Exam 5: HTN Flashcards
1
Q
What is the definition of hypertension?
A
Sustained SBP > 130 mmHg and/or DBP > 80 mmHg
Hypertension affects over 100 million people in the US
2
Q
What percentage of adults in the US are affected by hypertension?
A
Nearly ½ of adults
40% of African Americans, 30% of Whites, 29% of Asians, 27% of Hispanics
3
Q
What is the lifetime risk of developing hypertension in the US?
A
90%
This indicates a high prevalence of the condition
4
Q
What are some chronic complications of hypertension?
A
- Ischemic heart disease
- Stroke
- Renal failure
- Retinopathy
- Peripheral vascular disease
- Increased mortality
5
Q
How does chronic hypertension affect the surgical population?
A
It is a common risk factor for perioperative morbidity and mortality, particularly if undiagnosed or untreated
6
Q
What are the different types of hypertension based on systolic and diastolic measurements?
A
- Isolated systolic hypertension (SBP > 130 mmHg, DBP < 80 mmHg)
- Isolated diastolic hypertension (SBP < 130 mmHg, DBP > 80 mmHg)
- Combined systolic and diastolic hypertension (SBP > 130 mmHg, DBP > 80 mmHg)
7
Q
Widen pulse pressure correlated with what?
A
Widened pulse pressure is also a risk factor for cardiovascular morbidity as it correlates with vascular remodeling and “stiffness”
8
Q
you can do it
A
:)
9
Q
What are some contributing factors to primary hypertension?
A
- SNS hyperactivity
- Dysregulation of the RAAS
- Deficiency in endogenous vasodilators
10
Q
What lifestyle factors are associated with hypertension?
A
- Obesity
- Alcoholism
- Tobacco use
11
Q
What are common causes of secondary hypertension in adults?
A
- Hyperaldosteronism
- Thyroid dysfunction
- Obstructive sleep apnea (OSA)
- Cushing’s syndrome
- Pheochromocytoma
- kids with HTN usually have a secondary cause
12
Q
Children w/ HTN generally have secondary HTN d/t _____ disease or ____ of the aorta
A
renal; coarctation
13
Q
List some drugs that can cause HTN
A
14
Q
Chronic HTN leads to…..
A
remodeling of small & large arteries, endothelial dysfunction, and potentially irreversible end-organ damage
15
Q
how can vasculopathy be detected?
A
Vasculopathy can be detected early on ultrasound with measurement of the common carotid intimal-to-medial thickness and arterial pulse-wave velocity
16
Q
EKG and echocardiogram trends can track the progression of ______
A
left ventricular hypertrophy
17
Q
What is the relationship between body weight and blood pressure?
A
There is a continuous relationship;
1 mmHg reduction in BP for every 1 kg of weight loss
18
Q
What is the general therapeutic goal for blood pressure management?
A
< 130/< 80 mmHg
19
Q
What characterizes resistant hypertension?
A
Above-goal BP despite 3+ antihypertensive drugs at maximum dose
20
Q
What is controlled HTN
A
controlled BP requiring 4+ medications
21
Q
What is refractory HTN
A
Refractory HTN: uncontrolled BP on 5+ drugs, present in 0.5% of pts
22
Q
What is Pseudo-resistant HTN
A
Pseudo-resistant HTN (appears resistant to drugs): often d/t BP inaccuracies (i.e. white-coat syndrome) or medication noncompliance
23
Q
What are the main components of lifestyle modifications for hypertension management?
A
- Weight loss
- Reducing alcohol intake (leads to an increase in excessive catecholamines)
- Exercise
- Smoking cessation
24
Q
What dietary factors are inversely related to hypertension?
A
- Potassium intake
- Calcium intake
these are related to CVD
25
What are the ACC/AHA guidelines for blood pressure management? (8 guidelines)
* Out-of-office BP's recommended for diagnosis and titration
* Treat patients with ischemic heart disease, cerebrovascular disease, CKD, or atherosclerotic disease if SBP > 130 mmHg
* Limited data supports treating patients without cardiovascular issues nonpharmacologically if SBP > 130 or DBP > 80
* Same goals for hypertension patients with diabetes or CKD as general population
* ACE-I’s, ARBs, CCBs, or thiazide diuretics effective in nonblack patients
* In black patients without heart failure or CKD, initial therapy with CCB or thiazide recommended
* Moderate evidence supports ACE-I or ARB therapy in CKD patients
* Nonpharmacologic interventions important for comprehensive management
26
If renal artery repair not possible, BP can be controlled w/ what drugs
ACE-I with or without diuretics
ACE-I’s, ARBs, and direct renin inhibitors are not recommended in bilateral renal artery stenosis as they can accelerate renal failure
27
What is the treatment approach for secondary hypertension?
Often interventional, including surgical correction of renal artery stenosis or adrenal adenoma
28
Primary hyperaldosteronism can be treated w/ ______
spironolactone
29
When should the surgery be delayed for BP?
Surgery should not be delayed d/t a transient HTN, unless the pt is experiencing extreme HTN (SBP >180 or DBP >110) or end-organ injury that could be reversed w/BP control
you can hold off until they can have more tests run to find if there is an issue
30
What symptoms may indicate the cause of secondary hypertension?
* Flushing, sweating, palpitations (pheochromocytoma)
* Renal bruit (renal artery stenosis)
* Hypokalemia (hyperaldosteronism)
31
Stopping BBs or clonidine can be associated with what?
rebound HTN
32
Stopping CCBs is associated with what increased perioperative effents?
cardiovascular events
33
When is an A-line ideal?
if you suspect hypotension and blood loss
34
When would you not want to volume load your patient for induction?
if they have LVH or diastolic dysfunction
35
Women w/PIH may experience end-organ dysfunction (such as encephalopathy) with a DBP >_____
100
36
Current guidelines for peripartum HTN recommend immediate intervention for SBP >____ / DBP>___
SBP >160 / DBP>110
37
What is the 1st line drug for peripartum HTN?
labetolol
38
For rapid arterial dilation, ____ infusion is the gold standard d/t fast onset and titratability
sodium nitroprusside
39
_______, a 3rd-generation dihydropyridine CCB with an ultrashort DoA (≈1-min half-life) and selective arteriolar vasodilating properties is another option
Clevidipine
40
_____, a second-generation dihydropyridine CCB, can also be used but has a longer half-life (≈30 min), making it less titratable than clevidipine
Nicardipine
41
What are the best HTN drugs for intracranial HTN?
clevidipine, nitroprusside, labetolol, cardene
42
What are the primary HTN agents for aortic dissection?
clevidipine, emolol, labetolol, cardene
43
What are the primary HTN agents for Kidney injury?
clevidipine, labetolol, cardene
44
beta blockers can reduce ____ _____ ____ and inhibit labor
uterine blood flow
45
Why dont you give ACE-I to a preg lady?
they are teratogenic
46
List the 5 types of pulm HTN?
47
Precapillary PH
Precapillary PH: Primary issue lies in the pulmonary arterial circulation.
Pulmonary vasc resistance (PVR) ≥3.0 wood units w/ normal LAP or PAWP(<15mmHg)
48
Postcapillary PH
Postcapillary PH: increased pulmonary venous pressure d/t elevated LAP usually c/b left heart disease
Elevated PAWP (>15mmHg), Normal PVR
49
Combined pre- and postcapillary PH
Combined pre- and postcapillary PH: chronic pulmonary venous HTN with secondary pulmonary arterial vasoconstriction and remodeling
Characterized by a PVR > 3.0 WU and PAWP >15mmHg
Can be subcategorized as fixed or vasoreactive d/o the response to vasodilators, diuretics, or mechanical assistance
50
High-flow PH
High-flow PH occurs w/o an elevation in PAWP or PVR and results from increased pulmonary blood flow c/b systemic-to-pulmonary shunt or high cardiac output states
51
What is the significance of right heart catheterization in pulmonary hypertension?
Required for diagnosis, classification, and treatment plan
52
Mild PH (mPAP = ___-___ mmHg)
Moderate PH (mPAP = __-___ mmHg)
Severe PH (mPAP >__ mmHg)
Mild PH (mPAP = 20–30 mmHg)
Moderate PH (mPAP = 31–40 mmHg)
Severe PH (mPAP >40 mmHg)
53
3% of PAH cases are genetic, with mutations in what protein receptor?
bone morphogenetic protein receptor type 2 (BMPR2)
54
Nearly 1: 8 PAH pts have long-term improvements w/ what drug?
CCB
55
What are the main classes of pulmonary vasodilator drugs for pulmonary arterial hypertension?
* Prostanoids
* Endothelin receptor antagonists (ERAs)
* Drugs that enhance nitric oxide/guanylate cyclase pathways
56
What is the mean pulmonary arterial pressure (mPAP) threshold for diagnosing pulmonary hypertension?
> 20 mmHg
57
What is the treatment for idiopathic pulmonary arterial hypertension?
Combination therapy often required for adequate treatment
58
What is the significance of echocardiogram in estimating pulmonary arterial pressure?
Commonly used to estimate pulmonary arterial systolic pressure (PASP) as a screening tool for pulmonary hypertension
59
What are the anti-inflammatory effects of certain PAH treatments?
They may reduce proliferation of vascular smooth muscle cells
## Footnote
Treatments include epoprostenol, iloprost, treprostinil, and beraprost.
60
Which PAH treatment is proven to reduce mortality?
Epoprostenol
61
What is the role of Endothelin Receptor antagonists (ERAs) in PAH treatment?
vascular endothelial dysfunction associated with PAH involves an imbalance btw vasodilating (nitric oxide) and vasoconstricting (endothelin) substances. ERAs improve hemodynamics and exercise capacity.
They improve hemodynamics and exercise capacity
62
How does nitric oxide contribute to pulmonary vasodilation?
By stimulating guanylate cyclase and cGMP in smooth muscle cells
63
What is a key characteristic of the effect of nitric oxide?
The effect is transient
64
What is the purpose of continuous inhaled nitric oxide in medical settings?
Used in perioperative and critical care settings
65
What sx may you see on assessment of a pt with PHTN
On assessment, pts may exhibit a parasternal lift, accentuated S2, S3, or S4 gallop, JVD, peripheral edema, hepatomegaly, and ascites
Rarely, compression of a dilated PA may lead to RLN damage and hoarseness
66
What should be done prior to surgery for a pt with PHTN?
right heart cath
67
If a patient responds well to inhaled nitric oxide they will also respond well to what other drug?
CCB
68
What is the focus of chronic therapy in PAH?
Directed toward PD-5 inhibitors to prolong the half-life of nitric oxide
69
What should be considered in PAH preoperative considerations?
Procedures with potential for venous embolism and other complications
70
What are common symptoms of PAH?
Fatigue, dyspnea, and cough
71
What severe symptoms can occur with exercise in PAH patients?
Angina and syncope
72
What physical exam findings may indicate PAH?
Parasternal lift, accentuated S2, S3, or S4 gallop, JVD, peripheral edema, hepatomegaly, and ascites
73
What is a rare complication of PAH that can lead to hoarseness?
Compression of a dilated PA leading to RLN damage
74
What is recommended for patients with moderate/severe PH prior to surgery?
Right heart catheterization
75
What is the significance of left heart catheterization in PH patients?
Indicated in patients with left heart disease to avoid misclassification of PH
76
What percentage of PAH patients are nonresponsive to inhaled nitric oxide?
85–90%
77
What is the primary intraoperative goal for PAH patients?
Maintaining optimal mechanical coupling between the right ventricle and pulmonary circulation
78
What are the factors that can affect RV preload, inotropy, afterload, and O2 supply/demand?
Any intervention during surgery
79
What is a hallmark of PAH related to right ventricular (RV) function?
Increased RV afterload
80
How does PAH affect myocardial supply and demand?
Increased RV pressure leads to increased coronary flow during diastole
81
What can the combination of RV dilatation, insufficient LV filling, and systemic hypotension lead to?
RV ischemia
82
What is a significant risk factor for CV disease, stroke, and renal disease?
Hypertension
83
What is the goal for systolic blood pressure (SBP) in hypertensive patients?
<130 mmHg
84
What is the definition of pulmonary hypertension (PH)?
Mean PA pressure > 20 mmHg
85
What is required to diagnose PAH and guide treatment?
Right heart catheterization
86
Which patients are likely to respond to calcium channel blockers (CCBs)?
Only a small percentage of PAH patients
87
What types of pulmonary vasodilators are used in PAH?
* Prostacyclin analogues
* Endothelin receptor antagonists
* Drugs activating the nitric oxide/guanylate cyclase pathway
88
What should be continued intraoperatively and postoperatively for PAH patients?
Pulmonary vasodilators
89
What is the prognosis for PAH despite treatment with vasodilators?
Remains poor
90
