Exam 4 Hypertension part I Flashcards
1
Q
how is HTN defined by the american college of cardiology and AHA?
A
- sustained SBP > 130 mmHg
- and/or a DBP > 80 mmHg
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2
Q
HTN
* effects > ____ million people in US
* nearly ____ adults
A
- 100 million
- 1/2
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3
Q
HTN effects ____% of African Americans, ____% of Whites, ____% of Asians, ____% of Hispanics
A
- 40%
- 30%
- 29%
- 27%
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4
Q
HTN Ddsproportionately effects ____ income countries, and the lifetime rx of developing HTN in the US is ____%
A
- low-middle
- 90%
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5
Q
What are the classifications of BP in adults:
* normal
* elevated
* stage 1 HTN
* stage 2 HTN
A
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6
Q
Clinical consequences of chronically elevated BP underscore a high age-related association with …?
A
- ischemic heart disease
- stroke
- renal failure
- retinopathy
- PVD
- overall mortality
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7
Q
In the surgical population, studies have found HTN to be a common risk factor for perioperative ____, particularly if untreated
A
morbidity & mortality
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8
Q
Chronic HTN represents a spectrum of elevated blood pressure to severe disease. What are the 3 different classes and how are they defined?
A
- 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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9
Q
In addition to SBP and DBP elevation, a ____ is alsoa risk factor for cardiovascular morbidity as it correlates withvascular remodeling and “stiffness”
A
widened pulse pressure
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10
Q
HTN can result from a wide range of primary & secondary processes that increase …?
A
- cardiac output
- vascular resistance
- or both
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11
Q
The cause of primary HTN is unclear, but contributing factors include ?
A
- SNS activity
- dysregulation of the RAAS
- deficiency in endogenous vasodilators
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12
Q
Genetic and lifestyle risk factors assoc w/HTN include
A
- obesity
- alcoholism
- tobacco
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13
Q
A minority of pts w/ HTN havesecondary HTN resulting from a potentially correctable ____ or ____ cause
A
physiologic or pharmacologic
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14
Q
what does this graph show?
A
- 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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15
Q
what drugs may elevate blood pressure?
A
- antiinfective
- antiinflammatory
- chemotherapeutc
- herbal
- illicit
- immunosuppressive agents
- psychiatric
- sex hormones
- steroirds
- sympathomimietics
CHIAA PISSS elevates my BP
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16
Q
Most comon causes of secondary HTN in children (birth -12 yr) and % of pt with thunderlying cause.
A
- renal parenchymal disease 70-85%
- coartation of the aorta
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17
Q
Most comon causes of secondary HTN in adolescents (12 -18 yr) and % of pt with thunderlying cause.
A
- coratation of aorta 10-15%
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18
Q
Most comon causes of secondary HTN in young adults (19-39 yr) and % of pt with thunderlying cause.
A
- thyroid dysfunction 5%
- fibromuscular dysplasia
- renal parenchymal disease
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19
Q
Most comon causes of secondary HTN in middle aged adults (40-64yr) and % of pt with thunderlying cause.
A
- hyperaldosteronism 8-12%
- thyroid disfunction
- OSA
- cushing syndrome
- pheochromacytome
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20
Q
Most comon causes of secondary HTN in older adults (> 65 yr) and % of pt with underlying cause.
A
- 17%
- atherosclerotic renal artery stenosis
- renal failure
- hypothyroidism
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21
Q
Chronic HTN leads to remodeling of ____, ____ dysfunction, and potentially irreversible ____.
A
- small & large arteries
- endothelial
- end-organ damage
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22
Q
Disseminated vasculopathy plays a major role in:
A
- ischemic heart dz
- LVH
- CHF
- CVA
- PAD
- aortic aneurysm
- nephropathy
I like Coochies Cuz Pussies Are Nasty
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23
Q
- ____ of the common carotid intimal to medial thickness and arterial pulse-wave velocity can provide an early dx of vasculopathy
A
- Ultrasound measurement
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24
Q
____ and ____ indexes may track progression of LVH
A
Echocardiographic and electrocardiographic
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25
MRI can be used to follow microangiopathic changes indicative of ____
cerebrovascular damage
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26
what are examples of end organ damage d/t HTN?
Vasculopathies
Cerebrovascular Damage
Heart Disease
Nephropathy
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27
what is the general therauptic goal for HTN?
SBP < 130
DBP < 80
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28
* ____ million people in US have untreated HTN
* ____ million treated pts are above their BP goal
* 28
* 29
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29
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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30
what is controlled resistant HTN?
controlled BP requiring 4+ medications
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31
what is refractory HTN?
* uncontrolled BP on 5+ drugs
* present in 0.5% of pts
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32
____ HTN (intolerance to drugs) can result from BP inaccuracies (including white-coat syndrome) or medication noncompliance
Pseudo-resistant
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33
what are lifestyle modifications that decrease BP?
* weight loss
* ↓ETOH
* exercise
* smoking cessation
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34
there is a continous relationship between increased ____ and ____
increased BMI and HTN
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35
____ is an effective nonpharmacologic intervention, through direct BP reduction and synergistic enhancement of drug efficacy
Weight loss
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36
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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37
Even modest increases in physical activity are assoc with?
BP decrease
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38
Excessive alcohol use is associated with?
* ↑HTN
* may cause resistance to antihypertensive drugs
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39
Dietary ____ and ____ intake are inversely related to HTN and cerebrovascular disease
potassium and calcium
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40
____ is assoc w/small but consistent BP decreases
Salt restriction
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41
the most recent ACC/AHA guidelines for BP management outlined 8 conclusions:
1. Out-of-office BP's are recommended for diagnosis and titration of antihypertensive meds
2. Evidence supports treating pts with ischemic heart dz, cerebrovascular dz, CKD, or atherosclerotic cardiovascular dz w/ BP meds if SBP > 130 mmHg
3. There is limited data to support treating pts w/o cardiovascular or cerebrovascular dz with nonpharmacologic therapy if SBP > 130 or DBP >80
4. The same goals are recommended for HTN pts w/DM or CKD as for the general HTN population
5. ACE-I’s, ARBs, CCBs, or thiazide diuretics are useful and effective in nonblack HTN pts, including those with diabetes
6. In black adult HTN pts w/o heart failure or CKD, including those with DM, there is moderate evidence to support initial antihypertensive therapy with a CCB or thiazide diuretic
7. There is moderate evidence to support antihypertensive therapy with an ACE-I or ARB in those with CKD to improve kidney outcomes
8. Nonpharmacologic interventions are important components to a comprehensive BP management approach
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## Footnote
sorry this is so long :(
42
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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43
what 15 different drug classes have been approved for HTN?
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44
Treatment of secondary HTN is often interventional, including
* surgical correction of renal artery stenosis, adrenal adenoma or pheochromocytoma
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45
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 recommended in bilateral renal artery stenosis because?
they can accelerate renal failure
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46
Primary hyperaldosteronism can be treated w/ an aldosterone antagonist such as ____
spironolactone
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47
Certain disease processes, such as ____, require a combined pharmacologic and surgical approach
pheochromocytoma
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48
# 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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49
* 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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50
what should you do is BP is elevated?
a pressure on the contralateral arm should be obtained
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51
* A careful review of clinic data, home BP’s, and a thorough history are necessary to gain an overall picture of ____
* ____ is not a direct prompt to delay surgery in asymptomatic pts w/o other risk factors
* cardiovascular health
* Elevated BP
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52
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 be reversed w/BP control
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53
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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54
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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55
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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56
Hypertensive pts are prone to ____ d/t physiologic factors along with the BP meds on-board
intraop hemodynamic volatility
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57
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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58
Clinicians need to consider acute intraoperative BP changes in the context of ____?
end-organ functional reserve
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59
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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60
what can LVH lead to?
* reduced coronary reserve [microangiopathy]
* impaired contractility
* reduced LV filling
* Afib or ventricular dystrhymias
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61
what does reduced cornary rserve (microangiopathy) lead to?
myocardial infarction [macroangiopathy]
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62
what does impaired contractility [systolic] and reduced LV filling [diastolic] cause?
heart failure
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63
what does afib or ventricular dysrhytmias lead to?
* sudden death
* cardiac emboli
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64
HTN pt are hemodynamically vulnerable to induction of ?
general anesthesia
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65
* Induction drugs produce ____
* DL & intubation elicit ____ & ____
* HoTN
* HTN & tachycardia
| slide 22
66
A pre-induction A-line, followed by a multimodal induction that includes ____ may be beneficial
short acting beta blocker (Esmolol)
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67
Poorly controlled HTN is often accompanied by ____, especially if the pt is on a diuretic
volume depletion
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68
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*
| slide 22
69
vasoactive drug considerations should take into account:
* pt's age
* functional reserve
* medications
* planned operation
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70
____ is categorized as either urgent or emergent, b/o the presence of progressive organ damage
hypertensive crisiis
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71
Pts w/chronic HTN tend to tolerate a higher ____ than normotensive pts
SBP
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72
Perioperative emergencies in HTN crisis may include:
* CNS injury
* kidney injury
* cardiovascular insult
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73
Women w/ PIH may show evidence of end-organ dysfunction (in particular encephalopathy) with a DBP ____.
>100
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74
Current guidelines for peripartum HTN recommends immediate intervention for what BP parameters?
SBP >160 / DBP>110
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75
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
| slide 24
76
For rapid arterial dilation and BP reduction, ____ infusion is the gold standard, as it has a fast onset and titratable
SNP [sodium nitropresside]
| slide 24
77
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
| slide 24
78
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
| slide 24
