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Health Assessment > HTN > Flashcards

HTN Flashcards

1
Q

New standard/definition of HTN is sustained ranges of ___ systolic and ____ diastolic:

A

> 130/ >80

systolic: when the heart contracts

diastolic: is when the heart rests

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2
Q

Order from the most affected population to the least with HTN:

A

African Americans 40%, Whites 30%, 29% Asians, 27% Hispanics

disproportionately affects low-middle income countries

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3
Q

Chronic HTN can lead to 6 things

A
  1. ischemic heart disease
  2. stroke
  3. renal failure
  4. retinopathy
  5. PVD
  6. overall mortality
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4
Q

SBP >130 mm Hg and DBP <80 mm Hg represents ____ systolic HTN

A

Isolated systolic HTN

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5
Q

SBP <130 mm Hg with DBP >80 mm Hg represents ___ HTN

A

Diastolic HTN

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6
Q

SBP >130 mm Hg and DBP >80 mm Hg represets ____ HTN

A

Combined systolic and diastolic HTN

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7
Q

___ ___ ____: is also a risk factor for cardiovascular morbidity as it correlates with vascular remodeling and “stiffness”

A

Widened pulse pressure

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8
Q

HTN can result from a wide range of primary and secondary processes that increase ____, ___ ___, or both

A

CO, vascular resistance, or both

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9
Q

SNS activity, dysregulation of RAAs, and deficiency in endogenous vasodilators can be contributing factors to ___

A

HTN

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10
Q

A physiologic or pharmacologic cause is considered ____ HTN. (minority amount of Pt’s with HTN)

A

Secondary HTN

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11
Q

Genetic and lifestyle risk factors associated with HTN include: 3 things

A

obesity, alcoholism, and tobacco

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12
Q

Hyperaldosteronism, Thyroid dysfucntion, OSA, Cushings, and pheochromocytoma are causes/examples of ____ HTN

A

secondary HTN

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13
Q

Children typically have secondary HTN dt renal ____ ___ or coarctation of the ____

A

renal parenchymal disease

coarctation of the aorta

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14
Q

List of drugs that increase BP:

A
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15
Q

Secondary HTN cause for Young adults (19-39yrs) 5%

A

Thyroid dysfunction and fibromuscular dysplasia

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16
Q

Secondary HTN cause for adolescents (12-18 yrs) 10-15%

A

Coarctation of the aorta

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17
Q

Secondary HTN cause for Middle-aged adults (40-64 yrs) 8-12%

A

Hyperaldosteronism, thyroid dysfunction, obstructive sleep apnea

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18
Q

Secondary HTN cause for Older adults (>65 yrs) 17%

A

atherosclerotic renal artery stenosis, renal failure, hypothyroidism

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19
Q

_____ ____ leads to remodeling of small & large arteries, endothelial dysfunction, and potentially irreversible end-organ damage

A

Chronic HTN

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20
Q

_____ _____: plays a major role in ischemic heart dz, LVH, CHF, CVA, PAD, aortic aneurysm, and nephropathy

A

Disseminated Vasculopathy

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21
Q

Vasculopathy can be early diagnosed with _____ measurements of the common carotid intimal-to-medial thickness and arterial pulse-wave velocity

A

Ultrasound

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22
Q

____ & ____ TRENDS may track the progression of LVH

____ can be used to follow microangiopathic changes indicative of cerebrovascular damage

A

EKG and echocardiogram

MRI

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23
Q

End-Organ Damage in HTN chart

A
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24
Q

_____ HTN: above goal HTN depsit 3+ antihypertensive drugs @ max dose

tx usually include: long acting CCB, ACI-I or ARB, and a diuretic

A

Resistant HTN

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25
Q

Controlled resistant HTN is controlled BP requiring __ + medications

A

4 + HTN medications

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26
Q

_____ HTN: uncontrolled BP on 5 drugs, present in 0.5% of pts

A

Refractory HTN

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27
Q

_______ HTN can result from BP inaccuracies (including white-coat syndrome) or medication noncompliance

A

Pseudo-resistant HTN

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28
Q

Weight loss, decrease ETOH, exercise, and smoking cessation are ____ _____ for HTN

A

lifestyle modifications

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29
Q

_____ correlation with BMI and HTN

Weight loss is an effective nonpharmacologic intervention, through direct BP reduction and synergistic enhancement of drug ____

A

Positive correlation

drug efficacy

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30
Q

1 lb weight loss can drop BP by ___ mmHg

A

1 mmHg

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31
Q

Excessive alchol use is associated with increase in HTN and resistance to ____ ____

A

antihypertensive drugs

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32
Q

Dietary potassium and calcium intake are inversely related to ____ & ____

A

HTN andcerebrovascular disease

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33
Q

The most recent ACC/AHA guidelines for BP management outlined 8 conclusions

What are they

A
  1. BP’s outside of the office 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. limited data to support tx pts w/ 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 ismoderate evidence to support initial antihypertensive therapy with a CCB or thiazidediuretics
  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 BPmanagement approach
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34
Q

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

A

Beta blockers

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35
Q

How many drug classes have been approved for HTN?

A

15

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36
Q

Tx of secondary HTN is often ____, including surgical correction of renal artery stenosis, adrenal adenoma or pheochromocytoma

A

Interventional

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37
Q

Secondary HTN:

If renal artery reapir not possible, BP can be controlled w/ _____ alone or w/ _____

A

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

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38
Q

Primary hyperaldosteronism can be treated w/ an aldosterone antagonist such as ______

A

spironolactone

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39
Q

Certain disease processes, such as pheochromocytoma, require a _____ pharmacologic and _____ approach

A

combined pharmacologic and surgical approach

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40
Q

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

A

On the day of surgery

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41
Q

_____ elevated BP readings over time are necessary for a diagnosis of HTN

A

Multiple

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42
Q

Secondary HTN:

If BP is elevated, pressure on the _____ arm should be obtained

A

contralateral

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43
Q

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

A

(SBP >180 or DBP >110)

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44
Q

These symptoms are all signs of _______ _____:

-flushing, sweating & palpitations suggestive of pheochromocytoma

-renal bruit suggestive of renal artery stenosis

-hypokalemia suggestive of hyperaldosteronism

A

Secondary HTN

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45
Q

Pt with secondary HTN who are proceeding with surgery may be informed to continue antihypertensive meds, with the possible exclusion of ___ & ____

A

ACE-Is and ARBs

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46
Q

Stopping BB or clonidine can be associated with _____ effects

A

rebound

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47
Q

Stopping CCBs is associated with increased perioperative ______ events

A

cardiovascular

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48
Q

Perioperative HTN increased blood loss as well as the incidence of ___ and ___

A

MI and CVA

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49
Q

HTN pts are prone to intra-op ______ volatility dt physiologic factors along with the BP meds on board.

A

hemodynamic volatility

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50
Q

With Chronic HTN brief periods of hypotension are associated w/ 3 things:

A

kidney injury, myocardial injury, and death

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51
Q

PWV: pulse wave velocity chart

A
52
Q

Induction with HTN:

-Induction drugs induce HoTN; while DL and intubation elicit HTN and tachycardia so _____ induction that includes SA BB may be beneficial

A

multimodal

ex. SA BB (esmolol)

53
Q

Poorly controlled HTN patients who take diuretics can be associated with volume _____

A

volume depletion

54
Q

With some pts, modest volume loading prior to induction may provide better ______ ______

but this could be counterproductive in pts with LVH and diastolic dysfunction

A

hemodynamic stability

55
Q

The vasoactive drugs should be based off of pt’s age, functional reserve, _____, and planned operation

A

medications

56
Q

Hypertensive crisis can be urgent or ____, based on the presences of progressive organ damage

A

emergent

57
Q

T/F Normotensive pts tend to tolerate a higher SBP than chronic HTN pts

A

False: chronic HTN pts tend to tolerate a higher SBP than normotensive pts

58
Q

Perioperative hypertensive emergencies may lead to 3 types of injuries

A

CNS injury, kidney injury, and cardiovascular insult

59
Q

Women with ____ may show evidence of end-organ dysfunction (in particular encephalopathy) with a DBP >100

A

PIH: pregnancy-induced HTN

60
Q

Peripartum HTN recommends immediate intervention for SBP > ___ and DBP > ___

A

SBP > 160
DBP >110

61
Q

What beta blocker is the first line drug for peripartum HTN?

A

Labetalol

** BP must be titrated down slowly to avoid overshooting, a-lines can be useful

62
Q

For rapid arterial dilation, _____ infusion is the gold standard, dt its fast onset and is easily titratable

A

SNP: sodium nitroprusside

63
Q

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

A

Clevidipine

64
Q

____, a second-generation dihydropyridine CCB, can also be used but has a longer half-life (about 30 mins), making it less titratable than clevidipine

A

Nicardipine (Cardene)

65
Q

Tx for hypertensive emergencies (chart)

A
66
Q

With Pulmonary HTN the mean pulmonary artery pressure (mPAP) > ____

A

> 20 mmHg

67
Q

Accentuated S2 and S4 “gallop” heart sounds and LE swelling are signs of ____

A

Pulmonary HTN

68
Q

What are the three classifications for Pulmonary HTN?

The classifications are based on PA wedge pressure (PAWP) and pulmonary vascular resistance (PVR)

A

-Isolated precapillary PH

-Isolated postcapillary PH

-Combined pre & postcapillary PH

69
Q

Precapillary PH is defined as PVR of greater than or equal to ___ wood units w/o elevated LAP or PAWP

A

> than or equal to 3

70
Q

Isolated postcapillary PH results from increased pulmonary ____ ____, usually d/t elevated LAP caused by valve disease or LV dysfunction

A

pulmonary venous pressure

71
Q

Combined pre and postcapillary PH (reactive PH) reflects chronic pulmonary venous HTN with ____ pulmonary arterial vasoconstriction and remodeling

A

secondary

72
Q

Combined pre and postcapillary PH is characterized by PAWP > ___ mmHg and a PVR > ___ wu

A

PAWP> 15 mmHg

PVR > 3.0 wu

73
Q

Combined pre and postcapillary PH can be subcategorized as ____ or ____ due to the response to vasodilators, diuretics, or mechanical assistance.

A

fixed or vasoreactive

74
Q

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.

A

without

75
Q

What type of PH is this with these values?

mPAP: > 20 mmHg

PAWP: <15 mmHg

PVR: >3 wu

group: 1,3,4,5

A

isolated precapillary PH

76
Q

What type of PH is this with these values?

mPAP: >20 mmHg

PAWP> 15 mmHg

PVR: < 3 wu

group: 2,5

A

isolated postcapillary PH

77
Q

What type of PH is this with these values?

mPAP: > 20 mmHg

PAWP: > 15 mmHg

PVR: >3

group: 2,5

A

Combined pre and postcapillary PH

78
Q

What procedure is required for a dx, classification, and tx plan for Pulmonary Artery HTN?

A

Right heart catheterization

79
Q

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 ____

A

mPAP

80
Q

What is the formula to calculate PVR?

A

(mPAP-PAWP)/CO

81
Q

PH can result from abnormalities in the ___ or ___ components of the lung circulation, sometimes including contribution from both

A

arterial or venous components

82
Q

A patient with pulmonary artery HTN, who receives a TTE, will show ___ &___ enlargement and elevated peak tricuspid-regurgitation velocity

A

RA and RV enlargement

83
Q

This scan is a screening tool to estimate pulmonary arterial systolic pressure (PASP) for PH

A

Echocardiogram

84
Q

T/F: A PASP >41 mmHg estimated by an echocardiogram provides an accurate mPAP for definitive diagnosis.

A

False: Echocardiographic PASP is relatively sensitive and specific for PH, but it cannot provide the accurate mPAP for definitive diagnosis

85
Q

Once right heart cath is perfromed, the severity of PH can be determined:

-Mild PH (mPAP =_____ )
-Moderate PH (mPAP = ____ )
-severe PH (mPAP = ____ )

A

-Mild PH (mPAP = 20-30 mmHg )
-Moderate PH (mPAP = 31-40 mmHg )
-severe PH (mPAP = > 40 mmHg )

86
Q

Normal pulmonary circulation can accommodate a ____ increase CO without a marked change in mPAP

A

fourfold

87
Q

_____ PAH: no identifiable risk factor

A

idiopathic PAH

88
Q

1:8 patients have long-term improvements w/ ____ blockers

A

calcium channel blockers

89
Q

3% of PAH cases are deemed inheritable with a mutation in bone _____ ____ receptor type 2 (BMPR2), the remaining cases are designated “associated” PAH

A

Bone morphogenetic protein receptor type 2

90
Q

Despite improved diagnosis and therapy, 1-year mortality isabout ___ %

A

15%

91
Q

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

A

older pts and more men being diagnosed.

92
Q

With Pulmonary Artery HTN, sustained vasoconstriction and remodeling processes to pathologic distortion of ____ pulmonary arteries

A

small

93
Q

What are the three main classes of pulmonary vasodilator drugs from PAH?

*Combination therapy is often required for adequate tx of PAH

A

-Prostanoids

-Endothelin receptor antagonists (ERAs)

-Those working through nitric oxide/guanylate cyclase pathways

94
Q

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.

A

Prostanoids

95
Q

epoprostenol (IV)
iloprost (inhaled)
treprostinil (SQ, IV, INH, PO)
beraprost(PO)

These are all examples of what type of drug class for PAH tx

A

Prostanoids

96
Q

This specific prostanoid is the only medication that has been proven to reduce mortality in PAH pt

A

Epoprostenol

97
Q

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

A

Endothilin Receptor Antagonists (ERAs)

98
Q

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

A

Nitric oxide/guanylate cyclase

99
Q

Continuously inhaled _____ has been widely used in both preoperative and critical care settings, and preparations for home use have become available

A

nitric oxide

100
Q

Chronic therapy for PAH tx has been directed towards _____ inhibitors

A

PD-5 inhibitors

101
Q

____ pts often present with nonspecific sx of fatigue, dyspnea, and cough

A

PAH

102
Q

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

A

angina and syncope

103
Q

On physical exam, pts with PAH may exhibit a ____ lift, accentuated S2, S3 and/or s4 gallop, JVD, peripheral edema, hepatomegaly, and ascites

A

parasternal

104
Q

Rarely, compression of a dilated PA may lead to ___ damage and hoarseness

A

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

105
Q

T/F: PH should prompt further evaluation of functional status, cardiac performance, and pulmonary function tests

A

True

106
Q

T/F: For pts with moderate or severe PH, a right heart cath prior to moderate-high risk surgery is not recommended

A

False: R heart cath IS recommended before a moderate-high risk surgery

107
Q

Should a patient that has PH and coexisting left heart dz also have a left heart cath?

A

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

108
Q

Can vasoreactivity testing be performed during right heart cath in PH patients?

A

Yes, vasoreactivity testing, often with inhaled nitric oxide, is performed during right heart catheterization to determine responsiveness to vasodilator therapy

109
Q

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?

A

85-90%

110
Q

PAH screening/ tx algorithm

A
111
Q

Chart: risk factors for PAH pt in noncardiac surgery

A
112
Q

Primary intraoperative goal is maintaining optimal “ _____ ______ “ btw the right ventricle and pulmonary circulation to promote adequate left-sided filling and systemic perfusion

A

“Mechanical coupling”

113
Q

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 _____

A

serious consequences

114
Q

A hallmark of PAH is _____ RV afterload –> leads to RV dilation, increased wall stress, and RV hypertrophy

A

increased RV afterload

115
Q

The interaction btw the RV and the pulmonary circulation is ___ and dynamic, involving the compliance and “stiffness” of lg & small vessels

A

pulsatile

**This is relevant during acute insults that occur during surgeries which affect RV pulsatile load

116
Q

Ventilator management can have effects on RV afterload through the addition of: 5 things

A

PEEP

hypoventilation

hypercarbia

acidosis

atelectasis

117
Q

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 ____ _____

A

oxygen demand

118
Q

T/F: RV coronary perfusion only occurs during diastole

A

F: Under normal circumstances, the RV intramyocardial pressure is lower than the aorticroot pressure, and RV coronary perfusion occurs throughout the cardiac cycle

119
Q

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

A

True

120
Q

What is the “lethal combination” with PAH?

A

SystemicHoTNalong with RV ischemia and high afterload can result in the “lethalcombination” of RV dilatation, insufficient LV filling, reduced stroke volume, andfurther systemic hypotension

121
Q

T/F: There is an increase in perioperative morbidity and mortality in pts with PH undergoing hip and knee replacement

A

True

122
Q

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

A

acute

123
Q

Procedural considerations:

Thoracic surgery: Thoracic procedures involve _____ and ____ of the operative lung

A

non-ventilation and atelectasis

124
Q

Procedural Considerations:

Thoracic Surgery:

-3 Features of lung collapse that are particularly relevant for PAH

A

(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

125
Q

PAH is the only class of Ph found to benefit from pulmonary ______

A

vasodilators

126
Q

PAH pts on vasodilators should have them continued intraoperatively and _______, and converted from oral to IV or inhaled when necessary

A

postoperatively

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