Hypertension (Exam IV) Flashcards
(124 cards)
1
Q
Hypertension is defined as sustained systolic BP > ______ mmHg.
A
130
2
Q
Hypertension is defined as sustained diastolic BP > ______ mmHg.
A
80
3
Q
Isolated systolic hypertension is defined as systolic BP greater than ______ and diastolic BP less than ______ mmHg.
A
130
80
4
Q
Isolated diastolic hypertension is defined as systolic BP less than ______ and diastolic BP greater than ______ mmHg.
A
130
80
5
Q
Lifetime Risk of developing HTN
A
90%
6
Q
Differentiate stage 1 and stage 2 hypertension.
A
Stage 1:
- sBP of 130 - 139
- dBP of 80 - 89
Stage 2:
- sBP ≥ 140
- dBP ≥ 90
7
Q
Combined systolic and diastolic HTN SBP and DBP
A
SBP >130mmHg and DBP >80 mmHg
8
Q
T/F Widened pulse pressure is a risk factor for CV morbidity
It correlates with ___________ and __________
A
T
Vascular remodeling and stiffness
9
Q
What is the cause of Primary (essential) HTN?
A
Etiology unclear
10
Q
What factors contribute to primary HTN?
A
- SNS hyperactivity
- Dysregulation of RAAS
- Deficient endogenous vasodilators
11
Q
Genetic and lifestyle risk factors include
A
Obesity, alcoholism, tobacco
12
Q
Primary or Secondary: Which one is rare
A
secondary.
The cause is potentially curable
13
Q
Common causes of secondary HTN in adults are:
A
Hyperaldosteronism, Thyroid dysfunction, OSA, Cushings, Pheochromocytoma
14
Q
Children (birth to 12yrs) with HTN generally have secondary HTN d/t:
A
Renal disease or Coarctation of the Aorta
15
Q
Drugs that increase BP
A
Ketoconazole
COX-2 inhibitors, NSAIDS
Vascular Endothelial GF inhibitors
Ephedra, ginseng, ma huang
amphetamines, coccaine
Cyclosporine, sirolimus, tacrolimus
Psych meds (SSRIs, etc)
Oral contraceptives (estrogen and progesterone)
steroids
Decongestants, diet pills
16
Q
Adolescents (12-18yr) secondary HTN causes
A
Coarctation of the aorta
17
Q
Young adults (19-39yr) Secondary HTN causes:
A
Thyroid dysfunction
Fibromuscular dysplasia
Renal Parenchymal disease
18
Q
Middle-aged adults (40-64 yr) secondary HTN causes
A
Hyoeraldosteronism
Thyroid dysfunction
OSA
Cushing syndrome
Pheochromocytoma
19
Q
Older adults (>65yr)
A
atherosclerotic renal artery stenosis
renal failure
Hypothyroidism
20
Q
T/F: Chronic HTN leads to remodelling of small and large arteries, endothelial dysfunction and end organ damage
A
T
21
Q
Disseminated vasculopathy plays a major role in:
A
Ischemic Heart dz
LVH
CHF
CVA
PAD
Aortic aneurysm and
nephropathy
22
Q
Vasculopathy can be detected on what:
A
US with measurement of the common carotid intimal-to-medial thickness and
arterial pulse wave velocity
23
Q
Which 2 tests can track the progression of LVH
A
EKG and Echocardiogram
24
Q
What is used to track the microvascular changes associated with cerebrovascular damage
A
MRI
25
End organ damage in VASCULOPATHY
Endothelial dysfunction
remodeling
Generalized atherosclerosis
Arteriosclerotic stenosis
Aortic aneurysm
26
End organ damage in Cerebrovascular Damage
Acute hypertensive encephalopathy
Stroke
Intracerebral hemorrhage
lacunar infarction
vascular dementia
retinopathy
27
End organ damage in Heart Disease
LVH
AFIB
Coronary microangiography
Coronary Heart disease, MI
HF
28
End organ damage in Nephropathy
Albuminuria
Proteinuria
Chronic renal insufficiency
Renal failure
29
Resistant HTN definition:
Tx includes:
BP above goal despite 3+ antihypertensive drugs at Max dose
Long acting CCB, ACE-I or ARB and a diuretic
30
Refractory HTN definition:
Uncontrolled BP on 5+ drugs (present in 0.5% of pts)
31
Pseudo-resistant HTN definition (appears resistant to other drugs)
often d/t BP inaccuracies
i.e White coat syndrome or medication noncompliance
32
Controlled resistant HTN: Definition
Controlled BP requiring 4+ medications
33
Wt. loss helps with HTN in what 2 ways
Direct BP reduction
Synergistic enhancement of drug efficacy
(even modest increase in physical activity are assoc w BP decrease)
34
1mmHg reduction is associated with ____ kg of Wt loss
1kg
Overweight adults should aim for ideal body wt
35
T/F dietary Potassiums and Calcium are ___________ related to HTN and Cerebrovascular Disease
Inversely
36
ACC/AHA guidelines for BP management
ACC/AHA Guidelines
1. Out-of-office BP's are recommended for dx and titration of BP 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 nonpharmacologically 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
5. ACE-l's, ARBs, CCBs, or thiazide diuretics are effective in nonblack HTN pts
6. In black adult HTN pts w/o heart failure or CKD, there is moderate evidence to support initial therapy with a CCB or thiazide diuretics
7. Moderate evidence supports antihypertensive therapy with an ACE-I or ARB in those with CKD to improve kidney outcomes
8. Nonpharmacologic interventions are important components of comprehensive
BP management
37
What class of meds are absent from 1st line therapy:
Beta Blockers
38
What class of patients are B-blockers reserved for:
CAD and tachy-dysrhythmias
or COmponent of multidrug tx in resistant HTN
39
Tx of secondary HTN is often ______
This includes correction of renal artery ________
adrenal____________
and ________________
interventional
stenosis
adenoma
pheochromocytoma
40
Renal repair not possible: WHat is done:
ACE-Is +/- diuretics
ACE-I’s, ARBs, and direct renin inhibitors are not recommended in bilateral renal artery stenosis as they can accelerate renal failure
41
Primary hyperaldosteronism can be treated w/
aldosterone antagonist such as spironolactone
42
pheochromocytoma is treated with ___________ and ___________
pharmacologic and surgical approach
43
Elevated BP is a reason to delay surgery T/F
not a direct prompt to delay surgery in asymptomatic pts w/o risk factors
44
The cause of secondary HTN may be indicated by:
* flushing, sweating & palpitations suggestive of pheochromocytoma
* renal bruit may suggest renal artery stenosis
* hypokalemia may suggest hyperaldosteronism
45
Once the decision is made to proceed with surgery, which drug do you continue taking:
Exception?
All antihypertensive meds;
ARBs and ACE-Is
46
Stopping BBs or clonidine can be associated with:
Rebound HTN
47
Stopping CCBs is associated with increased
perioperative cardiovascular events
48
Hemodynamic Load Diagram:
49
HTN and induction: HTN pt’s are hemodynamically vulnerable to
induction medication
50
A pre-induction________, followed by a multimodal induction that includes ______ may be beneficial
A-line
Short-Acting B-Blockers (Esmolol)
51
Poorly controlled HTN is often accompanied by _______,
hypovolemia
esp if pt is on diuretics
Modest volume loading before induction may provide better hemodynamic stability
this may be counterproductive in pts with
LVH and diastolic dysfunction
52
Vasoactive drug considerations should take into account:
AGE
Functional reserve
Medications
Planned surgery
53
T/F: Pts w/chronic HTN tend to NOT tolerate a higher SBP than normotensive pts
False:
They do!
54
Women w/PIH may experience end-organ dysfunction such as:
With a DBP of:
Encephalopathy
>100
55
* Current guidelines for peripartum HTN recommend immediate intervention for SBP of ______ and DBP_______
>160
>110
56
For rapid arterial dilation _________ infusion is the gold standard d/t fast onset and titratability
Sodium Nitroprusside
A-line needed
57
Which drug has an ultrashort DoA (≈1min half-life) and selective arteriolar vasodilating properties is another option
Whats the downside:
Clevidipine, a 3rd-generation dihydropyridine CCB
Expensive $$
Nicardipine, a second-generation dihydropyridine CCB, can also be used but has a longer half-life (≈30 min), making it less titratable than clevidipine
58
Treatments of Hypertensive Emergencies (Table)
Goodnotes** tape
59
Updated classifications of Pulmonary Hypertension
Pulmonary Arterial Hypertension
Pulmonary hypertension d/t LHD
PH d/t lung diseases and/or hypoxia
Chronic thromboembolic Pulmonary Hypertension
Pulmonary Hypertension with unclear multifactorial mechanisms
60
Pulmonary HTN defined as a mean PA pressure (mPAP)_________
>20 mmHg
61
PH Sx include: ________ and ___________
Accentuated S2 & S4 "gallop" heart sounds, Lower Extremity swelling
62
Pulmonary HTN is further divided into 3 hemodynamic profiles based on _________ and _________
PA wedge pressure (PAWP) and pulmonary vascular resistance (PVR)
63
Classifications of PH are:
* isolated precapillary PH
* isolated postcapillary PH
* combined pre & postcapillary PH
64
Precapillary PH:
Primary issue lies in the pulmonary arterial circulation.
* Pulmonary vasc resistance (PVR) ≥3.0 wood units w/ normal LAP or PAWP(<15mmHg)
65
Postcapillary PH:
ncreased pulmonary venous pressure d/t elevated LAP usually c/b left heart disease
* Elevated PAWP (>15mmHg), Normal PVR
66
Combined pre- and postcapillary PH:
Chronic pulmonary venous HTN with secondary pulmonary arterial vasoconstriction and remodeling
Characterized by a PVR > 3.0 WU and PAWP >15mmHg
Can be subcategorized as fixed or vasoreactive d/o the response to vasodilators, diuretics, or mechanical assistance
67
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
68
Table for hemodynamic Definitions of PH
69
Most specific dx of PH
Right heart catheterization is required for a dx, classification and tx plan
70
mPAP can be increased by:
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
71
PVR formula:
PVR = (mPAP − PAWP)/COP
72
* PH can occur d/t abnormalities in _________ or _________ components of pulmonary circulation, sometimes including contributions from both
arterial, venous
73
In PH: TTE reveals__________ and ______________
RA & RV enlargement and elevated tricuspid-regurgitation velocity
74
______________ is commonly used to estimate pulmonary arterial systolic pressure (PASP) as a screening tool for PH
Echocardiogram
75
Although PASP > _______mmHg on echo is relatively sensitive and specific for PH, it can’t provide an accurate mPAP for definitive PH diagnosis.
WHAT shows the dx and degree of PH severity
41
Right heart Cath
76
Ranges for mild, Moderate and Severe PH:
mPAP
Mild PH (mPAP = 20–30 mmHg)
Moderate PH (mPAP = 31–40 mmHg)
Severe PH (mPAP >40 mmHg)
77
Normally, pulmonary circulation can accommodate a ________ increase in COP without a marked change in mPAP
Fourfold
78
What is the major risk factor for PAH
idiopathic.
No identifiable risk factor
79
______ of PAH cases are _________, with mutations in bone morphogenetic protein receptor type 2 (BMPR2)
3%
genetic
80
What are the remaining cases of PAH called?
(the non genetic ones. )
“associated PAH,” since they can be attributed to disease processes, drugs or toxins
81
PAH was historically a disease of ________ w/ median survival rate of ______
young women
3 yrs
* Demographic shift now shows older pts and more men being diagnosed
82
Nearly _______PAH pts have long-term improvements w/CCB’s.
Despite improvements in therapy, 1-year mortality is_______
1: 8
~15%
83
Ultimately, sustained __________ and __________leads to pathologic distortion of the pulmonary arteries
vasoconstriction; remodeling
84
3 main classes of pulmonary vasodilator drugs for PAH:
Prostanoids
Endothelin receptor antagonists (ERAs)
Drugs that enhance nitric oxide/guanylate cyclase pathways
Combination therapy is often required for adequate tx of PAH
85
Prostanoids MOA:
Also inhibit?
Mimic the effect of prostacyclin to produce vasodilation
Also inhibit platelet aggregation.
Anti-inflammatory effects and may reduce proliferation of vascular smooth muscle cells
86
Prostanoids examples with routes:
All provide improvement, but only _________ is proven to reduce mortality
* epoprostenol (IV)
* iloprost (inhaled)
* treprostinil (SQ, IV, INH, PO)
* beraprost(PO)
epoprostenol
87
Endothilin Receptor antagonists (ERAs): MOA
Improves what and what?
ERAs improve hemodynamics and exercise capacity.
vascular endothelial dysfunction associated with PAH involves an imbalance btw vasodilating (nitric oxide) and vasoconstricting (endothelin) substances.
88
Nitric oxide/guanylate cyclase MOA:
Nitric oxide produces pulmonary vasodilation by stimulating guanylate cyclase and cGMP in smooth muscle cells.
The effect is transient because nitric oxide is quickly bound by hgb and degraded by phosphodiesterase type 5
89
Continuous inhaled nitric oxide is used in perioperative and critical care settings
sure
90
What can be done to prolong the life of Nitric Oxide
Chronic therapy has been directed toward PDE-5 inhibitors to prolong the half-life of nitric oxide
91
PAH Pre-op considerations
procedures with potential for venous embolism
elevations in venous and/or airway pressure
hypoxic pulmonary vasoconstriction
reduction in pulmonary vascular volume
systemic inflammation,
and emergency procedures
92
PAH often presents with nonspecific sx s/a _________, _________, and __________
fatigue, dyspnea, and cough
93
severe sx include _________and _________, which can occur with exercise if coronary blood flow doesn’t meet the demands of a hypertrophied RV
angina and syncope.
94
On assessment, pts may exhibit a parasternal ______, accentuated ___________, JVD, ____________, __________, ____________
lift
S2, S3, or S4 gallop
peripheral edema, hepatomegaly, and ascites
95
Thought it occurs rarely, very dilated PA can lead to ___________ and cause _________(Hint: RFK)
RLN damage and hoarseness.
96
History of PH should prompt ______________, ___________, and _______________.
further evaluation of functional status,
cardiac performance,
and pulmonary function tests
97
For pts with moderate/severe PH, a right heart cath is recommended prior to ___________________ surgery
moderate-high risk
98
Due to potential discrepancies btw PAWP and LVEDP, a ____________ is indicated in pts with left heart dz, because inaccurate LVEDP may lead to misclassification of PH and inappropriate treatment
left heart cath
99
During right heart cath, _____________ testing with inhaled nitric oxide, is performed to determine ____________________
vasoreactivity
responsiveness to vasodilator therapy
100
__________ % of PAH pts are nonresponsive to inhaled nitric oxide, but those that are responsive also respond to CCBs and may benefit from other targeted therapy
85–90%
101
A flowsheet for PAH
102
table
103
Added perioperative complexities can increase risks of complications
transient HoTN
mechanical ventilation
modest hypercarbia
small bubbles in IV
T-burg position
Pneumoperitoneum
single-lung ventilation
104
a hallmark of PAH is __________, leading to _________, increased _________, and ___________
increased RV afterload
RV dilation
wall stress
RV hypertrophy
105
The interaction btw the RV and pulmonary circulation is __________ and _________, involving the compliance and “stiffness” of lg & small vessels
pulsatile, dynamic
* This is exacerbated during surgerical stimulation, which affect RV pulsatile load
106
In contrast to the LV, the __________ RV is subject to greater wall tension for the same degree of end-diastolic volume, leading to increased RV ___________
thinner-walled
02 demand
107
Under normal circumstances the RV _____________ is lower than the aortic root pressure, and RV coronary perfusion occurs throughout the cardiac cycle
intramyocardial pressure
108
In PAH, the elevated RV pressure leads to increased coronary flow during diastole, making the RV more vulnerable to systemic HoTN, worsening the ________________ and potentially causing myocardial ischemia
02 supply/demand mismatch
109
The “lethal combination of __________, ___________, _________ and _____________can lead to RV ischemia
RV dilatation, insufficient LV filling, reduced stroke volume, and systemic hypotension
110
studies show increased perioperative morbidity and mortality in pts with PH undergoing ______________________ (shay shay)
hip and knee replacement
111
Laparoscopy: _____________ impacts biventricular load and pump function. The combination of pneumoperitoneum, ______________, and increased AW pressure increases RV pressures and afterload
Pneumoperitoneum
head-down position
112
Thoracic procedures involve nonventilation and atelectasis of the operative lung
si
113
3 features of lung collapse are particularly relevant:
(1) 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
* PAH pts are often converted from oral to inhaled or pulmonary vasodilators
* inhaled pulmonary vasodilators are recommended during single-lung ventilation
114
Primary intraoperative goal is maintaining optimal ____________ btw the right ventricle and pulmonary circulation to promote adequate left-sided filling and systemic perfusion
"mechanical coupling”
115
Where are vasodilatory substances produced?
Vascular endothelium
116
What age group comprises 75-80% of secondary hypertension cases?
Children (0 - 12yo)
117
What are the major consequences of chronic hypertension?
- Arterial vasculature remodeling
- Endothelial dysfunction
- End-organ damage
118
What drugs would be utilized for HTN in a CKD patient?
- ACEi
- ARBs
119
What drug class needs to be avoided in patients with Heart failure w/ reduced EF?
CCBs
120
What drug class needs to be avoided in patients with history of angioedema?
ACE-Inhibitors and ARBs
121
When are aldosterone antagonists (spironolactone) preferred?
- Patients with primary aldosteronism
- Patients with resistant hypertension
122
What anti-hypertensives have to be avoided in pregnant patients?
- ACE-Inhibitors
- ARBs
123
What drug is firstline treatment for peripartum hypertension?
Labetalol
124
Key Points: Recap
