271 - Hypertensive Vascular Disease Flashcards
1
Q
Which disease are doubled in frequency due to HTN (HyperTensioN)?
A
- CHD
- CHF
- Stroke (ischemic/ hemorrhagic)
- RF (Renal failure)
- PAD (Peripheral Arterial Disease)
2
Q
_____ and _____ are strong independent risk factors for HTN
A
- Obesity
2. Weight increase
3
Q
The ratio between ____ and ____ in the urine has higher correlation to HTN risk than when considered separately
A
- Sodium
2. Potassium
4
Q
_____ of patients with HTN are > ____ overweight
A
- 60%
2. 20%
5
Q
____ and ____ are the two determinants of arterial pressure
A
- Cardiac output
2. Peripheral resistance
6
Q
What are the two adrenergic receptor groups
A
- Alpha (A1, A2)
2. Beta
7
Q
Explain what are the Alpha1 receptors (4)
A
- Activated by norepinephrine
- Found in the post synaptic cells of smooth muscle
- Cause vasoconstriction when stimulated
- Increase tubular absorption of sodium in kidney
8
Q
Explain what are the Alpha2 receptors (2)
A
- Found in the presynaptic membrane- synthesizing norepinephrine.
- When stimulated by catecholamines they create negative feedback- blocking norepinephrine release
9
Q
How HTN drugs affect A1 and A2?
A
- Inhibit A1 receptors
2. Act as agonists for A2
10
Q
Beta receptors are activated by ____
A
Epinephrine
11
Q
How does the activation of B1 receptors increase CO?
A
Increase the rate and contractility of the heart
12
Q
Activation of B2 receptors by ____ cause ____ of smooth muscle and _____
A
Epinephrine
Relaxation
Vasodilatation
13
Q
the RAAS system contribute to the regulation of _____ mainly by _____ of _____ and sodium absorption by_____
A
Arterial pressure
Vasoconstriction
AT2
Aldosterone
14
Q
Where does renin ins mostly synthesized from?
A
Afferent arteriole
15
Q
What are the 3 triggers for the release of renin?
A
- Decrease in the transition of NaCl to the distal part of the thick ascending limb bordering the macula densa
- Decrease in the pressure inside the afferent arteriole (baroreceptor mechanism_
- Sympathetic stimulation of the renin-secreting-cells through B1 receptors
16
Q
____ is the main factor leading to the synthesis and secretion of _____ from the zona glomerulosa in the ______
A
AT2
Aldosterone
Adrenal cortex
17
Q
AT2 is a growth stimulator and when in excess may contribute to process such as (3)
A
- Atherosclerosis
- Cardiac hypertrophy
- RF
18
Q
Aldosterone is a potent mineralocorticoid which increase ____ absorption through ____ in the _____ cells in the cortical collecting duct
A
Sodium
ENaC (Epithelial sodium channel_
Principle
19
Q
Which organs are affected due to HTN?
A
Heart
Brain
Kidney
Peripheral arteries
20
Q
What is the range for: Normal, Prehypertension, Stage 1 hypertension, Stage 2 hypertension, Isolated systolic hypertension?
A
- <120 / <80
- 120-138 / 80-89
- 140-159 / 90-99
- > =160 / or >=100
- > =140 / and <90
21
Q
____% of patients are diagnosed with primary HTN while ____% have a secondary reason for HTN
A
80-95
2-20
22
Q
Primary HTN tends to be more ______and is a combination of _____ and _____ factors
A
Familial
Environmental
Genetic
23
Q
In BMI of > ____ developing HTN is more likely
A
30
24
Q
What is the metabolic syndrome?
A
- Insulin resistance
- Visceral fat and weight gain
- Dyslipidemia
25
HTN exist in more than ____ of patients with CRF. Proteinuria of > ____ and urine sediments are indicative for primary ______ disease
80%
1000 mg/dl
Renal
26
What are the two in risk groups for renal artery blockage?
1. Old age patients with a blocking plaque in the proximal renal vein
2. Patients with fibromuscular dysplasia (usually Caucasian young females0
27
What is the gold standard for diagnosing and assessing renal artery lesions?
Contrast arteriography
28
How much of the artery needs to be blocked to have a functional effect?
70%
29
What are the most effective treatments for HTN
ACEI
| ARBS
30
How many of HTN patients have primary aldostrenism?
15%
31
Most of the primary aldosteronism patients are symptomatic, but may suffer from:
1. Polyuria
2. Polydipsia
3. Paresthesia/ muscle weakness (due to hypokalemia/ alkalosis)
32
A good screening test for primary aldosteronism is____ taken in the morning
PA (Plasma Aldosterone) / PRA (Plasma Renin Activity)
33
A ratio of > ____ together with ____ serum concentration of > ____ has high specificity and sensitivity for _____
30:1
Aldosterone
555 pmol/L
Aldosterone producing adenoma
34
In patients with increase ratio diagnosis may be based on showing failure for _____ _____ in the plasma to a level below ____ after giving ___ liters of isotonic saline within ___ hours
Aldosterone suppression
277 pmol/L
2
4
35
The two most common causes for primary aldosteronism are____, ____. together they comprise ____ of cases
1. Aldosterone producing adenoma
2. Bilateral adrenal hyperplasia
3. 90%
36
Aldosterone producing adenoma is almost always ____, and measures < ____ cm
Unilateral
| 3
37
Most of the patients with aldosterone producing adenoma have higher levels of aldosterone in the _____, reflecting the ____
Morning
| ACTH cadence
38
What is the best way to differentiate between unilateral and bilateral PA?
Bilateral adrenal venous sampling for aldosterone plasma levels
39
Which adrenal related HTN patients may benefit from surgery?
patients with adenoma
40
What does Cushing syndrome has to do with?
Excessive synthesis of cortisol due to hyper secretion of ACTH or non-dependent ACTH synthesis of cortisol
41
HTN develops in ___ of patients
80%
42
How would you diagnose patients with clinical signs for Cushing's syndrome?
```
1. Urine free cortisol for 24 hours
or
2. Dexamethasone suppression test
or
3. Late night salivary cortisol
```
43
Pheochromocytoma are ______ producing tumors found in the ____ of the _____ or in the ______ tissue
Catecholamines
Medulla
Adrenal gland
extra adrenal pre ganglionic
44
What is the definitive treatment for pheochromocytoma?
Surgical excision, leading to treatment in 90% of cases
45
What is the most common reason for HTN due to innate cardiovascular defect?
Coarctation of the aorta
46
Coarctation of the aorta is usually sporadic , but occurs in ____ of ___ cases
35%
| Turner's syndrome
47
The basic laboratory test for the renal system in HTN include: (3)
1. Microscopic urinalysis
2. Albumin exertion
3. BUN and/ or creatinine
48
The basic laboratory test for the endocrine system in HTN include:
Serum electrolytes (Na, K, Ca) and TSH
49
The basic laboratory metabolic lab test in HTN include:
1. Fasting blood glucose
2. Total cholesterol
3. HDL and LDL
4. Triglycerides
50
We recommend ____ for patients with per-HTN and HTN
Life style interventions
51
Using drugs to decrease systemic BP in ___ (systolic) and ___ (diastolic) maylead to a decrease of ____ in risk for CHD and 16% for risk of ____
10-12 mm/Hg
5-6 mm/Hg
40%
52
Thiazide inhibit _____ in the ____, therefor increase ____ excretion
Na/Cl pump
Distal convoluted tubule
Na
53
In the long range thiazides act as _____
Vasodilators
54
Thiazides have an additive effect when combined with: (3), adding ____ is less effective
1. BB
2. ACEi
3. ARB
4. CCB
55
What are the side effects of thiazides?
1. Hypokalemia
2. Insulin resistance
3. Increase in cholesterol levels
56
Give an example for 2 thiazide drugs
1. Hydrochlorothiazide
| 2. Chlorthalidone
57
Loop diuretics such as ____ act on the co transporter NA-K-2Cl in the ____ of the ____. They are used in patients with HTN and ____, ____, ____.
```
Furosemide
Thick ascending limb
Loop of Henle
GFR decrease ( Cr>2.5 mg/dL)
CHF
Edema for other reasons
```
58
ACEi decrease the synthesis of ____ and increase the levels of ____ therefor turn down ____
AT2
Bradykinin
Sympathetic system activity
59
ARB selectively block ____ receptors and the effect of ___ on the unblocked AT2 receptors, which may lead to their ____ effect
AT1
AT2
Hypotensive
60
RAAS drugs such as ACEi and ARB have a benefitable effect on ____ function, and reduce the S/E of ___ on glucose metabolism
Insulin
| Diuretics
61
ACEi S/E are: (4)
1. RF
2. Hypokalemia
3. Dry cough
4. Angioedema
62
Name 3 ACEi drugs:
1. Captopril
2. Lisinopril
3. Ramipril
63
Name 3 ARB drugs:
1. Losartan
2. Valsartan
3. Candesartan
64
The aldosterone antagonist _____ is a non selective agent that can be used alone or together with ____
Spironolactone
| Thiazides
65
Spironolactone is effective treating patients with ____, ____, and _____
Low renin primary HTN
Resistant HTN
Primary aldosteronism
66
Spironolactone binds to ___ and androgenic receptors leading to S/E such as: ___,___, and ____.
Progesterone
Gynecomastia
Impotence
Menstrual abnormalities
67
____ is a selective aldosterone antagonist
Eplerenone
68
BB are especially effective in patients with _____ and _____
HTN
| Tachycardia
69
Labetalol and Carvedilol block both ____ and ____ receptors
Alpha
| Beta
70
Name 2 cadioselective BB
Atenolol
| Metoprolol
71
Name a nonselective BB
Propranolol
72
Name 3 CCB drugs
1. Nifedipine
2. Verapamil
3. Diltiazem
73
What are CCB S/E
1. Blushing
2. Headache
3. Edema
74
Decreasing BP in young patients is more effective using: ___, and ____
BB
| ACEi
75
Decreasing BP in old patients is more effective using: ___, and ____
Diuretics
| CCB
76
What is the BP goal we try to reach using HTN drugs?
under 135-140/80-85
77
What is resistant HTN?
1. >140/90 although taking >=3 different HTN drugs
| 2. More common in patients >60
78
What is malignant HTN?
A syndrome associated with an abrupt increase of blood pressure in a patient with underlying HTN or related to the sudden onset of HTN in a previously normotensive individual
79
What should we pay attention to when suspecting malignant HTN?
The rate of HTN increase
80
What is malignant HTN associated with?
1. Diffuse necrotizing vasculitis
2. Arteriolar thrombi
3. Fibrin deposition in arteriolar wall
81
What is the clinical signs of malignant HTN?
1. Progressive retinopathy
2. Renal deterioration + proteinuria
3. Microangiopathic anemia
4. Encephalopathy
82
What is the first step in treating malignant HTN?
Decrease MAP in no more than 25% within minutes- to 2 hours to a BP in the range of 110-160/110 mm/Hg
83
What is the go to drug treating malignant HTN?
Nitroprusside IV
84
When the patient suffering from malignant HTN has no encephalopathy how long will we prefer the decrease in BP to last?
better hours than minutes
85
In patients with ____ who are not candidate for ____ one recommended guideline is to institute antihypertensive therapy only for patients with a ____. If thrombolytic therapy is to be used, the recommended goal BP is _____
Cerebral infraction
Thrombolytic therapy
Systolic BP >200 mmHg or diastolic BO> 130 mmHg
<185/119
