HTN Only Flashcards
How did the American College of Cardiology & American Heart Association redefine hypertension in 2017?
Systolic BP > 130 mmHg and/or Diastolic BP > 80 mmHg
What percentage of adults in the US does hypertension affect?
Nearly 50%
What percentage of African Americans are affected by hypertension?
40%
What is the lifetime risk of developing hypertension in the US?
90%
What are some complications of chronic hypertension?
Ischemic heart disease, stroke, renal failure, retinopathy, PVD, and overall mortality
What is an important risk factor for perioperative morbidity and mortality in the surgical population?
Hypertension if untreated
What are the three subtypes of chronic hypertension based on blood pressure measurements?
Isolated systolic HTN, isolated diastolic HTN, combined systolic and diastolic HTN
Besides SBP and DBP elevation, what else is considered a risk factor for cardiovascular morbidity in hypertension?
Widened pulse pressure
What can result from a wide range of primary & secondary processes that increase cardiac output, vascular resistance, or both?
Hypertension
What are some contributing factors to primary HTN?
SNS activity, dysregulation of the RAAS, deficiency in endogenous vasodilators
What are some genetic and lifestyle risk factors associated with HTN?
Obesity, alcoholism, tobacco
What do a minority of patients with HTN have?
Secondary HTN
What are common causes of secondary HTN in middle-aged adults?
Hyperaldosteronism, thyroid dysfunction, OSA, Cushings, pheochromocytoma
What do children with HTN generally have?
Secondary HTN r/t renal parenchymal disease or aortic coarctation
Drug class that may elevate BP: Antiinfective
Ketoconazole
Drug class that may elevate BP: Antiinflammatory
Cyclooxygenase-2 inhibitors, NSAIDs
Drug class that may elevate BP: Chemotherapeutic
Vascular endothelial growth factor inhibitors
Herbal substances that may elevate BP
Ephedra, ginseng, ma huang
Illicit drugs that may elevate BP
Amphetamines, cocaine
Drug class that may elevate BP: Immunosuppressive agents
Cyclosporine, sirolimus, tacrolimus
Drug class that may elevate BP: Psychiatric
Buspirone, carbamazepine, clozapine, lithium, MAO inhibitors, SSRIs, tricyclic antidepressants
Sex hormones that may elevate BP
Estrogen, progesterone, androgens
Steroid drugs that may elevate BP
Methylprednisolone, prednisone
Drug class that may elevate BP: Sympathomimetic
Decongestants, diet pills
What are the most common causes of secondary hypertension in adolescents?
Thyroid dysfunction, Fibromuscular dysplasia
What is a common etiology of secondary hypertension in older adults aged 65 and above?
Hypothyroidism
What are some consequences of chronic hypertension?
Remodeling of arteries, endothelial dysfunction, end-organ damage
How can vasculopathy affect different organs in hypertension?
Ischemic heart disease, LVH, CHF, CVA, PAD, aortic aneurysm, nephropathy
What diagnostic tools can provide early detection of vasculopathy?
Ultrasound measurement of carotid intimal-to-medial thickness, arterial pulse-wave velocity
How can the progression of left ventricular hypertrophy be tracked?
EKG and echocardiogram trends
How can microangiopathic changes due to cerebrovascular damage be monitored?
MRI
What is the general therapeutic goal for hypertension treatment?
<130/<80
How many people in the US have untreated hypertension?
28 million
How many treated patients in the US are above their blood pressure goal?
29 million
What is defined as resistant hypertension?
Above-goal BP despite 3+ antihypertensive drugs @ max dose
What is included in the usual treatment for resistant hypertension?
LA CCB, an ACI-I or ARB + a diuretic
What is controlled resistant hypertension?
Controlled BP requiring 4+ medications
What is refractory hypertension?
Uncontrolled BP on 5+ drugs, present in 0.5% of patients
What is pseudo-resistant hypertension?
(Intolerance to drugs) can result from BP inaccuracies or medication noncompliance
What lifestyle modifications can help manage hypertension?
Weight loss, decrease alcohol consumption, exercise, quit smoking
What is the relationship between BMI and hypertension?
Continuous relationship
How does weight loss help with hypertension?
Direct BP reduction and enhances drug efficacy
What reduction in blood pressure can overweight adults expect for every 1 kg of weight loss?
1 mmHg
What is hypertension?
High blood pressure
How is physical activity related to blood pressure?
Even modest increases decrease BP
How is excessive alcohol use linked to hypertension?
Associated with increased HTN
What is the relationship between dietary potassium/calcium intake and HTN?
Inversely related
What is the impact of salt restriction on blood pressure?
Small but consistent BP decreases
What is recommended for diagnosis and titration of antihypertensive medications?
Out-of-office BP measurements.
When should patients with certain conditions be treated with BP medications according to the ACC/AHA guidelines?
When SBP is >130 mmHg.
What does the evidence support regarding BP medication treatment for patients without cardiovascular or cerebrovascular disease?
Limited data.
What are the recommended blood pressure goals for hypertensive patients with diabetes mellitus or chronic kidney disease?
Same as for the general hypertensive population.
Which medications are useful and effective in nonblack hypertensive patients, including those with diabetes?
ACE-I’s, ARBs, CCBs, thiazide diuretics
What is the recommended initial antihypertensive therapy in black adult hypertensive patients without heart failure or CKD?
CCB or thiazide diuretics
What is the moderate evidence supporting antihypertensive therapy with ACE-I or ARB in patients with CKD?
Improve kidney outcomes
What is an important component of a comprehensive blood pressure management approach?
Nonpharmacologic interventions
What type of patients are β blockers reserved for in first-line therapy for hypertension?
CAD or tachydysrhythmia
How many different drug classes have been approved for hypertension?
15
How is secondary HTN often treated?
Interventional, including surgical correction
What can be done if renal artery repair is not possible in secondary HTN?
BP controlled with ACE-I’s or diuretics
What treatment is recommended for primary hyperaldosteronism?
Aldosterone antagonist like spironolactone
Why are ACE-I’s, ARBs, and direct renin inhibitors not recommended in bilateral renal artery stenosis?
Can accelerate renal failure
How should certain disease processes like pheochromocytoma be treated?
Combined pharmacologic and surgical approach
Why is preoperative blood pressure assessment complicated?
Anxiety (white-coat HTN)
What are patients often instructed to do with their blood pressure medications on the day of surgery?
Pause ACE-I’s & diuretics
Why is assessing blood pressure in a single moment not ideal?
Doesn’t give accurate overall BP trends
What is necessary for a diagnosis of hypertension according to current guidelines?
Multiple elevated BP readings over time
What should be done if BP is elevated in a patient with suspected secondary HTN?
Check pressure on contralateral arm
What helps provide an overall picture of cardiovascular health in patients with secondary HTN?
Review clinic data, home BP’s, and history
Should surgery be delayed in asymptomatic patients without risk factors solely due to elevated BP?
No
When should surgery be delayed in patients with transient HTN and secondary HTN?
Extreme HTN (SBP >180 or DBP >110) or end-organ injury
What are symptoms that may indicate pheochromocytoma as the cause of secondary HTN?
Flushing, sweating & palpitations
What symptom suggests renal artery stenosis as the cause of secondary HTN?
Renal bruit
What condition does hypokalemia suggest as the cause of secondary HTN?
Hyperaldosteronism
What is the common practice with antihypertensive medications when surgery is planned for secondary HTN?
Continue, exclude ARBs and ACE-I’s
What can be associated with rebound effects if stopped before surgery in secondary HTN?
BBs or clonidine
What is associated with increased perioperative cardiovascular events if stopped in secondary HTN?
CCBs
Why don’t guidelines support delaying surgery for poorly controlled BP?
Increases blood loss, MI, and CVA
What risks does perioperative hypertension pose?
Increased blood loss, MI, CVA
Why are hypertensive patients prone to intraoperative hemodynamic volatility?
Physiologic factors, BP meds
What are the consequences of even brief periods of hypotension in hypertensive patients?
Acute kidney injury, myocardial injury, death
What should clinicians consider regarding acute intraoperative BP changes?
End-organ functional reserve
Why are hypertension patients considered hemodynamically vulnerable to induction of general anesthesia?
HTN pt’s are hemodynamically vulnerable to induction of GA
What effects do induction drugs have on hypertension patients?
Produce HoTN; DL & intubation elicit HTN & tachycardia
What could be beneficial before induction in a hypertensive patient?
Pre-induction A-line, multimodal induction with SA BB (Esmolol)
What might accompany poorly controlled hypertension, especially in patients on diuretics?
Volume depletion
When might modest volume loading before induction be helpful in hypertensive patients?
In some patients
When might volume loading before induction be counterproductive?
In patients with LVH and diastolic dysfunction
What factors should be considered when choosing vasoactive drugs for hypertensive patients?
Age, functional reserve, medications, planned operation
What is a hypertensive crisis categorized as?
Urgent or emergent
Who tend to tolerate a higher SBP than normotensive patients?
Pts with chronic HTN
What may perioperative emergencies include related to hypertensive crisis?
CNS, kidney, cardiovascular
Which patients with pregnancy-induced hypertension may show evidence of end-organ dysfunction with a DBP >100?
Women
What is the immediate intervention recommendation for peripartum hypertension regarding SBP and DBP?
> 160 / >110
What is a first-line drug for peripartum HTN?
Labetalol
What is the gold standard for rapid arterial dilation?
SNP infusion
What is the advantage of Clevidipine over Nicardipine in arterial dilation?
Ultrashort DoA
What are the primary agents used for treating hypertensive emergencies?
Clevidipine, nitroprusside, labetalol, nicardipine
How should hypertensive emergencies in preeclampsia and eclampsia be treated?
Labetalol, nicardipine
What caution should be taken in treating hypertensive emergencies to avoid cerebral ischemia?
Cerebral ischemia may result from lower BP due to altered autoregulation
What is a risk associated with nitroprusside?
Cyanide toxicity
What effect can nitroprusside have on intracranial pressure?
Increases it
What may a marked drop in blood pressure from vasodilators lead to?
End-organ ischemia
How may beta blockers affect uterine blood flow?
Reduce it and inhibit labor
What worsens hypertension following alpha-blockade?
Unopposed alpha-adrenergic stimulation
In intracerebral hemorrhage, how may lowering blood pressure affect bleeding?
Lessen it
What is the goal in managing elevated BP?
Lessening of pulsatile force of left ventricular contraction
What may be required if elevated BP progresses to renal failure?
Emergent hemodialysis
What is the definitive therapy for managing elevated BP?
Delivery
Why are ACE inhibitors and ARBs contraindicated during pregnancy?
Teratogenicity
