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Cardio > Determine HTN > Flashcards

Determine HTN Flashcards

1
Q

-Arterioles are thin-layer vessels
-Compared to veins arteries have a larger layer of smooth muscle as well as a larger dense outer layer.

A

Pertinent Anatomy HTN

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2
Q

Maintenance of _________ pressure is essential for organ perfusion and nutrients.

A

arterial blood

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3
Q

(1) Have the patient relax for>5 minutes without having them talk
(2) patient’s arm at the level of their heart.
(3) appropriately sized cuff
(4) Use either the diaphragm or the bell for auscultation listening over the brachial artery.
(5) Inflate the cuff 20-30 mm Hg above the level where the auscultatory sound disappears.
(6) Deflate the cuff pressure to 2 mm Hg per second and listen for the Korotkoff sounds to appear

A

How to appropriately measure blood pressure

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4
Q

SBP: 120-129
DBP: < 80

A

Elevated BP

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5
Q

SBP: 130-139
DBP: 80-89

A

Stage I
Hypertension

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6
Q

SBP: ≥140
DBP: ≥ 90

A

Stage II
Hypertension

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7
Q

(a) Sympathetic hyperactivity, abnormal cardiovascular development, renin-angiotensin, and/or defects in natriuresis (sodium)
(b) Exacerbated by smoking, obesity, and/or excessive alcohol intake.

A

A mix of genetic and environmental factors:

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8
Q

(1) Renal Disease
(2) Renal Artery Stenosis
(3) Pregnancy
(4) Pheochromocytoma (tumor)
(5) Cushing Syndrome
(6) Hyperthyroidism
(7) Estrogen Use
(8) Drug-Induced

A

Secondary hypertension has an identifiable cause.

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9
Q

(1) Essential hypertension is usually asymptomatic.
(2) Blood pressure will be elevated on 3 or more separate occasions.
(3) In patients with long term uncontrolled HTN.
(a) Can have displaced PMI.
(b) Can hear mitral valve murmurs
(c) Can hear S4

A

Physical Findings: HTN

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10
Q

As the LV has to pump against such high Aortic pressures, the mitral valve starts having all that force upon it, which can lead to insufficiency. What sound is this?

A

mitral valve murmurs

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11
Q

This is a low-frequency sound so best heard with the bell. It
occurs just before S1 when the atria contract to force blood into the left ventricle. If the LV is non-compliant (thickened for example), the atrial contraction forces blood through the atrioventricular valves, and an _______ is produced by the blood striking the left ventricle. What sound is this?

A

S4

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12
Q

Lab/Imaging: HTN

A

To evaluate new diagnoses of HTN (looking specifically for evidence of end-organ damage or comorbidities).

(a) Fasting glucose
(b) UA for proteinuria, hematuria, casts
(c) CBC
(d) Chemistry
(e) TSH
(f) Lipid panel
(g) EKG
(h) Calculate 10-year atherosclerotic cardiovascular disease risk (if over age 40).

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13
Q

Assessment: HCL

A

Patients must have elevated blood pressure recordings on 3-5 separate visits.

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14
Q

(1) Lifestyle modifications: Yields modest results
(a) Diets rich in fruits and vegetables and low in saturated fats
(b) Weight reduction (10 kg can lower SBP 5-20 mm Hg)
(c) Reduced alcohol consumption
(d) Increase in physical activity
(f) Medications

A

Treatment: HCL

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15
Q

Goal BP for most pt and diabetes pt

A

< 140/90 in most patients
< 130/80 in patients with diabetes or kidney disease

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16
Q

(a) Diuretics (First line):
Hydrochlorothiazide (HCTZ)
- 12.5-25 mg daily and can titrate to a maximum of 50 mg
-Syncoped association

(b) Angiotensin Converting Enzyme Inhibitors (ACEi) (First Line)
–pril
- work well in younger white patients and are less effective in black patients.
Lisinopril (Prinivil, Zestril), Enalapril (Vasotec), Captopril
- a) Initial dose 5-10 mg daily max 50mg
- cough

(c) Angiotensin Receptor Blockers (ARBs)
- sartan
Losartan (Cozaar): Initial dose 50mg daily max 100mg
- cough

(d) Calcium Channel Blockers (CCB)
1. Diltiazem
- Initial dose 180 mg daily max 360mg
- second or third-degree heart block
2. Amlodipine (Norvasc) 2.5 mg daily max 10mg

(e) Alpha Blockers
Terazosin: 1 mg once daily; 20 mg daily in 1 or 2 divided doses.

A

Pharmacological: HCL

17
Q

Pt taking AntiHTN should manage and f/u:

A
  • should be taking their blood pressure at home at least 3 times per week and keeping a log of their readings
  • re-evaluate them 1 month after any medication change, usually, give it 3 months before adjusting doses of medication.
18
Q

(1) Referral to MO to work up accompanying cardiovascular disease or 2nd hypertension on discovery and have had 3-5 readings that qualify as HTN.
(2) You may renew the medication if they are well controlled. Need to document each visit any side effects of medication and any symptoms or signs of end-organ damage.
(3) Should have blood work (chemistry) every year to evaluate for kidney dysfunction.

A

Initial Care for HTN as an IDC:*

19
Q

(1) This arises due to sustained elevations of BP with consequent structural changes in the heart and vasculature.
(2) Cardiovascular disease: CAD, CHF, LVH
(3) Renal: Chronic renal failure
(4) Aortic dissection
(5) Cerebrovascular disease: Ischemic and hemorrhagic stroke, dementia, and Alzheimer’s.
(6) Peripheral vascular disease
(7) Eyes: Retinal damage, hemorrhage

A

Complications: HTN*

20
Q

(a) SBP > 220 mm Hg or DBP > 125 mm Hg

(b) +/- optic disk edema, progressive target organ complications.

(c) NO SIGNS OF END ORGAN DAMAGE (nephropathy,
encephalopathy, etc.)

(d) Blood pressure must be reduced within a few hours.

A

Hypertensive Urgency

21
Q

(a) Blood pressure is usually strikingly elevated DBP > 130 mm Hg, but the correlation between pressure and end-organ damage is poor.

(b) SIGNS OF END ORGAN DAMAGE is occurring:

A

Hypertensive Emergency

22
Q

1) Hypertensive **[brain] encephalopathy (mental status changes,
confusion, headache).
2) Intracranial hemorrhage
3) Ischemic stroke
4) **Hypertensive nephropathy (proteinuria, hematuria, and progressive kidney dysfunction).
5) Unstable angina, AMI, CHF, or Aortic dissection.
(8) Secondary causes of HTN
(9) Pre-eclampsia
(10) Heavy alcohol use

NOTE: theses are usually acute and they look sick

A

SIGNS OF END ORGAN DAMAGE is occurring:

23
Q

-Signs of end organ damage
(stroke, CHF, acute kidney injury, AMI, pulmonary edema, aortic dissection, papillary edema, retinal hemorrhage).

-Neurological examination for deficits, mental status changes, changes in vision, headache, nausea/vomiting.

-Cardio/Pulmonary exam looking for signs of heart failure (S3, new murmurs), auscultate for carotid bruits, pulmonary edema (rales, crackles), complaints of sudden onset SOB, chest pain.

-Fundoscopic examination looking for papilledema or hemorrhage.

A

Physical Findings: Hypertensive Emergency

24
Q

(1) UA looking for proteinuria or hematuria.
(2) Comprehensive metabolic panel looking for renal or liver dysfunction.
(3) Troponins is looking for signs of myocardial injury.
(4) EKG looking for signs of AMI.
(5) CXR looking for widened mediastinum (aortic dissection) or pulmonary
edema.
(6) CT Head or Aorta if indicated.

A

Labs/Imaging - Remember you are looking for signs of end organ damage:

25
Q

Labs signs of end organ damage: UA looking for

A

proteinuria or hematuria.

26
Q

Labs signs of end organ damage: CMP looking for

A

renal or liver dysfunction.

27
Q

Labs signs of end organ damage: Troponins looking for

A

signs of myocardial injury.

28
Q

Labs signs of end organ damage: EKG looking for

A

signs of acute myocardial injury.

29
Q

Labs signs of end organ damage: CXR looking for

A

widened mediastinum (aortic dissection) or pulmonary edema.

30
Q

If there are signs of end organ damage: what is indicated?

A

CT Head or Aorta

31
Q

Use PO medications to reduce DBP < 110 over 24 hours.

(b) If the patient is already on an antihypertensive agent, re-initiate it (E.g. if patient on HCTZ, give HCTZ 25 mg PO x one, then restart HCTZ at
the previous dose. If dose is unknown, give HCTZ 25 mg PO.

(c) If the patient is not on an anti-hypertensive agent, initiate oral alpha-blocker or beta- blocker (Clonidine or Labetalol is typically used first line).

A

Treatment
Hypertensive Urgency:

32
Q

Alpha Blocker
- Clonidine (primary treatment for hypertensive urgency)
a) Initial dose: 0.1 - 0.2 mg orally, then 0.1 mg orally every hour 0.8 mg orally.

Beta Blocker Medications
Beta 1 selective blockers:
- Metoprolol (Lopressor).- Initial dose 50 mg twice daily, titrate up to 200 mg daily.
Non-selective Beta Blockers
- Labetalol (Trandate)- Starting dose 100mg twice daily, titrate up to max dose of 1200mg

A

Hypertensive Urgency: Medication

33
Q

(a) ***Need to establish IV (GOLD STANDARD), Oxygen if saturation < 94%, monitor with telemetry.

(b) Goal is to reduce BP by 25% within 1-2 hours, then slowly decrease to 160/100 in the next 24 hours.

(c) After the first 25%, you want to go slowly as excessive reductions in BP may precipitate renal, cerebral, or coronary ischemia due to those vessels used to seeing high perfusion pressures.

(d) ***Start treatment with LABETALOL 20 mg IV (over 10 minutes), then 40-80 mg IV q10 min PRN, max 300 mg. Contraindications: Asthma/COPD,
bradycardia.

(e) Once stable, start METOPROLOL 25-50 mg PO twice daily.

(f) You must closely monitor whatever end organ was damaged.

A

Hypertensive Emergency: Medication

34
Q

(1) Initially look for signs of END ORGAN DAMAGE to determine HTN Urgency vs HTN Emergency.

(2) If Hypertensive Urgency, then start PO medication per above.

(3) If Hypertensive Emergency, then start IV medication per above.

(4) You need to stabilize and transfer to a higher level of care/MEDEVAC.

A

Initial Care: Hypertensive Urgency vs Hypertensive Emergency

35
Q

(1) Aortic dissection
(2) AMI
(3) Ischemic Stroke
(4) Hemorrhagic Stroke
(5) Acute kidney injury
(6) Retinal hemorrhage and blindness
(7) CHF with pulmonary edema and acute respiratory failure
(8) Death

A

Complications: Hypertensive Urgency vs Hypertensive Emergency

36
Q

-Signs of end organ damage
(stroke, CHF, acute kidney injury, AMI, pulmonary edema, aortic dissection, papillary edema, retinal hemorrhage).

-Neurological examination for deficits, mental status changes, changes in vision, headache, nausea/vomiting.

-Cardio/Pulmonary exam looking for signs of heart failure (S3, new murmurs), auscultate for carotid bruits, pulmonary edema (rales, crackles), complaints of sudden onset SOB, chest pain.

-Fundoscopic examination looking for papilledema or hemorrhage.

A

Physical Findings: Hypertensive Emergency

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