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AP + Phys > Antihypertensives > Flashcards

Antihypertensives Flashcards

1
Q

1st line anti HTN for surgery

A

There is none but there are general recommendations
Different for all diseases
Common options: clevidipine, hydralazine, cardene, nitroglycerin, esmolol, labetalol, phentolamines

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2
Q

Prevalence of perioperative HTN

A

80% cardiac surgery
25% noncardiac surgery patients
Does NOT have to have previous diagnosis of HTN

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3
Q

What causes idiopathic HTN

A

Over reactivity of ANS and RAAS
Related to sodium and volume factors

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4
Q

Causes of perioperative HTN

A

Light anesthesia
Airway manipulation/ Pain
Hypoxia Hypercarbia
Medications
Aortic Cross clamp
Hypervolemia
Hypothermia
Type of procedure

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5
Q

Pre exhisting diseases that can lead to perioperative HTN

A

Pheocromocytoma
Hyperthyroid
Autonomic hyperreflexia
MH
Intracranial HTN
Renal disease
Poorly controlled HTN

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6
Q

Primary cause of perioperative HTN

A

Increased sympathetic discharge with systemic vasoconstriction

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7
Q

Complications of perioperative HTN

A

CVA MI Ischemia LV dysfunciton arrhythmias
Increased suture tension/ hemmorhage
Pulmonary edema
Cognitive dysfunction

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8
Q

What to do when intraoperative HTN happens

A

Check depth of anesthesia
Administer analgesia

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9
Q

R/O during intraoperative HTN

A

Hypoxia / hypercarbia
Distended bladder
Thyroid storm
MH
Hyperthermia

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10
Q

A1 blockers

A

SIN to take A1 blocker
oral except labetalol
Prazosin
terazosin
doxazosin
tamsulosin
Labetalol

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11
Q

A2 agonist

A

Clonidine
alpha-methyldopa

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12
Q

How do vasodilators effect systemic circulation (arteries vs venous)

A

Pure arterial dilation with minimal effect on preload
Pure venodilators are not available bc its big size, although NTG is closest

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13
Q

SE of vasodilator

A

Reflex tachycardia

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14
Q

Why NTG for hearts?

A

Improves collateral circulation
Others cause coronary steal

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15
Q

What governs myocardial oxygen perfusion?

A

Aortic diastolic pressure
90% of coronary artery perfusion is during diastole

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16
Q

When are collaterals maximally dilated?

A

Ischemic heart disease
Coronary arteries are largely pressure dependent

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17
Q

What is coronary steal?

A

Narrowed arteries are always maximally dilated,so when a med comes in and dilates good arteries, it takes away from ischemic areas
“The rich get richer, the poor get poorer”

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18
Q

Hydralazine Pharmacodynamics

A

Direct arterial vasodilator
Alters calcium and movement
Increases HR, contracticlity, renin, fluid retention, CO, and SV
Decreases BP (diastolic more) and thus SVR

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19
Q

Hydralazine SE

A

CNS headache, dizziness, tremor, caution inICP
CV Palpiatations, angina, tachycardia, flushing, increases o2 demand and ischemia, caution in CAD
GI anorexia, N/V/ abpn, paralytic ileus
Other: Anemia, agranulocytosis, nasal congestion, muscle cramps, SLE

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20
Q

Hydralazine pharmacokinetics and dose

A

Onset 30 min
Peak 30-60 min
Duration 4-6 hours
Metabolized liver and kidney excretes
Protein bound? highly
Dose 10-20mg q4-6h

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21
Q

NO MOA

A

Synthesizes cGMP to cause smooth muscle relaxation

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22
Q

NTG

A

Veins> arteries
Decreases PVR, venous return, myocardial o2 consumption
Relaxes coronary vessels and relives spasms

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23
Q

Non cardiac effects of NTG

A

Dilates meningeal vessels (caution ICP)
Decreases renal blood flow as decrease in BP
Dilates pulmonary vessels
Used in ACS and acute pulmonary edema
Dont use in volume depleted patients

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24
Q

NTG pharmacokinetics

A

onset 1 minute
duration 3-5 min
half life 1-4 min
Dose- start at 0.5mcg/kg/min titrate 3-5 min up to 20mcg/kg/min

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25
NTG Metabolism
Glutathion nitrate in the liver Oxidizes HGB to methoglobin Tolerance in arterial vessels can occur but not in veins
26
NTG Side effects and CX
CNS headache, apprehension, blurred vision, vertigo, dizzy, faintness CV postural hypotension, palpitations, increased heart rate, syncope GI n/v/abpn, dry mouth Other methemoglobinemia, flushing, rash, anaphylaxis, conjuctival edema CX: PDE5 inhibitors, narrow angle glycoma, head trauma/ hemorrhage, anemia, hypotension
27
NTG pros/cons ???? SNP??
Pros: rapid onset, short diration, coronary vasodilates, decreases o2 consumption, no toxicities, reduced PVR Cons: Decreases DBP, reflex tachycardia, HOTN, tachyphylaxis, methemoglobinemia
28
SNP effects
Directly vasodilates arteries and veins Decrease BP with slight increase in HR Increases cereberal blood flow and ICP Slight reduction BP to renal Reduction in Myocardial O2 demand With abrupt stop can cause reflex tachycardia and HTN
29
SNP pharmacokinetics
onset less than 1 min peak 2 minutes duration 5-10 min half life 3-7 days Dose- 0.5-10 mcg/kg/min
30
Na NTP SE and CX
CNS CV GI Other
31
Major SE in SNP
Cyanide toxicity (thiocyanite) Presentation: hypotension, blurred vision, fatigue, metabolic acidosis, pink skin, no reflexes, feint heart sounds, Risk increases over 4mcg/kg/min for over 2 days
32
Cyanide and thiocyanate levels
toxic 2 fatal >3 toxic 35-100 fatal >200
33
Treatment of SNP Cyanide toxicity
Stop infusion Administer 100% fio2 Correct Met acidosis 3% sodium nitrite sodium theiosulfate hydroxocobalmin Vitamin b12
34
Advantages and disadvantages of SNP
A: immediate onset, short duration, reduced heart o2 demand D: reflex tachycardia, cyanide toxicity, shunting, extreme hypotension, methoglobinemia,
35
IP3
inosotol triphosphate Contractions
36
Phenoxybenzamine receptors, uses, MOA, SE, PK
A1 A2 blocker vasodilates arteries IRREVERSABLE For pheochoromocytoma long term Severe PVD SE: Increase in NE and cause arhythmias? but if not, sedation, depression, tiredness, NV, hypotension, crosses BBB Half life 24 hours duration 4 days
37
Clonidine receptors and effects
Central acting A2 agonist Affitinity for 220:1 A2 over A1 Decreases HR, BP, CO, SVR
38
Risk of Clonidine
Abrupt stoppage causes severe vasoconstriction, restlessness, insomnia, due to NE At risk if using for at least 6 days
39
RAAS
Angiotensinogen (LIVER) Renin CONVERTS TO A1 (KIDNEYS) ACE CONVERTS TO A1 (LUNGS)
40
ACE I effects, indications
Arterial vasodilations Used for CHF, MI, DM PRIL
41
ACEI Risks
AKI if hypotensive already, ACEI reduce compenstatory effect of kidneys that normally constrict and increase blood flow AVOID IN PT W SIGNIFICANT RENAL DYSFUNCTION/ RENAL ARTERY STENOSIS
42
ARB
TAN Similar effects and considerations of ACEI Less cough/ angioedema
43
CA channel blockers
Negative inotropic and dromotropic effects
44
NDHP
Verapamil Diltiazem (cardizem) Arterial vasodilators, negative inotropes, negative chronotropes
45
CACB DHP
Pure vasodilators only decreases negative inotropic and dromotropic slightly
46
How does glucagon work?
ATP-cAMP- PKA- contraction
47
BB OD
Glucagon Atropine Insulin Lipid emulsion Calcium, NaHCO3
48
Clonidine effects on anesthesia
Reduces Propofol requirements Alternative to N2O for shortening induction time Supplement of regional blocks
49
Methyldopa
Decreases sympathetic output Treatment for HTN
50
AT2 Receptors and function
Increases sympathetic activity Increases aldosterone (Na and H2O retention Arterial vasoconstriction ADH secretion (increase BV) Na Cl absorption / K excretion
51
SNP pros and cons
Pro: immediate onset, short duration, reduced o2 demand Cons: Reflex tachycardia, cyanide, methemoglobinemia, coronary steal,
52
What oxidizes HGB to methemoglobin?
Nitrite ion in NTG metabolism
53
Phentolamine
HTN from pheocromocytoma HTN from clonidine withdrawal Extravasation of catecholamines
54
Phentolamine PK
Onset- Immediate IV, 15 minutes IM
55
Teratogenic BP med:
ACE Inhibitor
55
ACE Inhibitor SE
Cough, angioedema, hyperkalemia, hyponatremia
56
ACE I + other meds
NSAIDS/ ASA- decreased antihypertensive effect and increased hyperkalemia risk and ARF Diuretics, vasodilators, anesthetics- increased antihypertensive effect
57
Rules for ACEI/ ARB
Hold day of CARDIAC surgery only Can cause prolonged hypotension if using GA Can cause acute renal failure
58
Other RAAS medications besides ACE/ ARB
Aliskiren (renin inhibitor) Sacubitril/valsartan (neprilysin inhibitor, ARB)
59
Cardene PK/ dose
Onset 5 mins Duration 15 minutes 1mg bolus, then 1mg/min until 5mg has been administered IV infusion- 2.5-15mg/hr
60
When to use cardene and why?
PACU/ICU Less swings in NP No rebound hypertension on withdrawal Although, slower onset and offset than SNP Slower offset may be beneficial postop May cause tachycardia
61
Clevedipine pros/ cons
Pros: reliable BP control, onset 5 mins, quickly cleared t1/2 1 minute Cons: lipid emulsion ( no more than 1L or 21mg/hr recommended) Contraindicated in soy, egg allergies
62
Verapamil effects and uses
Negative inotrope, dromotrope, vasodilator, coronary artery vasodilator Atrial tachyarrhythmias Aortic stenosis HTN Prinzmetal angina
63
Cardizem uses and metabolism
Not as much negative inotropy as Verapamil A fib CYP3A4 Inhibits CYP3a4, CYP2D6
64
CCB SE
CNS dizzy, fatigue CV flushing, edema, palpitations(DHP) bradycardia (NDHP) GI NVD
65
CCB Effect on myocardial consumption
Decrease O2 consumption by decreasing afterload and inotropy
66
CCB Rules
continue surgery day May enhance hotn Use adequate fluids Clevedipine reduces gastric emptying Cardizem increases sedation of versed
67
cAMP
Contraction!
68
Antihypertensives in pregnancy
NO ACEI !!!! Labetalol in 2/3 trimesters SNP, alpha-methyldopa, cardene
69
Pre eclampsia treatment
When >160/110 Reduce by 20% first hour Reduce to 120/80 next 6-24 hours
69
BB OD
Atropine Fluids Glucagon B agonist Insulin Lipid emulsion
70
BB + anesthesia
Negative inotropic effects are potentiated Continue BB, lower anesthetics
71
BB SE
Hypoglycemia unawareness Bradycardia/ hypotension Mask hyperthyroidism Bronchoconstriction in asthma/COPD
72
Cardioselective BB
Atenolol/ acetbuylol Bisoprolol Esmolol Metoprolol
73
Nonselective BB
Propanolol Timolol Pindolol Carteolol
74
Combined BB + A1 blocker
Labetalol Carvedilol
75
cGMP
Relaxation!

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