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cft ii > Exam 3 - Systemic Hypertension > Flashcards

Exam 3 - Systemic Hypertension Flashcards

1
Q

what is the formula for blood pressure?

A

BP = HR X SV X SVR

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2
Q

blood pressure is the product of what?

A

cardiac output & systemic vascular resistance

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3
Q

what is the gold standard for measuring blood pressure? how is it done? what does it measure? is it commonly done?

A

direct blood pressure measurement - measured via catheterization of an artery & electronic transducer

measures systolic, diastolic, & mean arterial pressure

not commonly done - not practical for screening & management of hypertension

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4
Q

what is the best way to measure blood pressure in cats & small dogs? how is it done?

A

doppler sphygmomanometry - indirect, non-invasive way to measure

uses the frequency changes between emitted ultrasound & returning echos from moving blood cells or vessel walls to detect blood flow in an artery

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5
Q

why is oscillometry not the best way to measure blood pressure in cats?

A

it underestimates when blood pressure is high

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6
Q

how does oscillometry measure blood pressure?

A

microprocessor detects pressure oscillations that result when flow is occluded

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7
Q

what blood pressure reading is used for clinical assessment?

A

systolic blood pressure

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8
Q

where do you place the cuff for reading blood pressure?

A

midway between the elbow & carpus

in the tibial region

base of tail

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9
Q

what is the protocol that should be used for measuring blood pressure in a small animal patient?

A

same individual should take all measurements - allow 5-10 minutes for acclimation, keep patient calm & motionless & not sedated - need to be gently/minimally restrained in ventral or lateral recumbency with the cuff at the base of the heart

discard first measurement - 5-7 consecutive values are recorded & averaged - if they trend down over time, take measurements until plateau is reached & then record 5-7 measurements

written record should include person taking measurements, cuff size & site, values obtained, rationale for excluding any values, & mean result

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10
Q

how is pressure cuff size determined for blood pressure readings? what happens if the wrong size is used?

A

cuff width should be 30-40% of the limb circumference at the cuff site

if too small - falsely high readings

if too big - falsely low readings

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11
Q

how is doppler used to get blood pressure readings?

A

good contact between doppler probe & skin achieved with alcohol to dampen hair & plenty of ultrasound gel

inflate cuff 20-40 mmHg above the point where blood flow is no longer heard

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12
Q

what patients should you measure blood pressure on?

A

in patients with signs of target organ damage

in patients with conditions known to be associated with hypertension

in patients on meds/following toxin ingestion

screening of aging patients

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13
Q

T/F: sighthounds have higher normal ranges of blood pressures than other breeds

A

true

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14
Q

what were definitions of hypertension developed based off of?

A

risk of target organ damage

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15
Q

what defines normotensive?

A

minimal target organ damage risk - systolic blood pressure < 140 mmHg

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16
Q

what defines prehypertensive?

A

low target organ damage risk - systolic blood pressure 140-159 mmHg

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17
Q

what defines hypertensive?

A

moderate target organ damage risk - systolic blood pressure 160-179 mmHg

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18
Q

what defines severely hypertensive?

A

high target organ damage risk - systolic blood pressure > 180 mmHg

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19
Q

in general, hypertension should be documented as persistent for how many occasions?

A

needs to be documented as persistent for 2 or more occasions

over 4-8 weeks for patients with low or moderate target organ damage risk

over 1-2 weeks for patients with high target organ damage risk

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20
Q

T/F: hypertension with evidence of target organ damage warrants treatment after a single measurement session

A

true

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21
Q

what is white coat hypertension?

A

increase in blood pressure that occurs in clinic in a patient that is otherwise normotensive - important to differentiate from true hypertension

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22
Q

how is idiopathic hypertension diagnosed?

A

diagnosis is suspected when reliable measurements demonstrate persistent increase in blood pressure with a normal CBC, chem panel, & urinalysis

can be difficult to rule out subclinical kidney disease - also hypertension can cause pu/pd

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23
Q

what is secondary hypertension?

A

> 80% of cases & more common than idiopathic!!!

increased blood pressure due to a concurrent illness, medication, or toxin - hypertension may persist after treatment of the underlying condition

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24
Q

hypertension can occur with any IRIS CKD stage, so is severity of hypertension related to severity of CKD?

A

nope

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25
Q

what is the pathogenesis of hypertension from chronic kidney disease?

A

involves sodium & water retention, activation of the RAAS, sympathetic nervous system, structural changes to arterioles, & endothelial dysfunction

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26
Q

what is the pathogenesis of hypertension in cushingoid dogs?

A

glucocorticoid induced production of angiotensinogen by the liver & exaggerated sympathetic nervous system response

can cause mild to moderate dose-dependent hypertension

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27
Q

what is the pathogenesis of hypertension in hyperthyroid cats?

A

may involve increased sensitivity to catecholamines & direct effect of thyroid hormone on cardiac myocytes

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28
Q

what are some toxins associated with causing hypertension?

A

ephedrine/pseudoepinephrine

cocaine

methamphetamine

5-hydroxytryptophan

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29
Q

T/F: hypertension can cause retinal detachment & acute onset blindness

A

true

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30
Q

what is seen on physical exam that clues you into hypertension?

A

ocular lesions are common in both dogs & cats

CNS signs from hypertensive encephalopathy

systolic murmur/gallop sounds associated with left ventricular hypertrophy

epistaxis due to hypertension-induced vascular changes

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31
Q

what should you include in your diagnostic work up for a hypertensive patient?

A

BUN, creatinine, SDMA, usg - assess kidney function

assess for proteinuria

look at liver enzymes & electrolytes

look at blood glucose

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32
Q

what is the purpose of doing a urine protein:urine creatinine ratio in a hypertensive patient?

A

need to quantify the proteinuria

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33
Q

when may you do an echo in a cat with hypertension?

A

left ventricular hypertrophy secondary to hyperthyroidism!!! but may be indistinguishable from feline idiopathic hypertrophic cardiomyopathy

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34
Q

what organ damage occurs to the kidneys from hypertension?

A

hypertension associated with proteinuria

anti-hypertensive medication decreases severity of proteinuria!

hypertension results in histological renal injury - sclerosis

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35
Q

what organ damage occurs to the eyes from hypertension?

A

retinopathy/choroidopathy!!! retina & choroid have separate blood supplies & either can be affected

acute onset blindness, exudative retinal detachment, retinal hemorrhage/edema, tortuosity, perivascular edema, papilledema, vitreal hemorrhage, hyphema, secondary glaucoma, & retinal degeneration

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36
Q

what organ damage occurs to the brain from hypertension?

A

encephalopathy or stroke - neuro signs reported in 1/3-1/2 of cats with hypertension

signs - lethargy, seizures, acutely altered mentation, altered behavior, disorientation, & central vestibular signs

37
Q

in hypertensive animals that become acutely blind, is vision restored after blood pressure is corrected?

A

not commonly restored

38
Q

what organ damage occurs to the cardiovascular system from hypertension?

A

can result in concentric left ventricular hypertrophy

left sided heart failure rarely develops (but can happen after fluid therapy is started)

aortic aneurysm - rare

hemorrhage - epistaxis or stroke

39
Q

what is your first step before deciding to treat a patient for hypertension?

A

you must exclude situational hypertension!!!!

40
Q

if there is an underlying condition causing hypertension in a patient, do you just treat that without anti-hypertensive medications? why?

A

no - treating the underlying cause often doesn’t resolve it!!!! don’t without treatment!!!

41
Q

what is the optimal goal for treating a hypertensive patient? what is your minimal goal?

A

optimal - < 140 mmHg

minimal - < 160 mmHg

42
Q

if you are managing a patient for hypertension with medication and they come in with a systolic blood pressure < 120 mmHg with weakness, syncope, & tachycardia, what do you do?

A

need to lower the dose of the anti-hypertensive!!!

43
Q

once blood pressure is controlled in a hypertensive patient, how often should you schedule rechecks?

A

at least every 3 months

44
Q

how do you treat a patient that is prehypertensive with a condition that is predisposed to causing hypertension?

A

need to monitor them every 6 months

45
Q

how do you treat a patient with gradual onset hypertension without target organ damage?

A

gradual persistent decrease in blood pressure should be achieved over several weeks, so begin therapy & recheck after 7-10 days

adjust meds as needed & recheck again after 7-10 days

monitor every 4-6 months once target blood pressure is reached

be aware of potential for acute exacerbation of azotemia when combining anti-hypertensive therapies

46
Q

how do you treat a patient with systolic blood pressure > 200 mmHg and/or hypertension with target organ damage?

A

begin therapy - monitor blood pressure & clinical signs closely in the first 24-72 hours & adjust meds as needed

47
Q

what is considered to be a hypertensive emergency? what is the goal of treatment? what is required?

A

acute ocular or neurological target organ damage

goal is an incremental decrease in blood pressure because an acute drop can result in hypoperfusion

treatment should be immediate & aggressive & requires in hospital 24 hour care

48
Q

why do you not want to just use amlodipine for a hypertensive dog? how do you counter act this?

A

preferential dilation of the afferent arteriole may increase glomerular pressure which may be detrimental - may worsen proteinuria

offset this by concurrent administration of ace inhibitors

49
Q

what is the mechanism of action of amlodipine? what patients do we commonly use it in?

A

calcium channel blocker! potent peripheral arteriolar vasodilator that acts directly on vascular smooth muscle with minimal cardiac effects

commonly used in cats - may also decrease their proteinuria

used in dogs with severe hypertension alongside ace inhibitors

50
Q

what side effects are associated with amlodipine?

A

generally well tolerated medication but:

hypotension, gingival hyperplasia, & peripheral edema

51
Q

what are your ace inhibitor drug options?

A

enalapril or benazepril

52
Q

what is the mechanism of action of ace inhibitors?

A

reduce angiotensin concentration thereby reducing vascular resistance & volume retention - also selectively dilates glomerular efferent arteriole thus decreasing glomerular pressure & proteinuria

53
Q

what is the effect that ace inhibitors have on blood pressure?

A

mild reduction - only 10-20%

54
Q

why are ace inhibitors listed as first line therapy for hypertensive dogs?

A

high prevalence of ckd & the antiproteinuric effect!

55
Q

why are ace inhibitors not recommended as first line therapy for hypertensive cats?

A

they have a small effect on systolic blood pressure

56
Q

T/F: you can continue using ace inhibitors in dehydrated patients

A

false

57
Q

what drugs can be used alongside ace inhibitors?

A

amlodipine & telmisartan (with caution)

58
Q

what side effects are associated with ace inhibitors?

A

generally well tolerated, but:

may worsen azotemia, cause hyperkalemia, hypotension, or gi upset

59
Q

what is the starting dose used for ace inhibitors for hypertensive animals?

A

0.5 mg/kg po every 12-24 hours

60
Q

what is the mechanism of action of telmisartan?

A

angiotensin receptor blocker - inhibits effect of angiotensin II at AT type 1 receptors thereby reducing vascular resistance & volume retention

can also decrease proteinuria

labeled for treatment of hypertension in cats in the USA

61
Q

what is the dosing used for telmisartan for hypertensive patients?

A

cats 1-3 mg/kg po every 24 hours

dogs 1 mg/kg po every 24 hours

62
Q

what is the mechanism of phenoxybenzamine? when may you use it? what are some other examples of drugs that have this same action?

A

alpha-blocker - opposes the vasoconstrictive effects of alpha receptors

mainly used in patients with pheochromocytomas

acepromazine, prazosin, etc

63
Q

how is diet used as a part of therapy for a hypertensive patient?

A

low salt diet, but salt restriction alone will not decrease blood pressure

so select a diet based on all other medical conditions & avoid a high salt diet

can use diet to promote weight loss in obese patients

64
Q

why are beta-blockers not used for treating hypertensive animals?

A

they have negligible anti-hypertensive effects

65
Q

what are some direct vasodilator drugs that may be used for emergency management of hypertension?

A

hydralazine & nitroprusside

66
Q

when may you use spironolactone for a hypertensive patient?

A

used to manage hypertension secondary to hyperaldosteronism along with potassium supplementation & adrenalectomy often with amlodipine

67
Q

what kind of blood pressure measurement is shown in this photo?

A

doppler

68
Q

what kind of blood pressure measurement is shown in this photo?

A

oscillometry

69
Q

what kind of blood pressure measurement is shown in this photo? what is the only reliable measurement taken from this method? what may cause false readings?

A

high definition oscillometry

provides systolic, diastolic, & mean, but only systolic is reliable!!!

movement may cause false readings

70
Q

what dosing of amlodipine is used in cats for treating hypertension? what about dogs?

A

cat with BP < 200 mmHg, 0.625 mg/cat po every 24 hours

cat with BP > 200 mmHg, 1.25 mg/cat po every 24 hours

titrate up to maximum dose of 2.5 mg/cat or 0.5 mg/kg po every 24 hours

dogs - 0.1-0.25 mg/kg po every 24 hours - dose may be increased as needed

71
Q

T/F: telmisartan has not been evaluated for cats with blood pressures > 200 mmHg

A

true

72
Q

if you start anti-hypertensive therapy on an animal with hypertension & a moderate risk of target organ damage, when do you schedule a recheck for monitoring?

A

recheck in 1 week

73
Q

if you start anti-hypertensive therapy on an animal with severe hypertension & a high risk of target organ damage, when do you schedule a recheck for monitoring?

A

recheck in 2-3 days

74
Q

if you start anti-hypertensive therapy on an animal with blood pressure > 200 mmHg and/or target organ damage, when do you schedule a recheck for monitoring?

A

recheck them in 24-48 hours!

75
Q

what is it called when you see bilateral mydriasis & the appearance of retinal vessels on retro-illumination?

A

retinal detachment

76
Q

T/F: complete retinal detachment is considered to be a penlight diagnosis

A

true

77
Q

what does retinal detachment look like on ocular exam?

A

appearance of a floating sheet (detached retina) may be seen behind the lens without the use of an ophthalmoscope - retinal vessels are clearly visible as the retina moves up against the lens

78
Q

what diagnostic test can be used if the retina can’t be visualized, for example, due to hyphema when looking for retinal detachment?

A

ocular ultrasound

79
Q

what does a detached retina look like on ultrasound?

A

seagull sign - detached retina that remains fixed to the optic nerve head & the ora ciliaris retinae (periphery)

80
Q

what is the pathophysiology of hypertensive retinopathy in regards to the retinal vasculature?

A

systemic hypertension leads to vasoconstriction of retinal arterioles

auto-regulation breaks down at critical pressures leading to compromise of vascular integrity

this leads to plasma & RBCs within the retina

leads to retinal edema & detachment

81
Q

what are the ocular manifestations of hypertensive retinopathy?

A

retinal arteriole tortuosity & ‘box car’ lesions

intra-retinal hemorrhage

retinal edema

82
Q

what is the pathophysiology of hypertensive retinopathy in regards to the choroidal vasculature? what lesions are seen with this?

A

choroidal vasculature lacks auto-regulation, so when systemic hypertension happens, there is compromise of vascular integrity

this leads to leakage of plasma & RBCs into the sub-retinal space & bullous retinal detachment

sub-retinal hemorrhage, focal retinal bullae, & bullous retinal detachment

83
Q

what is this lesion? what is its importance?

A

multifocal retinal bullae

can be recognized before blindness occurs with a fundic exam!!!!! usually gradual progression over several months

84
Q

what is the mechanism of hypertension from chronic kidney disease?

A
  1. reduced pressure natriuresis leads to increased sodium retention = increased blood volume, venous return, & cardiac output = increased arterial blood pressure & increased total peripheral resistance
  2. activation of RAAS causes increased aldosterone levels & increased sodium retention = increased blood volume, venous return, & cardiac output = increased arterial blood pressure & increased total peripheral resistance
  3. reduced renalase activity leads to increased catecholamine levels which causes increased total peripheral resistance
  4. uremic environment leads to increased vasoconstriction & reduced vasodilation which causes increased total peripheral resistance
85
Q

what are angiotensin type 2 receptors in charge of?

A

vasodilation

anti-inflammatory

inhibits hypertrophy

86
Q

what are angiotensin type 1 receptors in charge of?

A

aldosterone release, vasopressin release, inflammation, myocyte hypertrophy, fibrosis, vasoconstriction, & glomerular hypertension

87
Q

how quickly does hypertensive retinopathy need to be addressed?

A

very fast - can reverse blindness if quickly controlled

detached retinas will start to atrophy in about 1 weeks

retina will re-attach if underlying sub-retinal effusion is controlled - retinal hemorrhage & edema will also resolve if BP is controlled

88
Q

what are the consequences if retinal hypertrophy goes untreated?

A

retinal degeneration

permanent blindness

hyphema

secondary glaucoma

cft ii (28 decks)

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