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Final Exam - Hypertension Flashcards

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1
Q

What blood pressure define hypertension?

A

> 130/80

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2
Q

What BP define normal, elevated, stage 1 hypertension, and stage 2 hypertension?

A
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3
Q

This risk factor for cardiovascular morbidity correlates to vascular remodeling and stiffness?

A

Widened pulse pressure

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4
Q

Common causes of primary HTN?

A
  • SNS hyperactivity
  • RAAS dysregulation
  • Endogenous vasodilator deficency
  • Obesity
  • Alcoholism
  • Tobacco
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5
Q

Common causes of secondary HTN?

A
  • Hyperaldosteronism
  • Thyroid dysfunction
  • OSA
  • Cushings
  • Pheochromocytoma
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6
Q

Why do children generally have HTN?

A

Secondary to renal dx or coarctation of the aorta

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7
Q

Correlation between increasing blood pressure along with increasing age?

A

The higher the SBP or DBP the increased mortality at any age but increases dramatically with age

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8
Q

What drug categories can increase BP?

A

All – Antiinfective
Angry – Antiinflammatory
Cats – Chemotherapeutic
Hate – Herbal
Ignoring – Illicit
Important – Immunosuppressive agents
Psychotic – Psychiatric
Super – Sex hormones
Stereotyped – Steroid
Sympathizers – Sympathomimetic

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9
Q

How can vasculopathy be detected early?

A

Ultrasound with measurement of the common carotid intimal-to-medial thickness and arterial pulse-wave velocity

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10
Q

____ and ____ can track the progression of LVH

A

EKG and echocardiogram

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11
Q

What can be used to track microvascular changes associated with cerebrovascular damage?

A

MRI

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12
Q

What are the end organs damaged by HTN?

A
  • Blood vessels
  • Brain
  • Heart
  • Kidneys
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13
Q

What is resistant HTN?

A

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

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14
Q

What is the normal treatment for someone with resistant HTN?

A
  • LA CCB
  • ACEi/ARB
  • Diuretic
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15
Q

What is controlled resistant HTN?

A

Controlled BP requiring 4+ meds

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16
Q

What is refractory HTN?

A

Uncontrolled BP on 5+ drugs

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17
Q

What is pseudo-resistant HTN?

A

HTN that appears resistant to drugs - caused by anxiety or medication non-compliance

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18
Q

How is weight loss effective at BP reduction?

A
  • Directly reduces BP
  • Improves drug efficacy
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19
Q

How much is BP dropped when losing weight?

A

1 mmHg reduction for every 1 kg lost

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20
Q

What two electrolytes are inversely related to HTN and cerebrovascular disease?

A
  • Potassium
  • Calcium
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21
Q

Is Na+ restriction effective at lowering BP?

A

Yes, causes small but consistent decreases in BP

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22
Q

What drugs are absent from 1st line HTN therapy?
Why?

A
  • Beta Blockers
  • Reserved for pts with CAD, tachyarrythmia, or multidrug resistant HTN
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23
Q

How many drug classes are approved for HTN?

A

15

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24
Q

What treatment is usually required for secondary HTN?

A

Surgical correction (renal artery stenosis, pheochromocytoma)

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25
What drugs can be used for unilateral renal artery stenosis but not bilateral stenosis?
ACE-i, ARB, and direct renin inhibitors
26
Primary hyperaldosteronism can be treated w/ an ____ such as ____
- aldosterone antagonist - spirinolactone
27
When should we delay surgery in regards to a patient's blood pressure?
- Extreme HTN (> 180/110) - End organ injury r/t to HTN
28
Flushing, sweating and palpitations are suggestive of what?
Pheochromocytoma
29
What assessment finding may indicate renal artery stenosis?
Renl bruit
30
What lab finding could suggest hyperaldosteronism?
Hypokalemia
31
What BP meds should be *continued* prior to surgery?
BB, CCB, clonidine
32
Concerns with proceeding to surgery with a HTN patient?
- Increased blood loss - MI - CVA - Hemodynamic volatility - Less resilient to periods of hypotension
33
What are the 4 cardiac changes that can occur from LVH? What can these lead to?
34
What should you consider for a HTN patient on induction?
- Pre-op A-line - Esmolol - Modest volume loading d/t hypovolemia - Vasoactive drugs choosen based on patient specific factors
35
At what BP could a women with PIH experience end-organ dysfunction?
DBP > 100
36
When should immedate interventions be taken for a women wit peripartum HTN?
SBP > 160, DBP > 110
37
What is the 1st line drug for peripartum HTN?
Labetalol
38
What 2 CCB could be considered for hypertensive crisis? Pros and cons of each?
**Clevidipine** - ultrashort 1/2 life of ~1 min, selectively vasodilates arteries, *expensive* **Nicardipine** - longer 1/2 life of ~30 mins = less titratable
39
Primary BP agents used for HTN induced encephalopathy/intracranial HTN?
- Clevidipine - Nitroprusside - Labetalol - Nicardipine | Arterial dilators
40
Primary HTN agents for an aortic dissection?
- Clevidipine - Nicardipine - Esmolol - Labetalol
41
Primary HTN agents for AKI?
- Clevidipine - Nicardipine - Labetalol
42
Drugs of choice for preeclampsia/eclampsia?
- Labetalol - Nicardipine
43
Concerns with using BB during pregnancy?
They may reduce uterine blood flow and inhibit labor
44
What is the cure for preeclampsia? What drugs are contraindicated?
- Delivery - ACEi/ARBs d/t teratogenicity
45
Drugs to treat HTN from pheochromocytoma?
- Phenoxybenzamine - Phentolamine - Propanolol - Labetalol
46
Drugs to treat HTN d/t cocaine intoxication?
- Labetalol - Dexmedetomidine - Clevidipine
47
Wht are the 5 classes of pulmonary hypertension?
1. Pulmonary arterial hypertension (PAH) 2. PH due to left heart disease 3. PH due to lung disease and/or hypoxia 4. Chronic thromboembolic pulmonary hypertension (CTEPH) 5. Pulmonary hypertension with unclear multifactorial mechanisms
48
What defines pulmonary HTN?
mPAP > 20 mmHg
49
Symptoms of PH?
- Accentuated S2 and S4 gallop - LE swelling
50
What are the 3 subcategories of PH?
- Isolated precapillary HTN - Isolated postcapillary PH - Combined pre and post capillary PH
51
What is precapillary PH and what are the parameters that define it?
- Primary issue lies in the pulmonary arterial circulation - Pulmonary vasc resistance (PVR) ≥ 3.0 wood units w/ normal LAP or PAWP (< 15mmHg)
52
What is postcapillary PH and what are the parameters that define it?
- Increased pulmonary venous pressure d/t elevated LAP usually c/b left heart disease - Elevated PAWP (>15mmHg), Normal PVR
53
What is combined pre- and postcapillary PH and what are the parameters that define it?
- Chronic pulmonary venous HTN with secondary pulmonary arterial vasoconstriction and remodeling - Characterized by a PVR > 3.0 WU and PAWP >15mmHg
54
What is high flow PH?
Occurs w/o an elevation in PAWP or PVR and results from increased pulmonary blood flow c/b systemic-to-pulmonary shunt or high cardiac output states
55
What is required for PAH diagnosis?
Right heart catheterization
56
4 reasons that mPAP may be elevated?
1) elevated resistance to blood flow within the arterial circulation 2) increased pulmonary venous pressure from left heart disease 3) chronically increased pulmonary blood flow 4) a combination of these processes
57
Formula for PVR? | Think about A&P
R= △P / Flow PVR = (mPAP-PAWP) ÷ CO
58
What mPAP pressures correlate to mild, moderate, and severe PH?
Mild = 20-30 mmHg Moderate = 31-40 mmHg Severe = > 40 mmHg
59
What does a TTE reveal in patients with PAH? Can it be used to diagnose?
- RA and RV enlargement; increased tricuspid regurgitation velocity - Estimates pulmonary arterial systolic pressure (PASP) - PASP not definitive enough to diagnose PAH
60
Normally, the pulmonary circulation can accommodate a ____ increase in COP without a marked changed in mPAP
fourfold
61
What gene is mutated in genetic PAH?
Bone morphogenetic protein recptor type 2 (BMPR2)
62
CCB can have long term improvements in ____ PAH patients
1:8 Only helps a small percentage of patients
63
1 year mortality of PAH?
15%
64
What are the 3 main classes of pulmonary vasodilator drugs for PAH?
- Prostanoids - Endothelin Receptor Antagonists (ERA) - Drugs that enhance the NO/GC pathways
65
MOA of prostanoids?
Mimic the effect of prostacyclin to produce vasodilation while inhibiting platelet aggregation. They also have anti-inflammatory effects and may reduce proliferation of vascular smooth muscle cells.
66
Examples of prostanoids? What is the only one that reduces mortality?
epoprostenol (IV) - *only one that reduces mortality* iloprost (inhaled) treprostinil (SQ, IV, INH, PO) beraprost (PO)
67
ERA MOA for PAH?
Vascular endothelial dysfunction associated with PAH involves an imbalance btw vasodilating (nitric oxide) and vasoconstricting (endothelin) substances. ERAs improve hemodynamics and exercise capacity
68
NO/GC MOA for PAH?
Nitric oxide produces pulmonary vasodilation by stimulating guanylate cyclase and cGMP in smooth muscle cells
69
What drug prolongs the 1/2 life of NO? Why is it necessary?
- PDE-5 inhibitors - NO effects are transient because nitric oxide is quickly bound by hgb and degraded by phosphodiesterase type 5
70
Patients with PAH often present with nonspecific symptoms like:
Faigue, dyspnea, and cough
71
Rarely, compression of a dilated PA may lead to ____ and hoarseness
RLN damage
72
How is vasoreactivity testing done during a right heart cath?
Inhaled nitric oxide to determine responsiveness to vasodilator therapy
73
____ of PAH are not responsive to inhaled nitric oxide
85-90%
74
If a PAH is responsive to inhaled NO, what other drugs are they usually responsive to?
CCB
75
What is the primary intraoperative goal for PAH?
Maintaining optimal “mechanical coupling” btw the right ventricle and pulmonary circulation to promote adequate left-sided filling and systemic perfusion
76
What other perioperative complexities inrease the risk of complications in PAH patients?
* transient HoTN * mechanical ventilation * modest hypercarbia * small bubbles in IV * T-burg position * Pneumoperitoneum * single-lung ventilation 
77
What ventilator effects can affect RV pulsatile load?
- PEEP - Hypoventilation - Hypercarbia - Acidosis - Atelectasis
77
Patho of RVH in PAH?
Increased RV afterload, leading to RV dilation, increased wall stress, and RV hypertrophy
78
What 3 surgeries can cause adverse effects in patients with PAH?
- Orthopedics - esp hip and knee replacement - Laproscopy - d/t pneumoperitoneum, trendelenburg, and increased AW pressure - Thoracic surgery - involves one lung ventilation and atelectasis
79
HPV effect on RV afterload? Intraop treatment?
* Increases RV afterload * Converted to inhaled vasodilators if doing single lung ventilation

Assessment (23 decks)

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