HTN/Pulm. HTN Flashcards
HTN is a sustained SBP > ____ and/or DBP > ____
SBP > 130; DBP > 80
HTN affects what % of adults?
In order of most to least, who is affected by HTN?
What is the lifetime risk of dev. HTN?
Nearly half
Most: African American, White, Asian, Hispanics
90%
Normal BP Parameters
SBP < 120 DPB < 80
Elevated BP Parameters
SBP 120-129
DBP <80
Stage 1 HTN
SBP 130-139
DBP 80-89
Stage 2 HTN
SBP ≥ 140
DBP ≥ 90
Isolated Systolic HTN
SBP > 130
DBP < 80
Isolated diastolic HTN
SBP < 130
DBP > 80
Combined Systolic & diastolic HTN
SBP > 130
DBP > 80
What is a risk factor for CV mortality that correlates with vascular remodeling and “stiffness”
Widened Pulse pressure
What are some causes of Primary HTN?
-Increased CO, Vascular resistance, or both
-SNS hyperactivity (catecholamine release)
-RAAS Dysregulation (Na and H2O retention)
-Deficiency in endogenous vasodilators
What are genetic/lifestyle risk factors for HTN?
Obesity
Alcohol
Tobacco
What are the potentially correctable causes of secondary HTN?
More rare;
1. Hyperaldosteronism
2. Thyroid Dysfunction
3. OSA
4. Cushings
5. Pheochromocytoma
6. Renal artery stenosis
What type of HTN is associated with children?
What causes this?
Secondary HTN
Causes: Renal disease or Coarctation of the aorta
Herbal drugs that increase BP
-Ephedra
-Ginseng
-Ma Huang
Major cause of HTN in Adolescents (8-12 yrs)
Coarctation of the Aorta
Main cause of HTN for young adults (19-39)
Thyroid Dysfunction
Main cause of HTN for middle-aged adults (40-64)
Hyperaldosteronism
Main cause of HTN for older adults (≥ 65)
Atherosclerotic Renal Artery sclerosis
What pathology plays a major role in heart disease pathologies?
disseminated vasculopathy
How is vasculopathy detected?
Early on US - Measurement of the common carotid’s intima-medial thickness and arterial pulse wave velocity
What tests track the progression of LV hypertrophy?
EKG and Echocardiogram
What test is used to track microvascular changes ass w/ cerebrovascular damage?
MRI
____ million ppl have untreated HTN and ___ million treated patients are above their BP goal
28 million; 29 million
HTN above goal BP despite 3+ antihypertensive drugs at the MAX dose?
What 3 Drugs?
Resistant HTN
1. Long acting CCB
2. ACE-I
3. Diuretic
controlled BP requiring 4+ medications?
Controlled resistant HTN
Uncontrolled BP on 5+ drugs, rare, present in 0.5% of patients
Refractory HTN
HTN related to BP inaccuracies (white coat) or medication non-compliance
Pseudo-resistant HTN (resistant to drugs)
What is an effective nonpharmacologic intervention thru direct BP reduction and has synergistic enhancement of drug efficacy?
Even modest increases in this is associated with ___ decrease
Weight loss
BP
For every 1 kg of weight loss _____ mmHg reduction in BP
1 mmHg
What is associated w/ HTN & resistance to antihypertensive drugs?
Excessive alcohol use
These e- intakes are inversely related to HTN and cerebrovascular disesase
Potassium and Calcium
____ restriction is associated with a small, but consistent BP decrease
Salt restriction
What type of BP should be used for Dx and titration of BP meds?
Out of office BP
AHA guidelines: your patient has ischemic heart dx, stroke, DM, CKD, and atherosclerosis. When should you treat with BP meds?
SBP > 130 mmHg
AHA guidelines: There is limited data to support treating patients with CV or CVA Dx ____ _______ if SBP > 130 or DBP > 80
Non-pharmacologically
AHA guidelines: Which drug class are effective in nonblack HTN patients?
ACE-I
ARBS
CCB
Thiazide Diuretics
AHA guidelines: Your patient is black without HF or CKD, there is moderate evidence to support initial therapy with ____ ______
CCB or Thiazides
AHA guidelines: These medications reduce proteinuria, and support antihypertension in patients with CKD
ACE-I or ARBs
What drug is absent from first line therapy of the AHA guidelines and are reserved for patients with: CAD, Tachyarrhythmia, or a component of multidrug tx in resistant HTN
Beta blockers
Treatment for this HTN is interventional, including surgical correction of renal artery stenosis, adrenal adenoma and pheochromocytoma?
Secondary HTN
If your patient has bilateral renal artery stenosis, what drugs can accelerate renal failure?
ACE-I or ARBs or Direct renin inhibitors
What drug is used to treat primary Hyperaldosteronism?
Spironolactone
Treatment for pheochromocytoma?
Alpha blocker & tumor removal
What is necessary for dx of HTN?
Multiple elevated BP readings over time
If your patient has HTN with no risk factors and is asymptomatic, should you delay surgery?
No
When should you delay surgery?
Extreme HTN (SBP > 180 DBP >110) or end-organ injury that can be reversed with BP control
Flushing, sweating, palpitations are signs of: ______
Renal Bruit is a sign of ______
Hypokalemia may suggest _____
Pheochromocytoma
Renal artery stenosis
Hyperaldosteronism
Stopping these drugs can be associated with rebound HTN
Stopping BB or Clonidine
Stopping this drug can be associated with increased perioperative CV events
Stopping CCB
Do guidelines support delaying surgery for poorly controlled HTN?
However, Periop HTN is associated with _____ & _____
No - continue with surgery
MI & CVA
Patients who have end-organ damage from HTN are ____ resilient to hypotensive periods and have an increased risk of ______ & ______
Less resilient
Increased risk of AKI and Myocardial injury
What intervention and drug should you have during induction of a HTN patient?
Pre-induction A-line
Esmolol might be beneficial
What often accompanies poorly controlled HTN, especially if the pt. is on Diuretics?
What can you do to provide better hemodynamic stability?
Hypovolemia
Modest Volume load
Who is volume loading not ideal in?
LVH and diastolic dysfunction patients
Not tolerated in kidney patients
What do you take into account when considering vasoactive drugs for your patient?
Age
Functional Reserve
Medications
Planned Surgery
Periop emergencies associated w/ HTN includes:
CNS injury
Kidney injury
CV injury
Pregnant patients may experience end-organ dysfunction (such as _______) with a DBP > _____
Encephalopathy
DBP > 100
Peripartum HTN recommend immediate intervention for:
First line drug for peripartum HTN?
SBP > 160
DBP > 110
Labetalol (fast, alpha/beta blockade)
For rapid arterial dilation, _____ is the gold standard due to its fast onset and titratability
Sodium Nitroprusside
What is a 3rd gen. CCB (dihydropyridine) with a very short half life (______ min) is used for selective arteriolar vasodilation?
Clevidipine; ~ 1 min half life
What 2nd gen. CCB, has a longer half life ( ___ min) and is less titratable than clevidipine?
Nicardipine
What drug class is teratogenic?
Ace-i and ARBs
What drug class might reduce uterine blood flow and inhibit labor? Used for preeclampsia and eclampsia but should not be given to laboring moms on the floor?
Beta blockers (Labetalol)
What are the 5 types of Pulmonary HTN?
- Pulmonary arterial HTN (PAH)
- PH d/t Left Heart Dx
- PH due to Lung disease or hypoxia
- Chronic thromboembolic pulmonary HTN (CTEPH)
- PH with unclear multifactorial mechanisms
PH is defined as mean PA pressure > ____ mmHg
Symptoms of PH?
> 20 mmHg
S2 and S4 gallop heart sounds, LE swelling
2 categories for PHTN based on what
PA wedge pressure (PAWP) & Pulmonary Vascular resistance (PVR)
Pre-capillary HTN is an issue with the pulmonary ____ circulation
PVR ≥ ______ wood units
LAP is _____
PAWP is _____
Arterial
PVR ≥ 3 wood units
Normal LAP
Normal PAWP ( < 15 mmHg)
Post-capillary HTN is an issue with the pulmonary _____ pressure
LAP is ______
PAWP is ______
PVR is _____
Venous pressure
LAP: Elevated (d/t heart dx)
PAWP: elevated (>15)
PVR: normal
Chronic pulmonary venous HTN with secondary pulmonary arterial vasoconstriction and remodeling is:
Combined pre and post capillary PH
Pre and post-capillary PH is characterized by:
PVR: _____
PAWP ______
PVR > 3 wood units
PAWP > 15 mmHg
This type of PH occurs without an elevation in PAWP or PVR and results just from increased pulmonary blood flow caused by systemic to pulmonary shunt or high CO states?
High flow PH
This test is required to diagnose, classify, and treat pulmonary artery HTN
Right heart catheterization
What are certain things that can increase mean PAP?
1) elevated resistance to blood flow within the arterial circulation
2) increased pulmonary venous pressure from left heart disease
3) chronically increased pulmonary blood flow
4) a combination of these processes
PVR equation
PVR = (mPAP-PAWP)/CO
What test reveals RA and RV enlargement, and elevated tricuspid-regurgitation velocity?
TTE
What test is commonly used to estimate pulmonary arterial systolic pressure (PASP) as a screening tool?
Echocardiogram
PASP > _____ mmHg on echo is sensitive and specific for PH, but it cannot provide an accurate ____ for DEFINITIVE PH diagnosis
PASP > 41 mmHg
Mild Pulmonary HTN is defined as mPAP =
mPAP = 20-30 mmHg
Moderate pulmonary HTN is defined as mPAP =
mPAP = 31-40 mmHg
Severe pulmonary HTN is defined as mPAP =
mPAP > 40 mmHg
The pulmonary circulation can accommodate a _______ increase in CO without a change in mPAP
fourfold (but not for someone with PH)
3% of PAH cases are genetic, with mutations in this receptor
Bone morphogenetic protein receptor type 2 (BMPR2)
Historically, PH was a disease of _____ with a median survival of __ years (but now the demographic shifted to older patients and ___)
young women w/ median survival of 3 years
shifted to older and men diagnosed
What ratio of PAH patients have long-term improvement with CCB?
What is the 1-year mortality despite improvements in PH therapy?
1:8
1 year mortality: 15%
Sustained _____ and ______ leads to pathological distortion of the pulmonary arteries
Vasoconstriction and remodeling
3 main classes of pulmonary vasodilator drugs for PAH:
Combination therapy is often required for adequate treatment of PH
- Prostanoids
- Endothelin Receptor Antagonists
- Drugs that enhance NO/Guanylate Cyclase pathways
Drug class mimics the effect of prostacyclin to produce vasodilation while inhibiting platelet aggregation. Also have an anti-inflammatory effect and reduce proliferation of vascular smooth muscle cells
Examples?
Which is the only proven to reduce mortality?
Prostanoids
ex: Epoprostenol, Iloprost, Treprostinil, Beraprost
Epoprostenol reduces mortality
Vascular endothelial dysfunction associated with PAH involves an imbalance btw _______ (nitric oxide) and _______ (endothelin) substances. This drug class improve hemodynamics and exercise capacity
Vasodilating and vasoconstricting
Endothelin Receptor Antagonists
________ produces pulmonary vasodilation by stimulating
guanylate cyclase and cGMP in smooth muscle cells.
The effect is transient because _______ is quickly bound by Hgb and degraded by __________
Nitric Oxide; Nitric Oxide; Phosphodiasterase type 5
This drug prolongs the half-life of nitric oxide
PDE-5 inhibitors
PAH patients present with nonspecific symptoms such as:
Dyspnea
Fatigue
Cough
Severe PAH symptoms include ____ and _____ which occur with exercise if coronary blood flow does not meet the demands of the hypertrophied RV
Angina and syncope
These might be seen on assessment of a PAH patient:
Parasternal Lift
Accentuated S2, S3, and S4 gallop
JVD
Peripheral Edema
Hepatomegaly
Ascites
Rarely, compression of a dilated pulmonary artery can lead to _____ damage and hoarseness
Recurrent laryngeal nerve
For moderate/severe PH, right heart cath is recommended prior to
moderate-high risk surgery
In patients with LEFT heart disease, this test is indicated because inaccurate LVEDP might lead to misclassification of PH and inappropriate treatment
Left heart catheterization
During right heart cath, vasoreactivity testing with inhaled _____ is performed to determine responsiveness to vasodilator therapy
Nitric oxide
85-90% of PAH patients are unresponseive to __________
Those that ARE responsive also respond to _____
Inhaled NO
those that are responsive are also responsive to CCB
The primary intraoperative goal for PH patients is maintaining optimal ______ ______ between the RV and Pulmonary circulation to promote adequate left-sided filling and systemic perfusion
mechanical coupling
PH patients have low tolerance for these complications and increases the risk for other complications:
-Transient Hypotension, cannot tolerate this
-Mechanical ventilation
-Modest hypercarbia
-Small bubbles in IV
-Trendelenburg position
-Pneumoperitoneum
-Single-lung ventilation
A hallmark of PAH is increased __ ______
This leads to RV dilation, increased wall stress, and RV hypertrophy
RV afterload
What things can affect RV afterload?
Vent settings (PEEP)
Hypoventilation
Hypercarbia
Acidosis
Atelectasis
Surgical stimulation (affects pulsatile load of RV)
This ventricle is subject to greater wall tension for the same degree of end-diastolic volume, leading to increased O2 demand
Right ventricle > Left ventricle
Normally, the RV intramyocardial pressure is ____ than the aortic root pressure, and _____ coronary perfusion occurs throughout the cardiac cycle
Lower than; RV
In PAH, increased RV pressure leads to increased RV coronary flow during _____, making the RV more vulnerable to systemic _______ which worsens the O2 demand/supply mismatch and potentially causing MI
Diastole; hypotension
These 4 things lead to RV ischemia
RV dilation, insufficient LV filling, Reduced SV, systemic Hypotension
Studies show increased periop mortality and morbidity in PH patients undergoing these surgeries
Hip and knee replacement
This surgery increases airway pressure, causes pneumoperitoneum, head down position, RV pressure and afterload
Laparoscopy
Thoracic surgery involves non-ventilation and atelectasis of the operative lung. 3 Features of lung collapse are:
(1) some centers transiently pressurize the chest to induce atelectasis
(2) there is a potential for systemic hypoxia
(3) hypoxic pulmonary vasoconstriction (HPV) will further increase RV afterload
During single-lung ventilation, ______ are recommended
Inhaled pulmonary vasodilators
______ is the only class of PH found to benefit from pulmonary vasodilators
Pulmonary Arterial Hypertension (Class 1)
PAH pts on vasodilators should discontinue or continue their drugs intra and post-operatively?
Continue intra and pos-operatively
Converted from oral to IV or inhaled
