Health Asses 4: Hypertension Flashcards

Question

For tracking the progression of Left Ventricular Hypertrophy (LVH) in hypertensive patients, which tests are most indicative? A. EKG and echocardiogram trends B. Spirometry and bronchoscopy C. MRI D. EEG and nerve conduction velocity

Answer 1

Correct Answer: A. EKG and echocardiogram trends Rationale: Electrocardiogram (EKG) and echocardiogram trends are useful for tracking the progression of LVH, which is a common consequence of sustained high blood pressure.

Answer 2

Correct Answer: B. Microangiopathic changes indicative of cerebrovascular damage Rationale: Magnetic Resonance Imaging (MRI) can be utilized to follow microangiopathic changes in hypertensive patients, which are indicative of cerebrovascular damage that can occur due to chronic high blood pressure.

Answer 3

Correct Answer: D. Nephropathy Rationale: Nephropathy, a type of kidney damage, is often indicated by the presence of albuminuria and proteinuria, which are hallmarks of renal damage from hypertension.

Answer 4

Correct Answer: A. Vasculopathy Rationale: Vasculopathy due to hypertension includes endothelial dysfunction, which can lead to remodeling, generalized atherosclerosis, arteriosclerotic stenosis, and aortic aneurysm.

Answer 5

Correct Answer: A. Acute hypertensive encephalopathy Rationale: Acute hypertensive encephalopathy is a severe and potentially life-threatening condition that results from acute failure of the cerebrovascular autoregulatory system, usually due to a sudden rise in blood pressure.

Answer 6

Correct Answer: C. Heart Disease Rationale: Heart Disease as a result of chronic hypertension can lead to left ventricular hypertrophy, a response to increased workload and pressure in the heart, commonly detectable by ECG and echocardiogram.

Answer 7

Correct Answer: B. Blood pressure <130/80 Rationale: The general therapeutic goal for hypertension treatment is to achieve a blood pressure level below 130/80 mmHg.

Answer 8

Correct Answer: B. 3+ Rationale: Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite the concurrent use of 3 or more antihypertensive drugs at maximum recommended doses, typically including a long-acting calcium channel blocker (LA CCB), an ACE inhibitor (ACI) or angiotensin receptor blocker (ARB), and a diuretic.

Answer 9

Correct Answer: B. Controlled resistant hypertension Rationale: Controlled resistant hypertension refers to blood pressure that is controlled but requires four or more medications to do so.

Answer 10

Correct Answer: C. 5 or more Rationale: Refractory hypertension is a term for uncontrolled blood pressure on 5 or more antihypertensive drugs, including a diuretic, and is present in 0.5% of patients with hypertension.

Answer 11

Correct Answer: C. Consistent blood pressure control with 1 or 2 drugs Rationale: Pseudo-resistant hypertension is a condition where it appears that the blood pressure is uncontrolled despite therapy, but this can be due to inaccurate blood pressure measurements, white-coat syndrome, or medication noncompliance. Consistent blood pressure control with 1 or 2 drugs is not indicative of pseudo-resistant hypertension.

Answer 12

Correct Answer: B. 1 mmHg Rationale: Overweight adults can expect a 1 mmHg reduction in blood pressure for every 1 kg of weight loss.

Answer 13

Correct Answer: A. Sodium restriction Rationale: Although sodium restriction is commonly advised for hypertension management, it is not listed among the lifestyle modifications on this slide. The ones mentioned include weight loss, reduced alcohol consumption (↓ETOH), exercise, and smoking cessation.

Answer 14

Correct Answer: C. Continuous Rationale: There is a continuous relationship between increased Body Mass Index (BMI) and hypertension, suggesting that as BMI increases, the risk and severity of hypertension also increase.

Answer 15

Correct Answer: C. Through direct blood pressure reduction and synergistic enhancement of drug efficacy Rationale: Weight loss serves as an effective nonpharmacologic intervention for hypertension management by directly reducing blood pressure and enhancing the efficacy of antihypertensive drugs.

Answer 16

Correct Answer: C. It is associated with increased hypertension and resistance to antihypertensive drugs. Rationale: Excessive alcohol use is associated with an increase in blood pressure and can lead to resistance to antihypertensive medications, making hypertension more difficult to control.

Answer 17

Correct Answer: B. It is associated with small but consistent decreases in blood pressure. Rationale: Salt restriction in the diet is associated with small but consistent blood pressure reductions in individuals with hypertension.

Answer 18

Correct Answer: B. Potassium and calcium Rationale: Dietary potassium and calcium intake have been shown to have an inverse relationship with hypertension and cerebrovascular disease. Adequate intake of these minerals can contribute to lower blood pressure levels and reduced risk of stroke.

Answer 19

Correct Answer: E. Rigorous Anal- (aka. Physical activity) Rationale: Even modest increases in physical activity are associated with decreases in blood pressure, highlighting the importance of regular exercise in the management of hypertension.

Answer 20

Correct Answer: A. Increased alcohol consumption Rationale: While salt restriction, increased physical activity, and adequate intake of potassium and calcium are beneficial lifestyle modifications for managing hypertension, increased alcohol consumption is detrimental and associated with worse hypertension control.

Answer 21

Correct Answer: C. Patients with ischemic heart disease, cerebrovascular disease, CKD, or atherosclerotic cardiovascular disease Rationale: The guidelines support treating patients with specific cardiovascular conditions such as ischemic heart disease, cerebrovascular disease, chronic kidney disease (CKD), or atherosclerotic cardiovascular disease with antihypertensive medications if their systolic BP is above 130 mmHg.

Answer 22

Correct Answer: C. The goals are the same for patients with DM or CKD as for the general hypertension population Rationale: The ACC/AHA guidelines recommend the same blood pressure goals for patients with hypertension with comorbid conditions like diabetes mellitus or chronic kidney disease as for the general hypertension population.

Answer 23

Correct Answer: C. They advise using out-of-office blood pressure measurements Rationale: The guidelines recommend using out-of-office blood pressure measurements for the diagnosis and titration of antihypertensive medications, acknowledging the value of these measurements in capturing the patient's typical blood pressure.

Answer 24

Correct Answer: B. There is limited data to support its use if systolic BP >130 mmHg or diastolic BP >80 mmHg Rationale: The ACC/AHA guidelines suggest that there is limited data to support the use of nonpharmacologic therapy in patients without cardiovascular or cerebrovascular disease if their systolic blood pressure is over 130 mmHg or diastolic blood pressure is over 80 mmHg.

Answer 25

Correct Answer: B. Atherosclerotic cardiovascular disease Rationale: The guidelines indicate that patients with atherosclerotic cardiovascular disease should start antihypertensive medications if their systolic blood pressure is above 130 mmHg. This recommendation is based on evidence supporting the treatment of such patients to prevent adverse cardiovascular outcomes.

Answer 26

Correct Answer: C. ACE-Inhibitors, ARBs, CCBs, or thiazide diuretics Rationale: The ACC/AHA guidelines note that ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), or thiazide diuretics are useful and effective for managing hypertension in nonblack patients, including those diagnosed with diabetes.

Answer 27

Correct Answer: C. CCBs or thiazide diuretics Rationale: The guidelines recommend CCBs or thiazide diuretics for initial antihypertensive therapy in black patients without heart failure or CKD due to moderate evidence of efficacy.

Answer 28

Correct Answer: B. There is moderate evidence to support their use to improve renal outcomes Rationale: According to the guidelines, there is moderate evidence suggesting that antihypertensive therapy with an ACE inhibitor or an angiotensin receptor blocker can improve kidney outcomes in patients with CKD.

Answer 29

Correct Answer: C. They are important components of a comprehensive blood pressure management approach Rationale: Nonpharmacologic interventions are considered important aspects of comprehensive blood pressure management according to the ACC/AHA guidelines, suggesting that lifestyle modifications and other non-drug approaches play a vital role in treating hypertension.

Answer 30

Correct Answer: C. Black adults without heart failure or CKD Rationale: The ACC/AHA guidelines suggest moderate evidence to start black adult patients without heart failure or CKD on a calcium channel blocker (CCB) or a thiazide diuretic as initial antihypertensive therapy.

Answer 31

Correct Answer: C. Patients with hypertension and coronary artery disease or tachydysrhythmia. Rationale: β blockers are notably absent from first-line therapy options for hypertension. They are reserved for patients with specific conditions such as coronary artery disease (CAD) or tachydysrhythmias, or as a component of multidrug treatment in resistant hypertension.

Answer 32

Correct Answer: C. 15 Rationale: The slide notes that 15 different drug classes have been approved for the treatment of hypertension, reflecting the diversity of pharmacological agents available to manage this condition.

Answer 33

Correct Answer: D. All of the above Rationale: New treatment approaches for hypertension listed include dopamine β-hydroxylase inhibitors, vaccines against components of the renin-angiotensin system, and interventional procedures like renal artery stenting.

Answer 34

Correct Answer: C. ACE inhibitors, ARBs, and direct renin inhibitors Rationale: Although ACE inhibitors, ARBs, and direct renin inhibitors are effective in controlling blood pressure, they are not recommended in cases of bilateral renal artery stenosis due to the risk of precipitating renal failure.

Answer 35

Correct Answer: B. Primary hyperaldosteronism Rationale: Primary hyperaldosteronism, a condition characterized by excessive secretion of aldosterone, is commonly treated with aldosterone antagonists like spironolactone to block the hormone's effects and manage hypertension.

Answer 36

Correct Answer: B. Use of ACE inhibitors alone or with diuretics Rationale: If renal artery stenosis cannot be surgically corrected, blood pressure may be managed with ACE inhibitors, either alone or in combination with diuretics, as long as there is no bilateral stenosis

Answer 37

Correct Answer: C. Pheochromocytoma Rationale: Pheochromocytoma, a tumor of the adrenal glands that secretes excessive catecholamines, often requires a combination of medical management to control hypertension preoperatively and surgical resection for definitive treatment.

Answer 38

Correct Answer: B. White-coat hypertension Rationale: Preoperative blood pressure assessment can be influenced by the patient's anxiety in the clinical setting, known as white-coat hypertension, where BP readings are higher than those typically recorded at home.

Answer 39

Correct Answer: C. To avoid intraoperative hypotension Rationale: Pausing ACE inhibitors and diuretics preoperatively may be recommended to reduce the risk of intraoperative hypotension due to their blood pressure-lowering effects and potential alteration of fluid and electrolyte balance.

Answer 40

Correct Answer: D. All of the above. Rationale: A single blood pressure measurement may not accurately represent overall blood pressure trends due to various influencing factors including stress, physical activity, and normal daily variations.

Answer 41

Correct Answer: B. By consistently elevated blood pressure readings over a period of time Rationale: Hypertension is diagnosed by evaluating multiple elevated blood pressure readings over time to ensure that the diagnosis is not based on transient changes in blood pressure.

Answer 42

Correct Answer: B. Measurement of BP in the contralateral arm Rationale: When a patient presents with elevated blood pressure, it is advisable to measure the BP in the other arm to confirm the reading, as there can be variations between the two arms.

Answer 43

Correct Answer: B. It provides a comprehensive picture of the patient’s cardiovascular health. Rationale: A careful review of clinic data, home BP readings, and medical history helps provide an overall picture of cardiovascular health, which is crucial for preoperative assessment.

Answer 44

Correct Answer: C. When BP is extremely high or there is evidence of end-organ damage Rationale: Elective surgery may need to be delayed if the patient has extreme hypertension (SBP >180 mmHg or DBP >110 mmHg) or evidence of end-organ injury that could potentially be reversed with blood pressure control.

Answer 45

Correct Answer: B. No, unless accompanied by other risk factors or symptoms. Rationale: Elevated blood pressure alone is not a prompt to delay surgery in asymptomatic patients without additional risk factors, as it may not indicate a serious issue requiring immediate attention.

Answer 46

Correct Answer: B. Renal bruit Rationale: Renal bruit is typically associated with renal artery stenosis rather than pheochromocytoma, which commonly presents with symptoms like headaches, palpitations, flushing, and sweating due to catecholamine release.

Answer 47

Correct Answer: C. Continue antihypertensive medications with the possible exclusion of ARBs and ACE-Is. Rationale: It is common to continue antihypertensive medications on the day of surgery to maintain blood pressure control, although angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) may be held due to the risk of intraoperative hypotension.

Answer 48

Correct Answer: B. Beta-blockers (BBs) or clonidine Rationale: Stopping BBs or clonidine abruptly can lead to rebound hypertension due to a sudden increase in sympathetic activity.

Answer 49

Correct Answer: C. Increased perioperative cardiovascular events Rationale: Stopping CCBs can be associated with increased perioperative cardiovascular events due to loss of their protective effects against hypertension and tachycardia.

Answer 50

Correct Answer: D. Owing to elevated intravascular pressure Rationale: Perioperative hypertension can lead to increased blood loss due to elevated intravascular pressure, which may cause more bleeding from surgical sites.

Answer 51

Correct Answer: C. Physiological factors along with the effects of blood pressure medications Rationale: Hypertensive patients often experience intraoperative hemodynamic fluctuations due to the interplay between physiological stressors and the pharmacological effects of antihypertensive medications they are taking.

Answer 52

Correct Answer: C. They can cause acute kidney injury, myocardial injury, or even death. Rationale: In patients with chronic hypertension, whose organs may already have damage, even short periods of hypotension can cause further acute injury to organs like the kidneys and heart due to compromised perfusion.

Answer 53

Correct Answer: C. They must evaluate the context of end-organ functional reserve. Rationale: During surgery, clinicians need to assess blood pressure changes with an understanding of the patient's end-organ functional reserve, as chronic hypertension may have led to compromised organ reserve, altering the tolerance to blood pressure fluctuations.

Answer 54

Answer: C) Elevated pulse wave velocity Rationale: Elevated pulse wave velocity indicates stiffer arterial walls, which can increase afterload, leading to compensatory LVH as the heart works harder to eject blood against greater vascular resistance.

Answer 55

Answer: B) Physical activity level Rationale: The schematic indicates age, sex, and ethnic factors as predisposing factors for LVH but does not list physical activity level, which is generally considered protective against LVH.

Answer 56

Answer: C) Increased sympathetic nervous system activity Rationale: Obesity is associated with increased sympathetic nervous system activity, which can increase heart rate and contractility, leading to higher metabolic demands on the heart and promoting LVH.

Answer 57

Answer: B) Diastolic phase Rationale: LVH can lead to decreased compliance of the left ventricle, which primarily affects the diastolic phase of cardiac function when the ventricles are supposed to be filling with blood.

Answer 58

Answer: A) Reduced coronary reserve Rationale: LVH can lead to reduced coronary reserve due to increased heart muscle mass, which demands more oxygen and nutrients, potentially leading to ischemia and other cardiac complications such as heart failure and arrhythmias.

Answer 59

Answer: C) They are at increased risk of hemodynamic instability. Rationale: Hypertensive patients are at increased risk of hemodynamic instability during GA induction due to the potential exaggerated response to the physiological stress of induction drugs, leading to hypotension or hypertension and tachycardia.

Answer 60

Answer: C) It may enhance hemodynamic stability in volume-depleted patients. Rationale: Modest volume loading prior to induction may improve hemodynamic stability, especially in hypertensive patients who are volume-depleted, potentially from diuretic use.

Answer 61

Answer: B) Patients with LVH and diastolic dysfunction. Rationale: In patients with LVH and diastolic dysfunction, volume loading can exacerbate the impairment in ventricular filling and potentially worsen hemodynamic stability due to the heart's decreased compliance.

Answer 62

Answer: C) The patient's age, functional reserve, medications, and the planned operation. Rationale: Selecting vasoactive drugs during induction must consider the patient's overall cardiovascular health, including their age, functional reserve, current medications, and the specifics of the planned surgical procedure to tailor the induction plan effectively.

Answer 63

Answer: D) The patient is asymptomatic. Rationale: A hypertensive crisis is classified as urgent mainly due to the presence of severe hypertension that may not yet have caused end-organ damage or life-threatening complications, but immediate management is needed to prevent such outcomes.

Answer 64

Answer: C) Tend to tolerate a higher systolic blood pressure than normotensive patients. Rationale: Chronic hypertensive patients often have a higher tolerance for elevated systolic blood pressure due to physiological adaptations that occur over time, but this does not negate the need for careful monitoring and management.

Answer 65

Answer: C) Diastolic blood pressure above 100 mmHg. Rationale: In the context of PIH, a diastolic blood pressure (DBP) above 100 mmHg may indicate end-organ dysfunction, particularly encephalopathy, and necessitates urgent management.

Answer 66

Answer: C) Hyperglycemic crisis. Rationale: While CNS injury, kidney injury, and cardiovascular insult are directly related to hypertension and can be perioperative emergencies, hyperglycemic crisis is primarily related to

Answer 67

Answer: C) SBP >160 mmHg / DBP >110 mmHg Rationale: Current guidelines recommend immediate intervention for peripartum hypertension when blood pressure reaches SBP >160 mmHg or DBP >110 mmHg to prevent complications associated with severe hypertension during this critical period.

Answer 68

Answer: A) To reduce the risk of overshooting and causing hypotension. Rationale: When treating a hypertensive crisis, it is crucial to lower BP gradually to avoid a sudden drop in blood pressure, which could lead to hypotension and potential end-organ ischemia.

Answer 69

Answer: B) It facilitates continuous BP monitoring for precise titration of antihypertensive medications. Rationale: A-line monitoring provides real-time blood pressure readings, allowing for precise and immediate adjustments in medication to manage acute hypertension effectively.

Answer 70

Answer: C) Peripartum hypertension. Rationale: Labetalol is often used as a first-line agent for the management of hypertension in the peripartum period due to its safety profile and effectiveness.

Answer 71

Answer: C) It has a fast onset and is easily titratable. Rationale: SNP is a potent vasodilator with a rapid onset of action, which is beneficial for quickly reducing BP in a hypertensive crisis, and its effects can be easily adjusted based on the patient's response.

Answer 72

Answer: B) Clevidipine has a shorter half-life, making it more easily titratable than nicardipine. Rationale: Clevidipine is an ultrashort-acting dihydropyridine calcium channel blocker, which makes it advantageous in situations where rapid and precise control of BP is required. Nicardipine also has vasodilatory effects but with a longer half-life, which makes it less amenable to rapid titration.

Answer 73

Answer: B) To lessen the pulsatile force of left ventricular contraction. Rationale: In the management of aortic dissection, the aim is to reduce the pulsatile force exerted by the left ventricle during contraction, which minimizes the propagation of the dissection and the risk of rupture.

Answer 74

Answer: C) It has both alpha- and beta-blocking properties. Rationale: Labetalol is beneficial in pre-eclampsia and eclampsia because of its ability to block both alpha- and beta-adrenergic receptors, providing better blood pressure control without significantly reducing uterine blood flow.

Answer 75

Answer: C) Alpha-blockers. Rationale: In the case of pheochromocytoma, alpha-blockade is critical to prevent unopposed alpha-adrenergic receptor stimulation that can occur if beta-blockers are used first, which would worsen hypertension.

Answer 76

Answer: B) Labetalol. Rationale: Labetalol is used in cocaine-induced hypertensive emergencies because it can counteract both alpha- and beta-adrenergic effects of cocaine, which helps to manage hypertension without worsening vasoconstriction.

Answer 77

Answer: C) There is a risk of cyanide toxicity. Rationale: While sodium nitroprusside is a potent and quickly titratable antihypertensive agent, it can lead to cyanide toxicity, especially if used in high doses or for a prolonged duration. Also, can also increase intracranial pressures.

Answer 78

Answer: C) Pulmonary arterial hypertension. Rationale: PPHN is included under the umbrella of PAH as a persistent condition of high pulmonary arterial pressure in newborns.

Answer 79

Answer: B) 20 mmHg. Rationale: The updated definition for pulmonary hypertension is an mPAP greater than 20 mmHg, as stated in the slide.

Answer 80

Answer: C) Accentuated S2 and S4 "gallop" heart sounds. Rationale: An accentuated S2 and an S4 gallop rhythm are clinical findings suggestive of pulmonary hypertension, as noted on the slide.

Answer 81

Answer: B) Isolated postcapillary PH. Rationale: Isolated postcapillary PH is characterized by an elevated pulmonary artery wedge pressure (PAWP), which is indicative of issues in the left side of the heart.

Answer 82

Answer: A) Isolated precapillary PH. Rationale: Isolated precapillary PH involves increased PVR but normal PA wedge pressure, indicating the problem lies in the pulmonary vasculature and not the left heart.

Answer 83

Answer: B) 3.0 Wood units or more without elevated left atrial pressure. Rationale: Precapillary PH is described as a PVR of ≥3.0 Wood units without elevated left atrial pressure or PAWP, where PAWP is ≤15mmHg (considered normal).

Answer 84

Answer: C) Increased pulmonary venous pressure typically due to left ventricular (LV) dysfunction. Rationale: Isolated postcapillary PH results from increased pulmonary venous pressure often related to LV dysfunction or valve disease, leading to a PAWP of >15mmHg.

Answer 85

Answer: C) PAWP >15mmHg and PVR >3.0 Wood units. Rationale: Combined pre- and postcapillary PH is characterized by PAWP >15mmHg and a PVR >3.0 Wood units, reflecting venous and arterial involvement in the pulmonary circulation.

Answer 86

Answer: C) Normal PAWP and PVR but increased pulmonary blood flow. Rationale: High-flow PH occurs without an increase in PAWP or PVR but is due to increased pulmonary blood flow, such as from a systemic-to-pulmonary shunt or high cardiac output.

Answer 87

Answer: D) High-flow PH. Rationale: High-flow PH is a unique category where the increased blood flow, rather than pressure or resistance, is the cause of the pulmonary hypertension, as stated in the slide.

Answer 88

Answer: B) Diagnosis, classification, and treatment planning. Rationale: Right heart catheterization is necessary to measure hemodynamic parameters that are crucial for diagnosing PAH, classifying the type of PAH, and planning appropriate treatment

Answer 89

Answer: A) Decreased cardiac output. Rationale: Decreased cardiac output is not a mechanism that leads to elevated mPAP. Instead, increased mPAP can be due to elevated resistance to blood flow within the arterial circulation, increased pulmonary venous pressure from left heart disease, or chronically increased pulmonary blood flow.

Answer 90

Answer: B) PVR = (mPAP – PAWP) / COP. Rationale: PVR is calculated by subtracting pulmonary artery wedge pressure (PAWP) from mPAP and dividing by the cardiac output (CO), often represented by the abbreviation COP, which stands for cardiac output in pulmonary circulation.

Answer 91

Answer: B) Right ventricular hypertrophy. Rationale: Right ventricular hypertrophy is a result, not a direct cause, of increased mPAP. Increased mPAP can be due to problems with the pulmonary arteries such as vasculopathy, chronically increased blood flow, or issues leading to increased left heart pressures.

Answer 92

Answer: D) Arterial, venous, or both. Rationale: PH can stem from issues in either the arterial or venous components of lung circulation, and sometimes it may include contributions from both areas.

Answer 93

Answer: A) RA & RV enlargement and elevated peak tricuspid-regurgitation velocity Rationale: The echocardiogram showing right atrial (RA) and right ventricular (RV) enlargement along with elevated peak tricuspid-regurgitation velocity is indicative of increased pressure in the pulmonary circulation, suggestive of PH.

Answer 94

Answer: C) It is relatively sensitive for PH but not definitive. Rationale: An echocardiographic PASP > 41 mmHg is relatively sensitive and specific for PH; however, it cannot provide the accurate mean pulmonary arterial pressure (mPAP) necessary for a definitive diagnosis of PH.

Answer 95

Answer: C) It is the gold standard for diagnosing and assessing the severity of PH. Rationale: Right heart catheterization is required for definitive diagnosis of PH and for determining its severity (mild, moderate, or severe based on mPAP levels).

Answer 96

Answer: C) mPAP of >40 mmHg Rationale: Severe PH is characterized by a mean pulmonary artery pressure (mPAP) greater than 40 mmHg as measured by right heart catheterization.

Answer 97

Answer: C) It can accommodate a fourfold increase in COP without a significant change in mPAP. Rationale: Normal pulmonary circulation has the capacity to accommodate significant increases in blood flow without a substantial change in the mPAP, due to its ability to vasodilate and recruit additional pulmonary vessels to handle the increased flow

Answer 98

Answer: C) PAH with no identifiable risk factors Rationale: Idiopathic PAH is defined as pulmonary arterial hypertension that lacks an identifiable cause, and it cannot be attributed to other diseases or genetic defects.

Answer 99

Answer: B) 15 people per million per year Rationale: The slide states that PAH affects 15 people per million per year according to the World Health Organization, classifying it as a rare disease.

Answer 100

Answer: C) BMPR2 Rationale: BMPR2, the bone morphogenetic protein receptor type 2 gene, is commonly mutated in heritable forms of PAH, accounting for approximately 3% of cases.

Answer 101

Answer: B) Young women Rationale: PAH was traditionally seen as a disease primarily affecting young women, though current data suggests a demographic shift to older patients and more men being diagnosed.

Answer 102

Answer: C) Approximately 15% Rationale: Despite improved diagnostic and therapeutic options, the slide notes that the 1-year mortality rate for PAH remains around 15%. Nearly 1: 8 PAH pts have long-term improvements w/CCB’s

Answer 103

Answer: C) Genetic predisposition and multiple event accumulation Rationale: The development of PAH is multifactorial, often involving a genetic predisposition along with other contributing events that lead to the disease.

Answer 104

Answer: B) Sustained vasoconstriction and remodeling Rationale: PAH is characterized by sustained vasoconstriction and remodeling of the small pulmonary arteries, leading to pathologic changes that can impair pulmonary circulation.

Answer 105

Answer: C) Prostanoids, endothelin receptor antagonists (ERAs), and drugs working through nitric oxide/guanylate cyclase pathways Rationale: The three main classes of pulmonary vasodilator drugs for PAH include prostanoids, ERAs, and those that enhance the nitric oxide/guanylate cyclase signaling pathways.

Answer 106

Answer: B) Vasodilation and inhibition of platelet aggregation Rationale: Prostanoids mimic prostacyclin, which causes vasodilation and prevents platelets from clumping together, thereby reducing the risk of thrombus formation in the pulmonary circulation.

Answer 107

Answer: D) Epoprostenol Rationale: Epoprostenol is the only medication among the listed options that has been proven to reduce mortality in patients with PAH. It is administered intravenously due to its short half-life.

Answer 108

Answer: C) Intranasal (IN) Rationale: Treprostinil can be administered through subcutaneous, intravenous, inhalation, and oral routes, but there is no mention of intranasal administration for this medication.

Answer 109

Answer: B) They have anti-inflammatory effects and may reduce the proliferation of vascular smooth muscle cells. Rationale: In addition to vasodilatory effects, prostanoids have anti-inflammatory properties and can inhibit the abnormal proliferation of cells in the walls of the pulmonary arteries, a feature characteristic of PAH.

Answer 110

Answer: B) Balance the effects of nitric oxide and endothelin, improving hemodynamics. Rationale: ERAs work by blocking the effects of endothelin, a substance that causes vasoconstriction, thus restoring the balance between vasoconstriction and vasodilation in the blood vessels, which is beneficial for patients with PAH.

Answer 111

Answer: B) Producing vasodilation by stimulating guanylate cyclase. Rationale: Nitric oxide is a vasodilator that works by stimulating the enzyme guanylate cyclase, leading to the formation of cGMP in vascular smooth muscle cells, which causes relaxation and vasodilation.

Answer 112

Answer: B) Due to its rapid uptake and metabolism by red blood cells and degradation by phosphodiesterase type 5. Rationale: Nitric oxide has a transient effect because it is quickly bound by hemoglobin in red blood cells and is rapidly degraded by enzymes like phosphodiesterase type 5.

Answer 113

Answer: C) Phosphodiesterase type 5 (PD-5) inhibitors Rationale: Chronic therapy for PAH often involves PD-5 inhibitors, which prolong the vasodilatory effect of nitric oxide by preventing the degradation of cGMP, thus contributing to the relaxation of pulmonary vascular smooth muscle cells. Continuously inhaled nitric oxide has been widely used in both perioperative and critical care settings, and preparations for home use have become available

Answer 114

Answer: B) The venous embolism can further elevate venous and airway pressures in an already compromised pulmonary circulatory system. Rationale: In patients with PAH, venous embolisms are particularly dangerous as they can exacerbate an already elevated pulmonary vascular resistance and pressure, leading to further strain on the right ventricle and potential decompensation.

Answer 115

Answer: B) Coronary blood flow that cannot meet the demand of a hypertrophied right ventricle. Rationale: PAH can lead to right ventricular hypertrophy due to increased afterload. Angina and syncope during exercise indicate that the coronary blood flow is insufficient to meet the oxygen demands of the enlarged right ventricle.

Answer 116

Answer: B) Parasternal lift, accentuated heart sounds, and signs of right heart failure. Rationale: The increased pressure and resistance in the pulmonary circuit lead to right ventricular hypertrophy and subsequent failure, which may manifest as a parasternal lift, accentuated second heart sound (S2), third (S3) or fourth (S4) heart sounds, jugular venous distension (JVD), peripheral edema, hepatomegaly, and ascites.

Answer 117

Answer: B) Hoarseness. Rationale: The recurrent laryngeal nerve innervates the vocal cords. Compression by a dilated pulmonary artery can cause nerve damage leading to vocal cord dysfunction and hoarseness.

Answer 118

Answer: B) Right heart catheterization Rationale: Right heart catheterization is the gold standard for diagnosing PAH and assessing its severity. It allows for direct measurement of pulmonary pressures and assessment of cardiac function, which is critical before considering moderate to high-risk surgery.

Answer 119

Answer: B) Left heart catheterization Rationale: Discrepancies between pulmonary artery wedge pressure (PAWP) and left ventricular end-diastolic pressure (LVEDP) can lead to misclassification of the type of PH. Left heart catheterization can help accurately determine LVEDP, thus guiding appropriate treatment.

Answer 120

Answer: B) Responsiveness to vasodilator therapy Rationale: Vasoreactivity testing, often with inhaled nitric oxide, assesses whether pulmonary artery pressures decrease in response to vasodilators, which can indicate potential benefit from calcium channel blockers (CCBs) or other vasodilatory therapies.

Answer 121

Answer: B) 85–90% Rationale: Most PAH patients do not show a significant response to acute vasoreactivity testing with inhaled nitric oxide. However, those who are responsive often have a favorable prognosis and may respond well to CCBs.

Answer 122

Answer: B) Right heart catheterization Rationale: Right heart catheterization is required to confirm PAH by measuring mean pulmonary arterial pressure (mPAP) and pulmonary artery wedge pressure (PAWP).

Answer 123

Answer: C) Calcium channel blockers Rationale: Patients with PAH who respond positively to vasoreactivity testing are treated with calcium channel blockers, which can lead to long-term improvements in selected patients.

Answer 124

Answer: B) Start PAH-specific therapy Rationale: If there is no sustained response to calcium channel blockers, the treatment proceeds to PAH-specific therapy tailored according to the patient’s risk stratification.

Answer 125

Answer: C) Referral for lung transplantation or atrial septostomy Rationale: For PAH patients with an inadequate response to combination therapy, advanced options like lung transplantation or atrial septostomy may be considered, highlighting the progressive nature of the disease and the need for aggressive management.

Answer 126

Answer: B) To promote optimal mechanical coupling between the right ventricle and pulmonary circulation. Rationale: The goal is to maintain a balance that ensures adequate left-sided filling and systemic perfusion, which is crucial for patient stability during surgery.

Answer 127

Answer: A) Transient hypotension Rationale: Transient hypotension can have serious consequences due to its potential impact on cardiac output and systemic perfusion, particularly if the right ventricle is compromised.

Answer 128

Answer: C) To maintain hemodynamic stability and adequate organ perfusion. Rationale: Interventions that impact these factors are critical to maintaining the delicate balance necessary for the right ventricle to function effectively, especially in the face of perioperative complexities.

Answer 129

Answer: C) Pneumothorax Rationale: The complexities listed on the slide include transient hypotension, mechanical ventilation, hypercarbia, bubbles in IV fluids, Trendelenburg position, pneumoperitoneum, and single-lung ventilation. Pneumothorax is not mentioned but is indeed a condition that can impact right ventricular function.

Answer 130

Answer: B) RV dilation and hypertrophy. Rationale: PAH leads to increased afterload on the right ventricle, which can result in RV dilation and hypertrophy due to the increased workload and wall stress.

Answer 131

Answer: B) Pulsatile and dynamic. Rationale: The slide emphasizes the pulsatile and dynamic nature of the interaction, highlighting the importance of compliance and vessel "stiffness."

Answer 132

Answer: D) Its greater wall tension for the same increase in end-diastolic volume. Rationale: The thinner walls of the RV are indeed a factor, but the key issue is that for the same degree of volume increase, the RV experiences greater wall tension, which leads to increased oxygen demand.

Answer 133

Answer: B) Hyperventilation leading to respiratory alkalosis. Rationale: While PEEP, hypoventilation, and atelectasis can affect RV afterload by increasing intrathoracic pressure or altering gas exchange, hyperventilation generally decreases CO2, which can lead to alkalosis and does not typically increase afterload.

Answer 134

Answer: C) Throughout the entire cardiac cycle. Rationale: Unlike the left ventricle (LV), which primarily receives coronary perfusion during diastole, the RV is perfused throughout the cardiac cycle due to its lower intramyocardial pressure compared to the aortic root pressure.

Answer 135

Answer: C) It increases coronary flow during diastole and exacerbates systemic hypotension. Rationale: In PAH, the increased afterload leads to elevated RV pressures, which increase coronary flow during diastole but also make the RV more vulnerable to systemic hypotension, worsening the supply/demand mismatch.

Answer 136

Answer: B) RV dilation, insufficient LV filling, reduced stroke volume, and further systemic hypotension. Rationale: Systemic hypotension, especially when combined with RV ischemia and high afterload, can lead to RV failure, which negatively impacts left-sided filling and stroke volume, further exacerbating systemic hypotension.

Answer 137

Answer: B) It acutely impacts biventricular load and pump function. Rationale: CO2 pneumoperitoneum increases intra-abdominal pressure, which can acutely increase RV afterload and affect biventricular load and pump function due to increased intrathoracic pressure and altered venous return.

Answer 138

Answer: C) Increased RV pressures and afterload. Rationale: The head-down (Trendelenburg) position can increase venous return to the heart, raising RV pressures and afterload, which can be detrimental in patients with PH.

Answer 139

Answer: D) Potential for systemic hypoxia and increased RV afterload due to HPV. Rationale: Nonventilation and atelectasis of the operative lung can lead to HPV, which is a protective mechanism that directs blood away from poorly ventilated areas of the lung. This can increase RV afterload and lead to systemic hypoxia.

Answer 140

Answer: B) <130 mmHg. Rationale: Current guidelines recommend a target SBP goal of <130 mmHg, although it is noted that a significant percentage of patients remain poorly controlled.

Answer 141

Answer: B) Adequate BP control, treatment regimen, and presence of end-organ damage. Rationale: The preoperative evaluation should assess the adequacy of blood pressure control, the treatment regimen, and whether there is any evidence of damage to organs that can be affected by prolonged hypertension.

Answer 142

Answer: B) 20 mmHg. Rationale: PH is defined as a mean PA pressure > 20 mmHg. This elevation in pressure can be due to a variety of processes including arterial constriction, remodeling, elevated venous pressure, or increased blood flow.

Answer 143

Answer: B) 5. Rationale: PAH is one of five PH groups defined by the WHO. PAH is the only class of PH found to benefit from pulmonary vasodilators

Answer 144

Answer: C) Right heart catheterization. Rationale: A right heart catheterization is required to diagnose PAH

Answer 145

Answer: B) Pulmonary vasodilators. Rationale: The mainstay of PAH treatment includes pulmonary vasodilators such as prostacyclin analogues, endothelin receptor antagonists, and drugs that act on the nitric oxide/guanylate cyclase pathway.

Answer 146

Answer: C) It has improved quality of life and survival, but the overall prognosis remains poor. Rationale: Despite the improvement in quality of life and survival with the use of vasodilators, the prognosis for patients with PAH remains poor.

Answer 147

Answer: B) Continuation of vasodilators intraoperatively and conversion from oral to IV or inhaled as necessary. Rationale: PAH patients on vasodilator therapy should have their medications continued intraoperatively and postoperatively, with conversion from oral to IV or inhaled forms when necessary.