HTN/Hypotension

Question 1

elevated BP
stage 1 hypertension

treat if
stage 2 htn

Answer 1

SBP 120-129 and DBP <80 mm Hg
SBP 130-139 mm Hg or DBP 80-89 mm, lifestyle chngs (high potassium foods)
clinical ASCVD or 10-yr ASCVD risk score ≥10%,1 med
≥140/90, start 2 meds+reassess in 1 month

Question 2

HTN in AA without HF or CKD tx

Answer 2

thiazide-type diuretic or calcium channel blocker

Question 3

cardiogenic shock in STEMI

Right sided pulmonary edema in cardiogenic shock

Answer 3

LV infarction
papillary muscle rupture, ventricular septal rupture, free-wall rupture with tamponade, and (RV) infarction.
acute MR from lateral papillary muscle rupture (the regurgitant jet is directed towards the R pulm veins)

Question 4

acute stent thrombosis

Answer 4

recurrent or new ST elevations

Question 5

mixed venous o2 sat in cardiogenic shock vs septic

Answer 5

decreased

Question 6

orthostatic vital signs
normal

autonomic dysfunction

POTS
cardiodepressor syncope

Answer 6

5-10 drop in SBP, 5-10 increase in DBP, 10-25 increase in HR
brief rise in HR ff by >20+ >10 fall in SBP and DBP, HR doesn’t change much
modest drop in BP + extreme rise in HR
marked drop in HR, ff by drop in BP

Question 7

Newly diagnosed HTN

Answer 7

EKG to assess for LVH, arrhythmia, MI

Also get fasting glucose, CBC, BMP, TSH, u/a

Question 8

resistant HTN, early onset, abrupt onset or worsening or increasingly difficult to control, flash pulmonary edema, abdominal systolic-diastolic bruit

difficult to control HTN

Answer 8

suspect renovascular disease, -> renal doppler u/s

get sleep study

Question 9

MI c/b cardiogenic shock

Answer 9

IABP, start with NE for inotropy/vasopressor

*avoid phenylephrine and vasopressin-> vasoconstrict-> increase afterload-> may decrease CO

Question 10

use dobutamine for inotropy

milrinone

Answer 10

low CO but preserved BP
It can worsen hypotension by dilating peripheral arts
also causes hypotension, avoid in renal failure, induces arrhythmias

Question 11

HTN, already on 3 agents including diuretic

Answer 11

add spironolactone

reduces SBP by 24 mm Hg at 6 months

Question 12

hctz dosing

Answer 12

not much benefit beyond 25 mg daily if normal renal function

Question 13

HTN treatment target

Answer 13

<130/80

can start two agents at once if needed (CAD). Most patients need 2

Question 14

hypertensive emergency vs urgency treatment

Answer 14

inpatient, IV meds vs outpatient, PO meds (DBP> 120 in both)
lower SBP by no more than 25% in the first hour, then to approximately 160/100 mm Hg over the next 2-6 hours, and then eventually to normal over the next 24-48 hours.
lower SBP <140 in pheo/pre eclampsia, <120 in aortic dissection

Question 15

meds which cause orthostatic hypotension

Answer 15

alpha blockers like terazosin (schedule at bedtime)
tamsulosin, tizanidine, trazodone (and other antipsychotic/antidepressant medications), and carvedilol (with its alpha-blocking properties)

Question 16

HTN in DM/CKD/albuminuria

Answer 16

ACEI/ARB

Question 17

normal bump in creatinine after ACEI/ARB initiation

Answer 17

cause serum creatinine to increase ≤30% because of concurrent reduction in glomerular filtration rate (GFR).
Further GFR decline should be investigated and may be related to other factors, including volume contraction, use of nephrotoxic agents, or renovascular disease

Question 18

LVH with normal BP

Answer 18

ambulatory monitoring (masked hypertension)

Question 19

question in-office elevated BP if

pseudoresistant HTN

Answer 19

no LVH on ECG/echo, h/o dizziness

elevated in office, not elevated at home

Question 20

resistant htn in CKD tx

Answer 20

loop diuretics

Question 21

refractory htn

Answer 21

not controlled by 5 meds including diuretic and MRA

Question 22

white coat effect vs white coat HTN

Answer 22

hypertensive vs nonhypertensive

Question 23

cold, low BP, renal dysfunction

HF exac GDMT

Answer 23

poor perfusion, wet and cold HF-> perishock

continue unless hemodynamically unstable/ CI

Question 24

HTN from RAS due to fibromuscular dysplasia tx

HTN from RAS due to athero (elderly)

Answer 24

antihypertensives (ACEI/ARB)-> balloon angioplasty

same, meds-> revasc

Question 25

hemodynamic changes in aging

Answer 25

increased SBP
decreased DBP 
Increased pulse pressure
Increased pulse wave velocity
Increased arteriolar resistance, decreased NO

Question 26

causes of essential htn

Answer 26

increased sympathetic nerve activity
increased concentrations of vasoactive and salt-retaining hormones
endothelial dysfunction, increased vascular reactivity, arterial stiffness, and remodeling.

Question 27

HFpEF risk factors

Answer 27

hypertension, DM, obesity, h/o CAD

Question 28

Hypertensive emergency choice of treatment agent

Answer 28

NO LABETALOL OR ESMOLOL (decrease contractility) OR HYDRALAZINE (rebound tachycardia)
Use
nitroglycerin (if ACS/pulmonary edema, not if recent viagra)
nitroprusside (not if recent viagra)
nicardipine (not in AS)
phentolamine (pheo, cocaine, MAOI, meth, clonidine withdrawal)

Question 29

STEMI + cardiogenic shock

Answer 29

revascularize regardless of timing from onset of MI

CULPRIT-SHOCK: only treat culprit vessel with PCI

Question 30

NSAIDs (including aspirin) increase BP by

Answer 30

inhibition of cyclooxygenase 2 in the kidney, which results in reduced sodium excretion and an increase in intravascular volume.

Question 31

HTN diagnosis

Answer 31

2 readings on two or more occasions

Question 32

relationship between HTN and cardiovascular risk

Answer 32

log-linear

increase of 20/10= double risk

Question 33

exponential relationship
bimodal
deterministic

Answer 33

single point increase= double risk
different responses in different categories
certain regardless of severity/measure

Question 34

difficult to control htn+ hypokalemia
diagnosis

treatment

Answer 34

primary hyperaldosteronism
A plasma aldosterone concentration/plasma renin activity (PAC/PRA) ratio ≥20 with a PAC of ≥12 ng/d
MRA

Question 35

orthostatic hypotension on diuretic

Answer 35

decrease dose, may need to have permissive mild hypervolemia

Question 36

cardiac index formula

causes of cardiogenic shock

Answer 36

O2 consumption / arteriovenous O2 difference

MI, acute valvular insufficiency, or an acute intracardiac shunt.

Question 37

ARNI indicated in

Answer 37

(NYHA) functional class II-IV and an LVEF ≤40%.