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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
Q

NTG Metabolism

A

Glutathion nitrate in the liver
Oxidizes HGB to methoglobin
Tolerance in arterial vessels can occur but not in veins

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26
Q

NTG Side effects and CX

A

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

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27
Q

NTG pros/cons ???? SNP??

A

Pros: rapid onset, short diration, coronary vasodilates, decreases o2 consumption, no toxicities, reduced PVR
Cons: Decreases DBP, reflex tachycardia, HOTN, tachyphylaxis, methemoglobinemia

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28
Q

SNP effects

A

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

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29
Q

SNP pharmacokinetics

A

onset less than 1 min
peak 2 minutes
duration 5-10 min
half life 3-7 days
Dose- 0.5-10 mcg/kg/min

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30
Q

Na NTP SE and CX

A

CNS
CV
GI
Other

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31
Q

Major SE in SNP

A

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
Q

Cyanide and thiocyanate levels

A

toxic 2
fatal >3
toxic 35-100
fatal >200

33
Q

Treatment of SNP Cyanide toxicity

A

Stop infusion
Administer 100% fio2
Correct Met acidosis
3% sodium nitrite
sodium theiosulfate
hydroxocobalmin
Vitamin b12

34
Q

Advantages and disadvantages of SNP

A

A: immediate onset, short duration, reduced heart o2 demand
D: reflex tachycardia, cyanide toxicity, shunting, extreme hypotension, methoglobinemia,

35
Q

IP3

A

inosotol triphosphate
Contractions

36
Q

Phenoxybenzamine receptors, uses, MOA, SE, PK

A

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
Q

Clonidine receptors and effects

A

Central acting A2 agonist
Affitinity for 220:1 A2 over A1
Decreases HR, BP, CO, SVR

38
Q

Risk of Clonidine

A

Abrupt stoppage causes severe vasoconstriction, restlessness, insomnia, due to NE
At risk if using for at least 6 days

39
Q

RAAS

A

Angiotensinogen (LIVER)
Renin CONVERTS TO A1 (KIDNEYS)
ACE CONVERTS TO A1 (LUNGS)

40
Q

ACE I effects, indications

A

Arterial vasodilations
Used for CHF, MI, DM
PRIL

41
Q

ACEI Risks

A

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
Q

ARB

A

TAN
Similar effects and considerations of ACEI
Less cough/ angioedema

43
Q

CA channel blockers

A

Negative inotropic and dromotropic effects

44
Q

NDHP

A

Verapamil
Diltiazem (cardizem)
Arterial vasodilators, negative inotropes, negative chronotropes

45
Q

CACB DHP

A

Pure vasodilators
only decreases negative inotropic and dromotropic slightly

46
Q

How does glucagon work?

A

ATP-cAMP- PKA- contraction

47
Q

BB OD

A

Glucagon
Atropine
Insulin
Lipid emulsion
Calcium, NaHCO3

48
Q

Clonidine effects on anesthesia

A

Reduces Propofol requirements
Alternative to N2O for shortening induction time
Supplement of regional blocks

49
Q

Methyldopa

A

Decreases sympathetic output
Treatment for HTN

50
Q

AT2 Receptors and function

A

Increases sympathetic activity
Increases aldosterone (Na and H2O retention
Arterial vasoconstriction
ADH secretion (increase BV)
Na Cl absorption / K excretion

51
Q

SNP pros and cons

A

Pro: immediate onset, short duration, reduced o2 demand
Cons: Reflex tachycardia, cyanide, methemoglobinemia, coronary steal,

52
Q

What oxidizes HGB to methemoglobin?

A

Nitrite ion in NTG metabolism

53
Q

Phentolamine

A

HTN from pheocromocytoma
HTN from clonidine withdrawal
Extravasation of catecholamines

54
Q

Phentolamine PK

A

Onset- Immediate IV, 15 minutes IM

55
Q

Teratogenic BP med:

A

ACE Inhibitor

55
Q

ACE Inhibitor SE

A

Cough, angioedema, hyperkalemia, hyponatremia

56
Q

ACE I + other meds

A

NSAIDS/ ASA- decreased antihypertensive effect and increased hyperkalemia risk and ARF
Diuretics, vasodilators, anesthetics- increased antihypertensive effect

57
Q

Rules for ACEI/ ARB

A

Hold day of CARDIAC surgery only
Can cause prolonged hypotension if using GA
Can cause acute renal failure

58
Q

Other RAAS medications besides ACE/ ARB

A

Aliskiren (renin inhibitor)
Sacubitril/valsartan (neprilysin inhibitor, ARB)

59
Q

Cardene PK/ dose

A

Onset 5 mins
Duration 15 minutes
1mg bolus, then 1mg/min until 5mg has been administered
IV infusion- 2.5-15mg/hr

60
Q

When to use cardene and why?

A

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
Q

Clevedipine pros/ cons

A

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
Q

Verapamil effects and uses

A

Negative inotrope, dromotrope, vasodilator, coronary artery vasodilator
Atrial tachyarrhythmias
Aortic stenosis
HTN
Prinzmetal angina

63
Q

Cardizem uses and metabolism

A

Not as much negative inotropy as Verapamil
A fib
CYP3A4
Inhibits CYP3a4, CYP2D6

64
Q

CCB SE

A

CNS dizzy, fatigue
CV flushing, edema, palpitations(DHP) bradycardia (NDHP)
GI NVD

65
Q

CCB Effect on myocardial consumption

A

Decrease O2 consumption by decreasing afterload and inotropy

66
Q

CCB Rules

A

continue surgery day
May enhance hotn
Use adequate fluids
Clevedipine reduces gastric emptying
Cardizem increases sedation of versed

67
Q

cAMP

A

Contraction!

68
Q

Antihypertensives in pregnancy

A

NO ACEI !!!!
Labetalol in 2/3 trimesters
SNP, alpha-methyldopa, cardene

69
Q

Pre eclampsia treatment

A

When >160/110
Reduce by 20% first hour
Reduce to 120/80 next 6-24 hours

69
Q

BB OD

A

Atropine
Fluids
Glucagon
B agonist
Insulin
Lipid emulsion

70
Q

BB + anesthesia

A

Negative inotropic effects are potentiated
Continue BB, lower anesthetics

71
Q

BB SE

A

Hypoglycemia unawareness
Bradycardia/ hypotension
Mask hyperthyroidism
Bronchoconstriction in asthma/COPD

72
Q

Cardioselective BB

A

Atenolol/ acetbuylol
Bisoprolol
Esmolol
Metoprolol

73
Q

Nonselective BB

A

Propanolol
Timolol
Pindolol
Carteolol

74
Q

Combined BB + A1 blocker

A

Labetalol
Carvedilol

75
Q

cGMP

A

Relaxation!

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