HTN, CAD, and Valvular Heart Disease Flashcards
Elevated SDP as defined without an etiology; onset 25-50 years old
Primary (essential) hypertension
Elevated BP where the cause of the high BP can be identified and sometimes treated
Secondary HTN
BP uncontrolled despite adherence to an appropriate 3-drug regimen, in which all drugs are dosed at >50% of recommended dose
Resistant HTN
Patient with resistant HTN who cannot be controlled >4 medications
Refractory HTN
What is white coat syndrome?
BP that are high in the clinic or office but normal elsewhere
What is masked HTN?
BP that is consistently elevated out-of-office measurements but does not meet criteria for HTN upon office readings
What is a hypertensive urgency?
Severe HTN >120 DBP in asymptomatic patient
What is a hypertensive emergency?
Sever HTEN >120 DBP with acute end-organ damage
Blood Pressure = ?
Cardiac output x Vascular resistance (SVR)
What are the 3 factors affecting BP?
- Sympathetic nervous system
- Renin-angiotensin-aldosterone system
- Plasma volume (mediated by kidneys)
What is the average pressure in the arterial system?
Mean arterial pressure
MAP (mean arterial pressure) = ?
[(2xdiastolic) + systolic]/3
What is the normal range of mean arterial pressure?
70-110
<50% of people with HTN have it adequately controlled, why?
Poor access to healthcare, lack of adherence to long-term asymptomatic condition, therapeutic inertia
What is HTN a risk factor for?
Heart attack, stroke, CVD, kidney disease
When does the risk of major CV and stroke events double?
Above 115/75, for each increase of 20 mm Hg in systolic BP or 10 mmHg in diastolic BP
Who has an earlier age onset and worst outcomes of HTN?
Blacks
What are the benefits of lowering BP?
Stroke incidence decrease 35-40%
MI decrease 20-25%
Heart failure decrease 50%
What are some risk factors for primary HTN?
exact etiology is unknown age, obesity, family hx, race, high-sodium diet, excess alcohol consumption, physical inactivity, diabetes and dyslipidemia, hostile/angry/depression
What are the common etiologies for secondary HTN?
Chronic kidney disease renovascular disease/renal artery stenosis, mineralocorticoid excess, sleep breathing disorder, medications
What are the uncommon etiologies for secondary HTN?
Pheochromocytoma, endocrine disorders, coarctation of aorta
What is the most common cause of renovascular HTN in older patients?
Atherosclerosis
What is the most common cause of renovascular HTN in young patients (especially females)?
Fibromuscular dysplasia
Other causes of renovascular HTN?
Aortic/renal dissection, Takayasu’s arteritis, thrombotic/cholesterol emboli, CVD, post transplantation stenosis, post radiation
Brain complications of uncontrolled HTN?
Ischemic stroke, intracerebral hemorrhage, cerebral atrophy and dementia
Eye complications of uncontrolled HTN?
Retinopathy, retinal hemorrhages, vitreous hemorrhage, retinal detachment, impaired vision/blindness
Kidney complications of uncontrolled HTN?
CKD, ESRD
Cardiac complications of uncontrolled HTN?
Coronary heart disease, ischemic heart disease, LVH, HF, acute aortic dissection, arterial aneurysm, HTN emergency
What are the 4 stages of hypertensive retinopathy?
Stage 1: Narrowing
Stage 2: AV Nicking
Stage 3: Hemorrhages, cotton wool spots and exudates
Stage 4: Papilledema
What is the screening technique for 18-39YO (HTN) <130/80
Every 3-5 years
What is the screening technique for 18-39 YO with risk factors or >130-139/85-89 BP
Screen annually
What is the screening technique for someone >40YO (HTN)
Annually
Normal BP is considered what?
<120 / <80
PreHTN is considered what?
120-39 / 80-89
Stage 1 HTN is considered what?
140-159 / 90-99
Stage 2 HTN is considered what?
> 160 / >100
Isolated systolic HTN is what?
> 140
Isolated diastolic HTN is what?
> 90
What do you need in order to diagnose HTN?
BP readings >two separate office visits*
Average of 2 or more properly measured readings/visit
Weeks-months apart
HTN diagnosis
Home BP >130/80
24 hour ambulatory monitoring: daytime <135/85 nighttime: 120/70
What are some initial symptoms seen with HTN?
HA, dizziness, weakness, vision changes, SOB, orthopnea, chest pain, claudication, palpitations, sweating, fatigue, daytime sleepiness, weight gain
Secondary HTN hx clues
Onset at age <30 years, unresponsive to treatment, episodic, HA and chest pain/palpation (pheochromocytoma, thyroid dysfunction), morbid obesity with history of snoring and daytime sleepiness (sleep disorders)
Secondary HTN PE clues
Pallor, edema, other signs of renal disease, abdominal bruit especially with a diastolic component (renovascular), truncal obesity, purple striae, buffalo hump (hyercortisolism)
Labs for HTN
BMP, LFTs or CMP, Lipids (fasting), hemoglobin/hematocrit, Urinalysis, EKG
Lipids tested for HTN
HDL, LDL, triglycerides
What are some things that may trigger a clinician to investigate secondary causes of HTN?
New onset @ younger age, pts presenting with Stage 2 HTN, abrupt onset in previously normal, resistant HTN, abdominal bruits, hypokalemia
What are some non-pharmacologic treatments for preHTN and HTN?
Weight reduction, adopt DASH eating plan, dietary sodium reduction, physical activity, moderation of alcohol consumption
What is the DASH eating plan?
Diet rich in fruits, veggies, and low-fat dairy products with a reduced content of saturated and total fat
What type of physical activity is good for HTN and preHTN?
Regular aerobic activity such as brisk walking (at least 30 minutes per day, most days of the week)
What are the recommended pharmacologic treatments for HTN and preHTN?
Diuretics: HCTZ, Chlorthalidone
CCB: Amlodipine, Dihydropyridine preferred
ACE: Lisinopril, benazapril
ARB: Losartan
According to the JNC 8, what are the recommended treatments for HTN?
All therapy includes lifestyle modifications
What are the JNC recommendations for preHTN?
Non-pharmacological therapy only
CKD>?
CKD>Race>Comorbidities according to the JNC 8 for HTN recommendations
What is the proper treatment for someone with CKD?
Any age or race, ACE inhibitor or ARB
What is the proper treatment for someone who is >18YO and black?
Thiazide or CCB
What is the proper treatment for someone who is >18YO non black and non CKD?
Thiazide, CCB, ACE inhibitor, ARB
Most patient with HTN will require what?
More than one BP medication to reach the goal
When should a new drug be added to HTN regimen?
Increase or add new drug at 2-4 week intervals
After 5 years how many patients will require dual or triple therapy for HTN?
40-43%
Follow-up and monitoring for HTN
PreHTN: non-pharm management and f/u annually
Stage 1: non pharm-management 1-6mo f/u
Patients on pharmacological therapy should be monitored how often?
Re-evaluated every 2-4weeks until BP is achieved
Thiazide monitoring
Check K 3 weeks after each adjustment
After BP goal is stable, how often should they be monitored?
3-6 month intervals, most should reach the regimen within 6-8 weeks
Serum potassium and creatinine should be monitored how often?
1-2 times per year
Things to consider if BP therapy isnt working
Inaccurate BP measurement, poor adherence to meds, poor adherence to lifestyle and dietary approaches, suboptimal antihypertensive therapy, white coat syndrome, resistant HTN
How do you treat resistant HTN?
Refer to HTN specialist. Consider: lifestyle, diet or medications that interfere
Resistant HTN treatment
Add ons to the 3 original medications: Potassium-sparing diuretics Spironolactone, Eplerenone, Amiloride
BB Labetolol Carvedilol
Alpha-1 blocker Clonidine
Others: vasodilator like Hydralazine
What are the 3 original medications that should be used for resistant HTN?
Thiazide, CCB, ACE/ARB
HTN urgency si/sx
Systolic >180
Diastolic >120
Asymptomatic, no evidence of organ damage, no benefit in rapid reduction, slow reduction over days
HTN emergency si/sxi
Systolic >180
Diastolic >120
Symptomatic: HA, blindness, chest pain, dizziness
What end organ signs will be seen with HTN emergency?
Hypertensive encephalopathy, acute left ventricular failure with pulmonary edema, acute MI or unstable angina pectoris, dissecting aortic aneurysm
What is the management for hypertensive urgency?
Lower BP over a period of hours to days, goal is <160/<100 or no more than 25-30% baseline
Medication options for hypertensive urgency management
Furosemide: if not volume depleted
Oral clonidine or oral captopril: if not volume overload
Hypertensive emergency management
Immediate but careful reduction in BP is indicated, excessive hypotension may lead to ischemic complications
Parenteral agents for hypertensive emergency
Nitroprusside, Nitroglycerin, Nicardipine, Labetolol, Esmolol, Hydralazine
Pathophys of coronary artery disease
Atherosclerosis causes: Thickening of the arterial vessel wall, leading to deposits of cholesterol and other substances
Increased vascular resistance leads to what?
Increase vascular resistance -> progressive -> complete occlusion (ruptured clot) -> myocardial infarction
The Framingham Heart study
Began in 1948 with 5,209 adults. Much of “common knowledge” about heart disease has been learned through this study
Framingham study taught us what?
Risk factors: HTN, high cholesterol, cigarette smoking, healthy diet (good), weight, regular exercise (good)
What is the framingham risk score?
It estimates the 10 year cardiovascular risk of an individual
What does the risk score not include?
Diabetes or Family Hx, so it may underestimate the risk
Risk factors for CAD
> 65YO, M>F until menopause, smoking, dyslipidemia, HTN, DM, abdominal obesity, family Hx of 1st degree relative with premature MI (men <55 women <65), cocaine use
Stroke risk factors (also found in framingham study)
HTN and LVH
HF risk factors (found in framingham study)
HTN
Metabolic syndrome is three or more of the following
- Abdominal obesity
- Triglycerides >150mg/dL
- HDL <40 for men and <50 for women
- Fasting glucose >110
- HTN
Primary prevention of CAD involves what?
Maintaining or achieving ideal weight, physical activity, eat healthy diet, refrain from cigarette smoking, maintain BP at goal, maintain normal “bad” cholesterol, glycemic control in diabetes, high risk: take aspirin, small amount of alcohol consumption
What type of diet will help with primary prevention of CAD?
Fruits, veggies, fiber, low glycemic index, unsaturated fats, omega-3 fatty acids (Mediterranean diet)
Chest “pain” attributable to myocardial ischemia (oxygen supply/demand mismatch)
Angina pectoris
What is anginal equivalent?
Symptoms other than chest discomfort attributable to myocardial ischemia (SOB, dizziness, nausea, fatigue)
What are the 4 main factors that affect oxygen demand in angina pectoris?
- Heart Rate
- Systolic BP
- Myocardial wall tension or stress
- Myocardial contractility
What are the symptoms of chronic stable angina pectoris?
Chest discomfort or dyspnea WITH EXERTION lasting 5-15 mins, relieved by rest and/or nitro, typically located central or slightly left side of chest, lightheadedness, fatigue
Stable angina pectoris description of discomfort?
Tightness, squeezing, burning, gas, indigestion or ill characterized
Differential diagnosis of chest pain
Cardiac ischemia or infarction, aortic dissection, pulmonary embolism
Most patients with stable CAD will have what?
Fairly normal physical exam
What is the PE of someone with stable CAD?
General appearance: Central obesity, sweaty, SOB with minimal exertion
Vitals: High BP
Diminished peripheral pulses (peripheral artery disease)
Bruits of arteries: carotid, renal, aorta, femoral
Possible EKG findings in patients with CAD
Pathologic Q waves, non-specific ST-T wave abnormalities, LVH, ST depressions, ST elevations during STEMI
What does a pathologic Q wave suggest?
Previous infarction
What does a non-specific ST-T wave abnormality suggest?
Suggests previous or active ischemia or infarction
What does LVH on an EKG suggest?
Long standing HTN
What does ST depressions suggest on an EKG?
During active ischemia; when supply is less than demand
Stable angina
Patient is asymptomatic at rest, symptoms are provoked by predictable amount of exertion (or stress, high BP, etc.)
Unstable angina
Symptoms at rest or with less exertion than prior baseline
What is stress testing?
The method of diagnosing CAD in conjunction with the rest of the clinical assessment, non-invasive, appropriate for stable angina
What is stress testing C/I in?
Unstable angina
What is the “gold standard” for diagnosing CAD?
Coronary angiography, but not used as primary modality due to limitations (invasive, costly, does not yield physiologic information)
What are the 3 categories of chest pain?
- Classic (typical) angina
- Probably or atypical angina
- Nonanginal or nonischemic chest pain
What is classic (typical) angina?
Substernal chest discomfort, typical in quality and duration, provoked by exertion or stress & relieved by rest or NTG
What is probably or atypical angina?
Chest pain with 2/3 of the following characteristics:
Substernal chest discomfort, typical in quality and duration, provoked by exertion or stress & relieved by rest or NTG
What is nonanginal or nonischemic chest pain?
Chest pain with one or non of the following characteristics:
Substernal chest discomfort, typical in quality and duration, provoked by exertion or stress & relieved by rest or NTG
What are the indications for stress testing?
Patients with symptoms suggesting stable angina with intermediate pretest probability or disease
Pre-op risk assessment for non-cardiac surgery
Pts with significant change in cardiac symptoms
After resolution of acute chest pain
Prior to angiography to localize lesion
What can happen with the pretest probability?
High pretest probability will have some false negative rate of tests, while low pretest probability will have some false positive tests
What are some factors to consider when choosing the type of stress test?
Pts ability to exercise, pts resting EKG, the clinical indication for performing the test, pts body habitus, hx of prior re-evaluation
What are the 4 types of stress tests?
- Exercise tolerance testing (ETT) uses treadmill and EKG
Imaging Tests - Echocardiography (exercise or pharmacologic)
- Radionuclide myocardial perfusion imaging (exercise or pharmacologic)
- Positron emission tomography (PET) almost always pharmacologic
What type of stress test is first line for most patients?
ETT (exercise tolerance testing)
In order to do the ETT, what must the resting EKG be without? (exclusion criteria)
ST abnormalities, LVH, LBBB, vent-paced, WPW (CAD risk low to moderate)
ETT criteria
Patient must be able to exercise, simple and inexpensive!
False positives with ETT
Women have more than men, but its still first line for them
What test looks for stress induced regional wall motion abnormalities?
Stress echocardiogram
Stress Echocardiogram
Exercise or pharmacologic, echo at rest, then after stress Operator dependent (sensitivity relates to technician experience)
What are other names for the radionuclide myocardial perfusion imaging?
Stress myoview, stress MIBI (Sestamibi)
Radionuclide myocardial perfusion
Inject radioactive nucleotide, poorly perfused areas of the heart do not take up color, localize lesion to coronary artery
Nuclear medicine PET CT stress test
Very sensitive, very expensive, best test for obese patients, not readily available
Which test is best used for obese patients?
Nuclear medicine PET CT stress test
Acute Coronary Syndrome (ACS)
- Unstable angina
- Non-STEMI
- STEMI (most serious)
Classic presentation of ACS
Early am, substernal chest pressure “an elephant sitting on my chest,” severe, sense of impending doom, radiates to L arm, both arms or jaw, associated SOB, nausea, diaphoresis, light-headed, lasts >20min but <1hour
Unstable Angina
Ischemic symptoms suggestive of ACS and no elevation of cardiac biomarkers (Troponin)
Unstable plaque without plaque rupture
May or may not have ST depression or non-specific changes
NSTEMI
Potentially same manifestations as US but DO have elevated cardiac biomarkers (Troponin) suggestive of myocardial tissue death
Unstable plaque +/- rupture with complete occlusion
STEMI
More likely have “classic” presentation
Plaque rupture with complete occlusion
Diagnosing ACS
Story trumps all! EKG: look for changes compared to prior EKG
Cardiac biomarkers: CK, CKMB, Troponin, can show evidence of myocardial infarction
Women and diabetics are more likely to present with atypical symptoms
What are the CK isoenzymes?
Skeletal muscle: CK-MM 98%, CKMB 1%
Myocardium: CK-MM 70%, CKMB 25-30%\
Troponin: TnC skeletal muscle, TnI and T specific to cardiac muscle
Out of the cardiac isoenzymes, which are more specific to the heart and should be measured?
CKMB (mostly just in heart, not so much in skeletal muscle)
Troponin TnI and TnT