HTN Flashcards
1
Q
HTN is defined as ____ SBP and/or ____ DBP
A
> 130 SBP, >80 DBP
2
Q
Stage 1 Htn is _____ SBP and _____ DBP
A
130-139 SBP and 80-89 DBP
3
Q
Stage 2 HTN is ____ SBP and ____ DBP
A
> 140 SBP, >90 DBP
4
Q
What are the 3 spectrums of chronic HTN
A
- isolated systolic: high SBP, norm DBP
- isolated diastolic: norm SBP, high DBP
- combined
5
Q
Contributing factors of HTN include
A
- SNS hyperactivity
- dysregulation of RAAS
- deficiency of endogenous vasodilators
6
Q
lifestyle risk factors for HTN
A
obesity, alcoholism, tobacco
7
Q
Common causes of 2ndary HTN include
A
hyperaldosteronism, thyroid dysfunction, OSA, cushings, pheochromocytoma
8
Q
Children with HTN generally have ____ HTN d/t ______ or ______
A
2ndary d/t renal disease or aortic coarctation
9
Q
Select drugs that increase BP include
A
- Antiinfective - ketoconazole
- antiinflam - COX2 inhib, NSAIDs
- Chemo - vascular endothelial growth factors
- Herbal - ephedra, ginseng, ma huang
- illicit - amphetamines, cocaine
- Immunosuppresants - cyclosporine, sirolimus, tacrolimus
- psych - buspirone, carbamazepine, clozapine, lithium, MAOI, SSRI, TCAs
- Sex hormones - estrogen and progesterone; oral contraceptives
- steroid - methylprednisolone, prednisone
- sympathomimetic - decongestants, diet pills
10
Q
common causes of 2ndary HTN in young adults (19-39)
A
thyroid dysfunction, fibromuscular dysplasia, renal parenchymal disease
11
Q
common causes of 2ndary HTN in middle age adults (40-64)
A
hyperaldosteronism, thyroid dysfunction, OSA, cushing, pheochromocytoma
12
Q
Chronic HTN leads to
A
- remodeling of small & large arteries
- endothelial dysfunction
- end-organ damage
13
Q
Vasculopathy can be detected early using ______
A
ultrasound with measurement of the common carotid intimal-medial thickness and arterial pulse-wave velocity
14
Q
Treatment goal of HTN
A
SBP <130/<80
15
Q
Resistant HTN is
A
HTN despite 3+ anti-HTN drugs @ max dose
16
Q
Controlled resistant HTN is
A
controlled BP requiring 4+ meds
17
Q
refractory HTN is
A
uncontrolled BP on 5+ meds
18
Q
pseudo-resistant HTN is
A
appears resistant to drugs often d/t inaccuracies or noncompliance
19
Q
For every 1kg of weight loss, BP is reduced by how much
A
1 mmHg
20
Q
Dietary potassium and calcium intakes are ________ (indirectly/directly) related to HTN and CVA
A
inversely
21
Q
Describe the 8 ACC/AHA guidelines for BP management
A
- Out of office BP readings recommended
- Treat pts with ischemic dz, CVA dz, CKD or atherosclerosis w BP meds if HTN
- There is limited data to support treating pts w/o cardiovascular or CVA nonpharmagcologically if SBP>130 or DBP >80
- Same goals recommended for HTN patients with DM or CKD as general population
- ACE-I, ARBs, CCBs, or thiazide diuretics are effective in nonblack patients
- Black adult HTN patients w/o HF or CKD, moderate evidence to support CCB or thiazide diuretics
- Moderate evidence supports antihypertensive therapy with an ACE-I or ARB in those with CKD to improve kidney outcomes
- Nonpharmacologic interventions are important components of comprehensive BP management
22
Q
B-Blockers are reserved for HTN patients with
A
CAD or tachydysrhythmias or if multidrug resistant HTN
23
Q
Treatment of 2ndary HTN is often ______, including surgical correction of _____, _____, or ______
A
interventional, renal artery stenosis, adrenal adenoma, pheochromocytoma
24
Q
ACE-I and ARBS are not recommended in _______ because they can accelerate renal failureq
A
bilateral renal artery stenosis
25
Primary hyperaldosteronism can be treated with
aldosterone antagonist (i.e. spironolactone)
26
Surgery should not be delayed d/t hypertension unless patient experiencing
extreme HTN >180/>110 or end-organ injury that could be reversed w/ BP control
27
secondary HTN d/t pheochromocytoma can be indicated by what symptoms
flushing, sweating, palpitations
28
secondary HTN d/t renal artery stenosis can be indicated by what symptoms
renal bruit
29
secondary HTN d/t hyperaldosteronism can be indicated by
hypokalemia
30
The only anti-HTN that could/should be held before surgery are
ACE-I and ARBs
31
HTN patients are hemodynamically vulnerable to _____ medications
induction
32
_________ before induction may provide better hemodynamic stability
modest volume loading - unless LVH or diastolic dysfunction exists
33
Peripartum HTN requires immediate intervention when ____ SBP/ ____ DBP
>160 SBP/ >110 SBP
34
______ is the 1st line drug for peripartum HTN
labetalol
35
_____ is the gold standard for rapid arterial dilation
sodium nitroprusside
36
_____ is a 3rd generation dihydropyridine CCB with ultrashort (1min) half-life and selective arteriolar vasodilator
Clevidipine
37
_____ is a 2nd generation dihydropyridine CCB with a longer half life (30min)
Nicardipine
38
The primary agents for treating encephalopathy and intracranial hypertension includes _______, and what are the cautions?
Clevidipine, nitroprusside, labetalol, nicardipine
- risk of cyanide toxicity
- nitroprusside increases ICP
- cerebral ischemia may result from lower blood pressure due to altered autoregulation
39
The primary agents for treating aortic dissection includes ______, and what are the cautions?
Clevidipine, nicardipine, esmolol, labetalol
- vasodilators may caused marked drop in BP that can result in end-organ ischemia
- goal is decreasing pulsatile force of left ventricular contraction
40
The primary agents for treating acute kidney injury includes ______, and what are the cautions?
Clevidipine, nicardipine, labetalol
- vasodilators may caused marked drop in BP that can result in end-organ ischemia
- may require emergent hemodialysis if it progresses to renal failure
41
The primary agents for treating preeclampsia/eclampsia includes ______, and what are the cautions?
labetalol, nicardipine
- B-blockers may reduce uterine blood flow and inhibit labor
- Delivery is only definitive therapy
- ACE and ARBs are teratogenic and contraindicated during pregnancy
42
The primary agents for treating pheochromocytoma includes ______, and what are the cautions?
Phentolamine, phenoxybenzamine, propanolol, labetalol
- Unopposed a-adrenergic stimulation following B-blockade worsens HTN
**Give a-blocker first before B-blocker**
43
The primary agents for treating cocaine intoxication includes ______, and what are the cautions?
Labetalol, dexmedetomidine, clevidipine
- Unopposed a-adrenergic stimulation following B-blockade worsens HTN
44
What are the 5 classifications of pulmonary HTN
- 1. pulmonary arterial HTN (PAH)
- 2. PH d/t left heart disease
- 3. PH d/t lung disease, hypoxia
- 4. PH d/t chronic thromboembolism
- 5. PH d/t unknown or multifactoria
45
Pulmonary HTN is defined as
mean PA pressure (mPAP) >20mmHg
46
symptoms of pulm HTN include
accentuated S2, S4 gallop, LE swelling
47
Pulmonary HTN is further divided into which 3 hemodynamic profiles
- isolated precapillary PH (PVR > 3.0 wood units, norm PAWP (< 15mmHg)
- isolated postcapillary PH (PVR norm, PAWP >15mmHg)
- combined pre- and post-PH (PVR and PAWP both elevated); can be further subcategorized as fixed or vasoreactive d/o response to vasodilators or diuretics
48
High-flow PH occurs due to ______. are PVR and/or PAWP elevated?
increased pulmonary blood flow c/b systemic-pulmonary shunt or high cardiac output state
- PAWP and PVR not elevated
49
Isolated precapillary PH includes which groups, and what would hemodynamic profile look like?
Groups 1, 3, 4, 5
- mPAP >20mmHg
- PAWP < 15mmHg
- PVR > 3 woods units
50
Isolated post-capillary PH includes which groups, and what would hemodynamic profile look like?
Groups 2, 5
- mPAP >20 mmHg
- PAWP > 15mmHg
- PVR < 3 woods units
51
Combined pre- and post-capillary PH includes which groups, and what would hemodynamic profile look like?
Groups 2, 5
- mPAP >20 mmHg
- PAWP > 15 mmHg
- PVR > 3 woods units
52
_______ must be done to diagnose PAH
right heart cath
53
In PAH, mPAP can be increased by which 4 mechanisms
- elevated resistance to blood flow within arterial circulation
- increased pulmonary venous pressure from left heart disease
- chronically increased pulmonary flow
- combination of these
54
Calculation for PVR
PVR = (mPAP - PAWP) / CO
55
What would be seen on TTE in patient with PAH?
RA & RV enlargement and elevated tricuspid-regurg velocity
56
What are the ranges of mPAP in mild, mod, severe PH
- mild = 20-30 mmHg
- mod = 31-40 mmHg
- severe = >40 mmHg
57
___% of PAH cases are genetic with mutations in ______
3%, bone morphogenetic protein receptor type 2 (BMPR2)
58
Nearly 1:8 of patients have long-term improvement from _____ drugs
CCBs
59
the 3 main classes of vasodilator drugs for PAH are
prostanoids, endothelin receptor antagonists (ERAs), drugs that enhance NO/guanylyl cyclase pathways
60
Prostanoids mimic the effect of _______ to produce ______ while inhibiting ________. They also have _______ effects and may reduce ____________
mimic prostacycline, produce vasodilation, inhibit platelet aggregation. Also antiinflammatory effects, reduce proliferation of vascular smooth muscle cells
61
Which drugs are prostanoids
- epoprostenol (IV)
- iloprost (inhaled)
- treprostinil (SQ, IV, INH, PO)
- beraprost (PO)
*all provide improvement but only epoprostenol is proven to reduce mortality
62
Endothelin receptor antagonists (ERAs) improve hemodynamics and exercise capacity by which process?
vascular endothelial dysfunction associated with PAH involves an imbalance between vasodilating (nitric oxide) and vasoconstricting (endothelin) substances.
63
Nitric oxide/guanylate cyclase produces pulmonary vasodilation by ____________. The effect is transient because nitric oxide is quickly bound by _____ and degraded by ______
stimulating guanylate cyclase and cGMP in smooth muscle cells. bound by Hgb and degraded by PDE-5
64
Chronic therapy of PAH treatment has been directed towards ______ to prolong half-life of nitric oxide
PDE-5 inhibitors
65
PAH preop considerations should be given to procedures with
- potential for venous embolism
- elevations in venous and/or airway pressures
- hypoxic pulmonary vasoconstriction
- reduction in pulmonary vascular volume
- systemic inflammation
- emergency procedures
66
PAH often presents with nonspecific sx s/a
fatigue, dyspnea, cough
67
Severe sx of PAH include
angina, syncope, which can occur with exercise if coronary blood flow doesn't meet the demands of a hypertrophied RV
68
On assessment of patient with PAH may exhibit
parasternal lift, accentuated S2, S3, or S4 gallop, JVD, peripheral edema, hepatomegaly, ascites
- rarely compression of a dilated PA may lead to recurrent laryngeal nerve damage and hoarseness
69
During RHC, vasoreactivity testing with inhaled NO is performed to determine responsiveness vasodilator therapy.
85-90% of PAH patients are _______ to inhaled nitric oxide
nonresponsive. Those that are responsive also respond to CCBs and may benefit from other targeted therapy
70
Primary intraoperative goal in PH is _________
maintaining optimal "mechanical coupling" btw the RV and pulmonary circulation to promote adequate left-sided filling and systemic perfusion
71
Perioperative complexities that can increase the risk of complications in PH
- transient HoTN
- mechanical ventilation
- modest hypercarbia
- small bubbles in IV
- Trendelenburg position
- Pneumoperitoneum
- single-lung ventilation
72
A hallmark of PAH is
increased RV afterload, leading to RV dilation, increased wall stress, and RV hypertrophy
73
Vent settings such as PEEP, hypoventilation, hypercarbia, acidosis, and atelectasis can affect ________
RV afterload
74
In contrast to the LV, the thinner-walled RV is subject to _______ wall tension for the same degree of end-diastolic volume, leading to _____ RV O2 demand
greater, increased
75
Under normal circumstances the ________ pressure is lower than the aortic root pressure and ______ coronary perfusion occurs throughout the cardiac cycle
RV pressure, RV perfusion
76
In PAH, the elevated RV pressure leads to _______ coronary flow during diastole, making the _____ more vulnerable to systemic HoTN, worsening the O2 supply/demand mismatch and potentially causing MI
increased, RV more vulnerable
77
The lethal combination of RV dilation that can lead to RV ischemia are
insufficient LV filling, reduced stroke volume, and systemic HoTN
78
HTN is a significant risk factor for _____
CV disease, stroke, renal disease
79
Guidelines define SBP goal < ____
< 130 mmHg
80
preop evaluation of HTN pts should focus on
adequate BP control, tx regimen, and presence of end-organ damage
81
_______ is common during anesthesia in HTN pts
hemodynamic instability
82
PH is defined as a mPAP >_____ mmHg and can result from processes that _____, _____, or ______, leading to vascular remodeling
> 20mmHg, constric arteries, elevate pulm venous pressure, chronically increase blood flow
83
A ______ is required to provide a dx of PAH and guide tx
RHC
84
Only a small percentage of PAH patients respond to ______
CCBs
85
Pulmonary vasodilators include
- prostacyclin analogues
- endothelin receptor antagonists (ERAs)
- drugs that activate NO/guanylate cyclase pathway
86
PAH pts on vasodilators should have them _______ (continued/discontinued) intraoperatively and postoperatively.
continued, convert from oral to IV or inhaled when necessary
