HTN and IHD Flashcards
HTN is defined as SBP above ______ and DBP above ______
140
90
classic medicine involves sub-dividing any interval into ________ ______
smaller increments
HTN affects ____ of the global population
25%
_____ of surgical patients in the US will have HTN
1/3
______ ______ more frequently affected than caucasian
african american
prevalence is higher in men except at extremes of _____ where women are higher
age
HTN is an independent risk factor for _______ and ______ when left untreated
morbidity and mortality
small percentages of patients present with HTN r/t another _____ _____
system pathology
most of the time, it is not a _______ issue but we should be watching for unanticipated HTN
secondary
90-95% of pts with HTN have “_______ ______” which is unknown origin
essential HTN
if you consider the worsening of a pathology, a gradual progression of essential HTN should be ________ prior to presentation at the _____ _____
intercepted
severe level
diagnosis might include several readings to obtain an ______ (______) hypertensive state
average (sustained)
we know that there are several causes of HTN and a high reading might not reflect ________
pathology
3 essential systems that impact BP
- ANS
- RAAS
- vascular endothelium substance production
ANS encompasses:
HR x SV x SVR
primarily manages ______ term and ______ change
short
rapid
input from _____-______ and cardiac and peripheral receptors that automate cardiac and vascular function
baro-receptors
correlates with _____ and ______ response
[ANS]
inflammatory and stress
innervation of the sympathetic chain and subsequent peripheral nerves controls vasculature ________ and ______ ________ through input of the vasomotor center of the CNS
constriction and cardiac accelerators
stimulation of the ______ ______ can result in sympathetic hormone release
adrenal medulla
_____ _______ directly to an organ may result in excitatory changes
SNS stimulation
release by the _______ of sympathetic hormones _______ & _______ do the same thing but last longer because of metabolism
adrenals
NE and Epi
renal control of pressure includes control/excretion of ________ _______ and the ______ ______ ______ system
extracellular fluid
renin angiotensin aldosterone system
RAAS increases ______ ______ (intermediate term) and retention of _______ (long term)
vascular tone
fluid
renin from kidney is stimulated by ____ ______ ______
low arterial pressure
allows conversion of ________ to ________
angiontensinogen to angiotensin I
angiotensin I is converted to angiotensin II by ______ in the lung. It is _______ acting but a potent _______
ACE
short acting
potent vasoconstrictor
AT II also decreases excretion of _______ resulting in increased fluid retention in the _______
fluid
vasculature
AT reduces blood flow through the kidneys by _______ and thus decreased _______ and increased ________ ______
vasoconstriction
filtration
fluid retention
you cant lose fluid if it isnt _______ out, risk for _______
filtered
AKI
AT stimulates the adrenal glands to secrete ________. this results in increased reabsorption of fluid in the kidneys. ______ & ______ retention and _______ excretion
aldosterone
sodium and water
potassium
renal path
afferent arterioles > glomerulus > efferent arterioles > proximal tubules > loop > distal tubule > collecting duct
ANP is from the
atria
BNP is from the
ventricles
a high ANP does NOT
stimulate renin
low ANP
stimulates renin
renin cascade end result is higher systemic ______ and increased systemic ______-______ ________
pressure
fluid-volume retention
vascular growth can be the result of
hyperplasia
hypertrophy
vasoconstriction can be the result of
direct
via increased noradrenaline release from sympathetic nerves
salt retention can be the result of
aldosterone secretion
tubular Na+ reabsorption
VESP
nitric oxide results in _______ - produced naturally to counteract unopposed _______ forces
dilation
vasoconstrictive
endothelin results in ________ - produced naturally in vascular walls
constriction
endothelin is released primarily during vascular insult to _______ ______
control hemorrhage
ANP and BNP - released in the _______ and cause _______
heart
vasodilation
(we see high BNP in volume overload)
inflammatory and stress response on the vasculature can inhibit ______ ______ and result in positive feedback loop with _______ - progressively higher pressures
natural response
endothelin
actions or drugs can stimulate or inhibit the natural response of ______ and ______ effecting blood pressure
nitric or endothelin
competing forces are the _____ and _____
nitric and endothelin
bc short term manipulation is controlled by the ______, our anesthetic pharmacology often addresses manipulation of these componenets
ANS
stressors of surgery and anesthesia are not the same as
day to day life
BP is like other anesthesia goals - balance the effect of _______ against ______
surgery
normality
bc stress of surgery often stimulates ANS responses, our mitigation addresses these components:
1. _______ and sympathetic ______-______ fxns are concurrently stimulated
2. inhibition of PNS ______ _______ to the heart
3. both ______ and ______ are constricted
vasoconstrictor and sympathetic cardio-accelerators
vagal stimulation
arteries and veins
the resulting constriction increases ____ while an increased ____ and force of contraction increase ______
BP
HR
SV
increased stretch in the baroreceptors stimulates a reduction in __________
pressure
impact is a manipulation of the ______ elements of the ______. increased/decreased vagal stimulation results in the ability to change _____ and thus ______
parasympathetic elements of the ANS
HR and thus CO
practical example is change of body position when superior aspects of the body lose pressure and the ______ and _________ allow for reperfusion of brain and torso
CO and vasoconstriction
HR increases by inhibiting the baseline ______ _____
vagal stimulation
bainbridge reflex manipulates CO but not for the benefit of _____ _____ ______
blood pressure control
in response to an increase in atrial pressure, _________ stimulation results in increased or decreased stimulation to the heart for ______ ______
parasympathetic
rate control
this reflex addresses increases in blood volume to “_____” the heart
unload
effect of HTN on the general population correlates with:
vasculopathy/PVD
end organ damage
ischemic heart disease
cerebrovascular disease
stroke
aortic disease; specifically aneurysm
neuopathy
meaning that HTN results in all of these changes due to changes in vessel _______ and ______ _______
compliance
decreased flow
essential HTN addresses one or more of the primary ________ of BP
generators
“fixing the problem at its source”
ANS - drugs are used to blunt the _____, _____, and ______
HR, SV, and SVR
Renin/AT system - drugs reduce volume or intercede in one of the conversion processes to _____ ______
dilate vessels
endothelium vasodilation drugs - improve or enhance the direct acting dilation effect of ______
NO
as a general rule, beta blockers are reserved for _____ ____ _____ patients and not as a first line therapy for ______ ______
coronary artery disease
essential hypertension
some gains have been made by re-perfusing the kidney if _____ ______ ______ is thought to be the cause of renin/AT activation
renal artery stenosis
for long term control, renal blood ______ is increased or reabsorption of salt and water is _______
[addressing the problem]
flow
decreased
increased blood flow is accomplished by any number of
vasodilators
drugs that decrease reabsorption block the movement of ______ in ______
sodium in tubules (diuretics)
one thing to consider when choosing medications is the specific “______” being fixed or the _____ of intervention needed
problem
speed
general expectations are that the patient will continue their normally scheduled ___________ meds
anti-hypertensive
some exceptions are made with ______ and ______ drugs due to the likelihood of significant ________ intraop. UNLESS:
ACEIs and ATIIRBs
hypotension
UNLESS part of cardiac risk reduction
_____ ______ already scheduled are always continued bc they are primarily being used for ______ effect
beta blockers
cardioprotective effect
beta blockers are not routinely administered ________ in the absence of a schedule for ______ ______
prophylactically
essential HTN
general consensus is that essential HTN wont be cured in periop period and patient specific pressure should be maintained with the exception of _______ _______ pressure (____)
extraordinarily high pressure (> 180 SBP)
_____ pressure monitoring may be warranted, continuous ______ management of volume and heart fxn can be useful
arterial
TEE
_______ is of greater value than the absolute number and _______ is BETTER than _______ pressure
stability
higher is BETTER than lower pressure
drugs affecting HR/SV:
CCBs: cardizem, cleviprex, cardene
BBs: labetolol, esmolol, metoprolol
direct acting vasodilators
nitroglycerin, nitroprusside, hydralazine
pulm HTN value
mean PAP > 25 mmHg
PHTN diagnosed by _______ and clinically useful assessment by _____
RHC
TEE
PHTN can occur in several ways:
vascular abnormality and vasoconstriction
left heart failure leading to right heart failure
combined increase PVR with chronic disease (shunt response through HPV)
some of the more common causes are:
COPD/lung dz
OSA (as much as 50% of pts with OSA/hypoventilation have PHTN)
LVF
drug induced PHTN
parenchymal lung dz such as sarcoid and fibrosis
pa pressures - inflating the balloon captures the data on the ____ side of the balloon without the _____ side
distal
proximal
distal pressures can result in effects ______ (high PA may result in high ____/____)
proximally
RA/CVP
prostanoids treat PHTN - produce _______ and decrease ______ ______/_______ response
vasodilation and decrease platelet effect/inflammatory response
endothelin receptor antagonist treats PHTN - allow natural effect of NO to function by inhibiting _______
endothelin
this picture describes what pathologic process
LVH
