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Cardiologist in Rajanukunte, Bangalore • Factors that increase triglyceride levels 1 Obesity 2 Alcohol 3 Diabetes 4 Oestrogen (including HRT in 20% of users) 5 Diuretics 6 Beta-blockers Secondary causes: • Cushing’s syndrome • acromegaly • uraemia • acute hepatitis
HEART SPECIALISTS IN GANGAMMA CIRCLE BANGALORE Assessment of patients with hypertension A patient with definite or possible newly diagnosed hypertension needs at least a basic clinical assessment to look for possible aetiology, severity and signs of complications. The history Questioning should be directed towards the following areas. 1 Past history. Has hypertension been diagnosed before? What treatment was instituted? Why was it stopped? 2 Secondary causes. Important questions relate to: • a history of renal disease in the patient or his or her family, recurrent urinary tract infec-­ tions, heavy analgesic use or conditions leading to renal disease (e.g. systemic lupus erythematosus (SLE)) • symptoms suggesting phaeochromocytoma (flushing, sweats, palpitations) • symptoms suggesting sleep apnoea • muscle weakness suggesting the hypokalaemia of hyperaldosteronism • Cushing’s syndrome (weight gain, skin changes) • family history of hypertension. 3 Aggravating factors: • high salt intake • high alcohol intake • lack of exercise • use of medications: NSAIDs, appetite suppressants, nasal decongestants, monoamine oxidase inhibitors, ergotamine, cyclosporin, oestrogen-containing contraceptive pills • other: use of cocaine, liquorice, amphetamines. 4 Target organ damage: • stroke or transient ischaemic attack (TIA) • angina, dyspnoea • fatigue, oliguria • visual disturbance • claudication. 5 Coexisting risk factors: • smoking • diabetes • lipid levels, if known • existing vascular disease • family history of ischaemic heart disease. 2• HYPERTENSION 6 Factors affecting choice of treatment: • diabetes (problems with thiazides and beta-blockers) • gout (problems with thiazides) • asthma (problems with beta-blockers) • heart failure (problems with verapamil, diltiazem, some beta-blockers, monoxidine) • severe peripheral arterial disease (problems with beta-blockers) • bradycardia or heart block (problems with beta-blockers, verapamil, diltiazem) • renovascular disease (problems with ACE inhibitors, angiotensin receptor antagonists (ARAs)) • problems with previous anti-hypertensive agents • allergies • likelihood of pregnancy (ACE inhibitors, diuretics and some calcium antagonists are contraindicated). The examination The physical examination should be undertaken with a view to establishing severity. 1 Measure the blood pressure. 2 Look for secondary causes. • Check the appearance for Cushing’s syndrome (central obesity, striae, muscle wasting), acromegaly, polycythaemia and uraemia. • Undertake abdominal palpation for renal masses (polycystic kidneys), occasionally adrenal mass, and auscultation for renal bruit (heard to the left or right of the mid-line above the umbilicus, often into the flanks). • Assess radiofemoral pulse delay and listen for mid
HEART SPECIALISTS IN YELAHANKA NEW TOWN BANGALORE Triglycerides The independent effect of triglyceride levels is weak, and high triglyceride levels are often associated with other risk factors (e.g. low HDLs). Secondary causes of high triglycerides are common and confuse the picture, as does the fact that serum levels can vary greatly with fasting and recent alcohol intake. The combination of high triglycerides and elevated LDL (combined dyslipidaemia) is associated with a marked increase in coronary disease risk. Isolated extremely high triglycerides (greater than 15 mmol/L) are a risk factor for pancreatitis rather than vascular disease. Modest elevations of triglycerides can usually be managed by weight control, a reduction in alcohol consumption and changes in medication. Table 1.5 Factors that affect HDL levels Factors that increase HDL levels Factors that reduce HDL levels 1 Oestrogen 2 Exercise 3 Small amounts of alcohol (10–20 g per day in men) 1 Smoking 2 Obesity 3 Inactivity 4 Hypothyroidism 5 Postmenopausal state 6 Beta-blockers Table 1.6 Factors that increase triglyceride levels 1 Obesity 2 Alcohol 3 Diabetes 4 Oestrogen (including HRT in 20% of users) 5 Diuretics 6 Beta-blockers 7 Secondary causes: • Cushing’s syndrome • acromegaly • uraemia • acute hepatitis 8 High triglycerides and low HDLs are associated with insulin resistance
HEART SPECIALISTS IN YELAHANKA NEW TOWN BANGALORE Triglycerides The independent effect of triglyceride levels is weak, and high triglyceride levels are often associated with other risk factors (e.g. low HDLs). Secondary causes of high triglycerides are common and confuse the picture, as does the fact that serum levels can vary greatly with fasting and recent alcohol intake. The combination of high triglycerides and elevated LDL (combined dyslipidaemia) is associated with a marked increase in coronary disease risk. Isolated extremely high triglycerides (greater than 15 mmol/L) are a risk factor for pancreatitis rather than vascular disease. Modest elevations of triglycerides can usually be managed by weight control, a reduction in alcohol consumption and changes in medication. Table 1.5 Factors that affect HDL levels Factors that increase HDL levels Factors that reduce HDL levels 1 Oestrogen 2 Exercise 3 Small amounts of alcohol (10–20 g per day in men) 1 Smoking 2 Obesity 3 Inactivity 4 Hypothyroidism 5 Postmenopausal state 6 Beta-blockers Table 1.6 Factors that increase triglyceride levels 1 Obesity 2 Alcohol 3 Diabetes 4 Oestrogen (including HRT in 20% of users) 5 Diuretics 6 Beta-blockers 7 Secondary causes: • Cushing’s syndrome • acromegaly • uraemia • acute hepatitis 8 High triglycerides and low HDLs are associated with insulin resistance
Diabetes clinics in Sahakara Nagar, Bangalore • Factors that increase triglyceride levels 1 Obesity 2 Alcohol 3 Diabetes 4 Oestrogen (including HRT in 20% of users) 5 Diuretics 6 Beta-blockers 7 Secondary causes: • Cushing’s syndrome • acromegaly • uraemia • acute hepatitis 8 High triglycerides and low HDLs are associated with insulin resistance.
Diabetes clinics in Sahakara Nagar, Bangalore • Factors that increase triglyceride levels 1 Obesity 2 Alcohol 3 Diabetes 4 Oestrogen (including HRT in 20% of users) 5 Diuretics 6 Beta-blockers 7 Secondary causes: • Cushing’s syndrome • acromegaly • uraemia • acute hepatitis 8 High triglycerides and low HDLs are associated with insulin resistance.
Diabetologists in Vidyaranyapura, Bangalore • Secondary causes of dyslipidaemia System Disorder Lipoprotein elevated Pattern Endocrine Diabetes VLDL, chylomicrons IV Cushing’s syndrome VLDL IV Acromegaly VLDL IV Hypothyroidism LDL IIa Anorexia nervosa LDL IIa Porphyria LDL IIa Drugs Alcohol Chylomicrons, VLDL IV Oestrogen-containing Chylomicrons, VLDL IV contraceptive pill Glucocorticoids LDL, VLDL Renal Uraemia VLDL IV Nephrotic syndrome LDL, VLDL Hepatic Primary biliary cirrhosis LDL Acute hepatitis VLDL Immune Systemic lupus erythematosus (SLE) Chylomicrons Monoclonal gammopathy Chylomicrons, VLDL Injury Burns, acute myocardial infarction (AMI) LDL
Diabetologists in Vidyaranyapura, Bangalore • Secondary causes of dyslipidaemia System Disorder Lipoprotein elevated Pattern Endocrine Diabetes VLDL, chylomicrons IV Cushing’s syndrome VLDL IV Acromegaly VLDL IV Hypothyroidism LDL IIa Anorexia nervosa LDL IIa Porphyria LDL IIa Drugs Alcohol Chylomicrons, VLDL IV Oestrogen-containing Chylomicrons, VLDL IV contraceptive pill Glucocorticoids LDL, VLDL Renal Uraemia VLDL IV Nephrotic syndrome LDL, VLDL Hepatic Primary biliary cirrhosis LDL Acute hepatitis VLDL Immune Systemic lupus erythematosus (SLE) Chylomicrons Monoclonal gammopathy Chylomicrons, VLDL Injury Burns, acute myocardial infarction (AMI) LDL
heart doctors in Doddaballapur Road, Bangalore • Pericarditis Inflammation of the pericardial sac may occur as a result of scores of conditions.20 The principal causes of acute pericarditis, where chest pain has to be differentiated from ischaemia, are as follows: 1 infection: viral or bacterial, or associated with pneumonia and severe systemic symptoms, or as a complication of HIV infection or superinfection (e.g. mycobacterial) 2 systemic inflammatory disease: such as rheumatoid arthritis or systemic lupus erythematosus 3 myocardial infarction (epistenocardiac pericarditis, 4 Dressler’s syndrome (after some delay following an infarct or cardiac surgery) 5 uraemia 6 malignancy (not often presenting as chest pain) or radiotherapy. A large group, resembling acute viral pericarditis clinically, remains idiopathic. Symptoms The inflammation causes chest pain that can be difficult to distinguish from that of myocardial infarction but that tends to have a number of distinct features. There may be symptoms of a viral illness or of a connective tissue disease. Pericardial pain is usually pleuritic ; that is, it is worse with respiratory movements. This is because breathing, especially deep breathing, causes the inflamed pericardial surfaces to rub together. Oddly enough, the pain is practically never pulsatile—in keeping with the heart beat. Patients with pericarditis are often more comfortable if they sit up and lean forward. The pain is usually central or left-sided, especially in those with associated pleurisy. Trapezius ridge radiation is highly characteristic of pericarditis; it does not occur in ischaemia. There may be some dyspnoea, which is at least partly a result of the discomfort of breathing.
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