HTN Flashcards

1
Q

Special considerations

A

Renal disease- Initial increase in creatinine normal….. Contraindicated in bilateral renal artery stenosis ACE might temporarily increase creatinine but should level off if not they might have bilat renal artery stenosis- we are blocking BF to renal arteries

CAD- BB’s may be added to ACE-I

Diabetes Mellitus- Usually need multiple agents Avoid adverse glucose metabolism Lower BP goal ACE-I or ARB 1st line

Reproductive women- Estrogen stimulation of hepatic angiotensinogen

Elderly : > 75y/o Modest doses reduce stroke

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2
Q

Stages of hypertension

A

•Stage 1

Modify lifestyle

May add monotherapy anti-hypertensives w/ co-morbidities

CAD/stroke risk or DM/CRI (renal disease)

•Stage 2

Will use combo therapy (systolic 140 or higher/ diastolic 90 or higher) diuretic and beta blocker or something

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3
Q

Which number is more related to cardiovascular risk? Systolic or diastolic?

A
  • Systolic- Max pressure to eject blood out of heart; higher max pressure on a constant basis= more ling term weakening to BV’s
  • Diastolic- Lowest pressure arteries go thru; lowest pressure is still pressure; also not enough can cause poor coronary artery perfusion
  • Also pulse pressure matters= the wider it gets the less coronary artery filling you have
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4
Q

Why does BP control matter???

A
  • 7/10 people having their 1st MI= uncontrolled BP
  • 8/10 people having 1st stroke= uncontrolled BP
  • 7/10 people with CHF= uncontrolled BP
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5
Q

Types of Hypertension

A

Essential/ Primary/ Idiopathic: an identifiable cause cannot be found: Interrelated renal, hormonal, vascular

Secondary: an identifiable cause is present (pheocromcytoma

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6
Q

Essential: Commonalities

A
  • Familial incidence
  • Deficiencies of endogenous prostaglandins and NO
  • Renin or adrenergic dysfunction
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7
Q

RAAS

A
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8
Q

Low renin hypertension- subset of essential HTN

A
  • Salt-sensitivity
  • Diuretic responsiveness
  • Expanded extracellular fluid volume
  • African descent, diabetics, elderly- thiazides
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9
Q

High renin hypertension

A
  • Plasma renin levels above normal
  • Poorly responsive to competitive antagonists of angiotensin II- 50%
  • Increased adrenergic activity- give beta-blocker
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10
Q

Modulation defect

A
  • Salt-sensitivity: kidney doesn’t excrete Na+ properly
  • More insulin-resistant: getting type II DM at the same time
  • Susceptible to ACE-I
  • Males, postmenopausal
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11
Q

Diagnosis of HTN

A

•Persistently high resting blood pressure

Per month x 3

Seated, back supported, feet on floor

Not talking, arm on flat surface, level with heart

Correct sized cuff

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12
Q

Diagnosis Lab

A
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13
Q

Treatment of Stage I w/out co-morbidities

A

•Lifestyle modifications

***Diet/weight loss

Moderate alcohol intake

Increase physical activity

Cessation of smoking

Sodium restriction

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14
Q

Initial Pharmacotherapy- HTN

A

•Stage I – risk for CAD or stroke/ already have DM

Monotherapy: Diuretics, CCB, ACE/ARB

BP goal < 130/80

Sequential addition if needed- 2nd drug of different class

•Stage II

2 agents, different classes= usually ACE/ARB or CCB and diuretic

Separate or combo (can have both drugs in one pill)

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15
Q

Diuretics

A

thiazide most used for HTN, loop more short-term, can swap to K+ sparing if loop causing prob

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16
Q

Diuretic therapy considerations

A
  • Sodium diuresis/volume depletion
  • May decrease PVR: max pressure to artery
  • Effective within 3-4 days
  • Out of favor (d/t hypokalemic side effects but….. < 25 mg/day HCTZ we don’t have bad hypokalemia
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17
Q

ACE INhibitors

A
18
Q

ACE-I therapy

A
  • Inhibit generation of potent vasoconstrictor
  • Retards degradation of bradykinin- 2 armed approach w/ vasoconstriction
  • Especially useful in diabetic patients- prevent negative side effects of excessive carbohydrates
  • Cough 5-10%, hyperkalemia, angioedema- w/ ARBS don’t have
19
Q

ARB’s

A
20
Q

ARB therapy

A
  • Most selective blockers of R/A system
  • Fewer side effects than ACE-I
  • Blocks Ang II from attaching to receptor- we do not currently know if there is a long term effect of blocking but still circulating Ang II
21
Q

CCB’s

A
22
Q

CCB therapy

A
  • Modify calcium entry thru α-1 L-type voltage channels but more than 1 type (at least 3)
  • Specificity to unique binding sites…
  • All: vasodilation
  • Only Diltiazem and Verapamil: slow AV conduction
23
Q

Secondary Hypertension

A
  • 5% of cases
  • Renal artery stenosis most common cause
  • Other examples

Pheochromocytoma

PIH

Cushings’s syndrome

Coarctation of the aorta

24
Q

Systemic Hypertension: AHA

A
25
Q

NY classifications of CHF

A
26
Q
A

CXR of failure

27
Q
A

CXR of failure: Kerley B

28
Q

Echocardiogram

A
29
Q
A

•LVH-

Diagnostic criteria: look at V1 (tall S wave) and V5 (tall R waves >35)

•Strain pattern: ST changes

30
Q

Management strategies

A
31
Q

Management of failure

A
32
Q

Neurologic effects of HTN

A
33
Q

Altered Cerebral Autoregulation

A
34
Q

Autoregulation theory

A
35
Q

Anesthesia Considerations
for hypertensive patients

A
36
Q

Physical assessment changes fm HTN

A
37
Q

Where do we delay/cancel?

A
38
Q

Lab Parameters

A
39
Q

Special considerations- 5 subgroups in HTN

A
40
Q

what do wil we be considering?

A

A. Left ventricular hypertrophy

  • Concentric hypertrophy
  • Increased wall thickness

B. Heart Failure

  • Typically diastolic failure
  • Age dependent
  • <15% pts <45y/o
  • 35% pts 50-70y/o
  • >50% pts >70y/o

C. Neurologic effects of HTN

  • Retinal changes
  • CNS dysfunction
  • Occipital HA
  • Dizziness
  • Vertigo
  • Syncope
  • Cerebral infarction vs cerebral hemorrhage

D. Altered Cerebral Autoregulation