hypertention & shock Flashcards
(96 cards)
1
Q
What is the definition of hypertension?
A
BP above 140/90, based on 2 readings in separate occasions, unless severe HTN (systolic ≥180 or diastolic ≥110) or evidence of end-organ damage.
2
Q
What are the major health risks associated with hypertension?
A
Cerebrovascular events, ischemic heart disease, peripheral vascular disease.
3
Q
What are the key factors in the pathogenesis of hypertension?
A
- Increased activity of SNS
- RAAS overactivation
- Na overload
- Vascular remodeling
- Endothelial cell dysfunction
- Hyperinsulinemia
4
Q
What percentage of hypertension cases are classified as essential/primary?
A
80-90%.
5
Q
List some multifactorial etiologies of essential/primary hypertension.
A
- Genetic component
- Obesity
- High salt intake
- Metabolic syndrome
- Low birth weight
- Excess alcohol intake
6
Q
What types of drugs can induce or exacerbate hypertension?
A
- NSAIDs
- Combined OCP (especially high in estrogen)
- Antidepressants (SNRI)
- Acetaminophen
- Sympathomimetics
- Steroids
- Herbal (St. John’s wart)
7
Q
What are some causes of secondary hypertension?
A
- Renal parenchymal disease
- Renal artery stenosis
- Conn’s syndrome
- Cushing’s syndrome
- Pheochromocytoma
- Acromegaly
- Coarctation of aorta
- Drugs (OCP, steroids, NSAIDs, vasopressin)
8
Q
What are the recommended guidelines for hypertension screening?
A
- Opportunistic or community based
- Indicated in age 18 or above, or patients with CVD
- If BP is normal, check every 5 years in healthy adults
- If diabetic, check annually
9
Q
What is the appropriate cuff size for measuring blood pressure?
A
Cuff size should be 80% of arm height and 40% width.
10
Q
How should blood pressure be measured for accuracy?
A
- Measured in a quiet room
- Patient seated quietly for 5 minutes
- Outstretched arms supported at heart level
- Remove tight clothing
- 30 minutes since smoking/caffeine use/exercise
11
Q
What should be done if postural hypotension is suspected?
A
BP should be repeated after 1 minute of standing if a reduction in systolic BP ≥ 20 mmHg is observed.
12
Q
True or False: A diagnosis of hypertension can be made from a single reading.
A
False, unless it’s very high (≥ 180 or ≥ 110).
13
Q
What is the recommended action if the pulse is irregular during BP measurement?
A
Use a manual device.
14
Q
What should be done if two readings of blood pressure are taken?
A
Take the highest arm reading and write the lowest of the two readings.
15
Q
What is the blood pressure range for clinical diagnosis?
A
140/90 & 180/120
16
Q
How many measurements are required for Ambulatory Blood Pressure Monitoring (ABPM)?
A
At least 14 measurements during normal waking hours
2 measurements per hour
17
Q
How should Home Blood Pressure Measurement (HBPM) be conducted?
A
2 measurements per day, twice 1-minute apart with patient seated
18
Q
What is the threshold for confirming a diagnosis of hypertension?
A
≥ 140/90 clinic
≥ 135/85 ambulatory or home
19
Q
Define prehypertension according to systolic and diastolic values.
A
Systolic 120-139 or diastolic 80-89
20
Q
What defines Stage 1 hypertension?
A
Clinic systolic 140-159 or diastolic 90-99 & daytime average ABPM or HBPM ≥ 135/85
21
Q
What defines Stage 2 hypertension?
A
Clinic systolic ≥160 or diastolic ≥100 & daytime average ABPM or HBPM ≥ 150/95
22
Q
What constitutes a hypertensive urgency?
A
Systolic ≥180 and/or diastolic ≥120 without end organ damage
23
Q
What constitutes a hypertensive emergency?
A
Systolic ≥180 and/or diastolic ≥120 with end organ damage
(neurological/myocardial ischemia/aortic dissection)
24
Q
What tool should be used to assess cardiovascular risk in patients with hypertension?
A
ASCVD risk calculator or QRISK 2-2015
25
What tests are included in the investigations for hypertension?
* Urinalysis for protein, albumin: creatinine ratio & hematuria
* Blood tests for glucose, electrolytes, creatinine, eGFR & total & HDL cholesterol
* ECG to detect LVH
26
What are potential target organ damages to look for in hypertension?
* Atherosclerosis, aneurysms, aortic dissection
* Chronic kidney disease: hematuria, uremia, proteinemia
* Cardiac failure: pulmonary edema, MI, LVH
* Stroke/TIA: hemorrhage or infarction, seizures, vascular dementia
* Fundoscopy
27
What is the significance of fundoscopy in hypertension?
To detect hypertensive retinopathy
28
What characterizes Grade 1 hypertensive retinopathy?
Tortuosity of the retinal arteries with increased reflectiveness (silver wiring)
29
What additional findings are present in Grade 2 hypertensive retinopathy?
Grade 1 findings + appearance of arteriovenous nipping
30
What findings are associated with Grade 3 hypertensive retinopathy?
Grade 2 findings + flame-shaped hemorrhages & soft (cotton wool) exudates
31
What defines Grade 4 hypertensive retinopathy?
Grade 3 findings + papilledema (blurring of the optic disc)
32
What recommendations are suggested for lifestyle interventions?
- High vegetables & fruits, low-fat diet
- Reduction of alcohol
- Smoking cessation
33
What is the recommended sodium intake for lifestyle interventions?
5-6g/day & use of low sodium salt
## Footnote
Aims to reduce blood pressure and improve cardiovascular health
34
How often should one engage in moderate-intensity aerobic exercise for health benefits?
30 min of moderate-intensity aerobic exercise 5-7 days/week
35
What are the weight reduction goals in lifestyle interventions?
BMI 25, waist circumference < 102 cm men & < 88 cm women
36
When should antihypertensive drug therapy be initiated?
In patients with mean home or daytime ambulatory BP ≥135 mmHg systolic or ≥85 mmHg diastolic
37
What conditions warrant starting antihypertensive therapy at lower blood pressure thresholds?
Mean home or daytime ambulatory BP ≥130 mmHg systolic or ≥80 mmHg diastolic with one or more features:
* Established clinical cardiovascular disease
* Type 2 diabetes mellitus
* Chronic kidney disease
* Age 65 years or older
* Estimated 10-year risk of atherosclerotic CVD of at least 10%
38
What is the first-line treatment for patients under 55 years / 55 and above who are black African or Caribbean? with hypertension?
55: ACE inhibitor (or ARB if can't tolerate ACE)
> 55 black African or Caribbean: Start with CCB (or thiazide-like diuretic if heart failure or ankle edema develops)
39
What should be done if blood pressure control is inadequate after Step 1 treatment?
Step 2: Combine ACE-inhibitor (or ARB) with CCB (or thiazide-like diuretic)
40
What is the next step if blood pressure remains uncontrolled on ACE-inhibitor + CCB?
Add thiazide-like diuretic
41
What is the protocol if blood pressure remains above 140/90 on three agents?
Refer patient to a specialist
42
What can be added for resistant hypertension if renal function is preserved?
Spironolactone 25 mg daily if K+≤4.5 mmol/L
43
What is the target blood pressure for patients aged ≤60 years?
<140/90
44
What is the target blood pressure for patients aged ≥60 years?
<150/90
45
What is the target blood pressure for diabetic patients or those with CKD or cardiovascular disease?
130/80
46
Fill in the blank: Resistant hypertension is defined as inadequate BP control on _______ or more antihypertensive drugs.
3
47
What procedure may be effective for resistant hypertension after investigating underlying causes?
Endovascular renal denervation of sympathetic nerves with radio-frequency catheter
48
What is the preferred initial therapy for heart failure?
ACEI first then BB
49
What is the preferred initial therapy for post MI
BB first then ACEI
50
What is the preferred initial therapy for diabetes or CKD with microalbuminuria
ACEI, ARB
51
What is the preferred initial therapy for renal impairment with high creatine, AKI
CCB
52
What is the preferred initial therapy for BPH?
Alpha blockers
53
What is the preferred initial therapy approach for hyperthyroidism?
Beta blockers first
54
What is the preferred initial therapy for osteoporosis?
Thiazides
55
What is the preferred initial therapy for pregnancy
Methyldopa
56
In what situation should beta blockers be avoided?
Depression or asthma
57
What is a contraindication for certain antihypertensive medications?
Gout
58
What condition is a contraindication for the use of beta blockers?
Asthma
Grade 2 or 3 AV block
59
What is a potential side effect of thiazide diuretics?
Hypokalemia
Hyperglycemia
60
What are common side effects of ACE inhibitors?
Dry cough, first dose hypotension, hyperkalemia, rash, renal impairment
61
What is a side effect of ARBs?
Renal impairment
62
What renal conditions are contraindications for ARBs?
Bilateral renal artery stenosis, hyperkalemia, pregnancy
63
When are thiazide diuretics contraindicated?
Gout
64
What are potential side effects of dihydropyridine calcium channel blockers?
Ankle edema
flushing
dizziness
hypotension
headache
bradycardia
cardiac conduction defects
65
What is the blood pressure threshold for hypertensive urgency?
BP ≥ 180 systolic and/or ≥ 120 diastolic
with no end organ damage
## Footnote
Asymptomatic severely high BP
66
What are common causes of hypertensive urgency?
• Undiagnosed hypertension
• Nonadherence to prescribed antihypertensive therapy
## Footnote
These causes lead to severely elevated blood pressure without immediate complications.
67
What are the most commonly used oral agents for treating hypertensive urgency?
• Clonidine (α2 agonist)
• Nifedipine (CCB)
• Captopril (ACEI)
• Labetalol (BB)
68
What is the target blood pressure in the first few hours of treating hypertensive urgency?
< 160/100
69
How soon must a patient with hypertensive urgency be followed up?
Within 1-2 weeks
## Footnote
This follow-up ensures blood pressure improvement and monitors for complications.
70
What defines a hypertensive emergency?
BP ≥ 180 systolic and/or ≥ 120 diastolic WITH end-organ damage
## Footnote
End-organ damage can include cardiac, CNS, renal, and retinopathy issues.
71
What are some examples of end-organ damage in hypertensive emergencies?
• Cardiac: MI, acute LV failure, acute aortic dissection
• CNS: encephalopathy, stroke, SAH
• Renal: AKI
• Retinopathy: papilledema, loss of vision
• Cardiogenic shock
72
What should be the approach to blood pressure reduction in a hypertensive emergency?
Lower mean arterial pressure by 10-20% in the first hour, then gradually lower further to reach 25% lower of baseline
## Footnote
This avoids rapid drops that can cause ischemia.
73
What are some drug options for treating hypertensive emergencies?
• IV nitroprusside
• IV nitroglycerin
• IV nicardipine
• IV labetalol
74
What is the exception for blood pressure management in acute aortic dissection?
Must RAPIDLY lower BP ASAP to a target of 100 to 120 systolic
75
What is the recommended approach for blood pressure management in acute ischemic stroke?
Slower lowering of BP
This cautious approach helps prevent complications associated with rapid changes.
76
When are ACEI contraindicated
Pregnancy
Hyperkalemia
Bilateral renal artery stenosis
Stage 4 & 5 renal failure
Angioneurotic edema
High Cr
77
What is a common characteristic of all types of shock?
All have low BP and high HR
78
What causes distributive shock?
Peripheral blood vessel vasodilation leading to low systemic vascular resistance
79
List the signs of distributive shock.
Give examples
* Warm extremities
* Low BP
* High HR
* Low CVP
* Low PCWP
- sepsis, neurogenic
80
When are Dihydropyridine CCBs contraindicated
Tachyarrhythmias
Heart failure
81
What defines cardiogenic shock?
Pump failure
82
What are the vital signs in cardiogenic shock?
* Low BP
* High HR
* High CVP
* Increased SVR
* Cold extremities
83
List some causes of cardiogenic shock.
* ACS
* Valve failure
* Dysrhythmias
* High PCWP
84
What is hypovolemic shock characterized by?
Decreased circulatory volume or gastrointestinal bleed
85
What are the vital signs in hypovolemic shock?
* Low BP
* High HR
* Low CVP (less blood)
* Increased SVR
* Cold extremities
86
List some examples of obstructive shock.
* Cardiac tamponade
* Tension pneumothorax
* Pulmonary embolism
87
What are the vital signs in obstructive shock?
* Low BP
* High HR
* High CVP or normal
* Increased SVR
88
What is the management protocol for shock?
* ABC
* Strongly consider intubation
* Oxygen
* IV fluids
89
What should be done if hypovolemic shock is suspected?
Blood transfusion
90
What inotropic agents can be used if fluids do not improve hemodynamics?
* Epinephrine
* Dopamine
* Vasopressin
91
What is the treatment for sepsis in shock management?
Antibiotics (broad spectrum)
92
What is the treatment for pulmonary embolism in shock management?
Thrombolysis, anticoagulation
93
What is the treatment for cardiac tamponade in shock management?
Cardiocentesis
94
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95
What do patients with renal artery stenosis present with or physical examination?
Renal artery bruits
96
What’s the presentation of coarctation of aorta?
Brachio-femoral delay
