Cardiovascular Module Flashcards
Hypertension Risk Factors
Age/Gender - Men: Middle age; Women: Post Menopause Race - African Americans Family History Obesity Sedentary Lifestyle Low potassium diet High salt diet Tobacco Use Alcohol Stress
What race is correlated with higher blood pressure?
African American
When do women have a higher risk for HPTN?
Post menopause
When do men have a higher risk of HPTN?
Middle Age
How is a sedentary lifestyle correlated with HPTN?
Indirectly affects BP due to direct effect on weight.
What chronic conditions are HPTN risk factors?
Sleep Apnea - correlated with obesity
Endocrine diseases
Kidney disease- change in response to ADH and Aldosterone
How does the brain affect blood pressure?
The brain controls the adrenergic system.
What hormones affect blood pressure?
Adrenaline
Aldosterone
Angiotensin II
ADH
What are the symptoms of HPTN?
Headache
Fatigue
Dizziness
End Organ Damage
What is the most common way HPTN is discovered?
Screening
How do most patients with HPTN present?
Asympomatic
What are the signs of HPTN?
Usually related to other contributing conditions and/or end organ damage.
Why should we treat HPTN?
Reduce the risk of cardiovascular events.
What cardiovascular events can occur due to HPTN?
Stroke - ischemic or hemorrhagic Myocardial Infarction Peripheral Arterial Disease Congestive Heart Failure Left Ventricular Hypertrophy
What is the effect on the heart with left ventricular hypertrophy?
Heart becomes weaker and the ventricle becomes smaller.
How do you choose a medication?
Co-morbidity Contraindications Compliance Limitation Price Side effects Interactions
At what blood pressure would a patient sees benefits from medication?
> 140/90
According to the seventh national committee (JNC7) what is HPTN?
Elevated blood pressure in 2 or more visits.
Normal <80
Pre-hypertension: Systolic 120-139; Diastolic 80-89
Hypertension: systolic greater than or equal to 140; diastolic greater than or equal to 90
What is stage 1 HPTN?
SBP: 140-159
and/or
DBP: 90-99
What is stage 2 HPTN?
SBP >160
and/or
DBP >100
What is isolated systolic HPTN?
SBP > or equal to 140
DBP less than 90
What is isolated diastolic HPTN?
SBP less than 140
DBP > or equal to 90
What is optimal blood pressure?
SBP < 80
What is normal blood pressure?
SBP 120-129
DBP 80-84
What is high normal blood pressure?
SBP 130-139
DBP 85-89
What should be considered in a hypertensive patient with kidney disease?
More aggressive therapy and goals.
Ideally keep BP below 130/80
When should you consider starting a second medication for HPTN?
If BP is 20S/10D points higher from the target.
What are some calcium channel blockers?
Verapamil
Diltiazem
Amlodipine
What are side effects of calcium channel blockers?
Leg Edema- Dose dependent
Cancer?
What is long-acting Amlodipine used for?
Angina in COPD
What effect does Amlodipine have?
Vasodilator
What do Verapamil and Diltiazem do?
Effect heart rate
What negative impact can Verapamil and Diltiazem have?
Can worsen CHF
Is it beneficial to treat low risk patients?
Results unclear
What is the target BP for the elderly?
Variable
What work up should be done in those with HPTN?
EKG UA Renal Function Electrolytes Glucose CBC Lipid Panel ECHO
What drugs are superior in CAD?
Beta Blockers
What are some non-pharmacological approaches to HPTN?
Low sodium diet
Weight loss
Decrease alcohol intake
Aerobic exercise
What should be looked for in a UA with HPTN?
Protein in the urine
What are the top 4 medications for treating HPTN?
Diuretics (Thiazides)
Calcium channel blockers
Beta blockers
ACE Inhibitors/ Angiotensin Receptor Blockers
What medication is often used as an “add-on” for HPTN?
alpha blockers
What medication is inferior in protecting against stroke?
Beta blockers
What medication is often used in atrial fibrillation or CHF?
Beta blockers
What effect do beta-blockers have on migraines?
None
What are side effects of beta blockers?
Impaired glucose
Fatigue
Worsening COPD
Younger males - sexual dysfunction
What medication for HPTN is better after a heart attack?
Beta blockers
What are the types of beta blockers?
Selective
Non Selective
What are the thiazide medications?
Hydrochlorthiazide Chlorthalidone (longer hours 24-72)
What are common side effects of thiazides?
Hypokalemia
Glucose Intolerance
Hyperuricemia
Lipid disorder
What medications do not work in renal failure?
Thiazides
What is the most common dose for thiazides?
25 mg
Dose ranges from 6.5-50 mg
What are alpha 1 blockers used for?
Enlarged prostate symptoms
What are alpha 2 blockers used for?
Used in VERY high blood pressure
What are the side effects of alpha-1 blockers?
Dizziness
Orthostatic changes
What are the side effects of alpha 2 blockers?
Sedation
Fatigue
Depression
*Hypertensive rebound effect when medication is stopped
What are ACE inhibitors/ ARBs used for?
CHF
MI
Proteinuria
DM
What drug is highly contraindicated in pregnancy?
ACE I / ARB
What drugs for HPTN are #1 used in diabetics?
ACE I / ARB
What are the side effects of ACE I/ ARB?
*Dry cough
Hyperkalemia
Renal Failure
Where to ACE I’s work?
Stop conversion of Angiotensin I to Angiotensin II to stop binding with the AT1 receptor preventing vasoconstriction.
Where to ARBs work?
Block AT1 receptor which prevents vasoconstriction
What are the components of arterial pressure?
Cardiac Output and Peripheral Resistance
What are determines cardiac output?
Stroke Volume and Heart Rate
What determines stroke volume?
Myocardial contractility and Size of the vascular compartment
What determines peripheral resistance?
Vascular structure and function
What happens to the elasticity of blood vessels with age?
Elasticity decreases
What is the effect on blood pressure of increased myocardial contractility?
Increased Blood Pressure
What is the effect on blood pressure of decreased myocardial contractility?
Decreased blood pressure
What medications are used sparingly in hypertensive patients?
Hydralazine
A-Methyl Dopa
Minoxidil
What HPTN medications work on the CNS?
Beta Blockers
Alpha 2 Agonists
What HPTN medications work on the blood vessels?
Alpha 1 Receptor Blockers Calcium Channel Blockers Vasodilators AT1 Receptor Antagonists ACE Inhibitors
What HPTN medications work on the kidneys?
Diuretics
Beta Blockers
ACE Inhibitors
What HPTN medications do African Americans respond well to?
Diuretics and Calcium Channel Blockers
What HPTN medications do African Americans respond poorly to
ACE I and ARBs
What HPTN medications have dose-dependent side effects?
Beta Blockers
Calcium Channel Blockers
Should you look for a reason for secondary HPTN?
In general- looking for a reason has little value and is not cost effective unless there are clues suggestive for secondary causes.
When do you treat secondary HPTN?
Severe or resistant to treat.
Acute Rise.
Age <30, non-obese, no family history, no other risk factors.
Malignant or accelerated with end organ damage.
What work up should be performed for secondary hypertension?
Renal Imaging Plasma rennin activity Plasma and Urine Catecholamines MRA, duplex US CTA
What is the most common cause of secondary HPTN?
Renal Artery Stenosis
What is the most underestimated cause of secondary HPTN?
Sleep Apnea
What are the causes of secondary HPTN?
Genetics Abdominal bruits Primary Hyperaldosteronism Phenochromocytoma Cushing's Syndrome Sleep Apnea Coaractation of the Aorta (evidenced by radial-femoral delay; check pulse in lower limbs) Medications
What is hypertensive urgency?
SBP Greater than or Equal to 180
DBP Greater than or Equal to 120
What symptoms are seen in hypertensive urgency?
No symptoms or just a headache
What are the common causes of hypertensive urgency?
Not taking medications
Too much salt
What is the goal in treating hypertensive urgency?
Gradual reduction to safer level - 160/100
How do you treat hypertensive urgency?
Rest Reduce anxiety Restart medications Add or increase dose Decrease salt Send home with follow up in a few days
What is a hypertensive emergency?
End Organ Damage
SBP greater than or equal to 180
DBP greater than or equal to 120
What are signs of a hypertensive emergency?
Encephalopathy Retinal Hemorrhage Papiledema Acute Renal Failure Chest Pain EKG Changes
How do you treat a hypertensive emergency?
*Nitroprusside Nitroglycerine Labetalol Nicardipine Clevidipine Hydralazine Enalaprilat
Which medication is the most rapid and has the most potent duration of action?
Nitropusside
2-5 minutes
Important in hypotension
What is a side effect of Nitroprusside?
Cyanide Toxicity >24 hours or with renal failure.
Why do you want to avoid over reduction of blood pressure in stroke?
You must avoid ischemia to the surrounding healthy areas.
What should be considered in management of acute pulmonary edema?
Consider nitroglycerine and diuretics; avoid Labetalol which could affect contractility.
What management considerations are necessary for aortic dissection?
Nitroprusside should only be used after controlling the heart rate with a beta blocker.
What should not be used in acute increases in sympathetic activity caused by pheochromocytoma or cocaine?
Beta Blocker alone- will have alpha adrenergic unopposed and this will raise BP.
What should be used in acute increases in sympathetic activity caused by pheochromocytoma or cocaine?
Nitroprusside
Phetolamine (alpha adrenergic blocker)
What causes orthostatic hypotension?
Autonomic reflexes are impaired or intravascular volume is depleted.
What are risk factors for orthostatic hypotension?
Elderly Medications Diabetic Neuropathy Autonomic Dysfunction Parkinsons Pareneoplastic Familial
What is orthostatic hypotension similar to?
Aortic Stenosis
Arrhythmia
Postural Tachycardia Syndrome
Postprandial Hypotension
What are symptoms of orthostatic hypotension?
Dizziness
Weakness
Syncope
How is orthostatic hypotension diagnosed?
Fall of 20 systolic or 10 diastolic 2-5 minutes in supine position.
What does an increase in heart rate of greater than 30 BPM suggest?
Postural Tachycaridia Syndrome
What is the work up for orthostatic hypotension?
CBC
Renal Function
Glucose
What is the treatment for orthostatic hypotension?
Avoid/treat primary reason Fluids Arise slowly Avoid long standing Avoid coughing, hot weather, straining Wear elastic stocking extended to the waist Tense the legs
Increase salt and water consumption
Avoid large meals
What medications are used to treat orthostatic hypotension?
Fludrocortisone
Midodrine alpha1 adrenergic
Caffeine
What are the risk factors of coronary artery disease?
Smoking Dyslipidemia Hypertension Diabetes Abdominal obesity Psychosocial factors Physical activity Family History Age Gender Collagen Vascular Disease Infections! Sleep apnea Homocystiene Cocaine Methamphetamine Takotsubo stress cardiomyopathy Anemia Arrhythmia Hypoxia
What are the symptoms of an MI?
Chest Pain SOB GI Diaphoresis Dizziness Fatigue Sudden Death
What are signs of an MI?
Sweating Increased heart rate Change in blood pressure New murmurs/ heart sounds Chest congestion Irregular heart beat
What diagnostics are performed on someone with CAD?
EKG Cardiac Enzymes CXR CBC Renal Function Electrolytes Transthoracic Echo Stress Test/ coronary angiogram
What are appropriate questions to ask about a patient’s chest pain?
Location Radiation Quality Duration Response to medication Provoking factors Timing
What is the pathophysiology of an aortic dissection?
A tear in the aortic intema which could involve branch vessels, the aortic valve, or could enter the pericardial space.
What can aortic dissection cause?
Ischemia
Aortic regurgitation
Cardiac Tamponade
Who is most likely to get aortic dissection?
Mostly men aged 60-80.
What is the most predisposing factor for aortic dissection?
Hypertension
What are risk factors for aortic dissection?
Hypertension Inflammatory changes such as vasculitis, Giant Cell Arterities, Takayasu, Syphilitic Aortis, RA Marfan Syndrome Ehler-Danlos Syndrome Aortic coarctation Turner Syndrome CABG Cardiac catheterization High Intesnsity Weight Lifting
What are the signs and symptoms of aortic dissection?
Severe sharp or tearing chest pain Syncope CVA Myocardial Infarction Painless in cases like DM Patients are usually hypertensive but not always.
How is aortic dissection diagnosed?
CXR Ct scan MRI Aortogram TTE
How is a Type A aortic dissection treated?
Surgically
What is a Type A aortic dissection?
An aortic dissection which occurring in the ascending aorta.
What is a Type B aortic dissection?
An aortic dissection occurring in the descending aorta.
How is a Type B aortic dissection treated?
Medically
What is peripheral vascular disease?
Accumulation of lipid and fibers in the intimal and medial layers of the vessel.
What are the risk factors of PVD?
Age >50 DM Smoking Men Family History HTN Hyperlipidemia Homocysteinemia Metabolic Syndrome
What are the symptoms of PVD?
Claudication Diminished pulses Tissue loss Ulcer gangrene Limb threatening ischemia Erectile dysfunction (common iliac disease) Bruit, pale, ulcer, loss of hair Nerve involvement
What imaging should be ordered for PVD?
CTA
MRA
Angiogram
How is PVD managed?
Smoking
Risk Factors
Exercise
Phosphodiesterase inhibitors
How is PVD treated?
Angioplasty
Stent
Bypass graft - Aorto-femoral or axillo-femoral
What is the ankle-brachial index?
The blood pressure difference between the ankle and the brachial artery.
What ankle-brachial difference may indicate PVD?
<0.9
What is a normal Ankle-Brachial Index?
1-1.2
What are the symptoms of acute PVD?
Embolus or Thrombosis Pain Low Pulse Numbness Pallor especially on elevation Cool limb Acidosis
How is acute PVD treated?
QUICKLY!! Irreversible damage occurs >3 hours Heparin TPA Catheter based
What causes chronic venous insufficiency?
Trauma
DVT
Obstruction
What are the symptoms of chronic venous insufficiency?
Edema
Dull Pain
Skin Changes
Ulcers
What causes superficial thrombophlebitis?
Intravenous catheters
Trauma
Pregnancy
What are the symptoms of superficial thrombophlebitis?
Pain
Redness
Tenderness
Tends to improve in 1-2 weeks
How is superficial thrombophlebitis treated?
Head
NSAID
Anticoagulation
ABX with infection
What causes deep vein thrombosis?
Cancer Immobilization Coagulopathy Birth Control Major surgery
What are the symptoms of DVT?
Pain
Swelling
Redness
Pulmonary Embolism
What is Virchow’s Triad?
The three factors leading to thrombosis:
venous stasis
vessel wall injury
altered blood coagulation
How is a thrombus formed where there is no inflammation?
through phlebothrombosis
What leads to a thrombus formation where inflammation is present?
The thrombus would cause inflammation of the vein walls or what we call thrombophlebitis. This will eventually lead to thrombus formation.
What is Virchow’s Triad?
Stasis
Hypercoagulability
Intimal Change
What are venous thrombi?
Accumulation of platelets in response to inflammation which attach to the vein wall adn contain a tail-like attachment made of WBCs, RBCs, and fibrin.
How do you diagnose a DVT?
Duplex US
D-Dimer
Venogram
Serial US
How is a DVT treated?
Anticoagulation
Thrombolysis
Greenfield Filter
When is a Greenfield Filter used?
when anticoagulation therapy is contraindicated
