s and example, then in the vaccine, um these raise the BP. So you just want to take a nice detailed history because some of these are correctable. So you could change the medication you could do and and there's very good evidence that diet and lifestyle intervention is very effective for, for um managing hypertension. So how do you diagnose it? So do you think that um how would you make a diagnosis of hypertension? Does anyone know? Thanks for reading. How, how, how, how would you make a diagnosis hypertension? Obviously, you'd have to measure the BP reading, isn't it? You would have to do the BP reading. But a singular reading in the office we know is unreliable and it's not advisable unless the BP is very, very high um to start somebody on treatment. So if somebody has a BP at 1 50 by 90 it is okay to arrange an ambulatory 24 hour BP recording. And if you don't have ambulatory BP recording then the nice guidelines do recommend you do home BP readings. So you can do about four, maybe six readings a day, uh three or four hours apart for about seven days and then you'd look back and you'd see the average of the readings. And it also helps um seeing where the blood pressures are high because at 4 a.m. you get a cortisol surge. So one of the best times to recommend patient's to take the anti hypertensive medication is at night because that obviates the cortisol search. And you can also do a fundoscopy. You can examine their eyes, you can examine the abdomen, listen for a renal bruit. Um You can listen to their heart sounds and you do a total um overall cardiovascular risk assessment. When we come to ischemic heart disease, we're going to do uh primary prevention, secondary prevention. And we look at the scoring tools which is a cure risk, which is what we use in the UK. Um There is a condition called white coat hypertension in which you'll have a patient. He comes or she comes to the surgery and the BP is high. But when you see them outside in their home surroundings, the BP is completely normal and that's understandable because people are rushing in into the appointment, they may be uh tense, um they may be worried. Um and most often we would be screening for hypertension. So we would do a reading we'd found find that the reading is high, but that doesn't mean we should go and um, um, diagnosed hypertension on the singular reading. So, what you want to do is you want to either arrange a 24 hour ambulatory recording, which is really the gold standard or you can do some home BP readings. Um, and um, make sure that the patient is sitting down. Now, the cuff size is important. So if somebody is overweight and they have large arms, you should assess the size of the arm. So the average BP cuff should cover 80% of the arm. If it's less than that, you need to go one size above um make sure the patient is sitting down, the back is supported. And um if the patient has atrial fibrillation, you cannot use the automated machines, you have to do it manually. So I'm not sure how many of you were taught on the actual manual speak. Were you taught that how to do blood pressures in school? Sorry. Were you taught how to do blood pressures in school? Because I know we're doing uh we're doing a face to face uh club preparation day. Um And then you need to look at the the urine. So why would you want to dip, stick the urine? Any idea, any idea in the blood or the through custom or the acidity of it? Sorry, check the acidity or the blood glucose level to check the protein, I guess. What was that for protein? Um, like uh I mean, like protein level. What do you think? Um uh if you've, what, what, what about if you find, find protein in the urine? So, say, for example, I have a patient, he's come to me for his annual check up and I dip, stick the urine and I get some protein in the urine. What would you do? The natural party met property due to the hypertension, sorry, in a property because it's giving out which is supposed to be a little penetration. But, but a single lipstick can be unreliable. So what you'd want to do is you'd want to definitely repeat it and you can do a quantitative uh collection. So you can do a 24 hour urine collection. But a lot of these patient's when they've had poor control of hypertension, um they will progress towards um chronic disease. So they will go, go on to developing CKB. So at least once a year, it's not a bad idea if they have CKD to check their um uh urine. A cr um you need to arrange renal functions. And what do you see if you did a baseline E C G in somebody? Would you see any changes in a baseline E C G? Yes, hypertrophy. Um You'd see tall peaked um um QRS complex is you'd see large T waves uh because the, the hypertension causes remodeling of the heart and and this is the problem that if you treat hypertension late in, in, in the journey of the patient, then you cannot reverse the cardiac remodeling. So there is a great uh you know, uh consensus that earlier detection of hypertension, earlier reduction of blood pressures and um cardiovascular risk reduction as soon as possible protects the heart from cardiac remodeling. And you want to arrange a lipid profile. So you want to check their total cholesterol, the HDL, the LDL and you want to arrange a HBA one C just in case that you picked up diabetes and then you want to look for secondary causes. So, Cushingoid face features acromegaly and in a young person, if you get hypertension or you can feel a renal mass, obviously, you want to arrange um an ultrasound. Um And what we want to do is we want to uh get the BP 1 40 by 80 and below. And the reason I asked you about this number is in studies if the BP was kept at 1 40 by 80 and below the risk of cardiovascular complications was less than if the BP was higher than that. So there, this isn't a sort of a magic figure. This is an evidence based uh figure. Now what would happen if your patient was 80 years old? Would you go for a very, very strict BP control or what, what would your thinking be around the slightly older patient So certainly in diabetics, you want the BP to be pristine because this is part of, um, you know, secondary prevention because already with people the cardiovascular disease, the, the diabetes, the disease has already started. Um, but there are studies that have shown that very strict, very tight BP control in the elderly increases mortality. So in somebody that's 80 or 90 I don't tend to go for something like 100 and 20 by 70 because the studies actually show that mortality increases if you lower the BP too aggressively. So you just have to be that little bit careful. Now, um, lifestyle modification is really important, especially in the younger people. Um There's good evidence that cardiovascular exercise can lower the BP by five millimeters weight reduction by one millimeter. And if you reduce your saturated fats and increase the fiber, you can reduce it by about 10 millimeters of mercury salt production is effective and certainly alcohol. So putting all this together, people with borderline hypertension can probably be given one or two months unless the blood pressures are really, really high. And people with pre hypertension, you can, if you've got the capacity, you can run uh sort of a lifestyle clinic and then you can keep them under close follow up home BP. And you can see the effect of that, that this, this would have on their BP, but certainly not if you know, they're diabetic. Certainly not if you're looking at secondary prevention. Now, one of the biggest problems with treating people with hypertension is adherence to, to the medication. And the reason for that is hypertension is largely, is symptomatic. So when people come to our attention, they, they're not, you know, they're clueless, they weren't expecting to be diagnosed with hypertension, bless them. It comes to them as a shock. Um, and then because they're a symptomatic and we put them on medication, they develop more side effects from the treatment of a condition that they were a symptomatic for. And certainly in young men with some of the BP medication, you can see rectal dysfunction. So, um, what you need to do and this is what we do in our surgery is that we educate the patient's, we explain to them the reason we are treating them, um, that we're not just treating a number, it's to prevent heart disease and cardiovascular risk in the long term eight or 10 years. Um, and that it's important to stay on their drug regime. It's important to take it on time to drink plenty of fluids to make all the diet and lifestyle changes and then to keep them under close follow up. Um, and then what we do in our practice is we ask them to send us the BP readings about once every four months so that we can keep an eye on them. And we've done some studies and we found that the home BP readings actually have um, uh very much taken up by the patient's, especially post COVID. A lot of patient's now have their own BP machine. They're quite happy to be doing their BP monitoring. Um, so, um, now the treatment of hypertension and if you go on to uh the nice guidelines and if you don't have the nice guidelines, then what I can do is I'll download them and email them out to you. Um uh There are only three or four classes that we use of medication that is pretty much um uh the uh the common uh classes of drugs. So in the younger patient's, we tend to use a sin Him bitters or angiotensin two receptor blockers. One of the main side effects of ace inhibitors is they can develop a cough patient's are over the age of 50 then we would put them on calcium channel blockers and sometimes what we would do um is um we would use a combination of medications. So we would start them on calcium channel blockers and if their BP was not well controlled. So if you look at this table, um in the first one in patient's who are young, um we start them on is inhibitors and then we add a calcium channel blockers or thigh sides. And then the other one, we start with calcium channel blockers and then we add the ace inhibitors are pretty much the first two steps, you can swap them around and it's much the same and there's a third line, you can anti side diuretics and step forward a spironolactone. But if after three medications you're not getting control, you're looking at some really resistant hypertensives, readings really need to refer this patient. Now, one of the precautions when you start this inhibitors or angiotensin two receptor blockers is that you've got to check the renal function within about a week or two of starting the, within a week or two of starting the, the ace inhibitors. Does anybody know why? Because they, I think because they inhibit the uh they inhibit uh and your testing too. And it's actually uh a facto that has in uh glomerular filtration, literate it EPPS like it's the main uh peptide. I have to maintain the Jeffer. Yeah, I'm going to say the sympathetic, sorry, I was going to say that affect the sympathetic system. Yeah. And in some patient's, you see unbeknownst to you, especially if it's a young person and they've developed hypertension because they've got renal artery stenosis. Um then it would be a disaster because you have to stop the medication. The renal function would deteriorate catastrophically. So, one of the disadvantages of ace inhibitors is that your patient has to drink about 2 to 2.5 liters of water daily. They cannot be dehydrated. So what I usually tend to do when they are doing there home BP monitoring, I start getting them used to drinking water. So a lot of patient's are not used to drinking water. So I put them on uh three liters of water. So once they start drinking water, then you can be sure that they've understood the value of drinking the water, you can put them on a sin. Him bitters, angiotensin two receptor blockers. And within a week to 10 days, you need to check the renal function because that's a disaster if that patient has a renal artery stenosis. So you just don't want to miss that. Um And then at least once every four months, uh they should have, I mean, the nice guidelines are a bit more relaxed. Uh But sometimes in patient's when you put them and they're on multiple therapies there. On diuretics, we tend to monitor their renal function more closely. I I usually do it once every four months. Uh um And then um remember these are patient's that already have multiple co morbidity and they already have some renal compromise. Most of the time we diagnose hypertension quite late. Um And uh both ace inhibitors and angiotensin receptor blockers, they work on uh basal dilation um as do calcium channel blockers, thiazide diuretics cause basal dilation and they cause salt and water loss. The disadvantage with that is with some patients, especially the elderly, you'll get hypernatremia and you have to stop it. And that's the other problem that you can get with potassium spain diuretics like spironolactone, they can get hyperkalemic, men can get gynecomastia again, the sodium levels go down. So you need to continue to monitor their renal function. Uh Beta blockers are not great. They have a place. Um they can be used more often. We see them in patient's at hypertensive and their own heart failure medication. Um Alpha blockers are also effective especially in the older people and older men. Um And but if you're combining uh two or three classes, so you're looking at getting some really resistant hypertension and you're putting alpha blockers, um they can get a lot of hypertensions. You have to be really careful if you're using alpha blockers on top of the other three medication and you cannot, and of course, you, you wouldn't do that. You wouldn't combine an ace with an angiotensin two receptor blocker. Okay. And you wouldn't use a calcium channel blocker in anybody that has got heart failure. Okay. So you wouldn't want to use Kalfin shine blockers and somebody who has heart failure, you don't combine ace with angiotensin two receptor blockers. What we'll do is this is a lengthy lecture. There are two ways we can do this. I believe that we have obstetrics after this. So if you want to do this as a part one and part two, that's okay, or if you want to substitute uh we can do half of this as uh we can either finish hypertension in the next batch or what we can do because hypertension is big and it's important. Uh We can do this as a part one and come back to it with the next cardiology lecture. What would you like to do? Continue? Sorry. Where's part to you want me to continue once cut off? Because I think this link only works for an hour. So what do you uh want to do? Do you want to continue with this lecture and then do the Obstetrics lecture or leave this here? And we combine, we come back to this in the next obstetrics lecture. So we can do this as a part one and about two or I can take this up in the next slot that when I'm doing obstetrics, we can do it as a part to maybe sorry, better as a part to part. Let's see, you put your, uh put it in the chat because I cannot hear you, I'll carry on and if we get cut off, we'll pick it up again when we get to the next lecture. And then you can tell me how you want to do it. Okay. So, uh now when we are looking at overall cardiovascular risk reduction, it is important. In fact, it makes no sense that you treat just the BP and then you don't look at the lipid profile and you don't work on lipid lowering therapies. So I don't know if you've heard of statins they block an enzyme in the liver that enables the manufacturer of cholesterol. So it's very simple um methodology. It blocks that enzyme lowers the cholesterol but you can get side effects. The commonest side effects are people get muscle aches and pains and it can deranged the liver function. Um And that's a common reason why people stop taking them. Um You can use, is it to me, is it M B which reduces the, the adoption of the cholesterol from the gut? Um And then you've got these agents that work in, in the gut uh that uh binds bile acids. You can use fibrates, um nicotinic acid, I've had some limited experience with it but they, you get flushing and um it any bits lipid synthesis, but you get a lot of side effects. So they're not use that often. Um Omega three supplements reduce hepatic, very low density lipoprotein. And we have um uh newer agents which are the PCSK nine inhibitors. Uh They up regulate a liver LDL expression and they're newer agents. BMP do like acid. And what I'm hoping to do is to do hyperlipidemia as a separate talk in cardiology. So this is just to tell you that when you are looking after somebody with hypertension, you want to lower the cholesterol also. And we use a Q risk tool which when we do ischemic heart disease, cardiovascular disease, I'll show you what we use. Um Then there are secondary courses of hypertensions. We're looking at essential hypertension for which there's no secondary cause. Usually in the younger people, we see either renal artery stenosis. And um if you put these people on a sin, him bitters, you get a sudden deterioration of renal function. So make sure that you palpate the abdomen, check for a renal bruit. Uh and we don't as a, as a routine go and do an MRI or a CT angiogram. Uh But obviously, you'd have to stop the ace inhibitor. You'd refer them to secondary care to one of the renal physicians and they would undergo an MRI or a CT angiogram. Um If patient's and especially um young girls can develop if they develop frequent uti in childhood deposes scarring or they get autoimmune vascular. It is in young people who can get chronic kidney disease, um obstructive sleep apnea and obesity is also associated with hypertension. So, if you have an obese patient, not a bad idea to ask them about that. And people who have acromegaly, they have a typical clinical appearance at all. Large hands, large beat, primary hyperaldosteronism. Yes. No, potassium raised aldosterone levels. Um I'll just write on running ratios and again, you do an MRI or a CT uh with adrenal vein sampling. And if patients have a pheochromocytoma, then you would do plasma metanephrines and you do an MRI chest abdomen or pelvis because you want to localize that tumor and hypothyroidism is also associated with hypertension. So as a regular routine as a fasting baseline, we would run off a thyroid function for these people. Um No, actually, we, we, we've come to the end of the lecture. So I did run on time. Marvelous. Um What I was hoping to do, I wanted to ask you if you had any questions. And in the next talk, we're going to do acute coronary syndrome, ischemic heart disease, then we'll do atrial fibrillation, cardiac arrhythmias. We'll do E C G along with that. So either we will do it as a completely separate talk or we'll do bits and pieces of the E C G. When we are doing the conditions, we'll do a separate talk and lipid metabolism and heart failure and then screening in primary care. And I wanted to ask you if you all wanted to do some MCQ practice. Yes. Yes. So what do you use currently for? What do you use currently as your uh what are you using currently for um MCQ practice using you have any resources or because you know what I can talk until the cows come home. But what I need to know is um depending on what year you are, how many of you are preparing for the Plavix and how many of you want to do some MCQ practice as part of this. Because what we can do is we can uh we did a lecture on um amenorrhea. What I'm hoping to do is do you want to do a few M C Q s and hypertension, the next cardiology lecture that we do? Um, yeah, thank you. I'm relying on what's in the track. Okay. I can't hear you. I don't know why. It's, it's probably not my computer, but can you hear me? Yes, ma'am. Um, okay. Um, uh, for some reason I, I can't hear you but how would you want to, uh, do the M C Q s? Do you want me to just throw all the emcee cues together in an MCQ or do you want me to do the emcee queues at the end of every, every talk? I think it's nice and some time to explain it as well. So it's better than, but you have enough time to discuss that. Why? That is the right answer. Sorry. Could you put it in the chat, darling? I can barely hear you. Just, just put it in the chat. What would you like me to do? How would you like to do it? Because for me, I think at the end. Yeah, that's right. I think that would be the best because after last time in many real lecture, I had a whole set of MCQ is that I had prepared, but I didn't want to overload you. But I think that what we can do is if we put the MCQ is there, then we can sense check that if we're all understanding what's being said. So I'll do that next time. Um, I think we'll be going on to the next lecture, which is the Obstetrics lecture. Um, and we're going to be looking at the physiological changes in pregnancy and that's massive and huge. So that's going to be done as a part one and a part too. So I think we leave this room and then we'll try to get into the next room. Is that okay? I'll see you all there. Okay. Thank you.