HTN Cardiomyopathy CHF Flashcards
hypertension
-Elevation of BP at 2 or more office visits after an initial screening (3 total)
-With 2 or more readings at each office visit
-If there is a disparity in category between the systolic and diastolic pressures, the higher value*determines the stage
-normal- <120/<80
-prehypertension- 120-129/<80
-hypertension (stage 1)- 130-139/80-89
-hypertension (stage 2)- >140/>90
primary hypertension- essential
Description:
-90-95% of cases, no identifiable cause
-no treatable cause
-Hypothesized factors:
-SNS hyperactivity, abnormal renal development
Exacerbating factors:
-Alcohol, tobacco, sedentary lifestyle
-NSAIDs
-Polycythemia vera: thicker blood
-Males, African American
-Diet
-Obesity
secondary hypertension
5-10% of cases
Causes: “bella PORCH drives on the PCH -> shes just a secondary thought (forgotten influencer”
- parenchymal renal ds
- obstructive sleep apnea
- Renal artery stenosis
- coarctation of aorta
–hormone use
-pheochromocytoma
-cushing’s syndrome
-hypothyroidism
-coarctation of aorta - - (hypertensive on the left)- congential abnormality
-parenchymal renal ds - Angiotensin cascade
-Renal artery stenosis - Angiotensin cascade
-pheochromocytoma
-cushing’s syndrome
-hormone use
-hypothyroidism
-obstructive sleep apnea
reasons to screen for secondary HTN
-new/abrupt or uncontrolled HTN
-presence of drug resistant or drug induced HTN
-onset of HTN in young person <30
-exacerbation of previously controlled HTN
-disproportionate target ORGAN DAMAGE for the degree of HTN
-accelerated or malignant HTN
-onset of DIASTOLIC HTN in older adults >65
-unprovoked or excessive HYPOKALEMIA
hypertension complications
Cardiovascular:
-Coronary artery disease
-heart failure
-valvular disease
-left ventricular hypertrophy
-aortic aneurysm/dissection
-peripheral vascular disease
Nephro: Renal sclerosis
Neuro:
- TIA
- CVA
- encephalopathy
- aneurysms
Optic:
- Retinopathy
- retinal hemorrhage
- blindness
hypertension initial testing
-12 lead EKG: Left ventricular hypertropy (LVH)
Labs: Rule out secondary causes
-Potassium
- blood glucose (diabetes)
- creatinine/BUN kidney
-Pheochromocytoma: 24 hour urinary metanepharine and normetanephrine
-Thyroid and parathyroid disease- TSH, T3/T4, serum PTH
-Primary aldosteronism: 24 hour urinary aldosterone level
-Lipid profile- Atherosclerosis risk
echocardiogram
echocardiogram
-2-D echocardiogram (Transthoracic):
-Ultrasound technology allowing to view cardiac structures including atria, ventricles, and valves
-Transesophageal echocardiogram (TEE):
-Ultrasound technology through esophagus allowing better visualization of the mitral valve and left atrium
-Left atrial appendage thrombus*
-Mitral regurgitation
-best way to see aortic and mitral valve
Ejection fraction normal values
-Ejection fraction = percentage of blood ejected from left ventricle
-Normal: 55%
-Low normal: 50-55%
-Low: 45% and less
ICD at < 35%
hypertension goal BP and lifestyle management
Goal BP:
-DM or CKD < 130/80
-All others <140/90
Lifestyle management:
-1. Weight loss- BMI 18.5-24.9** best tx to lower BP
-2 Dietary Approach to Stopping Hypertension (DASH diet)- Low salt, low saturated fat, increasing fruits and vegetables
-<2000mg salt for low salt diet
-3. Aerobic exercise- 30 mins or more, 5 days or more
-4. Limitation of alcohol consumption- 2 or less drinks daily for men, 1 or less drinks daily for women
-STOP SMOKING **
hypertension: pharm modifications
hypertension: pharm modifications
-DM, CKD, and patient without comorbidities who have failed non-pharmacologic modifications
-Diuretics are first-line for all pt w/o comorbidities (hydrochlorothiazide) **
HTN: pharmacologic modifications for pts with comorbidities or those who have failed non-pharmacological modifications
Diabetes mellitus + Chronic Kidney Disease (stage I, II) + Cerebral Vascular Disease
- ACE inhibitors (-prils) or ARB
Coronary artery disease (post-MI)
- beta blockers or
- ACE inhibitors or
- ARB
Heart failure:
- beta blocker or
- ACE inhibitors or
- ARB or
- diuretics
What is first line pharmacologic treatment for patients with out comorbidities with hypertension?
Dieuretics
-THIAZIDE: HCTZ
Angiotensin 2 receptor (ARB)
MOA:
- vasodilation by inhibiting activation of angiotensin 2 receptor
-decrease preload/afterload
ADR:
- angioedema** BAD -> switch med
- hyperkalemia
- cough (less common)
- renal impairment
Drug names: -sartan drugs
-Valsartan
-Candesartan
-Losartan
ACE inhibitors MOA, ADR, drug names
MOA:
-vasodilation by inhibiting angiotensin-converting enzyme
-decrease preload/afterload
-category X in preg
ADR
- hyperkalemia**
- angioedema (mouth and lips) = BAD
- cough due to bradykinin production
- renal impairment
Drugs: -prils (X)
-Ramipril
- Lisinopril
-Enalipril
beta blockers
MOA:
-antagonists
-block receptor sites of epinephrine and norepinephrine on adrenergic beta receptors
ADR
- bronchospasm**
-> if bronchospams try a cardioselective b1
- hypotension
- fatigue (normal for 2 weeks)
- bradycardia
Drugs: -olol
- Metoprolol - beta 1 selective
- Bisoprolol - nonselective
- Propanerol -nonselective
- Carvediolol- mixed alpha and beta
calcium channel blockers
MOA
-decrease smooth muscle contraction and cardiac monocyte contraction by blocking calcium entry
-non-DHP have less vasodilation, selective to myocardium
-can cause dizziness when you stand - ask
ADR
- peripheral edema**
- fatigue
- hypotension
- muscle cramps (K shift)
Drug names:
- Amlodipine*
- Nifedipine*
- Verapamil
- Diltiazem
“think muscle and periphery with CCBs”
- non-DHP is more central but ADR causes PERIPHERAL EDEMA + muscle cramps, hypotension, fatigue”
diuretics
MOA:
-increase sodium excretion
-increasing water extrication
ADR
- hypokalemia
- hypochloremia
- hypotension
- renal failure
- pancreatitis
Thiazide :HCTZ (htn tx)
Loop: Flurosemide (Lasix) (HF symptomatic tx)
alpha blockers- HTN med; MOA, ADR, drug names
MOA:
-block alpha receptors in smooth muscle causing vasodilation
-only use when they are on meds and cant get BP down
ADR
- orthostatic hypotension**
- dizziness
- somnolence: excess sleepiness
- headache
Drugs:
-Clonidine
-Terazosin
-Doxazosin
“alpha males CANT stand up or lower BP
- only use when other meds arent working
- ADR: orthostatic hypotension”
meds to avoid with comorbities:
Chronic kidney disease (stage 3, 4),
Hyperkalemia, Hyponatremia, Asthma, gout, Angioedema, 2nd/3rd degree heart blocks, bradycardia
Chronic kidney disease (stage 3, 4):
- ACE inhibitors or ARB
Hyperkalemia
- ACE inhibitors or ARB
- aldosterone antagonist
Hyponatremia
- thiazide diuretics
Asthma
- beta blockers
Gout:
- thiazide and loop diuretics (first toe pain)
Angioedema-
ACE inhibitors
2nd/3rd degree heart blocks, bradycardia
- beta blockers
- non-dihydropyridine calcium channel blockers
hypertensive urgency definition
Definition:
-Blood pressure reading of systolic BP>180 mmHg and/or diastolic BP >120 mmHg
- WITHOUT evidence of end organ damage
hypertensive urgency management
Management:
-Gradual reduction of mean arterial pressure- Reduction should be no more than 25% over 24-48 hour period
-Oral Meds: goal is less than or equal 160/100mmHg
-Labetolol - Beta-blocker
-Nicardipine – Calcium channel blocker
-Captopril – ACE inhibitor
“need to go on a Norwegian Cruise Line (NCL) urgently”
-nicardipine (Calcium)
-labetolol (beta)
-catopril (ACE)
hypertensive emergency definition
Definition:
-Systolic >220
-Diastolic >120
-WITH END ORGAN DAMAGE -> may not be reversible
- NEED IMMEADIATE reduction of bp*
hypertensive emergency : Signs of end-organ damage
“UM I feel CRAPPIE this is an emergency!!-> we need to immediately reduce my BP or else i might get irreversible damage”
-Unstable angina (w/o exertion)
-MI
-CHF
-Renal Failure
-Aortic Dissection
-Papilledema
-Pulmonary edema
-Intracranial hemorrhage
-Encephalopathy
causes of hypertensive emergency
-Noncompliance*
No CAp Victor we in a PINCHER = Hypertensive emergency
-Noncompliance*
-Alcohol withdrawal
-Vasculitis
-Polycystic kidney disease
-Illicit drug use
-Noncompliance*
-Cushing’s syndrome
-Hyperaldosteronism
-Eclampsia
-Renal artery stenosis
hypertensive emergency tx
-Reduce mean arterial pressure (MAP) by 25% in 1-2hrs*
-Quick reduction of BP can lead to ischemic CVA**
IV agents:
-Esmolol, Labetolol
-Hydralazine
-Nitroglycerine
-Nitroprusside
MAP definition
MAP = average blood pressure during a single cardiac cycle:
-Cardiac output
-systemic vascular resistance
-central venous pressure “preload”
white coat hypertension
Definition: consistently elevated office blood pressure readings with out of office readings that do not meet criteria for hypertension
- In office elevated bp but then out of office they dont meet criteria for HTN
-Difficult to differentiate
-Increased risk of developing hypertension
-Ambulatory and home blood pressure monitoring
hypotension definition
-Systolic BP < 90 mm Hg and/or diastolic BP < 60 mm Hg
-Significant if symptoms are present
congestive heart failure
dx, labs and chest x-ray
CLINICAL DIAGNOSIS!
Labs:
-CBC, CMP, TFTs,
-B-type natriuretic peptide (BNP)- Released from the ventricles: volume OVERLOAD or EXPANSION
Chest radiography:
-Cardiomegaly
-Kerley B lines – interstitial edema- Horizontal lines at periphery of lungs
-Pulmonary dilations
-Pleural effusions- Blunting of costophrenic angles
dilated cardiomyopathy symptoms and dx
Symptoms/Signs:
-Heart failure signs and symptoms
-S3 and S4: S3 = volume overload; S4 = noncompliant ventricles
-Cardiomegaly
-Sudden death
Dx:
–Echocardiogram – diagnostic test of choice**
-Chest x-ray
-Genetic testing
