Blood Flow & Blood Pressure (Ch. 26)-- Definition First Flashcards by Hannah Hinckley

Asymptomatic
Swelling and/or pain in affected extremity
⇡ WBCs
⇡ Erythrocyte sedimentation rate (ESR)
- Inflammation indicator

Diagnosis– Ultrasound, CT, D-dimer (⇡ Blood clot fragments → Hypercoagulation)

Treatment– Prevention (SCDs, Ambulation, Anticoagulants)

Deep Vein Thrombosis Clinical Manifestations

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PANS
- Vagus nerve → Impulses to heart
  - ⇣ HR
SANS
- Spinal cord & peripheral nerves → impulses to heart & blood vessels
- ⇡ HR & Contractility → ⇡ CO, SV, & BP
- Vasoconstriction (small arteries) → ⇡ PVR

Acute BP Regulation– Neural Mechanism

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True Aneurysm

Small
Spherical
Located @ bifurcation
- Circle of Willis (brain)

Berry Aneurysm

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Amount of blood the heart pumps through circulatory system in one minute

~4-6 L

CO = SV x HR

Cardiac Output (CO)

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⇣ Vascular volume
- Diuretics
⇣ SANS
- Beta-blockers
  - ⇣ HR & CO
  - Block renin (juxtaglomerular cells of kidneys)
    - ⇣ Vasoconstriction
RAAS System
- ACE (Angiotensin Converting Enzyme) Inhibitors
  - ⇣ Angiotensin II → ⇣ Vasoconstriction & ⇣ Aldosterone
    - AEs: Chronic cough, Angioedema
- ARBs (Angiotensin II Receptor Blockers)
  - ⇣ Binding of Angiotensin II → ⇣ Vasoconstriction & ⇣ Aldosterone
    - Less AEs than ACE-Is
Vasodilation
- Calcium Channel Blockers
  - ⇣ Ca²⁺ into SMCs → Smooth muscle stays relaxed
- Hydralazine
  - Interferes w/ Ca²⁺ movement

Hypertension Pharmacologic Treatment

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Long-Term effects of HTN on organs

CKD → Renal Failure
PVD → Endothelial cell damage → Atherosclerosis
Retinopathy
CVD → TIA/Stroke
Cardiac
- ⇡ Afterload → LV Hypertrophy → HF
- MI
Sexual Dysfunction
- ED

Target-Organ Damage

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⇣ LDL receptors → Dyslipidemia

Hypothyroidism

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Sustained elevation of BP w/i arterial circuit

Primary risk factor for CVD

Leading cause of death worldwide

Primary
- HTN w/o evidence of cause
Secondary
- HTN d/t presence of another disease/condition
  - ex: Renal Failure

Hypertension (HTN)

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Hardening of the arteries due to fibrofatty lesions in the tunica intima of large and medium-sized arteries

Atherosclerosis

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Visual assessment
Lower extremity pain & edema
Stasis dermatitis
- CO₂-rich blood sits in dependent areas
  - Acidic gas damages tissue
Venous ulcers
- Skin easily injured

Treatment– Sclerotherapy, Prevention (Compression stockings, Avoid standing for extended periods, Weight loss)

Varicose Veins Clinical Manifestations

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Two major determinants
- CO
  - Adjustments accommodate changes in PVR
- ⇡ CO = ⇡ BP
  - ⇡ Blood volume → ⇡ Pressure on arterial walls
    - & vice versa
PVR
- Adjustments accommodate changes in CO
⇡ PVR = ⇡ BP
- ⇡ Vasoconstriction + ⇡ Blood viscosity → ⇡ Pressure on arterial walls
  - & vice versa

Blood Pressure (BP) Maintenance

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Migration of Inflammatory Cells

Leukocytes migrate & adhere to endothelial wall → Macrophages enter tunica media & endocytose LDL

Second Step of Atherosclerosis Development

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Three factors that promote venous thrombosis

Venous stasis
- Prolonged immobility
- Leg dependency
Venous endothelial damage
- Trauma
- Medications
- Surgery
- Fractures
Hypercoagulable states
- Genetic disorders
- Malignancies
- Pregnancy
- Oral contraceptives
- HRT
- Antiphospholipid syndrome

Triad of Virchow

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Independent of other health problems

Genetic (autosomal dominant)
- Heterozygous
  - LDL= 350 mg/dL
  - S/S in adulthood
  - Xanthomas
- Homozygous
  - LDL= 1000 mg/dL
  - S/S in childhood
  - ⇡ Risk of death d/t MI in young adulthood

Primary Dyslipidemia

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Endothelial Cell Injury

d/t– smoking, ⇡ LDL, HTN, inflammatory mediators

Hemodynamics (mechanical stress)

First Step of Atherosclerosis Development

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Structure–

Thinner layers
Smaller lumen

Function–

Transport blood away from heart
- To capillary beds
Vasoconstriction/Vasodilation

Arteriole Structure & Function

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3rd largest lipoprotein
- “bad” cholesterol when high levels in blood
Much denser
- TGs (10%)
- Protein (25%)
- Cholesterol (50%)
Endogenous
- Synthesized in liver

LDL

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True Aneurysm

Entire circumference of vessel
- Gradual & progressive vessel dilation

Fusiform Aneurysm

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Structure–

Thick tunica media
Contractile & elastic

Function–

Transport blood away from heart
- Toward capillary beds
BP maintenance

Artery Structure & Function

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Fatty streaks
- Thin, flat, yellow discolorations of the tunica intima
  - Macrophages
  - Foam cells
- Form in childhood for everyone
  - Stop or regress @ age 20
Fibrous atheromatous plaque
- Necrotic core
  - Foam cells
  - Necrotic SMC
- Fibrous cap
  - SMC→ ECM
Complicated lesion
- Deposits from:
  - Hemorrhage
  - Ulceration
  - Scar tissue
  - Thrombosis

Types of Atherosclerotic Legions

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Atherosclerotic Disorder

Occlusive disease
- Lower extremities

d/t– Hypercholesterolemia, ⇡ Blood LDL levels, Smoking, DM, other atherosclerosis risk factors…

Peripheral Artery Disease (PAD)

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Largest lipoprotein
Least dense
- TGs (80-90%)
- Protein (2%)
Dietary
- Absorbed in SI

Chylomicrons

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Reduce risk
- Evaluate for coronary or cerebrovascular atherosclerosis
- Smoking
- HTN
- Dyslipidemia
- DM
Reduce symptoms
- D.A.S.H. or Mediterranean diet
- Anti-platelet medication
- Statins
Move until point of claudication
- Walk until it hurts
Surgery
- Disabling claudication
- Limb-threatening ischemia

Peripheral Artery Disease Treatment

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Skin color change
- Palor → cyanosis
Cold sensation
Parasthesia
- Numbness/tingling
Ischemic episode
- Pale → blue → redness, throbbing, parasethesia → normal color

Severe–

Brittle nails
Skin on tips of fingers thickens
Arthritis
Ulceration
Superficial gangrene
- Fingers

Raynaud Disease/Phenomenon Clinical Manifestations

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* Energy storage * Protection * Insulation * Cellular communication * Phospholipid membrane * Lipoproteins

Lipid Function

d/t-- **HTN, Degeneration of tunica media**, Connective tissue disease **(Marfan syndrome)**, **Pregnancy**, **Congenital** aortic defect, **Cardiac surgery** complication Classifications-- * **Type A** * Proximal legions * Ascending aorta * Ascending AND Descending aorta * **Type B** * Distal to subclavian artery * **Acute** * w/i 14 days of S/S onset * **Chronic** * longer than 14 days of S/S onset

Aortic Dissection

* Tunica Externa * Outermost * Collagen & elastin fibers * Tunica Media * Middle * Smooth muscle cells (SMCs) * Vasoconstriction/Vasodilation * Synthesis of biomolecules (elastin, collagen…) * Vascular repair * Tunica intima * Innermost * Endothelial cells

3 Layers of Blood Vessels

**Lipid Accumulation and SMC Proliferation** * **Foam cell** formation * Lipid-filled macrophages * Release **growth factors** * **SMCs** secrete **ECM** * Stimulated by growth factors * Release **collagen & elastin** * **Reactive oxygen species** * Toxic ROS cause **damage**

Third Step of Atherosclerosis Development

**Fibrous Atheromatous Plaque Structure** * **Foam cells** * Lymphocytes * **Necrotic core** * Necrotic SMCs * Foam cells * **Fibrous cap** * SMCs * ECM (elastin & collagen) * Endothelial layer **Plaque Rupture →** Hemorrhage or Thrombosis **(Clot formation)** → Lumen blocked **(Occlusion)**

Fourth Step of Atherosclerosis Development

**⇡ Venous Hypertension** (⇡ Hydrostatic Pressure) → **Reflux** through incompetent veins → **Pooling of blood** in lower extremities → **Dilation & stretching** of vessel walls d/t-- Prolonged **standing**, **Incompetent valves, DVTs, Inflammation**, Endothelial dysfunction **(atherosclerosis)**, **⇣ Skeletal muscle pump function**

Venous Insufficiency

* **Elimination of tobacco/nicotine** * Vasodilation * **Injury prevention** * Difficult for injuries to heal w/ reduced blood flow to extremities

*Buerger Disease* (Thromboangiitis Obliterans) Treatment

* Secrete cytokines & enzymes * ⇣ Platelet aggregation * ⇡ Vasodilation

Endothelium Function

**Difference** between **systolic** and **diastolic** BP * Affected by * **SV** * Arterial **distensibility** (elasticity) * **⇣ Distensibility → ⇡ BP**

Pulse Pressure

**Inflammatory Disorder** Segmental, thrombosing, acute & chronic inflammation * **Thrombus** formation * Medium-sized arteries * Lower extremities * **Plantar** * **Digital** * Upper extremities * **Arms** * **Hands** d/t-- **Smoking/Vaping** (seen in \< 35 y.o), **Genetics**

*Buerger Disease* (Thromboangiitis Obliterans)

* Impaired venous flow * **Tissue congestion** * **Edema** * **Necrosis** of surrounding tissue * **Stasis dermatitis** * CO₂-rich blood sits in dependent areas * Acidic gas damages tissue * **Venous ulcers** * Skin easily injured

Venous Insufficiency Clinical Manifestations

**Average pressure** in arterial system during **ventricular contraction and relaxation** ## Footnote **MAP = .60 (DBP) + .40 (SBP)**

Mean Arterial Pressure (MAP)

* **Preeclampsia-Eclampsia** * **⇡ BP + Proteinuria** * **SBP \>140** and/or **DBP \>90** * \>20 weeks gestation or postpartum * S/S * **HA** * **Seizures** (Eclampsia) * EMERGENCY! * **Gestational HTN** * **New-onset HTN** w/o proteinuria * Resolves w/i 12 wks. of childbirth

Hypertension During Pregnancy

* **Risk Factors** * Non-modifiable * **Genetics** * **Age** * Modifiable * **Lifestyle** * **Metabolic abnormalities** * Insulin resistance * Obesity * **Dyslipidemia** * **Obstructive sleep apnea** * Hypoxemia → Endothelial dysfunction → **Atherosclerosis**

Primary Hypertension

**Amount of blood** ejected from **L ventricle** in **one contraction** (per beat)

Stroke Volume (SV)

**EMERGENCY!** **SBP \> 180** and/or **DBP \> 120** * End-organ damage * One year mortality rate (79%) * Hypertensive **encephalopathy** * AMS * Intracranial or subarachnoid **hemorrhage** * Brain * **HF** * **MI** * **Renal Failure** * Aortic Aneurysm * **Dissection** * **Retinopathy**

Hypertensive Crisis

* Physical exam * Inspect limbs * **Thick, malformed nails** * **Hair loss** * **Thin, shiny skin** * **Cyanosis** * **Coolness** * Level of Obstruction * Palpitation of pulses * Doppler ultrasound * **Radial, posterior tibial & dorsalis pedis pulses**

*Buerger Disease* (Thromboangiitis Obliterans) Diagnosis

Disruption in **lipid transport/synthesis** → **Dyslipidemia**

Obstructive Liver Disease

d/t-- **Atherosclerosis, HTN, Degeneration of tunica media**, Male smoker \> 50 y.o. * Asymptomatic (until rupture) * Common * **Substernal, back, & neck pain** * **Dyspnea, stridor, brassy cough** * Pressure on trachea * **Hoarseness** * Pressure on laryngeal nerve * **Difficulty swallowing** * Pressure on esophagus * Distention of neck veins **(JVD)** * **Facial & neck edema** * Pressure on superior vena cava Diagnosis-- Imaging (ultrasound, echocardiogram, CT, MRI) Treatment-- **Surgery**

Thoracic Aortic Aneurysm Clinical Manifestations

**Reduction of arterial flow** to a level **insufficient** to meet **O₂**demands of the tissue; causes pain.

Ischemia

**Pressure-sensitive receptors** that respond to stretch **⇣ BP →** **inactive → ⇡ SANS →** Vasoconstriction **⇡ BP →** **active** **→ ⇡ PANS →** Vasodilation * **High Pressure** * Stretch → **⇡** **HR & vasodilation** * Carotid & Aortic arteries * **Low Pressure** * Stretch → **⇡ ADH** * Large systemic veins * Pulmonary vessels * Walls of RA * Ventricles

Baroreceptors

Area of ischemic **necrosis** due to **occlusion** of **arterial** blood supply OR **venous** drainages.

Infarction

Associated with other health problems d/t-- **Diet, Obesity, T2DM** Chronic systemic inflammation → Insulin resistance * **⇡ TGs** * **⇡ LDL** * **⇣ HDL** Recommendation-- **D.A.S.H** Diet, **Mediterranean** Diet

Secondary Dyslipidemia

Determine by **radius of arterioles** and **blood viscosity**

Peripheral Vascular Resistance (PVR)

* Intermediate between VLDL & LDL * Non-functional

IDL

Structure-- * **Thinner tunica media** * **Larger lumen** * Internal valves * Unidirectional blood flow Function-- * Transport of **blood toward the heart** * To R atrium

Vein Structure & Function

**False** Aneurysm * Tear in tunica intima * Blood enters vessel wall * **Blood-filled cavity b/w tunica intima & tunica media**

Dissecting Aneurysm

Structure-- * Very **thin layers** * Gradually enlarge Function-- * Transport **blood toward the heart** * From capillary bed

Venule Structure & Function

Blood remains **within vascular compartment** * **Berry aneurysm** * **Fusiform aneurysm** * **Saccular aneurysm**

Types of True Aneurysms

* **RAAS** * **Angiotensin II** * **Vasoconstriction** → ⇡ PVR → ⇡ BP * **⇡ Blood volume** → ⇡ BP * via Aldosterone secretion * **Aldosterone** (adrenal cortex) * Na⁺& H₂O retention * **⇡ Blood volume** → ⇡ BP * **ADH/Vasopressin** (posterior pituitary) * Released in response to * **⇣ blood volume, ⇣ BP, or ⇡ osmolality** * ⇡ H₂O retention **→ ⇡ Blood volume →** ⇡ BP * **Vasoconstriction →** ⇡ BP

Acute BP Regulation-- Humoral Mechanism

* **Stage 1** * SBP: 130-139 mmHg * **OR** * DBP: 80-89 mmHg * **Stage 2** * SBP: \>140 mmHg * **OR** * DBP: \>90 mmHg **OR → AND** = Move up one stage

2021 AHA/ACC Hypertension Guidelines

* Beta-blockers * Estrogens * Protease inhibitors * HIV treatment

Medications that may cause dyslipidemia

Imbalance of lipid components within the blood * Low blood HDL * ⇣ Reverse cholesterol transport * High blood LDL * ⇡ Risk atherosclerosis * High blood TGs

Dyslipidemia

Tear in the artery wall leads to the formation of an **extravascular hematoma** & vessel enlargement * **Dissecting aneurysm**

Types of False Aneurysms

* Smallest lipoprotein * “good” cholesterol * Most dense * TGs (5%) * Protein (50%) * Cholesterol (20%) * Endogenous * Synthesized in liver * Reverse cholesterol transport

HDL

Structure-- * **Single-layer** * **Endothelial cells** surrounded by pericytes Function-- * Exchange of materials b/w blood and IF * **Gas exchange**

Capillary Structure & Function

Diagnosis-- History of **vasospastic attacks** Treatment-- **Smoking abstinence, Cold protection, Emotional stress control**

Raynaud Disease/Phenomena Diagnosis & Treatment

Diagnosis-- **History, Physical exam, Vascular imaging, CT, MRI** Treatment-- **Stabilize** (control HTN, medications to decrease force of systolic ejection), **Surgery** (resection and replacement with prosthetic graft)

Aortic Dissection Diagnosis and Treatment

* High mortality rate * Untreated * **Abrupt onset of excruciating pain** * Tearing/ripping pain * Pain in **anterior chest** * **Ascending** aorta * Pain in **back** * **Descending** aorta * Early-- * ⇡ BP * Later-- * **BP and pulse unobtainable** * One or both arms * Blood vessel occlusion * Brain & spinal cord * **Syncope** * **Hemiplegia** * **Paralysis** * Lower extremities * Heart failure * Aortic valve

Aortic Dissection Clinical Manifestations

* **Kidneys** * **⇡ BP** * Decrease blood volume * **Diuresis** * H₂O excretion * **Natriuresis** * Na⁺ excretion * **⇣ BP** * Increase blood volume * **Na⁺ & H₂O retention** * ⇡ CO and/or PVR

Long Term Blood Pressure Regulation Mechanism

**Corrects temporary imbalance** (emergency) Occurs w/i seconds → minutes * **Neural** * SANS * PANS * **Most rapid** * **Humoral** * RAAS * ADH/Vasopressin

Acute Blood Pressure Regulation Mechanisms

Insulin resistance + * ⇡ Fasting BG * HTN * ⇡ Waist circumference * **Dyslipidemia**

Metabolic Syndrome

Prevalence ⇡ w/ age * Stiffening of large arteries * ⇣ Baroreceptor sensitivity * ⇡ PVR * ⇣ Renal flow

Hypertension in the Elderly

**Clot formation in large veins** (primarily lower extremities) → Venous thromboembolism **(VTE)** → VTE to **pulmonary circuit** → Pulmonary embolism **(PE)** d/t-- * **Platelet & clotting factor** accumulation * **Venous thrombus** formation * **Inflammation** around thrombus * Platelet aggregation * VWF (adhere to endothelium) * **Thrombus grows** proximally

Deep Vein Thrombosis

**Blood clot** that **detaches** and migrates

Thromboembolus/Embolus

**Blood clot** that **remains attached** to vessel wall

Thrombus

* **Renal HTN** * ⇣ Renal blood flow → **RAAS over-activation** * **Adrenocortical hormone disorders** * H₂O retention * **Hyperaldosteronism** * **Hypercortisolism** (Cushing Syndrome) * **Pheochromocytoma** (Paraneoplasm) * Tumor of adrenal chromaffin cells * Catecholamine (Epi, NE) secretion * **⇡ SANS →** Vasoconstriction * **Oral contraceptives** * Na⁺ and H₂O retention

Secondary Hypertension

* Proteinuria * ⇣ Albumin * ⇡ LDL in blood → **Dyslipidemia**

Nephrotic Syndrome

d/t-- **Atherosclerosis, HTN, Degeneration of tunica media**, Male smoker \> 50 y.o. * Asymptomatic (until rupture) * Common * Aorta diameter \> 3 cm * \> 4 cm → Aneurysm is palpable * Saccular or Fusiform * **Pulsating mass** * Calcification * X-ray * **Mid-abdominal and lumbar pain** * Thrombus formation Diagnosis-- Imaging (ultrasound, echocardiogram, CT, MRI) Treatment-- **Surgery**

Abdominal Aortic Aneurysm Clinical Manifestations

**50% Narrowing** before S/S manifest-- * Pain w/ walking (calves) * **Intermittent claudication** * Aching/Numbness * Thinning of skin * Reduced muscle size * Legs * Cold feet * **Weak or absent popliteal pulse** * Stark change in limb color * **Blanches** w/ **elevation** * **Deep red** w/ **standing** **Progression--** Blood flow **insufficient** for **O₂**needs of muscles and nerves → **Necrosis** * Ischemic **pain at rest** * **Ulceration** * **Gangrene** * **Severe pain** in region of necrosis * Worse @ night * **Improved w/ standing**

Peripheral Artery Disease Clinical Manifestations

**Vasospastic Disorder** Intense vasospasm of arteries/arterioles of fingers and toes * Disease * No known cause d/t-- **⇡ SANS** (exposure to cold, strong emotions) * Phenomenon * Associated w/ other diseases d/t-- **Frostbite**, **Occupational trauma** (heavy vibrating tools, alternating hot/cold), **Neurological disorder**, **Chronic** **arterial occlusive disorder**, Collagen disorder (first sign-- **Scleroderma, Lupus**)

Raynaud Disease/Phenomenon

* **Hypercholesterolemia** * **⇡ Blood LDL levels** * Age * Family history * Male * Genetics * Smoking * Obesity * Visceral/Abdominal fat * HTN * DM * Inactivity * Stress * Inflammation * ⇡ CRP levels * Inadequate nutrition (low folic acid, B6, and/or B12) * ⇡ Homocysteine levels (homocystinuria) * Hypothyroidism * ⇡ Homocysteine levels (homocystinuria)

Risk Factors for Atherosclerosis

**True** Aneurysm * Extends over **part of vessel circumference** * Saclike

Saccular Aneurysm

* **Varicose Veins** * **Venous Insufficiency** * **Deep Vein Thrombosis**

Disorders of Systemic Venous Circulation

Dilated, tortuous **veins of lower extremities** d/t-- **prolonged standing, ⇡ Intraabdominal pressure** (pregnancy, occupations that require heavy lifting), **Incompetent venous valves** (backflow of blood) * **Primary** * Originate in superficial saphenous veins * **Secondary** (80-90%) * **Impaired blood flow** in deep venous channels

Varicose Veins

* Physical exam * Inspect limbs * Subcutaneous **atrophy** * **Brittle toenails** * **Hair loss** * **Pallor** * **Coolness** * Dependent **rubor** * Level of Obstruction * Palpitation of pulses * Doppler ultrasound * **Femoral, popliteal, posterior tibial & dorsalis pedis pulses** * **Low BP along leg** * Imaging * Ultrasound * MRI * Spiral CT * Invasive contrast angiography

Peripheral Artery Disease Diagnosis

Early Stages-- * **Intermittent claudication** * Arch of foot & digits * Cold sensitivity * **Weak or absent peripheral pulses** Advanced Stages-- * **Pain at rest** * Severe * Color change of extremities * **Cyanotic** w/ **standing** * **Reddish-blue** w/ **sitting/laying** * Thin, shiny skin * Slowed hair growth * **Thick, malformed nails** * Chronic * **Ulceration** * **Gangrene** * Possible limb amputation

*Buerger Disease* (Thromboangiitis Obliterans) Clinical Manifestations

Abnormal **⇣ in BP w/ change of position** from lying/sitting to standing → Dizziness or Syncope Within **3 minutes** of standing **⇣ SBP @ least 20 mmHg** and/or **⇣ DBP @ least 10 mmHg**

Orthostatic Hypertension

* 2nd largest lipoprotein * Denser * TGs (55-65%) * Protein (5-10%) * Cholesterol (10%) * Endogenous * Synthesized in liver

VLDL

Increasing prevalence d/t-- **Obesity, FMH**, Kidney abnormalities, **Coarctation of aorta**, Endocrine disorders * **⇡ Obesity** * Physical inactivity * Diet * **High Calorie/Fat/Na⁺** * **High fructose corn syrup** * Metabolic dysregulation

Hypertension in Children & Adolescents

* **⇣ Blood volume** (Diuretics, GI loss, Dehydration) * **Medications** (Anti-HTN, Psychotropics) * **Aging** (⇣ or slowed CV response) * **Bed rest/Immobility** * Physical deconditioning * ⇣ Blood volume * ANS Dysfunction * **Diabetic neuropathy** * **Spinal cord injury** * **CVA** (Stroke) * **Parkinson's**

Orthostatic Hypotension Causes

* Any organ * **Heart** * **Brain** * Kidneys * **Lower extremities (PAD)** * Small intestine * Vessel damage * Narrowing or ischemia * Sudden **obstruction/occlusion** * **Aneurysm** * Larger vessels * **Thrombus** formation * Medium arteries * **Ischemia** * **Infarction**

Atherosclerosis Clinical Manifestations

Blood Flow & Blood Pressure (Ch. 26)-- Definition First Flashcards

Exam 2