Blood pressure Flashcards
Warfarin is what type/class of medication?
anticoagulant
- inhibits production of vitamin K
Dabigatran (Pradaxa) is what type/class of medication?
direct acting oral anticoagulant (DOAC)
Rivaroxban (Xarelto) is what type/class of medication?
direct acting oral anticoagulant (DOAC)
- factor Xa inhibitor
Apixaban (Eliquis) is what type/class of medication?
direct acting oral anticoagulant (DOAC)
Edoxaban (Lixiana) is what type/class of medication?
direct acting oral anticoagulant (DOAC)
What is the antidote/reversal agent for Warfarin?
Vitamin K
Heparin is what type/class of medication?
anticoagulant
- factor Xa inhibitor
What are the 5 ausculatory areas when assessing/listening to heart sounds?
APETM:
- aortic
- pulmonic
- erbs point
- tricuspid
- mitral
Which heart sound denotes the closure of the mitral and tricuspid valves?
S1 heart sound
What does the S1 heart sound represent?
closing of the mitral and tricuspid valves
Which heart sound denotes closure of the aortic and pulmonic valves?
S2 heart sound
The S2 heart sound represents what?
closing of the semilunar and pulmonic valves
Murmurs heard in early diastole are due to what?
incompetent semilunar valves
- aortic or pulmonic regurg
- aortic regurg if sound intensifies when patient sits forward and holds their breath
Mitral stenosis is associated with what conditions?
- rheumatic heart disease
- myxomas
- congenital malformations
A friction rub or “scratchy” high-pitched sound heard when assessing the heart is a classic finding of what condition?
pericarditis
Hyperkalemia (K+ > 6 mEq/L) is associated with what ekg/cardiac?
- tall, peaked T-waves
- widening QRS complex
- p-wave flattens/widens
- prolongation of the PRI
- slowed AV conduction
- potential arrhythmias
Hypokalemia (< 3 mEq/L) is associated with what ekg/cardiac changes?
- PVC’s (uni or multi-focal)
- U-wave seen after T-wave
Hypercalcemia is associated with what ekg/cardiac changes?
- increases cardiac contractility
- shortens QT interval
- AV block
- BBB
- bradycardia
Hypocalcemia is associated with what ekg/cardiac changes?
- decreased cardiac contractiity
- bradycardia
- decreased CO
- hypotension
Does hyper or hypokalemia potentiate the effects of digitalis toxicity?
hypokalemia
Does hyper or hypocalcemia potentiate the effects of digitalis toxicity?
hypercalcemia
Does hyper or hypocalcemia potentiate the effects of digitalis toxicity?
hypercalcemia
Does hyper or hypocalcemia decrease the efficacy of digitalis?
hypocalcemia
At what magnesium level would ECG changes occur?
ECG changes may occur at magnesium levels > 5 mEq/L
According to current guidelines when should antihypertensive medications be started on a patient at high CVD risk?
SBP > 130 or DBP > 80 measured on 2 separate occasions
What is the term for HTN of unknown cause?
essential or primary
What medication(s) should be used to treat Isolated systolic HTN?
- SBP > 160 and DBP < 90
- diuretics
-Dihydropyridine calcium blockers- end in “dipine”
- angiotensin receptor blockers
- avoid beta blockers
What are the contraindications for the use of ACE inhibitors?
- potassium > 5.5 mEq/L
- pregancy
- bilateral renal artery stenosis
- not to be used with ARBs or renin inhibitors
- not effective in African Americans
- not to be used with lithium: Na stays and lithium is excreted
What are potential adverse effects of ace inhibitors?
- cough
- rash
- hyperkalemia
- angioedema
- renal impairment
What are the indications for ACEi/ARBs use?
- HTN (not very effective in AA)
- CAD
- previous MI
- heart failure
- nephroprotective in DM patients
Which antihypertensive meds should not be used in African Americans because they are not effective?
- ACE inhibitors
- ARBs
What are the 2 types of calcium channel blockers?
- dihydropyridine: causes peripheral vasodilation
- non dihydropyridine: directly relaxes the heart
Diltiazem and verapamil are what type of CCB?
- non dihydropyridine
- directly relax the heart
- avoid in patients with heart failure with reduced ejection fraction
- watch for bradycardia
Which class of BP medication is recommended for patients with aortic disease?
Beta-blockers
Which class of BP medication is recommended for patients with HF?
- Ace inhibitors
- Arb’s
- beta blockers
- aldosterone antagonists
- diuretics if fluid overloaded
Which class of BP medication is recommended for patients with BPH?
Alpha-1-blockers
Which class of BP medication is recommended for patients with peripheral artery disease?
- Diuretics
- ace inhibitors
- ARB’s
- CCB’s
Captopril is what class of medication?
- ACE inhibitor
Clonidine is what type of medication?
- centrally acting Alpha-2 adrenergic agonist
- anti-hypertensive
- inhibits NE release
Labetolol is what type and class of medication?
- alpha and beta adrenergic antagonist
- used to treat:
- HTN
- angina
- sympathetic over activity
syndrome
Which class of BP med is the 1st line option when starting therapy?
Thiazide diuretics
- hydrochlorothiazide
What is the MOA for hydrochlorothiazide?
- inhibits sodium absorption in the distal convoluted tubules causing increased sodium and water excretion
What affect does angiotensin II have on the body?
Increases BP by:
- stimulating aldosterone release for
adrenal cortex which increases Na and H20 reabsorption
- vasoconstriction of vascular smooth muscle
- triggers thirst center in hypothalamus
- stimulates ADH release from posterior pituitary
Which BP med(s) can be used in patients with heart failure with reduced ejection fraction?
Amlodipine and felodipine
Which diuretic class is preferred in patients with symptomatic HF and with GFR -30 ml/min?
Loop diuretics
Spironolactone is what Class/drug type?
Aldosterone antagonist
- diuretic
What is Clonidine’s MOA?
centrally acting alpha-2-agonist
- inhibits release of norepinephrine to reduce BP
How do hydralazine and minoxidil reduce BP?
BP reduction through arterial vasodilation
What medications should be considered to be given together with hydralazine or minoxidil and why?
- diuretic due to Na and H2O retention
- beta-blocker due to reflex tachycardia
What classes of medication is Aliskiren?
- direct renin inhibitor
- very long acting
Nicardipine (cardene) is what class of medication?
dihydropyridine CCB
Nitroglycerin gtt should be started on which patients during a hypertensive emergency?
only in patients with acute coronary syndrome and/or acute pulmonary edema
How do you calculate pulse pressure?
systolic BP minus diastolic
Cholesterol screening should begin at what age and be done how often?
start at 20 and retest q5 yrs
What is the normal triglyceride range?
TG < 150 mg/dl
When should statin therapy be initiated?
- LDL greater than or equal to 190 mg/dl
- 40-75 y/o with DM
What is the criteria needed to diagnose metabolic syndrome?
3 of the following:
- abdominal obesity
- TG > 150
- HDL < 40 males; < 50 females
- Systolic BP > 130
- Diastolic BP > 80
- taking anti-HTN med
- fasting glucose > 100 mg/dl
What is the mechanism of action and classification of Heparin?
Class: anticoagulant
MOA: inhibits factor Xa
A summation gallop (S3 and S4 heard together) is highly suggestive of what?
severe myocardial failure
What is the MOA for dihydropyridine CCBs?
- block binding to and blocking voltage-gated L-type calcium channels found on smooth muscle cells of arterial blood vessels causing vasodilation
- nifedipine
- nicardipine
- nimodipine
- amlodipine
What is the MOA for the following meds:
- nifedipine
- nicardipine
- nimodipine
- amlodipine
- dihydropyridine CCB
- bind to and block voltage-gated L-type calcium channels in smooth muscle cells of arterial blood vessels causing vasodilation
What is the MOA for the nifedipine?
- dihydropyridine CCB
- bind to and block voltage-gated L-type calcium channels in smooth muscle cells of arterial blood vessels causing vasodilation
What is the MOA for the nicardipine?
- dihydropyridine CCB
- bind to and block voltage-gated L-type calcium channels in smooth muscle cells of arterial blood vessels causing vasodilation
What is the MOA for the nimodipine?
- dihydropyridine CCB
- bind to and block voltage-gated L-type calcium channels in smooth muscle cells of arterial blood vessels causing vasodilation
What is the MOA for the amlodipine?
- dihydropyridine CCB
- bind to and block voltage-gated L-type calcium channels in smooth muscle cells of arterial blood vessels causing vasodilation
What is the MOA for the verapamil?
- non-dihydropyridine CCB
- blocks L-type calcium channels in the SA and AV node
- slows SA node = reduced HR
- decreased AV node conduction
- decreased contractility
What is the MOA for the diltiazem?
- non-dihydropyridine CCB
- blocks L-type calcium channels in the SA and AV node
Indications for CCB use?
- Arrhythmias:
- atrial fibrillation
- atrial flutter
- symptomatic PAC’s
- stable angina
- prinzmetal/vasospastic angina
- chronic HTN
- hypertensive emergencies
- HTN in pregnancy
- Raynaud’s disease
- vasospasm d/t SAH
Adverse effects of Non-Dihydropyridine CCB use?
- bradycardia
- AV block
- hypotension d/t reduced CO
Contraindications for CCB use?
- Wolf Parkinson White syndrome (may cause VT/VF)
- don’t use with Beta Blockers
- heart block
- HFrEF
- aortic valve stenosis
What is the reversal agent for CCB?
- give Calcium
- calcium gluconate
- calcium chloride
Adverse effects of Dihydropyridine CCB use?
- drugs end in -pine
- reflect tachycardia
- orthostatic hypotension
- peripheral edema
- flushed/red skin
Where is renin produced?
- in the Juxtaglomerular cells of the kidneys
- released d/t decreased blood flow through the renal arteries
What does renin do?
converts angiotensinogen to angiotensin I
Where is angiotensinogen produced?
in the liver
Where is Angiotensin Converting Enzyme produced?
in capillary endothelium of the lungs
What does ACE do?
converts angiotensin I in to angiotensin II
What is the MOA of Hydrochlorothiazide (HCTZ)?
- inhibits sodium reabsorption in the distal convoluted tubule causing increased sodium and H2O in the urine which decreases blood volume = reduced BP
- increases Calcium reabsorption from DCT
What causes the cough related to ACE inhibitors?
ACE usually breaks down Bradykinin, inhibition of ACE leads to increased levels of bradykinin which causes bronchoconstriction and cough
Indications for thiazide diuretic use?
1) HTN
2) fluid retention:
- peripheral edema r/t CHF or AKI
- pulmonary edema r/t CHF or AKI
- ascites r/t cirrhosis
3) osteopenia - since it increases Ca2+ absorption
What are adverse effects of thiazide diuretics?
- hyperuricemia d/t decreased uric acid excretion in the urine = gout
- hyponatremia
- hypochloremia (low chloride)
- hypercalcemia
- hypokalemia d/t increased urine loss
- metabolic acidosis r/t to increased hydrogen loss in urine
- hyperglycemia (d/t hypokalemia)
How does hypokalemia lead to hyperglycemia?
potassium is needed for insulin to be released from pancreatic cells. Low levels of potassium results in less insulin being released into the blood which leads to increased BG levels
What are causes of essential/primary HTN?
1) vessel thickening r/t
- advanced age
- smoking
- DM
2) vasoconstriction
- stress
- obesity
- high sodium diet
What are the causes of secondary HTN?
(RENALSS)
Renal vascular disease
Endocrine
Neurological
Aortic diseases
Little people (pregnant)
Substances
Sleep Apnea
HTN in the upper extremities and low blood pressure in the lower extremities is a sign of what condition?
coarctation of the aorta, a narrowing of the aorta causing the heart to pump harder (HTN in UE) to get blood out to the body
What are potential renal causes for secondary HTN?
Renal vascular disease
- CKD
- renal artery stenosis
above causes low renal perfusion which activates the RAAS leading to increase in BP
What are potential Endocrine causes for secondary HTN?
- hyperthyroidism = systolic HTN
- hypothyroidism = diastolic HTN
- hyperaldosteronism
- Cushing’s (high cortisol levels)
- high EPI/NE levels
What are potential neurological causes for secondary HTN?
- increased intracranial pressure
What are potential aortic vessel disease causes for secondary HTN?
- coarctation of the aorta
Where are Beta 1 receptors located?
- cardiac conduction system (SA, AV), activation increases HR
- contractile cells of the cardiac tissue, activation increases stroke volume/CO
- juxtaglomerular cells in kidneys, stimulation causes renin release
Where are Beta 2 receptors located?
- ciliary body in eye
- lungs, stimulation causes bronchodilation
- liver, increases glucose levels by stimulating gluconeogenesis and glycogenolysis
- pancreatic alpha cells, stimulates glucagon release, which tells liver to make more glucose through gluconeogenesis and glycogenolysis
- vessels supplying the brain and muscles, causes vasodilation
- GIT, slows motility and secretions of GIT
How do beta blockers reduce HTN?
1) blocks beta-1 receptors of the SNS:
- slows cardiac conduction and decreases contractility which reduces HR and stroke volume, which reduces CO = reduction in BP
- inhibits renin release from the kidneys, preventing the formation of angiotensin II through the RAAS = lower BP
2) blocks beta 2 receptors
- vasodilation = decreased SVR
What are the 1st generation beta blocker medication names?
- propanolol
- sotalol
- non-selective beta blockers bind to both B1 and B2 receptors
Propanolol and sotalol are what class of medication?
- 1st generation non selective beta blockers
- bind to both B1 and B2 receptors
What are the 2nd generation beta blocker medication names?
- Atenolol
- bisoprolol
- esmolol
- metoprolol
- primarily B1 selective, but will bind to B2 receptors at high doses
What are the 3rd generation beta blocker medication names?
- labetolol
- carvedilol
- non selective, bind to B1, B2 and Alpha-1 receptors
Atenolol is what class of medication?
- 2nd generation beta blocker
- primarily B1 selective, but will bind to B2 receptors at high dose
bisoprolol is what class of medication?
- 2nd generation beta blocker
- primarily B1 selective, but will bind to B2 receptors at high dose
metoprolol is what class of medication?
- 2nd generation beta blocker
- primarily B1 selective, but will bind to B2 receptors at high dose
esmolol is what class of medication?
- 2nd generation beta blocker
- primarily B1 selective, but will bind to B2 receptors at high dose
What class of medication is labetolol?
- 3rd generation beta blocker
- non selective, bind to B1, B2 and Alpha-1 receptors
What class of medication is carvedilol?
- 3rd generation beta blocker
- non selective, bind to B1, B2 and Alpha-1 receptors
What are the indications for beta-blocker use?
- CAD, decreases O2 demand by reducing HR and contractility
- SVT (Afib/Afl)
- HTN, reduces CO
- medical management of aortic dissection or aneurysm by lowering BP
Which HTN medication is contraindicating in patients with pheochromocytoma or cocaine use?
- 1st and 2nd generation beta blockers
- causes unopposed Alpha 1 agonism, medication blocks beta 2 receptors on artery, resulting in increased binding of catecholamines (EPI, NE) to Alph 1 receptors resulting increased vasoconstriction and BP
- doesn’t inhibit catecholamine release
Which beta blocker is used to anxiety?
- propranolol
- inhibits SNS to reduce symptoms
Which beta blocker is used in the treatment migraines?
- propranolol
- decrease blood flow to the brain which reduces the intracranial pressure
Why would a beta-blocker be used in the treatment of a patient experiencing thyrotoxicosis?
- increased levels of T3 and T4 increase the sensitivity and activation of the SNS, beta blockers will reduce the symptoms by inhibiting the SNS
- reduce BP
- slow HR
What are adverse effects r/t beta blocker use?
- AV block d/t slowed conduction
- syncope r/t low BP
- diarrhea r/t increased GIT motility and secretion production
- HLD r/t reduced conversion of triglycerides to FFA d/t inhibition of lipoprotein lipase release from capillary endothelium
- hypoglycemia d/t inhibition of glycogenolysis and gluconeogenesis in liver
- hypoglycemia d/t inhibition of glycogen release from the alpha cells of the pancreas
- Hypoglycemia unawareness r/t inhibition of SNS symptoms
- fatigue
Where are alpha-1 receptors located?
- stimulated by catecholamines (EPI/NE)
- peripheral vessels, causes vasoconstriction = increase BP
- smooth muscle of the prostate, causes prostate contraction
- urethral sphincter, causes contraction of the internal urethral sphincter = urine retention
What do the alpha-1 blocker medications names end with?
- osin
- terazosin
- tamsulosin
- prazosin
- doxazosin
What are the indications for Alpha blockers?
- 4th line med for HTN
- urine retention r/t BPH
- kidney stone in ureter, relaxes/dilates ureter to help pass the stone (tamsulosin)
Methyldopa is what type/class of medication?
- anti-hypertensive
- centrally acting Alpha-2 adrenergic agonist that inhibits NE release
What BP reading is defined as a hypertensive emergency?
> 180 / >120 with new or worsening organ damage
- intracranial hemorrhage
- acute ischemic stroke or MI
- unstable angina pectoris
- dissecting aortic aneurysm
- eclampsia
- acute renal failure
What is the goal of therapy for a patient experiencing a hypertensive crisis (> 180 / > 120 mmHg)?
- goal is systolic BP = 160-180 and/or diastolic BP 105 or less
- BP should be lowered no more than 25% within mins to 2hrs, then gradually lower over several days with oral meds
Beta blockers should be used as first line anti-HTN medications in what patient population?
patients with
- ischemic heart disease
- HFrEF
Why does clonidine need to be tapered down when discontinuing the medication?
may induce a hypertensive crisis d/t rebound HTN
What type/class of med is hydralazine?
- anti-HTN
- causes arterial vasodilation
What type/class of med is mynoxidil?
- anti-HTN
- causes arterial vasodilation
What conditions could cause low diastolic pressures (< 80) that would result in widening pulse pressures (sys - dia > 40mmHg)?
- aortic regurgitation, blood flows back into LV which lessens the volume and pressure in the artery
- anemia, less volume
- sepsis, causes vasodilation and fluid shift = less blood in vessels
What are the potential causes of systolic HTN (> 120) that would result in widening pulse pressures (sys - dia > 40mmHg)?
- atherosclerosis, systolic pressure needs to push through narrowed vessels
- hyperthyroidism, causes increased inotropic effects
- sepsis, compensatory increase in HR and contractility cause high systolic pressures
What are the potential causes of narrowing pulse pressures (sys - dia < 40mmHg)?
- cardiogenic shock
- bleeding = less volume
- aortic stenosis = less CO
- cardiac tamponade
