Exam 1: HTN, ischemic heart, HF, cardiomyopathies Flashcards
what is essential htn
a HTN state without a specific cause
what percent of HTN is essential
95%
what are causes of essential htn
genetics
increases SNS activity to stress
overproduction of sodium retaining hormones and vasoconstricors
what is patho of essential HTN
-high Na intake
-inadequate K and Ca
-increases Renin
-deficient vasodilators (prostaglandins, NO)
-medical diseases like DM and obesity
what are treatments for essential htn
lifestyle modification (alcohol, tobacco, exercise)
pharmacology (ACEI, ARBs, BB, CCBs, Diuretics)
what is BP goal for essential HTN
<140/90
prevents CVA
what are causes of secondary htn
renal artery stenosis, pheochromocytoma, primary aldosteronism
how is secondary HTN corrected
Sx correction (stent or open renal artery stenosis) (remove tumor for pheochromocytoma)
what percent of HTN is secondary
5%
what is the most common cause of secondary HTN
renal artery stenosis
what sound is associated with renal artery stenosis
abdominal bruit
if diastolic BP is above 125 it is likely to be
renal artery stenosis
how can hyperaldosterone be treated
spironolactone in females, amiloride in males
what must be monitored closely in HTN patients
renal function
K
what is the most common serious periop adverse event
CV complication
at what level should we keep patients MAP
20% and close to baseline
what are causes of decreased map intra op
meds
blood loss
what is the def of systemic HTN
BP >130/80 2 times 1-2 weeks apart
what is normal BP
<120/80
what is pre htn
120-139/80-89
what is stage 1 HTN
140-159/90-99
what is stage 2 HTN
> 160/>100
what is htn crisis
systolic >180 and/or diastolic >120
what can HTN crisis lead to?
end-organ damage, strain (ST changes, T wave change), LV hypertrophy, ischemia, atherosclerosis
what are EKG signs of blood pressure issue intraop
ST changes, T wave changes
when do we prescribe BP meds
CV event (heart attack, stroke)
DM
CKD
atherosclerosis
how does systolic BP change with age
increases
how does diastolic BP change with age
increases to peak at 50-59 then decreases
what can systemic HTN lead to
CHF
CVA
arterial aneurysm
end-stage renal
every 20 points above 120 increases disease risk by
2x
what is the most common organ damage from HTN
ischemic heart disease
chronic HTN leads to (complications)
-remodeling of arteries
-endothelial dysfunction
-irreversible end-organ damage
-vasculopathy:
-ischemic heart disease
-LVH
-CHF
-CVD
-stroke
-PVD
-nephropathy
-aortic aneurysm
how do you mitigate HTN risk
early intervention
what is the big problem with HTN
end organ damage
what does essential HTN lead to
ischemic heart disease
angina pectoris
LVH
CHF
Cerebrovascular disease
stroke
PVD
renal insufficiency
what labs do we monitor for HTN
-BUN/Creatinine- renal function
-potassium/electrolytes-meds affects
-blood glucose- 1/2 HTN patients have glucose intolerance
what can and EKG on HTN patients tell us
ischemia
LVH
what do you do if HTN patient has dyspnea of unknown origin
echo
what can angina be caused by
anxiety
acid reflux
esophageal spasm
what should you do if patients BP is 200/115
delay sx until BP is 180/110
do you stop DM drugs for sx
yes
do you stop ACE/ARBS for sx
potentially
do you stop BB for SX
NO
What drug ends in -sartan?
arbs
what drug ends in prils
ACE
do you stop clonidine for sx
no
rebound HTN
why do you not stop BB or clonidine for sx
rebound htn
what also might you continue HTN meds for
end organ damage
what is another use for clonidine
ADHD
if are non medical causes of HTN
cocaine
amphetamines
anabolic steroids
white coat syndrome
what causes white coat syndrome
increased sympathetic response to stress
what is common intra op in htn patients
hypotension, myocardial ischemia
what are signs of sympathetic response in monitor
increased BP, increased HR
how do you treat sympathetic response intra op
increase gas, prop, give ketamine etc
what should you expect if a HTN patient has dizziness and syncope with position changes
cerebrovascular disease
preop htn on a patient with previous MI has a higher incidence of
re infarction
preo-op htn can lead to __________ with those undergoing carotid endartectomy
poorer neurological outcomes
in autoregulation curve, HTN results in a shift to the
RIGHT, meaning they are used to a higher BP and we dont want to drop them too low
how do we manage MAP on a patient who is HTN
keep it higher, closer to baseline. to ensure cerebral perfusion
how does PVD affect arterial line
harder to place
how do HTN med affect autonomic nervous system
impair function
what is an example of anti-HTN impairing autonomic nervous system function
PRE-OP:
orthostatic HTN
INTRA-OP:
profound hypotension with PP ventilation, blood loss, or position change
how do you control peep on a patient on anti-hypertensives
less peep to prevent hypotension
what do you do for hypotension intraop
decrease gas
ephedrine, phenylephrine
fluids, blood
IF NONE OF THESE WORK:
decrease TV
how does a large TV affect a dry patient
increased pulm pressure decreases venous return and thus decreases BP maybe increased HR
when do you cancel a case for HTN?
maybe for diastolic >110
what do you anticipate on induction with pre-op HTN patient
hypotension
what anesthesia technique increases sns stimuli
Direct laryngoscopy, tracheal intubation
how can you blunt SNS response to intubation
gas, propofol, labetalol, LTA, narcs
how long should DL last
15 seconds
T/F video laryngoscopy causes a less of a SNS response with intubation
T, so dont use as much induction drugs/dont rely on response to bring up BP/HR
if you turn up gas what else must you turn up
O2 flow
what drug can be changed to rapidly respond to BP changes
volatiles
if SBP is >170 what responds
baroceptor reflex
what can a large dose of phenylephrine result in
decreased HR from baroceptor response (so give atropine or glyco)
what does peri op HTN increase
blood loss
myocardial ischemia
cerebrovascular events
what other methods can be used to control HTN intraop
volatiles
N2O
opioids
antiHTN by bolus or drip
how do we treat intraop hypotension
decrease volatiles
increase IV fluids
albumin
ephedrine, phenylephrine
what rhythm can result from hypotension
junctional
how do you treat junctional
atropine
what med do you give with neo
robinol
if CO2 drops with no resp changes what will drop next
BP
what is the best way to fix hypotension
fix the cause, see if they are dry and need fluid/albumin
what leads to post op HTN
SNS activity
hypervolemia
what conditions does post op HTN lead to
myocardial ischemia, dysrhythmias, CHF, stroke, bleeding
what can BBs mask under anesthesia
hyperthyroid, hypoglycemia, inadequate anesthesia
what can NMB reversal with anticholinesterase lead to
marked brady (give robinol)
what is a HTN crisis
180/120
how does indigo charmine (sx dye) affect BP? SpO2
increases BP
intermittenly decreases SpO2
what are examples of end organ damage from HTN
encephalopathy
intracerebral hmmg
acute LV failure with pulm edema
unstable angina
acute MI
eclampsia
microangiopathic hemolytic anemia
renal insufficiency
what is the goal of htn emergency
decrease MAP by 20% in first hour then gradually over the next 2-6 hours
what are clinical indicators of HTN
chest crackles
swelling
JVD
when a HTN crisis is associated with encephalopathy what drug do you avoid
hydralazine
what med is a good choice fro myocardial ischemia or cocaine overdose
nitroglycerine
what meds do you avoid in cocaine OD
labetalol, beta blockers (cause coronary vasospasm)
what toxicity does nipride lead to
cyanide toxicity
what do you want to block in pheochromocytoma FIRST
alpha blockade first, beta blocker second
what is the difference between HTN crisis and HTN urgency
HTN urgency doesnt have end organ damage
what are s/s of HTN urgency
HA, epistaxis, anxiety
what are causes of periop HTN
pain, anxiety, hypothermia
what beta blocker has a shorter DOA so is good to test response
esmolol
what beta blockers do you avoid with asthma
non-selective (labetalol)
what beta blockers are safe with asthma
esmolol metoprolol
what is acute postop HTN
increase in SBP more than 20% on admin to PACU
increase DBP above 110
SBP above 190 and or DBP above 100 on two consecutive readings
T/F elevated BP can lead to increased bleeding, bruising, and swelling
true
what are complications of post op HTN
bleeding
dehiscence
MI
dysrhythmias
CHF exacerbation with pulm edema
cerebral mmhg
stroke
TIA
encephalopathy
what are cuases of post of HTN
preexisting
chronic HTN med withdrawal
sx stress
pain
ANS activation
RAAS activation
Emergency delirium/anxiety
shivering
what helps with clonidine withdrawal
precedex
how can you blunt SNS response to intubation
gas, propofol, labetalol, LTA, narcs
what is the most common cause of RV failure
LV failure
in Systolic heart failure_______ is fixed so CO is dependent on ______
SV
HR
how does tachycardia affect CO in systolic HF
increases CO
how does tachycardia affect CO in diastolic HF
decreased CO
how is EF in systolic HF
decreased
how is EF is diastolic HF
preserved
what are s/s LV failure
high LVEDV
dyspnea
orthopnea
Paroxsymal nocturnal dyspnea (sleep apnea)
pulmonary edema
what position do you avoid in LV failure
steep Trendelenburg (heart cant handle increase in venous return)
what are s/s RV failure
peripheral edema
congestive hepatomegaly
RUQ pain
jaundice
increased LFTs
what are causes of RV failure
pulmonary HTN
RV MI
LV failure
what law tells us that increased volume in LV will increase SV
frank-starling
what do we try to avoid/treat in HF
remodeling
what is cardiac remodeling
changes in size, shape, and function of the LV (hypertrophy,dilation)
what causes LV hypertrophy
chronic pressure overload
what causes LV dilation
volume overload
what kind of remodeling causes wall thinning
dilation
what are other forms of remodeling
increased interstitial collagen deposition
myocardial fibrosis
scar formation from myocyte death
if BNP is < 100 HF is __________
unlikely
if BNP is 100-500 HF is __________
intermediate probability
if BNP is >500 HF is __________
diagnosable
T/F ECG has a high predictive value for HF
F, has a low predictive value
what can ECG detect in HF patients
previous MI
conduction abnormalities
dysrhythmias
T/F x-ray is the first indicator of pulmonary edema
F, lags 12 hours behind clinical evidence
what is the most useful test for the diagnosis of HF
ECHO
also tells us EF and ventricle size
if EF is low what kind of monitor do you want with anesthesia
arterial line
what two electrolytes do we monitor with CHF patients. Why?
potassium/magnesium
diuretics
what are s/s of electrolyte abnormalities we may see on monitor
dysrhythmias
what is class 1 HF (minimal)
No limitation of physical activity
no fatigue, dyspnea,palpitations
what is class 2 HF (mild)
Slight limitation of physical activity
comfortable at rest, symptoms occur with ordinary exertion
what is class 3 HF (moderate)
marked limitation of physical activity, comfortable at rest, symptoms occur with less than ordinary exertion
