HTN Flashcards
New standard/definition of HTN is sustained ranges of ___ systolic and ____ diastolic:
> 130/ >80
systolic: when the heart contracts
diastolic: is when the heart rests
Order from the most affected population to the least with HTN:
African Americans 40%, Whites 30%, 29% Asians, 27% Hispanics
disproportionately affects low-middle income countries
Chronic HTN can lead to 6 things
- ischemic heart disease
- stroke
- renal failure
- retinopathy
- PVD
- overall mortality
SBP >130 mm Hg and DBP <80 mm Hg represents ____ systolic HTN
Isolated systolic HTN
SBP <130 mm Hg with DBP >80 mm Hg represents ___ HTN
Diastolic HTN
SBP >130 mm Hg and DBP >80 mm Hg represets ____ HTN
Combined systolic and diastolic HTN
___ ___ ____: is also a risk factor for cardiovascular morbidity as it correlates with vascular remodeling and “stiffness”
Widened pulse pressure
HTN can result from a wide range of primary and secondary processes that increase ____, ___ ___, or both
CO, vascular resistance, or both
SNS activity, dysregulation of RAAs, and deficiency in endogenous vasodilators can be contributing factors to ___
HTN
A physiologic or pharmacologic cause is considered ____ HTN. (minority amount of Pt’s with HTN)
Secondary HTN
Genetic and lifestyle risk factors associated with HTN include: 3 things
obesity, alcoholism, and tobacco
Hyperaldosteronism, Thyroid dysfucntion, OSA, Cushings, and pheochromocytoma are causes/examples of ____ HTN
secondary HTN
Children typically have secondary HTN dt renal ____ ___ or coarctation of the ____
renal parenchymal disease
coarctation of the aorta
List of drugs that increase BP:
Secondary HTN cause for Young adults (19-39yrs) 5%
Thyroid dysfunction and fibromuscular dysplasia
Secondary HTN cause for adolescents (12-18 yrs) 10-15%
Coarctation of the aorta
Secondary HTN cause for Middle-aged adults (40-64 yrs) 8-12%
Hyperaldosteronism, thyroid dysfunction, obstructive sleep apnea
Secondary HTN cause for Older adults (>65 yrs) 17%
atherosclerotic renal artery stenosis, renal failure, hypothyroidism
_____ ____ leads to remodeling of small & large arteries, endothelial dysfunction, and potentially irreversible end-organ damage
Chronic HTN
_____ _____: plays a major role in ischemic heart dz, LVH, CHF, CVA, PAD, aortic aneurysm, and nephropathy
Disseminated Vasculopathy
Vasculopathy can be early diagnosed with _____ measurements of the common carotid intimal-to-medial thickness and arterial pulse-wave velocity
Ultrasound
____ & ____ TRENDS may track the progression of LVH
____ can be used to follow microangiopathic changes indicative of cerebrovascular damage
EKG and echocardiogram
MRI
End-Organ Damage in HTN chart
_____ HTN: above goal HTN depsit 3+ antihypertensive drugs @ max dose
tx usually include: long acting CCB, ACI-I or ARB, and a diuretic
Resistant HTN
Controlled resistant HTN is controlled BP requiring __ + medications
4 + HTN medications
_____ HTN: uncontrolled BP on 5 drugs, present in 0.5% of pts
Refractory HTN
_______ HTN can result from BP inaccuracies (including white-coat syndrome) or medication noncompliance
Pseudo-resistant HTN
Weight loss, decrease ETOH, exercise, and smoking cessation are ____ _____ for HTN
lifestyle modifications
_____ correlation with BMI and HTN
Weight loss is an effective nonpharmacologic intervention, through direct BP reduction and synergistic enhancement of drug ____
Positive correlation
drug efficacy
1 lb weight loss can drop BP by ___ mmHg
1 mmHg
Excessive alchol use is associated with increase in HTN and resistance to ____ ____
antihypertensive drugs
Dietary potassium and calcium intake are inversely related to ____ & ____
HTN andcerebrovascular disease
The most recent ACC/AHA guidelines for BP management outlined 8 conclusions
What are they
- BP’s outside of the office 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
- limited data to support tx pts w/ 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 thiazidediuretics
- 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
This drug class is notably absent from 1st line therapy for HTN, it is reserved for pts w/CAD or tachydysrhythmia, or as a component of multidrug tx in resistant HTN
Beta blockers
How many drug classes have been approved for HTN?
15
Tx of secondary HTN is often ____, including surgical correction of renal artery stenosis, adrenal adenoma or pheochromocytoma
Interventional
Secondary HTN:
If renal artery reapir not possible, BP can be controlled w/ _____ alone or w/ _____
w/ ACE-I’s alone or with diuretics
**Although ACE-I’s, ARBs, and direct renin inhibitors are not recommendedin bilateral renal artery stenosis as they can accelerate renal failure
Primary hyperaldosteronism can be treated w/ an aldosterone antagonist such as ______
spironolactone
Certain disease processes, such as pheochromocytoma, require a _____ pharmacologic and _____ approach
combined pharmacologic and surgical approach
With Secondary HTN, Preop BP can be complicated dt white-coat HTN, pt are often instructed to pause BP meds, such as ACE-I’s and diuretics ______ surgery
On the day of surgery
_____ elevated BP readings over time are necessary for a diagnosis of HTN
Multiple
Secondary HTN:
If BP is elevated, pressure on the _____ arm should be obtained
contralateral
Surgery should not be delayed d/t a transient HTN, unless the pt is experiencing extreme HTN SBP > ____ & DBP > ____ or end-organ injury that could bereversed w/BP control
(SBP >180 or DBP >110)
These symptoms are all signs of _______ _____:
-flushing, sweating & palpitations suggestive of pheochromocytoma
-renal bruit suggestive of renal artery stenosis
-hypokalemia suggestive of hyperaldosteronism
Secondary HTN
Pt with secondary HTN who are proceeding with surgery may be informed to continue antihypertensive meds, with the possible exclusion of ___ & ____
ACE-Is and ARBs
Stopping BB or clonidine can be associated with _____ effects
rebound
Stopping CCBs is associated with increased perioperative ______ events
cardiovascular
Perioperative HTN increased blood loss as well as the incidence of ___ and ___
MI and CVA
HTN pts are prone to intra-op ______ volatility dt physiologic factors along with the BP meds on board.
hemodynamic volatility
With Chronic HTN brief periods of hypotension are associated w/ 3 things:
kidney injury, myocardial injury, and death
PWV: pulse wave velocity chart
Induction with HTN:
-Induction drugs induce HoTN; while DL and intubation elicit HTN and tachycardia so _____ induction that includes SA BB may be beneficial
multimodal
ex. SA BB (esmolol)
Poorly controlled HTN patients who take diuretics can be associated with volume _____
volume depletion
With some pts, modest volume loading prior to induction may provide better ______ ______
but this could be counterproductive in pts with LVH and diastolic dysfunction
hemodynamic stability
The vasoactive drugs should be based off of pt’s age, functional reserve, _____, and planned operation
medications
Hypertensive crisis can be urgent or ____, based on the presences of progressive organ damage
emergent
T/F Normotensive pts tend to tolerate a higher SBP than chronic HTN pts
False: chronic HTN pts tend to tolerate a higher SBP than normotensive pts
Perioperative hypertensive emergencies may lead to 3 types of injuries
CNS injury, kidney injury, and cardiovascular insult
Women with ____ may show evidence of end-organ dysfunction (in particular encephalopathy) with a DBP >100
PIH: pregnancy-induced HTN
Peripartum HTN recommends immediate intervention for SBP > ___ and DBP > ___
SBP > 160
DBP >110
What beta blocker is the first line drug for peripartum HTN?
Labetalol
** BP must be titrated down slowly to avoid overshooting, a-lines can be useful
For rapid arterial dilation, _____ infusion is the gold standard, dt its fast onset and is easily titratable
SNP: sodium nitroprusside
A newer drug named, ____, has an ultrashort DOA of 1 min half-life and is a selective arteriolar vasodilating properties.
It is a 3rd-generation dihydropyridine CCB
Clevidipine
____, a second-generation dihydropyridine CCB, can also be used but has a longer half-life (about 30 mins), making it less titratable than clevidipine
Nicardipine (Cardene)
Tx for hypertensive emergencies (chart)
With Pulmonary HTN the mean pulmonary artery pressure (mPAP) > ____
> 20 mmHg
Accentuated S2 and S4 “gallop” heart sounds and LE swelling are signs of ____
Pulmonary HTN
What are the three classifications for Pulmonary HTN?
The classifications are based on PA wedge pressure (PAWP) and pulmonary vascular resistance (PVR)
-Isolated precapillary PH
-Isolated postcapillary PH
-Combined pre & postcapillary PH
Precapillary PH is defined as PVR of greater than or equal to ___ wood units w/o elevated LAP or PAWP
> than or equal to 3
Isolated postcapillary PH results from increased pulmonary ____ ____, usually d/t elevated LAP caused by valve disease or LV dysfunction
pulmonary venous pressure
Combined pre and postcapillary PH (reactive PH) reflects chronic pulmonary venous HTN with ____ pulmonary arterial vasoconstriction and remodeling
secondary
Combined pre and postcapillary PH is characterized by PAWP > ___ mmHg and a PVR > ___ wu
PAWP> 15 mmHg
PVR > 3.0 wu
Combined pre and postcapillary PH can be subcategorized as ____ or ____ due to the response to vasodilators, diuretics, or mechanical assistance.
fixed or vasoreactive
High-flow PH occurs _____ elevation in PAWP or PVR and results from increased pulmonary blood flow caused by a systemic-to-pulmonary shunt or high cardiac output.
without
What type of PH is this with these values?
mPAP: > 20 mmHg
PAWP: <15 mmHg
PVR: >3 wu
group: 1,3,4,5
isolated precapillary PH
What type of PH is this with these values?
mPAP: >20 mmHg
PAWP> 15 mmHg
PVR: < 3 wu
group: 2,5
isolated postcapillary PH
What type of PH is this with these values?
mPAP: > 20 mmHg
PAWP: > 15 mmHg
PVR: >3
group: 2,5
Combined pre and postcapillary PH
What procedure is required for a dx, classification, and tx plan for Pulmonary Artery HTN?
Right heart catheterization
1) elevated resistance to blood flow within the arterial circulation
2) increased pulmonary venous pressure from left heart disease
3) chronically increased pulmonary blood flow
4) a combination of these processes
These are a variety of mechanisms that can increase ____
mPAP
What is the formula to calculate PVR?
(mPAP-PAWP)/CO
PH can result from abnormalities in the ___ or ___ components of the lung circulation, sometimes including contribution from both
arterial or venous components
A patient with pulmonary artery HTN, who receives a TTE, will show ___ &___ enlargement and elevated peak tricuspid-regurgitation velocity
RA and RV enlargement
This scan is a screening tool to estimate pulmonary arterial systolic pressure (PASP) for PH
Echocardiogram
T/F: A PASP >41 mmHg estimated by an echocardiogram provides an accurate mPAP for definitive diagnosis.
False: Echocardiographic PASP is relatively sensitive and specific for PH, but it cannot provide the accurate mPAP for definitive diagnosis
Once right heart cath is perfromed, the severity of PH can be determined:
-Mild PH (mPAP =_____ )
-Moderate PH (mPAP = ____ )
-severe PH (mPAP = ____ )
-Mild PH (mPAP = 20-30 mmHg )
-Moderate PH (mPAP = 31-40 mmHg )
-severe PH (mPAP = > 40 mmHg )
Normal pulmonary circulation can accommodate a ____ increase CO without a marked change in mPAP
fourfold
_____ PAH: no identifiable risk factor
idiopathic PAH
1:8 patients have long-term improvements w/ ____ blockers
calcium channel blockers
3% of PAH cases are deemed inheritable with a mutation in bone _____ ____ receptor type 2 (BMPR2), the remaining cases are designated “associated” PAH
Bone morphogenetic protein receptor type 2
Despite improved diagnosis and therapy, 1-year mortality isabout ___ %
15%
PAH was traditionally a disease of young women, with a median survival rate of 3 yrs, current data shows a demographic shift, now with ____ pts and more ___ being diagnosed
older pts and more men being diagnosed.
With Pulmonary Artery HTN, sustained vasoconstriction and remodeling processes to pathologic distortion of ____ pulmonary arteries
small
What are the three main classes of pulmonary vasodilator drugs from PAH?
*Combination therapy is often required for adequate tx of PAH
-Prostanoids
-Endothelin receptor antagonists (ERAs)
-Those working through nitric oxide/guanylate cyclase pathways
Drug class for PAH tx
_____: mimic the effect of prostacyclin to produce vasodilation while inhibiting platelet aggregation. They also have anti-inflammatory effects and may reduce the proliferation of vascular smooth muscle cells.
Prostanoids
epoprostenol (IV)
iloprost (inhaled)
treprostinil (SQ, IV, INH, PO)
beraprost(PO)
These are all examples of what type of drug class for PAH tx
Prostanoids
This specific prostanoid is the only medication that has been proven to reduce mortality in PAH pt
Epoprostenol
Drug class for PAH tx
_______: The vascular endothelial dysfunction associated with PAH involves an imbalance btw vasodilating (nitric oxide) and vasoconstricting (endothelin) substances. ERAs have been shown to improve hemodynamics and exercise capacity
Endothilin Receptor Antagonists (ERAs)
Drug class for PAH tx
_____: produces pulmonary vasodilation by stimulating guanylate cyclase and cGMP formation in smooth muscle cells. This effect is transient because nitric oxide is quickly bound by hgb and degraded by phosphodiesterase type 5
Nitric oxide/guanylate cyclase
Continuously inhaled _____ has been widely used in both preoperative and critical care settings, and preparations for home use have become available
nitric oxide
Chronic therapy for PAH tx has been directed towards _____ inhibitors
PD-5 inhibitors
____ pts often present with nonspecific sx of fatigue, dyspnea, and cough
PAH
What are more advanced sx that can occur in PAH pts during exercise if coronary blood flow cannot meet the demand of a hypertrophied RV
angina and syncope
On physical exam, pts with PAH may exhibit a ____ lift, accentuated S2, S3 and/or s4 gallop, JVD, peripheral edema, hepatomegaly, and ascites
parasternal
Rarely, compression of a dilated PA may lead to ___ damage and hoarseness
RLN:
** per google: Dilation of the pulmonary artery results in the narrowing of the space between the pulmonary artery and aorta (red arrow) and causes compression of the recurrent laryngeal nerve
T/F: PH should prompt further evaluation of functional status, cardiac performance, and pulmonary function tests
True
T/F: For pts with moderate or severe PH, a right heart cath prior to moderate-high risk surgery is not recommended
False: R heart cath IS recommended before a moderate-high risk surgery
Should a patient that has PH and coexisting left heart dz also have a left heart cath?
Yes, dt potential discrepancies btw PAWP and LVEDP, a left heart cath should also be performed in pts with coexisting left heart dz because inaccurate LVEDP may lead to misclassification of PH and inappropriate treatment
Can vasoreactivity testing be performed during right heart cath in PH patients?
Yes, vasoreactivity testing, often with inhaled nitric oxide, is performed during right heart catheterization to determine responsiveness to vasodilator therapy
What percentage of PAH pts are nonresponsive to inhaled nitric oxide, but those that are responsive also respond to CCBs and may benefit from other targeted therapy?
85-90%
PAH screening/ tx algorithm
Chart: risk factors for PAH pt in noncardiac surgery
Primary intraoperative goal is maintaining optimal “ _____ ______ “ btw the right ventricle and pulmonary circulation to promote adequate left-sided filling and systemic perfusion
“Mechanical coupling”
exs. of added preoperative complexities for PAH
-transient HoTN
-mechanical ventilation
-modest hypercarbia
-small bubbles in IV
-T-burg position
-Pneumoperitoneum
-single-lung ventilation
All of these are potentially serious _____
serious consequences
A hallmark of PAH is _____ RV afterload –> leads to RV dilation, increased wall stress, and RV hypertrophy
increased RV afterload
The interaction btw the RV and the pulmonary circulation is ___ and dynamic, involving the compliance and “stiffness” of lg & small vessels
pulsatile
**This is relevant during acute insults that occur during surgeries which affect RV pulsatile load
Ventilator management can have effects on RV afterload through the addition of: 5 things
PEEP
hypoventilation
hypercarbia
acidosis
atelectasis
In contrast to the LV, the thinner-walled RV is subject togreater wall tension for the same degree of increase in end-diastolic volume, leading toincreased RV myocardial ____ _____
oxygen demand
T/F: RV coronary perfusion only occurs during diastole
F: Under normal circumstances, the RV intramyocardial pressure is lower than the aorticroot pressure, and RV coronary perfusion occurs throughout the cardiac cycle
T/F:
In PAH, the elevated RV pressure leads to increased coronary flow during diastole,making the RV more vulnerable to systemicHoTN, worsening the 02 supply/demandmismatch and potentially causing myocardial ischemia
True
What is the “lethal combination” with PAH?
SystemicHoTNalong with RV ischemia and high afterload can result in the “lethalcombination” of RV dilatation, insufficient LV filling, reduced stroke volume, andfurther systemic hypotension
T/F: There is an increase in perioperative morbidity and mortality in pts with PH undergoing hip and knee replacement
True
Procedural considerations:
Laparoscopy: C02 pneumoperitoneum has an ____ impact on biventricular load and pump function. The combination of pneumoperitoneum, head-down position, and increased inspiratory pressure affects RV pressures and afterload
acute
Procedural considerations:
Thoracic surgery: Thoracic procedures involve _____ and ____ of the operative lung
non-ventilation and atelectasis
Procedural Considerations:
Thoracic Surgery:
-3 Features of lung collapse that are particularly relevant for PAH
(1) some centers transiently pressurize the chest to induce atelectasis
(2) there is a potential for systemic hypoxia
(3) hypoxic pulmonary vasoconstriction (HPV) will further increase RV afterload
-PAH pts are often converted from oral to inhaled or pulmonary vasodilator therapy
-inhaled pulmonary vasodilators are recommended during single-lung ventilation
PAH is the only class of Ph found to benefit from pulmonary ______
vasodilators
PAH pts on vasodilators should have them continued intraoperatively and _______, and converted from oral to IV or inhaled when necessary
postoperatively
