Hyper and hypotension Flashcards
How many people over 65 hae hypertension
over 1/2
what is the most common risk factor for MI and stroke
uncontrolled hypertension
What race and ethnicity is htn seen more in
Men, african americans
Is there a genetic component to hypertension
yes
Different types of hypertension
Essential (Primary), Secondary, malignant
What percentage of people have essential hypertension
95%
Pre-hypertension
120-139mmHg / 80-90mmHg
Stage 1 hypertension
140-159mmHg/90-99mmHg
Stage 2 hypertension
> 160mmHg/ >100mmHg
How do you diagnose essential hypertension
2 or more readings during 2 or more visits with a mean BP of 140/90
When can you diagnose htn with just one reading
End organ damage
Is diastolic or systolic a greater predictor of risk in patients over 50?
Systolic
Is diastolic or systolic a greater predictor of mortality in patients under 50?
diastolic
What percentage of people get “white coat” syndrome
20-25%
Screening for individuals with normal bp
every 2 years
BP check for people with prehypertension
every year
Name some risk factors of primary hypertension
Excess sodium intake Excess alcohol intake Obesity & weight gain Physical Inactivity Dyslipidemia Type A personality Vitamin D deficiency OTC meds (NSAIDs, Decongestants, etc) Family Hx Ethnicity (African American) Age of onset/length of time
Symptoms in htn
Asymptomatic!
HA, dizziness, CP, palpitations, buzzing noise, fatigue, visual changes
PE findings for a person with Htn
retinopathy, papilledema, bruits, edema, CHF, weakness or confusion
What is some routine lab testing for Primary hypertension
electrolytes, BUN, creatinine, glucose, GFR, fasting lipid profile, TSH, UA,
What are some routine testing for primary hypertension
EKG, CXR and echo
Treatment of essential hypertension
Lifestyle modifications- weight loss, exercise, sodium restriction, stop smoking, increase potassium – for 6-12 months
How much does loosing 10kg decrease your blood pressure
5-20mmHg
How much can exercising 30min/day decrease your blood pressure
4-9mmHg
When do you start medication for hypertension
when lifestyle modifications fail
Diuretics
Stop Na from reabsorbing thus increasing the Na and water excretion
What do you need to monitor with loop diuretics
K- hypokalemia
Na- hyponatremia
Glucose- hyperglycemia
Uric acid- hyperuricemia
What are potassium sparing diuretics
Spironolactone
Beta blockers
decrease HR and cardiac output, decrease PVR, reduce renin activity
Cardioselective beta blockers
Inhibit beta 1 receptors
Metoprol, atenalol
Non cardioselective
Inhibit beta 1 and beta 2
Propanolol, labetalol
Side effect of beta blockers
bradyardia, fatigue/lethargy, impotence, hyperglycemia, masks signs of hypoglycemia
CCB
Cause peripheral vasodilation
Dihydropyridines
amlodipine, nifedipine
NonDihydropyridines
Slows conduction at the AV node
Verapamil, diltiazem
Side effects of CCB
Peripheral edema, constipation, HA, bradycardia (nondyhydropyridines)
ACE Inhibitors
Inhibit conversion of angiotensin 1 to angiotensin 2, and reduced aldosterone secretion
ARB
Directly inhibits angiotensin 2
Side effects of ACE and ARB
hyperkalemia, dizziness, angioedema and cough
are ACE’s and ARB’s indicated in pregnancy
NO they are contraindicated
What to ACE and ARB combined increase the risk of
Cancer
Alpha blockers
inhibits alpha1 receptors resulting in vasodilation of veins and arterioles. TX for BPH
Side effects of alpha blockers
Orthostatic hypotension, HA, dizziness
Central alpha-adrenergics
alpha 2 agonist redicing the sympathetic outflow from CNS producing a decrease in peripheral resistance - methyldopa
Side effects of Gentral alpha adrenergics
peripheral edema, drowsiness, dry mouth
Arteriolar dilators
RElax smooth muscles and produce peripheral dilation - hydralyzine and minoxidil (Rogaine)
Side effects of hydralazine
fluid/sodium retention, lupus like syndrome, T wave changes and excess hair growth
Does hydralyzine have a short or long half life
short- frequent dosing- 3X day
Direct renin inhibitors
Block the conversion of angiotensin to angiotensin 1’Aliskiren
ARD of renin inhibitors
increase BUN/CR, hyperkalemia if used with ACE
what is Prinzide
lisinopril +HCTZ
What is lotrel
Benazepril + amlodipine
Exforge HCT
Amlodipine +Valsartan + HCTZ
For an african american what blood pressure medications work best
CCB & diuretics
Forr a diabetes patient what blood pressure medications work best
ACE/ARB
For CHF patient what BP meds work best
BB, diuretics, ACE
For CAD what BP meds work best
BB, CCB
For CKD what BP meds work best
ACE/ARB
What is malignant htn
EMERGENCY- associated with end organ damage
BP >180/120
What is end organ damage
retinal hemorrhages, renal failure encephalopathy, MI
How do you treat malignant hypertension
Nitroprusside- can be titrated
Labetalol- IV bolus or continuous infusion
How fast should you lower BP in malifnant Htn
no more than 25% initially
Causes of secondary hypertension
1) Renovascular HTN - RAS 2. Primary Renal Dz. - due to glomerulonephritis, pyelo, ASHD 3. Primary Aldosteronism 4. Pheochromocytoma 5. Cushing’s Syndrome 6. Coarctation of the Aorta 7. Obstructive Sleep Apnea Syndrome
8. Hypothyroidism or Hyperparathyroidism 9. Drugs - cocaine
What is the most common correctable cause of secondary hypertension?
Renovascular hypertension (renal artery stenosis)
How does renal artery stenosis (RAS) cause hypertensoin
impairs blood flow to kiney, which increases renin and starts the cascade
How do you diagnose RAS
Renal arteriography- gold standard
MRA/CTA
Renal US with duplex imaging
Treatment of RAS
medication therapy or angioplast with stent
If I have bilateral RAS are ACE and ARBs good choices
NO- can lead to worsening renal function
I have unexplained hypokalemia and hypertension, why?
Primary aldosteronism
What is the main cause of primary aldosteronism
aldosterone producing adenoma or bilateral adreanal hyperplasia
What are the diagnostic features of secondary hypertension
Low -Plasma renin activity
High - plasma aldosterone concentration
CT adrenals
Treatment of primary aldosteronism
Adenoma- adrenalectomy
No adenoma- medical therapy with aldosterone antagonist (spiranolactone)
Phenochromocytoma symptoms
Epospdic eadache, sweating and tachycardia, sustained paroxysmal htn
diagnosis of phenochromocytoma
1) 24 hour urine catecholamines and metanephrines
2) plasma fractionated metanephrines
3) CT or MRI of abdomen/pelvis
What percentage of phenochromocytomas are in the abdomen
95%
Treatment of phenochromocytoma
adrenalectomy
Other causes of secondary hypertension
Cushings
Coactation
symptoms of coarctation of aorta
hypertension in both upper extremitis and low on unobtainable in LE. may have CP or claudication
Diagnosis of Coarctation
MRA, echocardiogram
Treatment of coarctation
Surgical correction, balloon angioplasty with stent
types of hypotension
cardiogenic shock
Orthostatic hypostions
Cardiac output and normal value
the volume of blood pumped by the heart in a unit of time. Normal:5L/min
Cardiac index and normal value
cardiac output corrected for body size Normal: 2.6- 4.2
Stroke volume and normal values
VOlume of blood in each beat/contraction. Normal: 70 ml/beat
Preload
the degree of ventricular filling during diastole
afterload
impedance of the ejection of blood from the ventricle
Ejection Fraction
The percent of the total blood volume in the ventricle at the end of diastole that is ejected during systole. Normal: 55-65%
Pulmonary Wedge pressure
Left atrial pressure measurement - measures preload in left ventricle. Normal = 12mmHg
What do you use to measure pulomnary wedge pressure
swan-ganz catheter
Chardiogenic shock
Inadequate tissue perfusion due to cardiac dysfunctio/decreased cardiac output
Caused by severe reduction in cardiac index and elevation of SVR
Hypotension <80-90 and MAP 30mmHg lower than basline
What is the most common cause of cardiogenic shock?
MI With LV dysfunction
Other causes of cardiogenic shock
Acute MR due to papillary muscle or chordae tendinae rupture Ventricular free wall rupture Pericardial tamponade Myocarditis End-stage cardiomyopathy
Clinical manifestations of cardiogenic shock
Hypotension Cool extremities/Pallor appearance Altered mental status Decreased or absent urine output/ARF Respiratory distress from CHF
Diagnosis of Cardiogenic shock
Echocardiogram (mainy
(TEE), Hemodynamic Monitoring, Cardiac catheterization
Normal pressure of the Right atrium
2-8 mmHg
Normal pressure of the Right Ventricle
systolic- 15-20/ diastolic 8-15
Normal pulmonary artery ressures
systolic 15-25/diatolic 8-15
Normal Pulmonary artery wedge pressure
6-12
Normal left ventricular end-diastolic pressure
6-12
If PCWP high or low in cardiogenic shock
High
Is PCWP high or low in septic shock
low
treatment of cardiogenic shock
1) reprofuse
2) intraaoritc baloon pump- decreased myocardial o2 consumption
3) meds- inotropes or vasopressors
Name some inotropes
Dopamine
Dobutamine
Dopamine causes and dose
increases contractility and vasoconstriction
Dose: 5-50 mcg/kg/min
Dobutamine causes and dose
increases contractility and cardiac output
Dose:5-40 mcg/kg/min
Name some Vasopressors
Norepi
Epi
What does norepi do and dose
vasoconstricts and increases contractility Dose: 1-30 mcg/min
What does epi do and dose
increases cardiac output and decreases SVR
Dose: 7-35 mcg/min
Orthostatic hypotension
symptomatic falls in bp after standing form a seated or supine position- may or may not have syncope
Who is orthostatic hypotension more common in
elderly and diabetics
what is the compensatory mechanism in which regulates bp
baroreceptors
What is a normal change in SBP
5-10 drop
What is a normal change in DBP
5-10 increase
What is a normal change in HR
10-25 bpm increase with standing
Causes of orthostatic hypotensio
volume depletion, autonomic dysfunction, medications, postprandial
symptoms of Orthostatic hypotension
Dizziness, Lightheadedness, Blurred vision, Confusion, Near syncope/syncope
Diagnosis of orthostatic hypotension
Check BP supine, sitting and standing 3 mins apart
Labs that could be helpful in diagnosing orthostatic hypotension
BUN/Creatinine levels, anemia
Treatment of rthostatic hypotension
increase salt and water intake, compression stockings,remove offending medications
What medications can be used for orthostatic hypotension
Fludrocortisone
Midodrine
Other name for orthostatic hypotension
postural hypotension
