Exam 4 Hypertension Flashcards
How many people have HTN in the US?
- 100 million people
African Americans are more affected.
Women over the age of _____ will have a greater prevalence of hypertension than men.
- 60 years
Worldwide, hypertension is the leading risk factor for _________ and __________.
- Morbidity
- Mortality
The clinical consequences of chronic ___________have been well characterized and underscore a high age-related association with ischemic heart disease, CVA, renal failure, retinopathy, peripheral vascular disease, and overall mortality.
- Hypertension
In anesthesia, hypertension increases pulse pressure which will lead to ________ and ___________.
- Intraoperative hemodynamic instability
- Adverse post-op outcomes
Definition of Hypertension
- Sustained systolic BP > 130 mm Hg
- Sustained diastolic BP > 80 mm Hg
Definition of Isolated systolic hypertension
- Systolic > 130 mm Hg
- Diastolic < 80 mm Hg
Definition of Isolated diastolic hypertension
- Systolic < 130 mm Hg
- Diastolic > 80 mm Hg
Definition of Combined systolic and
diastolic hypertension
- Systolic > 130 mm Hg
- Diastolic > 80 mm Hg
Normal BP
SBP
DBP
Normal
SBP: <120 mmHg
DBP < 80 mmHg
Elevated BP
SBP
DBP
Elevated BP
SBP: 120-129 mmHg
DBP: < 80 mmHg
Stage 1 Hypertension
SBP
DBP
Stage 1 Hypertension
SBP: 130-139 mmHg
DBP: 80-89 mmHg
Stage 2 Hypertension
SBP
DBP
Stage 2 Hypertension
SBP: >140 mmHg
DBP: > 90 mmHg
Contributing Factors to Primary HTN
- Dysregulation of SNS activity
- Dysregulation of RAAS
- Deficient production of endogenous vasodilators
What receptors regulate our BP and give us acute control of CO, vascular resistance, and blood volume?
- Cardiac Stretch Receptor
- Vascular Baroreceptor
- Peripheral Chemoreceptor
Chronic inflammation will disrupt the _________ and cause autonomic dysfunction leading to hypertension.
- Blood Brain Barrier
Oxidative stress and inflammation within the brain will
* _______SNS output
* increase_________ release
* _________ baroreflex regulation
- ↑ SNS output
- Increase Vasopressin release
- Inhibits baroreflex regulation
RAAS has acute and sustained control over what factors?
- ECF volume
- Peripheral Vascular Resistance
- BP
What is the result of dysregulated renin release?
- Elevated renin levels → ANG II overproduction → Increase aldosterone → HTN
The vascular endothelium produces what vasoactive substances that are major regulators of vascular tone?
- Nitric oxide
- Endothelin
What other vasoactive substances does the vascular endothelium produce that will cause vasodilation and blunt RAAS?
- ANP
- BNP
- CNP
- Urodilatin
What are the results of oxidative stress on the endothelium?
- Impaired endothelial function
- Disruption of natriuretic peptide release or receptor response → HTN
Secondary hypertension has a correctable cause that may be __________ or ____________.
______% of the population has secondary hypertension.
- Age-dependent
- Drug-induced
- 5%
What herbal drugs will cause elevated BP?
- Ephedra
- Ginseng
- Ma Huang
What illicit substance can elevate BP?
- Cocaine
- Meth
Cancel the case if the patient used meth/coke that morning.
70% to 85% of children who develop secondary hypertension is result from what two conditions?
- Renal parenchymal disease
- Coarctation of the aorta
Pathophysiology of chronic hypertension.
- Remodeling of small and large arteries
- Endothelial dysfunction
- Irreversible end-organ damage
HTN will lead to vasculopathy (inflamed/damaged blood vessels). What could result from vasculopathy? (Long List/ Common Sense)
- IHD
- LV hypertrophy
- CHF
- CVA
- PVD
- Aortic aneurysm
- Nephropathy
Resistant hypertension, defined as uncontrolled blood pressure despite ______ or more antihypertensive drugs of different classes,
- 3
__________ Hypertension is defined as 4 or more drugs to achieve BP control.
- Control-resistant
________ Hypertension, defined as uncontrolled blood pressure on 5 or more drugs. This affects 0.5% of the population.
- Refractory
At this point, there may be some drug intolerance or pseudo-resistant HTN
Lifestyle modification for HTN.
- Weight reduction
- Moderation of alcohol intake
- Increased aerobic exercise
- Smoking cessation
- ↑ Dietary intake of K+ and Ca2+
- Salt restriction
ACC/AHA Guidelines:
Pt with what conditions should be placed on BP meds when SBP >130 mmHg and DBP > 80 mmHg.
- IHD
- Cerebrovascular Disease
- CKD
- ↑ Risk of Atherosclerotic CV disease
ACC/AHA Guidelines:
Non-black hypertensive population (w/ or w/o DM) should be placed on what type of BP meds?
- ACE inhibitors
- ARBs
- CCBs
- thiazide-type diuretics
ACC/AHA Guidelines:
Black hypertensive population w/o HF nor CKD (w/ or w/o DM) should initiate treatment w/ what type of BP meds?
- CCB
- thiazide-type diuretics
ACC/AHA Guidelines:
CKD hypertensive patients should be placed on what BP meds?
- ACE inhibitors
- ARBs
First-line antihypertensive therapy
- Diuretics
- CCBs
- ACE inhibitors
- ARBs
When will β-blockers be added to antihypertensive therapy?
- CAD or tachydysrhythmia patients
- Multi-drug therapy in resistant HTN
What are some procedures/surgeries done to treat secondary hypertension?
- Correction of renal artery stenosis
- Direct arterial repair
- Adrenalectomy
Medications for secondary hypertension.
- ACE-inhibitors or in combination with diuretics
Patient with chronic hypertension (180/100) w/ no symptoms: urgent or emergent hypertensive crisis?
- Urgent
Emergent Hypertensive Crisis is usually acute and involves progressive end-organ damage.
Hypertensive Emergencies that may present in the perioperative setting include manifestations of _______ injury, _________ injury, and _________ insult.
- Central nervous system injury
- Kidney injury
- Cardiovascular insult
These need immediate attention and treatment.
Women w/ Pregnancy- Induced HTN (PIH) may show evidence of end-organ dysfunction by showing signs of ____________.
What BP in pregnant patients will require immediate attention and treatment?
- Encephalopathy
- SBP > 160 mmHg and/or DBP >110 mmHG
First-line drug for peripartum hypertension
- Labetalol
Medication to give for Aortic dissection
- β-blocker (esmolol, labetalol) plus arteriolar dilator
What medication will cause rapid arterial dilation and BP reduction?
- Sodium nitroprusside infusion
What is a CCB that is a selective arteriolar vasodilator?
- Clevidipine
This drug has a short half-life, making it very easy to titrate.
_________, is a second-gen dihydropyridine CCB that has a longer half-life and is less titratable than clevidipine.
- Nicardipine
Pre-op evaluation with hypertensive patients.
- Consider the white coat effect
- Evaluate vasculopathy and end-organ functions
- Consider whether to cancel or delay surgery
Surgery is usually canceled if the SBP > 180 mmHg
Antihypertensive meds are continued on the day of the surgery, except what meds?
- High-dose ARBs
- ACE-inhibitors
These drugs will lead to profound hypotension with anesthesia.
Induction consideration with hypertensive patients.
- Consider the drop in BP w/ the induction agent and gas
- Consider the increase in BP during intubation
- Consider A-line placement
- Consider transient β-blockade w/ esmolol
- Check for volume depletion
Peri-operative considerations
What does hypertension increase?
- Increase Blood loss
- Increase in Incidence of MI
- Increase cerebrovascular events
Hypertensive Patient Peri-operative Considerations
Volume depletion, loss of vascular elasticity, and baroreceptor desensitization combined w/ antihypertensive treatment will result in intraoperative _____________.
- hemodynamic volatility
You will be chasing your tail.
Too much of a drop in BP in chronic hypertensive patients will result in what injuries?
- Renal and myocardial injury
What is the most common cause of secondary HTN for middle age adults (40-64 years old)?
- Hyperaldosteronism
- Thyroid dysfunction
- OSA
- Cushing syndrome
- Phenochrmocytoma
