Exam 4 Hypertension part I Flashcards
how is HTN defined by the american college of cardiology and AHA?
- sustained SBP > 130 mmHg
- and/or a DBP > 80 mmHg
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HTN
* effects > ____ million people in US
* nearly ____ adults
- 100 million
- 1/2
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HTN effects ____% of African Americans, ____% of Whites, ____% of Asians, ____% of Hispanics
- 40%
- 30%
- 29%
- 27%
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HTN Ddsproportionately effects ____ income countries, and the lifetime rx of developing HTN in the US is ____%
- low-middle
- 90%
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What are the classifications of BP in adults:
* normal
* elevated
* stage 1 HTN
* stage 2 HTN
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Clinical consequences of chronically elevated BP underscore a high age-related association with …?
- ischemic heart disease
- stroke
- renal failure
- retinopathy
- PVD
- overall mortality
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In the surgical population, studies have found HTN to be a common risk factor for perioperative ____, particularly if untreated
morbidity & mortality
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Chronic HTN represents a spectrum of elevated blood pressure to severe disease. What are the 3 different classes and how are they defined?
- isolated systolic HTN (SBP >130 mm Hg and DBP < 80 mm Hg)
- isolated diastolic HTN (SBP < 130 mm Hg with DBP >80 mm Hg)
- combined systolic and diastolic HTN (SBP >130 mm Hg and DBP >80 mm Hg)
- risk association, pharmacologic therapy, and tx goals can vary among subtypes
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In addition to SBP and DBP elevation, a ____ is alsoa risk factor for cardiovascular morbidity as it correlates withvascular remodeling and “stiffness”
widened pulse pressure
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HTN can result from a wide range of primary & secondary processes that increase …?
- cardiac output
- vascular resistance
- or both
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The cause of primary HTN is unclear, but contributing factors include ?
- SNS activity
- dysregulation of the RAAS
- deficiency in endogenous vasodilators
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Genetic and lifestyle risk factors assoc w/HTN include
- obesity
- alcoholism
- tobacco
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A minority of pts w/ HTN havesecondary HTN resulting from a potentially correctable ____ or ____ cause
physiologic or pharmacologic
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what does this graph show?
- Top L: Correlation btw SBP and Ischemic heart dz mortality across 5 age groups
- Top R: Correlation btw DBP and Ischemic heart dz mortality across 5 age groups
- Bottom L:Correlation btw SBP and Stroke mortality across 5 age groups
- Bottom R: Correlation btw DBP and stroke mortality across 5 age groups
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what drugs may elevate blood pressure?
- antiinfective
- antiinflammatory
- chemotherapeutc
- herbal
- illicit
- immunosuppressive agents
- psychiatric
- sex hormones
- steroirds
- sympathomimietics
CHIAA PISSS elevates my BP
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Most comon causes of secondary HTN in children (birth -12 yr) and % of pt with thunderlying cause.
- renal parenchymal disease 70-85%
- coartation of the aorta
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Most comon causes of secondary HTN in adolescents (12 -18 yr) and % of pt with thunderlying cause.
- coratation of aorta 10-15%
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Most comon causes of secondary HTN in young adults (19-39 yr) and % of pt with thunderlying cause.
- thyroid dysfunction 5%
- fibromuscular dysplasia
- renal parenchymal disease
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Most comon causes of secondary HTN in middle aged adults (40-64yr) and % of pt with thunderlying cause.
- hyperaldosteronism 8-12%
- thyroid disfunction
- OSA
- cushing syndrome
- pheochromacytome
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Most comon causes of secondary HTN in older adults (> 65 yr) and % of pt with underlying cause.
- 17%
- atherosclerotic renal artery stenosis
- renal failure
- hypothyroidism
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Chronic HTN leads to remodeling of ____, ____ dysfunction, and potentially irreversible ____.
- small & large arteries
- endothelial
- end-organ damage
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Disseminated vasculopathy plays a major role in:
- ischemic heart dz
- LVH
- CHF
- CVA
- PAD
- aortic aneurysm
- nephropathy
I like Coochies Cuz Pussies Are Nasty
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- ____ of the common carotid intimal to medial thickness and arterial pulse-wave velocity can provide an early dx of vasculopathy
- Ultrasound measurement
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____ and ____ indexes may track progression of LVH
Echocardiographic and electrocardiographic
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MRI can be used to follow microangiopathic changes indicative of ____
cerebrovascular damage
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what are examples of end organ damage d/t HTN?
Vasculopathies
Cerebrovascular Damage
Heart Disease
Nephropathy
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what is the general therauptic goal for HTN?
SBP < 130
DBP < 80
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- ____ million people in US have untreated HTN
- ____ million treated pts are above their BP goal
- 28
- 29
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what is resistant HTN? what is the treatment?
- above-goal BP despite 3+ antihypertensive drugs @ max dose
- Tx usually includes a LA CCB, an ACI-I or ARB + a diuretic
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what is controlled resistant HTN?
controlled BP requiring 4+medications
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what is refractory HTN?
- uncontrolled BP on 5+ drugs
- present in 0.5% of pts
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____ HTN (intolerance to drugs) can result from BP inaccuracies (including white-coat syndrome) or medication noncompliance
Pseudo-resistant
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what are lifestyle modifications that decrease BP?
- weight loss
- ↓ETOH
- exercise
- smoking cessation
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there is a continous relationship between increased ____ and ____
increased BMI and HTN
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____ is an effective nonpharmacologic intervention, through direct BP reduction and synergistic enhancement of drug efficacy
Weight loss
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Overweight adults should aim for ideal body weight, but can expect a 1 mmHg reduction in BP for every ____kg of weight loss
1mmhg reduction in BP for every 1 kg of weight loss
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Even modest increases in physical activity areassocwith?
BP decrease
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Excessive alcohol use isassociated with?
- ↑HTN
- may cause resistance toantihypertensive drugs
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Dietary ____ and ____ intake are inversely related to HTN andcerebrovascular disease
potassium and calcium
sldie 12
____ isassocw/small but consistent BP decreases
Salt restriction
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the most recent ACC/AHA guidelines for BP management outlined 8 conclusions:
- Out-of-office BP’s are recommended for diagnosis and titration of antihypertensive meds
- Evidence supports treating pts with ischemic heart dz, cerebrovascular dz, CKD, or atherosclerotic cardiovascular dz w/ BP meds if SBP > 130 mmHg
- There is limited data to support treating pts w/o cardiovascular or cerebrovascular dz with nonpharmacologic therapy if SBP > 130 or DBP >80
- The same goals are recommended for HTN pts w/DM or CKD as for the general HTN population
- ACE-I’s, ARBs, CCBs, or thiazide diuretics are useful and effective in nonblack HTN pts,including those with diabetes
- In black adult HTN pts w/o heart failure or CKD, including those with DM, there ismoderate evidence to support initial antihypertensive therapy with a CCB or thiazidediuretic
- There is moderate evidence to support antihypertensive therapy with an ACE-I or ARB in those with CKD to improve kidney outcomes
- Nonpharmacologic interventions are important components to a comprehensive BPmanagement approach
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sorry this is so long :(
Notably absent from 1st line therapy are ____, which are reserved for pts w/ CAD or tachydysrhythmia, or a component of multidrug tx in resistant HTN
- β blockers
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what 15 different drug classes have been approved for HTN?
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Treatment of secondary HTN is often interventional, including
- surgical correction of renal artery stenosis, adrenal adenoma or pheochromocytoma
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If renal artery repair not possible, BP control may be accomplished w/ACE-I’s alone or w/ diuretics, although ACE-I’s, ARBs, and direct renin inhibitors are not recommendedin bilateral renal artery stenosis because?
they can accelerate renal failure
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Primary hyperaldosteronism can be treated w/ an aldosterone antagonist such as ____
spironolactone
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Certain disease processes, such as ____, require a combined pharmacologic and surgical approach
pheochromocytoma
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Preop considerations for Secondary HTN
- Preop BP assessment is often complicated by ____
- Pts are often instructed to pause BP meds, such as ____ on the day of surgery
- anxiety (white-coat HTN)
- ACE-I’s & diuretics
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- Can a single BP give an accurate picture of BP trends?
- What are current guidlines for a diagnosis of HTN?
- Assessing BP in a single moment in time does not give an accurate picture of overall BP trends
- Current guidelines state that multiple elevated BP readings over time are necessary for a diagnosis of HTN
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what should you do is BP is elevated?
a pressure on the contralateral arm should be obtained
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- A careful review of clinic data, homeBP’s, and a thorough history are necessaryto gain an overall picture of ____
- ____ is not a direct prompt to delay surgery in asymptomatic pts w/oother risk factors
- cardiovascular health
- Elevated BP
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surgery should NOT be delayed d/t transient elveated BP unless…?
- patient is experiencing extreme HTN (SBP >180 or DBP >110)
- or end-organ injury that could bereversed w/BP control
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The cause of secondary HTN may be indicated by the symptoms:
- flushing, sweating & palpitations suggestive of pheochromocytoma
- renal bruit suggestive of renal artery stenosis
- hypokalemia suggestive of hyperaldosteronism
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what antihypertensive meds should you stop before surgery and which ones do you continue?
- possibly stop ARBs and ACE-I’s
- dont stop BB, clonidine or CCB’s
- BB and clonidine can have rebound effects
- CCBs can have increased perioperative CV events
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Although guidelines don’t support delaying surgery for poorly controlled BP, perioperative HTN ____ as well as the incidence of ____ and ____
- increases blood loss
- MI & CVA
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Hypertensive pts are prone to ____ d/t physiologic factors along with the BP meds on-board
intraop hemodynamic volatility
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When superimposed on the organ damage from chronic HTN, even brief periods of hypotension are assoc with?
- acute kidney injury
- myocardial injury
- and death
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Clinicians need to consider acute intraoperative BP changes in the context of ____?
end-organ functional reserve
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what can lead to LVH?
- hemodynamic load
- BP magnitude [afterload]
- hypervolemia [preload]
- elevated pulse wave velocity
- age
- sex
- ethnic factors
- genes [positive FH]
- salt consumption
- obesity
- SNS
- catcolamines
- angiotesin II
- aldosterone
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what can LVH lead to?
- reduced coronary reserve [microangiopathy]
- impaired contractility
- reduced LV filling
- Afib or ventricular dystrhymias
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what does reduced cornary rserve (microangiopathy) lead to?
myocardial infarction [macroangiopathy]
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what does impaired contractility [systolic] and reduced LV filling [diastolic] cause?
heart failure
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what does afib or ventricular dysrhytmias lead to?
- sudden death
- cardiac emboli
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HTN pt are hemodynamically vulnerable to induction of ?
general anesthesia
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- Induction drugs produce ____
- DL & intubation elicit ____ & ____
- HoTN
- HTN & tachycardia
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A pre-induction A-line, followed by a multimodal induction that includes ____ may be beneficial
short acting beta blocker (Esmolol)
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Poorly controlled HTN is often accompanied by ____, especially if the pt ison a diuretic
volume depletion
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In some pts, modest volume loading prior to induction may provide better____
- hemodynamic stability
- this approach may be counterproductive in pts with LVH and diastolic dysfunction
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vasoactive drug considerations should take into account:
- pt’s age
- functional reserve
- medications
- planned operation
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____ is categorized as either urgent or emergent, b/o the presence of progressive organ damage
hypertensive crisiis
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Pts w/chronic HTN tend to tolerate a higher ____ than normotensive pts
SBP
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Perioperative emergencies in HTN crisis may include:
- CNS injury
- kidney injury
- cardiovascular insult
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Women w/ PIH may show evidence of end-organ dysfunction (in particular encephalopathy) with a DBP ____.
> 100
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Current guidelines for peripartum HTN recommends immediate intervention for what BP parameters?
SBP >160 / DBP>110
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In hypertension:
* BP must be titrated down slowly to avoid ____.
* ____ monitoring can facilitate this process
* ____ is a 1st line drug for peripartum HTN
- overshooting
- Aline
- Labetalol
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For rapid arterial dilation and BP reduction, ____ infusion isthe gold standard, as it has a fast onset and titratable
SNP [sodium nitropresside]
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if SNP is not available what is a newer medication that can be used?
Clevidipine, a 3rd-generation dihydropyridine CCB with an ultrashort DoA (≈1-min half-life) and selective arteriolar vasodilating properties
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in HTN crisis if SNP and clevidipine is not available what else can be used?
Nicardipine, a second-generation dihydropyridine CCB, but has a longer half-life (≈30 min), making it less titratable than clevidipine
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