EXAM 4 HTN

Question 1

Hypertension is defined by what SBP and DBP?

Answer 1

sustained SBP > 130 mmHg and/or a DBP > 80 mmHg

Question 2

Risk of Hypertension in the US?

Answer 2

90%

Question 3

Stage 2 hypertension parameters

Answer 3

> 140 mmHg and/or >90 DBP

Question 4

Like DM, HTN can lead to what?

Answer 4

ischemic heart disease, stroke, renal failure, retinopathy, PVD, and overall mortality

Question 5

What parameters do we keep our patients in regards to hemodynamics, especially BP?

Answer 5

20%. HTN patients have a shift to the right of their autoregulation curve.

Question 6

Why is a wide pulse pressure a concern?

Answer 6

suggest arterial stiffness, or reduced compliance.

Question 7

contributing factors to primary hypertension?

Answer 7

no clear cause per se.

Linked to SNS, RAAS, endothelial vasodilator dysfunction.

Question 8

Drugs that can increase BP
(chart from class)

Answer 8

Question 9

common cause of HTN in the youth?

Answer 9

coarctation of the aorta

Question 10

whats more treatable, primary or secondary HTN

Answer 10

secondary, as the BP is typically linked to another disorder.

Question 11

Quick noninvasive way to determine if your patient has had long term hypertension.

Answer 11

Look at their EKG, pay attention to axis shift suggesting hypertrophy

Question 12

Resistant HTN medical presentation?

Answer 12

above-goal BP despite 3+ antihypertensive drugs @ max dose

Question 13

controlled resistant presentation?

Answer 13

controlled BP requiring 4+medications

Question 14

Refractory HTN presentation?

Answer 14

5+ drugs and still hypertensive.

Question 15

What can cause psuedoresistant hypertension?

Answer 15

white coat syndrome. (some people freak themselves)

Question 16

Best treatment for HTN?

Answer 16

lifestyle modifications

Question 17

For every Kg lost we can roughly expect to see what decrease in BP?

Answer 17

about 1 mmHg. (this is not set in stone)

Question 18

How are K+ and Ca++ linked to HTN?

Answer 18

Inversely, correct dietary amounts of these electrolytes are associated with lower BPs.

Question 19

An easy dietary measure to keep BP low?

Answer 19

salt restriction

Question 20

AHA guidelines.

Answer 20

1. Out-of-office BP’s are recommended for diagnosis and titration of antihypertensive meds
2. Evidence supports treating pts with ischemic heart dz, cerebrovascular dz, CKD, or atherosclerotic cardiovascular dz w/ BP meds if SBP >130 mmHg
3. There is limited data to support treating pts w/o cardiovascular or cerebrovascular dz with nonpharmacologic therapy if SBP >130 or DBP >80
4. The same goals are recommended for HTN pts w/DM or CKD as for the general HTN population

Question 21

AHA guidelines continued

Answer 21

5. ACE-I’s,ARBs, CCBs, or thiazide diuretics are useful and effective in nonblack HTN pts,including those with diabetes
6. In black adult HTN pts w/o heart failure or CKD, including those with DM, there ismoderate evidence to support initial antihypertensive therapy with a CCB or thiazidediuretics
7. There is moderate evidence to support antihypertensive therapy with an ACE-I or ARB in those with CKD to improve kidney outcomes
8. Nonpharmacologic interventions are important components to a comprehensive BPmanagement approach

Question 22

Treatment of secondary HTN includes?

Answer 22

surgical correction of renal artery stenosis, adrenal adenoma or pheochromocytoma

can use meds as well

Question 23

should you delay surgery due to hypertension?

Answer 23

Not really, unless you expect end organ damage. Try and reduce your patients anxiety, and determine if the HTN is transient.

Question 24

which anti-htn med classes are typically held on day of surgery?

Answer 24

ARBs and ACE-Is

Question 25

why is perioperative HTN a concern?

Answer 25

Bleeding and CV complications.

Question 26

Why is chronic hypertension such a concern in the OR?

Answer 26

Brief periods of hypotension relative to the patient can have profound effects on perfusion dependent organs.

Question 26

LVH goes one of two ways what are they?

Answer 26

Reduced contractility or reduced filling.

Question 26

Hypertension leads to what in the heart?

Answer 26

LVH

Question 26

What attenuates the hypotension seen during induction?

Answer 26

direct laryngoscopy.

Question 27

A quick and easy antihypertensive med to keep near for our severely hypertensive patients?

Answer 27

esmolol, very short half life.

Question 28

Another way to attenuate hypotension on induction, something we can do on the floor or in pre op?

Answer 28

Tank them up. pay attention to presentation, make sure they are not a heart failure patient or already fluid overloaded.

Question 29

when should we concerned for our OB patients?

Answer 29

DBP pressures greater than 100 mmHg. linked to encephalopathy.

Question 30

parturient patients need medical intervention for these parameters?

Answer 30

SBP >160 / DBP>110 act immediately

Question 31

Drugs used in a hypertensive crisis?

Answer 31

Nitro, Nicardipene, clevidipine, esmolol, labetalol

Question 32

Hypertensive chart for your viewing pleasure

Answer 32

Question 33

S2 or s4 heart sound, extremity swelling, PA pressure greater then 20 mmHG, what am i?

Answer 33

PAH

Question 34

The classifications of PAH?

Answer 34

isolated precapillary PH isolated postcapillary PH combined pre & postcapillary PH

Question 35

Precapillary PH is defined as

Answer 35

PVR of ≥3.0 wood units w/o elevated LAP or PAWP (PAWP <15mmHg = normal)

Question 36

Isolated postcapillary PH =

Answer 36

characterized by a PAWP >15mmHg, w/normal PVR

Question 37

Combined pre- and postcapillary PH (aka reactive PH) =

Answer 37

Characterized by a PAWP >15mmHg and a PVR > 3.0 WU

Question 38

High-flow PH is due to?

Answer 38

systemic-to-pulmonary shunt or high cardiac output

Question 39

PVR = ?

Answer 39

= (mPAP − PAWP)/COP

Question 40

How do we confirm and diagnose PAH?

Answer 40

Right heart catheterization

Question 41

Non invasive way to examine if we suspect PAH?

Answer 41

TTE

Question 42

Severity of PAH levels

Answer 42

Mild PH (mPAP = 20–30 mmHg) Moderate PH (mPAP = 31–40 mmHg) Severe PH (mPAP >40 mmHg)

Question 43

The three methods used to treat PAH?

Answer 43

Prostanoids, ERAs, and PD-5 Is.

Question 44

PAH preop considerations?

Answer 44

venous embolism, elevations in venous and/or airway pressure, hypoxic pulmonary vasoconstriction, reduction in pulmonary vascular volume, systemic inflammation, and emergency procedures

Question 45

How does PAH present?

Answer 45

nonspecific symptoms of fatigue, dyspnea, and cough

Question 46

a dilated PA can lead to hoarseness albeit rarely?

Answer 46

recurrent laryngeal nerve compression

Question 47

Why is right ventricular hypertrophy such a problem?

Answer 47

the right heart is continuously perfused throughout the cardiac cycle in the healthy heart. RVH leads to increased demand that cannot be met.

Question 48

Why would need a left cath of the heart to determine LVEDP?

Answer 48

potential discrepancies could lead to mismanagement of our patients.

Question 49

why is a NO test performed on our patients?

Answer 49

If they vasodilate appropriately, they are typically responsive to CCBs

Question 50

What is important in dealing with pulmonary hypertensive patients?

Answer 50

To maintain the coupling between the Right and left heart.

Question 51

Why do we need to worry about our interventions in pulmonary hypertension?

Answer 51

preload, inotropy, afterload, and oxygen supply/demand can all be effected. Think about too much of a recruitment maneuver or too much PEEP. reducing venous return.

Question 52

What is something that we could see via ultrasound that is a hallmark of PAH?

Answer 52

increased RV afterload, leading to RV dilation, increased wall stress, and RV hypertrophy

Question 53

How can we effect right ventricular afterload?

Answer 53

Ventilator management can have effects on RV afterload through the addition of PEEP, hypoventilation, hypercarbia, acidosis, and atelectasis

Question 54

What is the lethal combination we can see with pulmonary hypertension?

Answer 54

Systemic HoTN along with RV ischemia and high afterload can result in the “lethal combination” of RV dilatation, insufficient LV filling, reduced stroke volume, and further systemic hypotension

Question 55

concerns of orthopedics?

Answer 55

perioperative morbidity and mortality in pts with PH undergoing hip and knee replacement

Question 56

Laparoscopic considerations?

Answer 56

C02 pneumoperitoneum has an acute impact on biventricular load and pump function. The combination of pneumoperitoneum, head-down position, and increased inspiratory pressure affects RV pressures and afterload

Question 57

Thoracic surgery considerations?

Answer 57

Intentional atelectasis will increase right ventricular afterload.

Question 58

3 features of lung collapse?

Answer 58

some centers transiently pressurize the chest to induce atelectasis (2) there is a potential for systemic hypoxia (3) hypoxic pulmonary vasoconstriction (HPV) will further increase RV afterload