Cardiac Flashcards
Prehypertension measurements
120-139/80-90
What is primary hypertension?
- Sustained elevation of 140/90 or higher
- Results from environmental or genetic factors
- Affects 90-95% of individuals with hypertension
- Also called essential or idiopathic hypertension
Modifiable Risk Factors for Hypertension
- Smoking
- DM
- HLD
- Obesity
- Physical inactivity
- Unhealthy diet
- Excessive sodium intake
- Excessive alcohol intake
Non-modifiable Risk Factors for Hypertension
- Chronic kidney disease
- Family history
- Increased age
- Low socioeconomic status
- Low educational status
- Male sex
- OSA
- Psychosocial stress
- Pregnancy
HTN increases the risk of developing…
- heart disease
- kidney disease
- hardening of the arteries (atherosclerosis or arteriosclerosis)
- eye damage (retinopathy)
- stroke (ischemic and hemorrhagic)
What is end-organ damage?
A complication of hypertension
- called this because damage to these organs is the end result of chronic (long duration) high blood pressure
What to ask for evaluation of hypertension?
- duration and levels of elevated BP
- past treatments (both successes and failures)
- associated symptoms that suggest secondary HTN
- symptoms of stress
- weight control
- physical activity/sedentary lifestyle
- tobacco use
- dietary intake
- medications
- psychosocial and environmental factors that may impact BP
Associated symptoms that suggest secondary HTN
- palpitations
- sweating
- dizziness
- abdominal pain
- back pain
Medications to ask about when evaluating HTN
- illicit drug use
- oral contraceptives
- NSAIDs (can increase BP)
- decongestants
- steroids
Diagnosis of HTN
- obtain 2 or more BP with patient in chair after 5 minutes of rest (no caffeine or smoking 30 minutes prior)
- measure height, weight, waist circumference with waist/hip ratio and BMI
- excess body fat: waist >34 in. for women and >39 in. for men there is an increased risk for CVD
- perform funduscopic exam
- perform complete heart exam (bruits, thrill, edema)
- perform complete neuro exam
- ECG
Lab Tests to do for HTN patients
- UA (may reveal proteinuria)
- electrolytes
- calcium
- creatinine
- fasting lipid profile
** Goal is to identify target organ damage, any underlying cause and/or additional risk factors
Hypertension Prevention
- maintenance of healthy weight and BMI
- smoking cessation
- regular aerobic exercise
- alcohol in moderation (<1 oz per day)
- stress management
- adherence to medication regimen
- assess for and treat OSA
Why is it important to assess medication adherence for HTN treatment?
It is important to identify obstacles to effective treatment
- cost?
- hard to get?
- sexual dysfunction/side effects?
**Ask them to bring their medications in to the office
Treatment strategy for HTN Stage 1
if no history of CVD, and risk score is <10%, initiate lifestyle changes first
Treatment strategy for HTN Stage 2
lifestyle changes AND medication
Things to consider when starting BP medications…
- ACE inhibitors can increase potassium
- Avoid beta blockers in individuals with DM and reactive airway disease
- Avoid ACE inhibitors in childbearing women: CategoryX
- Start low, go slow
- Maximize one medicine then consider adding a new medication (start at lowest dose, then increase)
- If cannot control BP… REFER!
How often to reassess HTN patients?
Reassess monthly until patient reaches goal, then every 3-6 months
Peripheral Artery Disease (PAD)
- atherosclerotic disease of arteries that perfuse the limbs, especially lower extremities
- especially prevalent in patients with DM
- often asymptomatic
- could have intermittent claudication
What is intermittent claudication?
Obstruction of arterial blood flow in the iliofemoral vessels resulting in pain with ambulation
- fatigue, discomfort and/or pain that occurs in specific leg muscle groups during walking because of exercised induced ischemia
What is critical limb ischemia?
- can occur with PAD
- it is pain that occurs at rest or impending loss of limb caused by severe restriction in blood flow.
- ischemia exceeds 2 weeks
What is acute limb ischemia?
- occurs with PAD
- has rapid onset (hours)
- urgent recognition with prompt revascularization is required to prevent loss of limb
What is OLDCARTS?
Used for PAD assessment
O - onset
L - location
D - duration
C - characteristics
A - alleviating/aggravating factors
R - radiation/relieving factors
T - timing
S - severity
Raynaud Phenomenon
- PAD
- episodic vasospasm (ischemia) in arteries and arterioles of the fingers, less commonly in the toes
- is secondary to other systemic diseases or conditions (exposure to cold, pulm htn, smoking, scleroderma)
Raynaud Disease
- PAD
- is a primarily vasospastic disorder of unknown origin
Thromboangniitis obliterans (Buerger disease)
- causes pain, tenderness, and hair loss in the affected area
- symptoms are caused by slow sluggish blood flow
- can often lead to gangrenous lesion
- occurs mainly in young men who smoke
- inflammatory disease of peripheral arteries resulting in nonatherosclerotic lesions (spasm, thrombi, T-cell activation)
- digital, tibial, plantar, ulnar, and palmar arteries
- obliterates the small and medium-sized arteries
PAD Clinical Presentations
- often have no complaints
- intermittent claudication or atypical leg pain (atypical pain usually due to co-morbidities)
- patients may present initially with a threatened limb (critical limb ischemia)
- may have non healing wound/ulcer
- skin discoloration and gangrene
- lack of hair growth on lower limbs
- thickened toenails
- diminished or absent pulses
- bruits in abdominal, femoral, or popliteal area
- pale, cool extremities
- muscular atrophy
- prolonged capillary refill
PAD Diagnostic Tests
- Ankle Brachial Index (ABI)
- Doppler ultrasound
- CBC
- BMP
- C reactive protein (CRP)
- erythrocyte sedimentation rate (ESR)
- X ray (especially if there are wounds [osteomyelitis])
- contrast angiography
Ankle-Brachial Index (ABI)
- used for PAD diagnostics
- a comparison of upper extremity BPs to lower extremity BPs
- looking at vascular health
- <0.9 diagnostic for occlusive arterial disease
- > 1.3 suggests presence of calcified vessels and need for additional testing such as exercise ABI
PAD Treatment
- lifestyle modifications
- stop smoking (smokers have a particularly strong risk of PAD)
- control DM
- control BP
- be physically active (including a supervised exercise program)
- eat a low saturated-fat, low-cholesterol diet
- drug treatment includes medicines to help improve walking distance (cilostazol, pentoxyfyline)
- antiplatelet agents
- cholesterol lowering agents (statins)
- angioplasty or surgery may be necessary
Consultation/Referral for patient with PAD
- refer to vascular surgeon for persistent symptoms or moderate or severe ischemia
- refer if exercise and meds have not helped after 3-6 months (75% of patients will improve on this regimen)
- refer all non healing ulcers
- critical limb ischemia, gangrene, ulceration or pain at rest are present
Complications of PAD
- amputation
- intractable pain
- immobility
- ischemia leads to necrosis leads to gangrene
Orthostatic Hypotension
- decrease in systolic (by 20 mm Hg or more) and diastolic (by 10 mm Hg or more) blood pressure upon standing
- lack of normal blood pressure compensation in response to gravitational changes on the circulation
- 2 types (acute and chronic)
Acute Orthostatic Hypotension
- common in diabetics, blood loss, and elderly
Chronic Orthostatic Hypotension
- primarily seen in older men
Atrial Fibrillation
- supraventricular tachyarrhythmia characterized by rapid uncontrolled uncoordinated atrial activation with deterioration of atrial mechanical function
- can reduce cardiac output by as much as 30%; blood can pool in the atrium, causing a clot in the left atrial appendage
- increases the risk of ischemic stroke fivefold
- up to 25% of all strokes in older adult population occur secondary to Afib
Types of Atrial Fibrillation
- paroxysmal
- persistent
- longstanding persistent
- permanent
- nonvalvular
Paroxysmal A fib
AF ends spontaneously or after intervention within 7 days of onset
Persistent A fib
AF continues for more than 7 days
Longstanding Persistent A fib
continuous A fib for more than 12 months
Permanent A fib
AF when no longer attempting to restore or maintain sinus rhythm
Nonvalvular A fib
AF in the absence of rheumatic mitral stenosis, heart valve replacement, or mitral valve repair
A-Fib Risk Factors
- increasing age
- hypertension
- DM
- vascular disease
- smoking
- inactivity
- hyperthyroidism
- heart failure or left ventricular hypertrophy (LVH)
- obesity
- obstructive sleep apnea
- genetic variants (fam hx, euro descent)
- cardiothoracic surgery
- valvular heart disease (VHD)
- increased pulse pressure
- LVH on EKG
- enlarged left atrium (LA), increased thickness of LV wall, decreased LV fractional shortening on echocardiogram
- increased CRP or BNP
** Reversible causes include pulmonary embolism, caffeine intake, alcohol, fevers, and infectious origin
Assessment Findings for Afib
- irregular or rapid heart tones
- irregular peripheral pulses
- subjective symptoms include unusual heartbeats (racing, fluttering, palpitations), shortness of breath, lightheadedness
- hypotension (due to poor blood perfusion)
- elevated jugular venous pressure (blood is pooling, so there is backflow)
