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Pance Re-Up > Cardiology #2 Hypertension & Shock > Flashcards

Cardiology #2 Hypertension & Shock Flashcards

1
Q

What is hypertension defined as?

What is considered Stage 1 and what is considered Stage 2?

A

Systolic BP > 130 and/or diastolic BP > 80 on two different occasions

Stage 1: SBP 130-139 or DBP 80-89
Stage 2: SBP 140+ or DBP 90+

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2
Q

What is the MCC of primary hypertension?

MCC of secondary hypertension? How about other secondary causes?

A

Primary: Idiopathic

Secondary: renovascular
-Others: Cushing’s, Hyperthyroidism, Etoh, OCP, Sleep apnea, Pheochromocytoma, Coarctation of Aorta

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3
Q

What are some symptoms of hypertension in general?

A

Most patients asymptomatic
-However, can have vision changes, chest pain, abdominal bruit, headache

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4
Q

When should you suspect secondary hypertension as a cause?

Explain the pathophysiology of renal artery stenosis in causing hypertension.

A

-Abrupt onset, age < 30, uncontrolled on 3 or more meds, excessive end organ damage

-narrowing of the renal arteries causes hormones to be pumped out (renin) to help –> hypertension

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5
Q

What is one common symptom of renal artery stenosis?

What diagnostics are done for this condition?

What medication class should you use if the rental artery stenosis is unilateral, and why should you NOT use it if bilateral?

A

Renal artery bruit

US or MRA is used to diagnose this. Renal arteriography is the gold standard but do not use if renal failure present!!!!!

ACE inhibitor if unilateral, but kidney failure is a high risk if bilateral. Instead, do stent or angioplasty

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6
Q

Initial treatment for hypertension

A

Lifestyle changes: weight loss, salt restriction, limit alcohol, DASH diet

Sodium: < 2.4g/day

Aerobic exercise and resistance training

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7
Q

First line medication options for everyone but AA

Medications for AA

Many patients need combinations of medications

A

-For non-AA: Thiazides, ACE, CCB, ARB

-In AA: Thiazides or CCB are first line

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8
Q

What medications for hypertension should you use if the patient has the following comorbidities?
-DM
-BPH
-Gout
-HF
-Post MI
-A-Fib
-Depression

A

DM: ACE or ARB (Slow nepropathy)
BPH: Alpha-Blockers (-Zosins)
Gout: CCB
HF: ACEi, Diuretics
Post MI: BB
A-Fib: BB, CCB
Depression: No BB

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9
Q

Is it more efficacious to add a 2nd drug class or increase dose of the first hypertension medication?

What two classes should NOT be used together?

A

Add a 2nd class

ACE and an ARB together should NOT be done

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10
Q

In Pregnancy, what drugs should you use for hypertension?

A

Labetolol, Hydralazine, Nifedipine, Methyldopa

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11
Q

Medication Facts: Diuretics

-Drug Names
-MOA
-Adverse Effects

A

-Hydrochlorothiazide, Chlorthalidone

MOA: Prevent kidney Na+/H20 reabsorption at the distal diluting tubule

Adverse Effects: hyponatremia, hypokalemia, hyperuricemia, hyperglycemia

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12
Q

Medication Facts: Loop Diuretics

-Drug Names
-MOA
-Adverse Effects

A

-Furosemide, Bumetanide

MOA: Inhibit water transport across Loop of Henle –> increasing excretion of water, Cl, Na, K

Adverse Effects: hypokalemia, hyponatremia, ototoxicity, hyperlipidemia

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13
Q

Medication Facts: ACE Inhibitors

-Drug Names
-MOA
-Adverse Effects

A

(-pril)

Synergistic if used with thiazides, decreases preload and after load. Increases bradykinin.

Adverse Effects: Cough, Hyperuricemia, hyperkalemia, Angioedema, 1st dose hypertension

DO NOT USE IF PREGNANT

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14
Q

Medications Facts: Angiotensin Receptor Blocker (ARB)

-Drug Names
-MOA
-Adverse Effects

A

(-sartan)

Like ACE, blocks ARB receptor, no effect on bradykinin

Adverse Effects: hyperkalemia

DO NOT USE IF PREGNANT

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15
Q

Medication Facts: CCB

-Drug Names
-MOA
-Adverse Effects

Which are dihydropines and which are non-dihydropines?

A

(-pine, -mil, -zem)

Dihydropines: (-pine): protect vasodilators, act on systemic vascular vasodilation

Nondihydropines: (-mil, -zem): Effect contractility and conduction. Act selectively on myocardium.

Adverse Effects: headache, flushing, dizziness, peripheral edema

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16
Q

Medication Facts: Beta Blockers

-Drug Names
-MOA
-Adverse Effects

A

(-lol)

Blocks renin release

Adverse Effects: fatigue, depression, impotence, use with caution in DM

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17
Q

Medication Facts: Alpha-Blockers

-Drug Names
-MOA
-Adverse Effects

A

(-zosin)

Alpha blockage leads to peripheral artery dilation

Adverse Effects: 1st dose syncope, dizziness, headache, weakness

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18
Q

What is hypertensive urgency and what are the symptoms?

A
  • SBP > 180 and/or DBP > 120 with no signs of end organ damage

-Symptoms: headache, dizziness, dyspnea, chest pain, AMS, seizures

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19
Q

Management for hypertensive urgency (hypertensive crisis)

A

-Gradual reduction of MAP by 25% over 24-48 hours with oral medications (Clonidine, Captopril, Furosemide, Labetalol, Nicardipine)

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20
Q

What is hypertensive emergency and what are examples of end organ damage?

A

SBP > 180 and/or DBP > 120 with evidence of end organ damage

End organ damage symptoms
-Headache (MC)
-AMS, seizures
-Retinopathy
-Proteinuria
-Renal Disease

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21
Q

Management for hypertensive emergency (malignant hypertension)

A

-Reduce MAP gradually by 10-20% in first hour, then 5-15% over the next 23 hours using IV BP agents

-Use Nitroprusside, Labetalol, Esmolol, Clonidine, Captopril, Nicardipine

Nicardipine or Clevidipine are two neuro symptom meds

22
Q

Shock is defined as….

What is it determined by (two things)?

A

Inadequate oxygen to tissues and perfusion

Low cardiac output or low systemic vascular resistance

23
Q

What is obstructive shock? Name some etiologies

A

Obstruction of blood flow due to physical obstruction of heart or great vessels

Massive PE, Pericardial tamponade, tension pneumothorax, aortic dissection

24
Q

What is the treatment for obstructive shock?

A

Oxygen, isotonic fluids, inotropic support (dobutamine, epinephrine, balloon pump)

25
Q

What is the pathophysiology of cardiogenic shock?

Name some etiologies of this condition

A

-Myocardial dysfunction –> inadequate tissue perfusion –> decreased CO and increased SVR

Cardiac disease: MI, CHD, cardiomyopathy, myocarditis, valve dysfunction

26
Q

What is the treatment for cardiogenic shock (how does it differ from the other types of shock treatment?)

A

-Oxygen, isotonic fluids, inotropic support (Dobutamine, Epinephrine, balloon pump)

Smaller amount of isotonic fluids. The only type that DOESN’T need a high volume of fluid replacement

27
Q

What is hypovolemic shock?

Name some etiologies of this condition.

A

Loss of blood or fluid volume due to hemorrhage or fluid loss

GI bleed, AAA, ectopic pregnancy, trauma, postpartum hemorrhage, vomiting, pancreatitis, burns, DKA
(Hemorrhagic vs Fluid Loss)

28
Q

Explain the pathophysiology of hypovolemic shock

Name some symptoms of this condition

A

-Deceased volume –> increased HR, vasoconstriction (increased SVR), hypotension, decreased CO

-Pale, cool, dry extremities
-Slow capillary refill
-Decreased skin turgor
-Dry mucous membranes
-AMS
-Tachycardia, lethargy
-Decreased urine output
-Confusion

29
Q

Management for hypovolemic shock

A

-Insert 2 large bore IV lines or a central line
-Volume resuscitation: crystalloids (Normale Saline or Lactated Ringers)
-Prevent hypothermia
-RBC transfusion if severe hemorrhage

30
Q

Explain what distributive shock is (its in the name). There are a few types of this, remember them…

Septic Shock
Anaphylactic Shock
Neurogenic Shock
Endocrine Shock

A

Excess vasodilation and altered distribution of blood flow with shunting of blood from vital organs to non-vital tissues

31
Q

Septic Shock (Warm Shock) has symptoms such as…

This is the ONLY type of shock with what

A

-Hypotension with wide pulse pressure
-Bounding peripheral pulses
-Fast capillary refill
-Warm/flushed extremities
-Sepsis: fever/hypothermia, pulse >90, RR > 20, WBC >12,000 or < 4,000 (need 2 of the 4)

-Increased CO (only type)

32
Q

Treatment for septic shock

A

-ABX
-Fluids IV (Isotonic crystalloids)
-Vasopressors +/- Hydrocortisone

33
Q

Anaphylactic shock can occur from bug bites, stings, food allergies. It is an IgE mediated hypersensitivity reaction. What is the first line medication for this type of shock?

A

Epinephrine

-Airway management
-Antihistamines
-IVF

34
Q

How long should you observe a patient with anaphylactic shock and why?

A

For 4-6 hours due to biphasic phenomenon in 3-4 hours

35
Q

Endocrine shock occurs due to adrenal insufficiency. What is the treatment?

A

Hydrocortisone 100mg IV

36
Q

During shock, there is inadequate tissue perfusion. Therefore, _______ is activated to try to improve oxygen delivery. There are a few things that are activated, they are listed below, explain them/why they occur.

Sympathetic System activation:
RAAS System Activation:
Metabolic Acidosis:

A

Autonomic nervous system activation

Sympathetic: causes increased SVR and increased CO to try to maintain heart and cerebral perfusion

RAAS: decreases urine output to lower Na and H20 loss

Metabolic Acidosis: due to lower oxygen so the cells produce lactic acid instead

37
Q

Therefore, what lab should be ordered when you suspect shock

A

Lactic acid, it will be high for the reason above

38
Q

General treatment for shock

A

-ABCDE

Airway
Breathing (mechanical ventilation and sedation)
Circulation (normal saline/LR)
Delivery of oxygen: lactate levels
Endpoint of Resuscitation: urine output, MAP, oxygen concentration

39
Q

What is postural (orthostatic) hypotension (definition)?

What are some etiologies of this condition?

A

Hypotension within 2-5 minutes of standing defined by at least 20 mmHg fall in systolic and/or at least 10mmHg fall in diastolic

Meds: Nitro, Alpha blockers, Ace, Narcotics, Etoh
DM, Parkinsons
Hypovolemia (vomiting, Loop Diuretics)

40
Q

What is one specific test that can be done for orthostatic hypotension?

You should order labs to evaluate for what as well?

A

Tilt Table Test: BP decreases at 60’ angle

Dehydration

40
Q

Management for orthostatic hypotension?

A

-Initial: Conservative (Increase Na, fluid intake), compression stockings, caffeine

-Fludrocortisone (first line)

-Midodrine or Droxidopa (2nd line)

41
Q

Reflex-Mediated Syncope is the MCC of syncope. What are some triggers?

What is another name for this condition?

A

Triggers: blood phobia, emotional stress, trauma

Vasovagal Syncope

42
Q

What is carotid sinus syndrome (syncope?

A

Syncope with carotid sinus stimulation
-tight collar, shaving, head turning

43
Q

What are some situations in which situational syncope occurs?

A

Defecation, sneezing, coughing

44
Q

What other lifestyle modification should you remember when recommending things a patient can do to lower high blood pressure?

A

Potassium supplementation has been shown to help

45
Q

What is one common side effect of CCB’s?

A

Peripheral or pedal edema

46
Q

What two drug classes for hypertension should NOT be used together?

A

ACE + ARB

47
Q

What drug class for hypertension has been shown to produce AV blocks on ECG’s?

A

CCB

48
Q

What drug is BEST used in a hypertensive emergency as an IV agent? Why?

A

Labetolol

It produces effects quicker

49
Q

What is the MOA of ACE inhibitors, specifically, how does it act on the kidneys?

A

Blocks conversion of angiotensin I to angiotensin II, which results in decreased renal blood flow

50
Q

What drug class for hypertension has been shown to increase mineral bone mass and help with osteoporosis?

A

Thiazide diuretics (Hctz, Chlorthalidone)

51
Q

When should screening for hypertension begin in a normal, healthy adult?

A

at 18 years old

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