Cardiology #2 Hypertension & Shock Flashcards
What is hypertension defined as?
What is considered Stage 1 and what is considered Stage 2?
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+
What is the MCC of primary hypertension?
MCC of secondary hypertension? How about other secondary causes?
Primary: Idiopathic
Secondary: renovascular
-Others: Cushing’s, Hyperthyroidism, Etoh, OCP, Sleep apnea, Pheochromocytoma, Coarctation of Aorta
What are some symptoms of hypertension in general?
Most patients asymptomatic
-However, can have vision changes, chest pain, abdominal bruit, headache
When should you suspect secondary hypertension as a cause?
Explain the pathophysiology of renal artery stenosis in causing hypertension.
-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
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?
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
Initial treatment for hypertension
Lifestyle changes: weight loss, salt restriction, limit alcohol, DASH diet
Sodium: < 2.4g/day
Aerobic exercise and resistance training
First line medication options for everyone but AA
Medications for AA
Many patients need combinations of medications
-For non-AA: Thiazides, ACE, CCB, ARB
-In AA: Thiazides or CCB are first line
What medications for hypertension should you use if the patient has the following comorbidities?
-DM
-BPH
-Gout
-HF
-Post MI
-A-Fib
-Depression
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
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?
Add a 2nd class
ACE and an ARB together should NOT be done
In Pregnancy, what drugs should you use for hypertension?
Labetolol, Hydralazine, Nifedipine, Methyldopa
Medication Facts: Diuretics
-Drug Names
-MOA
-Adverse Effects
-Hydrochlorothiazide, Chlorthalidone
MOA: Prevent kidney Na+/H20 reabsorption at the distal diluting tubule
Adverse Effects: hyponatremia, hypokalemia, hyperuricemia, hyperglycemia
Medication Facts: Loop Diuretics
-Drug Names
-MOA
-Adverse Effects
-Furosemide, Bumetanide
MOA: Inhibit water transport across Loop of Henle –> increasing excretion of water, Cl, Na, K
Adverse Effects: hypokalemia, hyponatremia, ototoxicity, hyperlipidemia
Medication Facts: ACE Inhibitors
-Drug Names
-MOA
-Adverse Effects
(-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
Medications Facts: Angiotensin Receptor Blocker (ARB)
-Drug Names
-MOA
-Adverse Effects
(-sartan)
Like ACE, blocks ARB receptor, no effect on bradykinin
Adverse Effects: hyperkalemia
DO NOT USE IF PREGNANT
Medication Facts: CCB
-Drug Names
-MOA
-Adverse Effects
Which are dihydropines and which are non-dihydropines?
(-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
Medication Facts: Beta Blockers
-Drug Names
-MOA
-Adverse Effects
(-lol)
Blocks renin release
Adverse Effects: fatigue, depression, impotence, use with caution in DM
Medication Facts: Alpha-Blockers
-Drug Names
-MOA
-Adverse Effects
(-zosin)
Alpha blockage leads to peripheral artery dilation
Adverse Effects: 1st dose syncope, dizziness, headache, weakness
What is hypertensive urgency and what are the symptoms?
- SBP > 180 and/or DBP > 120 with no signs of end organ damage
-Symptoms: headache, dizziness, dyspnea, chest pain, AMS, seizures
Management for hypertensive urgency (hypertensive crisis)
-Gradual reduction of MAP by 25% over 24-48 hours with oral medications (Clonidine, Captopril, Furosemide, Labetalol, Nicardipine)
What is hypertensive emergency and what are examples of end organ damage?
SBP > 180 and/or DBP > 120 with evidence of end organ damage
End organ damage symptoms
-Headache (MC)
-AMS, seizures
-Retinopathy
-Proteinuria
-Renal Disease
Management for hypertensive emergency (malignant hypertension)
-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
Shock is defined as….
What is it determined by (two things)?
Inadequate oxygen to tissues and perfusion
Low cardiac output or low systemic vascular resistance
What is obstructive shock? Name some etiologies
Obstruction of blood flow due to physical obstruction of heart or great vessels
Massive PE, Pericardial tamponade, tension pneumothorax, aortic dissection
What is the treatment for obstructive shock?
Oxygen, isotonic fluids, inotropic support (dobutamine, epinephrine, balloon pump)
What is the pathophysiology of cardiogenic shock?
Name some etiologies of this condition
-Myocardial dysfunction –> inadequate tissue perfusion –> decreased CO and increased SVR
Cardiac disease: MI, CHD, cardiomyopathy, myocarditis, valve dysfunction
What is the treatment for cardiogenic shock (how does it differ from the other types of shock treatment?)
-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
What is hypovolemic shock?
Name some etiologies of this condition.
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)
Explain the pathophysiology of hypovolemic shock
Name some symptoms of this condition
-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
Management for hypovolemic shock
-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
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
Excess vasodilation and altered distribution of blood flow with shunting of blood from vital organs to non-vital tissues
Septic Shock (Warm Shock) has symptoms such as…
This is the ONLY type of shock with what
-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)
Treatment for septic shock
-ABX
-Fluids IV (Isotonic crystalloids)
-Vasopressors +/- Hydrocortisone
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?
Epinephrine
-Airway management
-Antihistamines
-IVF
How long should you observe a patient with anaphylactic shock and why?
For 4-6 hours due to biphasic phenomenon in 3-4 hours
Endocrine shock occurs due to adrenal insufficiency. What is the treatment?
Hydrocortisone 100mg IV
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:
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
Therefore, what lab should be ordered when you suspect shock
Lactic acid, it will be high for the reason above
General treatment for shock
-ABCDE
Airway
Breathing (mechanical ventilation and sedation)
Circulation (normal saline/LR)
Delivery of oxygen: lactate levels
Endpoint of Resuscitation: urine output, MAP, oxygen concentration
What is postural (orthostatic) hypotension (definition)?
What are some etiologies of this condition?
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)
What is one specific test that can be done for orthostatic hypotension?
You should order labs to evaluate for what as well?
Tilt Table Test: BP decreases at 60’ angle
Dehydration
Management for orthostatic hypotension?
-Initial: Conservative (Increase Na, fluid intake), compression stockings, caffeine
-Fludrocortisone (first line)
-Midodrine or Droxidopa (2nd line)
Reflex-Mediated Syncope is the MCC of syncope. What are some triggers?
What is another name for this condition?
Triggers: blood phobia, emotional stress, trauma
Vasovagal Syncope
What is carotid sinus syndrome (syncope?
Syncope with carotid sinus stimulation
-tight collar, shaving, head turning
What are some situations in which situational syncope occurs?
Defecation, sneezing, coughing
What other lifestyle modification should you remember when recommending things a patient can do to lower high blood pressure?
Potassium supplementation has been shown to help
What is one common side effect of CCB’s?
Peripheral or pedal edema
What two drug classes for hypertension should NOT be used together?
ACE + ARB
What drug class for hypertension has been shown to produce AV blocks on ECG’s?
CCB
What drug is BEST used in a hypertensive emergency as an IV agent? Why?
Labetolol
It produces effects quicker
What is the MOA of ACE inhibitors, specifically, how does it act on the kidneys?
Blocks conversion of angiotensin I to angiotensin II, which results in decreased renal blood flow
What drug class for hypertension has been shown to increase mineral bone mass and help with osteoporosis?
Thiazide diuretics (Hctz, Chlorthalidone)
When should screening for hypertension begin in a normal, healthy adult?
at 18 years old
