Hypertension Flashcards
Average Heart Rate
70 beats per minute
What/how controls the heart beat? Where is it located?
SA Node
- Depolarizes about every second or 70 times a minute
- Located in right atrium
“Sick Sinus” Define. What population is it common in? What is the tx?
Sick sinus” syndrome is a fairly common problem among elderly. (SA NODE not firing at same cycle; so, Granny needs a pacemaker)
You will frequently come across people with “pacemakers”. –> Electrical signal that’s sets the pace; rather than the SA Node
What is the job of the AV Node?
Gateway for electrical impulse into ventricles (delays ventricular contraction*)
Only way for an impulse to trigger ventricles in a healthy heart
Describe the process of AV Node conduction? What drugs are used to decrease contraction?
The AV NODE DELAYS ventricular contraction
LUB –> After LUB, impulse goes to AV NODE
–> Allows one impulse in at one time, delays LUB-DUB to allow the ventricle to fill with blood
BETA-Blockers and NHCCB (non-hydromonium Calcium Channel Blcokers) –> Slow the conduction slower
What is AV block? What drugs are C.I.?
AV Block –> Conduction delayed for too long
Do not use NHPCCB and Beta-blockers
prior to conduction, what is the voltage of cardiac myoctes? This is ____ compared to outside of the cell?
Heart muscle cells are ‘polarized’
80-90mV negative compared to outside the cell
The resting membrane potential in cardiac myocytes is maintained by…..
Ion pumps work to maintain this resting membrane potential (RMP)
Describe a polarized cardiac myocyte? What ion is responsible for the membrane potential?
Pump out all Na+ ions –> little Na+ inside the cell
Too little positive ions or too many negative ions in there –> Mix of both
The Na+ ion is on the cell membrane and dying to get inside. The cell has created a force (magnetic force)
Are polarized cardiac myocytes leak proof? If not, what phase in cardiac cycle is leakage occuring? Why does it occur?
No –> There is some leakage through maintenance channels
- Phase 4
K+ loss diminishes negative charge.
Eventually, an abrupt increase in Na permeability will occur when a certain ‘threshold potential’ is reached
In cardiac myocytes the gates are ______ dependent
Voltage Dependent
- they will open up at a certain level of polarization
In phase 0 of the cardiac cycle, what occurs? What voltage does calcium need?
Increase in permeability to sodium influx (i..e, into cell)
Calcium channels open at around – 60 mV –> Ca2+ causes contraction
In phase 1 of the cardiac cycle, what occurs?
Brief re-polarization from K escaping cell
In phase 2 of the cardiac cycle, what occurs?
Calcium continues to enter cell (started in phase 0)
Calcium enters through “L type” calcium channels
Calcium movement initiates muscle contraction
How can an arrhythmia develop?
If a neighboring is depolarizing, it will depolarize its neighboring cell
If a cell is stimulated before further recovered can lead to an arrythymia
Can cardiac muscles contract in phase 2?
A cardiac muscle cannot contract during phase 2
Further impulse from neighbouring cell will not cause it to contract (if cell is phase 2)
Want cells to be in refractory period when stimulated
What occurs in phase 3 of the cardiac cycle?
Membrane remains permeable.
Na and K ejected to ‘repolarize’ the cell
What occurs in phase 4 of the cardiac cycle?
Na+ is cleared from the cell and K+ loss slows
Eventually, an abrupt increase in Na permeability will occur when a certain ‘threshold potential’ is reached
List the phases of the cardiac cycle in order?
Phase 4, 0,1,2,3
Depolarization means…
Muscle Contraction
What ion causes muscle contraction?
Calcium
More calcium entering a cell is indicative of…..
stronger contraction (inotropy/contractility)
Faster calcium entry into a cell is indicative of…
faster contraction (chronotropy/heart rate)
A cardiac muscle cannot contract again until….
Muscle cannot contract again until repolarization occurs
What is an ECG?
Graph of electrical activity in heart
An ECG is detected by…..
by electrodes (i.e., “leads”) attached to the patient
Why are leads placed in different locations?
The location of the “leads” allows different angles of the heart to be examined.
How many leads are often used?
6 or 12 leads are often used
On a 12 lead ECG, where are the leads placed?
6 “limb leads”
6 “precordial leads”
ECG’s are the test of choice for _____ Why?
Most sensitive and effective test to determine if having heart attack or not
The P-Wave of an ECG detects?
Depolarization of atria
Normal duration = 0.12 seconds
The QRS complex measures….
Depolarization of ventricles
Normal duration < 0.12 seconds
In a normal ECG, what is the width of the QRS complex?
Narrow
A wide QRS indicates what?
Tell tale sign that ventricular impulse did not originate AV node
The QT interval indicates…..
Represents the time it takes from ventricular contraction until repolarization –> Full cycle
What is QT prolongation? Why does it occur? What is it a risk factor for?
If have drugs that can prolong the QT interval, takes longer for repolarization. If have one cell that was not ready for depolarization, will be ready when others are in repolarization
Some people with long Q-T –> Risk factor arrhythmia –> Risk when one cell affects the neighbours so when AV conduction comes down a lot of cells are in the refractory period
The T-Wave is responsible for….
REPOLARIZATION of ventricles
Why is basic knowledge of the ECG important for pharmacists?
Assessing patients with ischemic conditions (ST elevation, Non-ST elevation, ST depression)
Evaluating the risk for arrythmia with drugs (QT prolongation)
Evaluating patients with arrythmia (narrow QRS, wide QRS, tacychardia, bradycardia, normal sinus rhythm - NSR)
Evaluating contraindications of drugs (QT prolongation, heart block (p-r delays))
What are the four approaches to asses blood pressure?
- Automated Office Blood Pressure (unattended)
- Office Blood Pressure Monitoring (attended)
- Ambulatory Blood Pressure Monitoring
- Home Blood Pressure Monitoring
AOBP Blood Pressure is considered high when….
Displayed mean SBP ≥ 135 mmHg or DBP ≥ 85 mmHg is high
OBPM blood pressure is considered high-normal and high when…..
Mean SBP 130-139 mmHg or mean DBP 85-89 mmHg is high-normal
Mean SBP ≥ 140 mm Hg or DBP ≥ 90 mmHg is high
ABPM is considered high when…..
Mean awake SBP ≥ 135 mmHg or DBP ≥ 85 mmHg or mean 24-hour SBP ≥ 130 mmHg or DBP ≥ 80 mmHg are high
HBPM is considered high when…..
Mean SBP ≥ 135 mmHg or DBP ≥ 85mm Hg are high and associated with an increased overall mortality risk
Should pharmacy blood pressure machines be used? What should they be used for?
Pharmacy BP machines have not been evaluated for their association with clinical outcomes
It is highly unlikely they can be relied upon for determining risk or deciding about treatment
These machines should serve as screening tools only
Home Blood pressure Monitors Benefits
Considered highly accurate
AND
Highly correlated with usual resting BP levels
What is the correlation between OBP, ABPM, and Home BP?
The correlation between target organ damage, such as left ventricular hypertrophy (LVH), and albumin excretion ratio was weaker with office BP (OBP) and stronger with ambulatory BP measurement (ABPM).
Moreover, the correlation with self (home) BP was higher than with OBP, but less than with ABPM, for both systolic and diastolic BP.
For home blood pressure monitoring, the home values reference is….
< 135/85
What advice should pharmacist give to pt’s about physician visits?
Take it with you to the physicians office
What are guidelines for blood pressure monitoring as set out by the Candian Hypertension Guidelines?
- Sitting position
- Back Supported
- Arm bare and supported
- Use an appropriate sized cuff
- Middle of cuff at heart level
- Lower edge of cuff 3 cm above elbow crease
- Do not talk or move
- Legs uncrossed
- feet flat on floor
- Traditionally recommended to avoid exercise, caffeine, or a full bladder prior to taking BP (30min).
Home Blood Pressure monitoring conditons….
Resting, –> stimulation/stimulants/irritants
Duplicate measures
Timing for patient of Home Blood Pressure Monitoring
Before doses of medication (troughs)
Morning and night (estimate 24 hr control)
Duration of Home Blood Pressure
One week blocks during times of interest
Do not have to measure every day for extended periods if stable.
What body part is blood pressure monitoring is preferred? Exception?
- Arm BP are preferred
- Validated wrist devices may be used for BP estimation ONLY in patients with large arm circumference when standard arm methods cannot be used (Grade D recommendation from Canadian hypertension guidelines)
High Blood Pressure during activity is (useful/bad) because….
↑ blood flow = ↑oxygen and
glucose delivered to muscle.
Very useful –>Run faster, hit harder, yell louder, etc…
Regular activity (with rests!) will trigger cellular changes (e.g., ↑protein, ↑ mitochondria)
High blood pressure during rest is (useful/bad) because….
↑ afterload = ↑ energy to pump blood
Wastes energy
Fatigues tissues/cells –> adverse changes over long term
Damages specific tissues/cells
High blood pressure is defined as…..
Continuous high blood pressure readings at rest
Damage as a result of hypertension is usually as a result of….
↑ afterload
Arterial damage
Hypertension risk increase with:
a) Diabetes
b) Age
c) Arthritis
d) Cancer
AGE
Hypertension is a ____ -factorial problem and can result due to….
MULTI
Fluid and electrolyte balance
RAAS
Natriuretic hormone
Electrolyte imbalance (e.g. Na*)
Renal dysfunction / poor renal perfusion
Sympathetic nervous system / baroreceptor function
Increased SNS activity
Metabolic syndrome
Hyperinsulinemia/insulin resistance, abdominal obesity, low HDL, high BP, high Tg
Vascular endothelial function
Prostacyclin, Nitric Oxide production
Since Hypertension is multifactorial, drug tx often involves…
Multiple agents
Chronically ’d BP results from multiple factors, no single factor predominates
Thus, single antihypertensive drug regimens often have limited success in control (-10/-5 average)
Single Anti-hypertensives on average, lower blood pressure by….
10/-5 average
Hypertension is often commonly associated with…..
Metabolic Syndrome
Secondary hypertension definition
is high blood pressure that’s caused by another medical condition
Is Hypertension often due to significant damage of a single system?
Rarely, HTN is caused by significant dysfunction of a single system
In secondary hypertension, hypertension is commonly not recognized until?
Often not recognized initially until patients show resistance to conventional treatment
Treatment resistant hypertension definition
“Treatment resistance” in hypertension is usually defined as lack of BP control despite a combination of 3 antihypertensive medications, one of which being a diuretic.
Risk factors for hypertension are often… and therefore….. is important
SILENT, SCREENING
In which stage of life would the identification of HTN have the biggest impact to lifespan?
Earlier stages of life
Is hypertension a disease?
Hypertension is a risk factor for disease; but it is not a disease itself
Modifiable risks for developing hypertension….
Obesity
Poor dietary habits
High sodium intake
Sedentary lifestyle
High alcohol consumption
High-normal blood pressure
Diabetes or metabolic syndrome (“pre-diabetes”)
The main goal of tx for blood pressure
Preventing life-threatening cardiac consequences
3 goals of tx for hypertension (specific)
- Reduce/prevent myocardial cell dysfunction
- Reduce/stabilize artherosclerosis burden and endothelial cell dysfunction
- Reduce/prevent weakened vessel walls
Overall, managing risk factors is important because…
Managing risk factors such as hypertension is meant to improve the health of blood vessels and myocytes (i.e., heart cells).
Preventing damage to these cells is meant to Prevent life-threatening events and slow deterioration of major organs over the lifespan.
Are guidelines perfect?
NO
Recognized guidelines have…..
Clear description of the committee and the potential conflicts of interest
Evidence of a “systematic search” of the literature (for all relevant information)
Clear description of strength of evidence supporting every recommendation
Clear description of the strength/certainty about every recommendation
Canadian Guidelines for Optimal Blood Pressure
less than 120/80
Normal Blood Pressure Values
less than 130 (systolic) and/or 85(diastloic)
High-Normal Blood Pressure
130-139 –> Systolic
and/or
85-89 diastolic
Grade 1 (mild hypertension) guideline values
140-159 and/or 90-99
Grade 2 (moderate hypertension) guideline values
160-179 and/or 100-109
Grade 3 (severe) hypertension values
Greater than or equal to 180 and/or greater than or equal to 110
Isolated systolic hypertension is defined as….
Greater than or eqaul to 140 and/or less than 90
For diagnosis of hypertension….
Must be high at rest
Unrelenting/ consistent
Can hypertension be diagnosed in a pharmacy?
CANNOT be diagnosed in a pharmacy
Hypertension diagnosis requires…..
Requires the physician to find if blood pressure is consistent and/or unrelenting
Hypertension can be directly diagnosed from blood pressure readings when….
Mean office BP ≥ 180/110 mmHg or hypertensive emergency
No need for additional BP assessment to make the hypertension diagnosis
Diagnose with hypertension and initiate treatment
What is normotensive?
No hypertension at office/clinic/hlthcare setting and no hypertension at home/nonhlthcare/ABPM Setting
Sustained hypertension is…
Hypertension at office/clinic/hlthcare setting and hypertension at home/nonhlthcare/ABPM Setting
Masked hypertension is….
No hypertension at office/clinic/hlthcare setting and hypertension at home/nonhlthcare/ABPM Setting
White coat hypertension is…
Hypertension at office/clinic/hlthcare setting and no hypertension at home/nonhlthcare/ABPM Setting
Think of white coat hypertension when….
- Young age
- Lean/healthy body weight
- No other risk factors or target organ damage
- No family history
- Blood pressure is high in clinic examinations
- Someone you wouldn’t expect to have htn
One should think about masked HTN when….
Older age
Overweight / sedentary lifestyle
Has other conditions (e.g., diabetes, kidney dysfunction) or other target organ damage
Possibly positive family history
Blood pressure is NORMAL in clinic examinations.
Someone you WOULD expect to have HTN
Metabolic syndrome consists of….
“Metabolic syndrome” (at least 3 of)
Insulin resistance / incr’d blood sugar
Low HDL
Abdominal obesity
High triglycerides
High blood pressure
Before starting tx of hypertension, a ___ assesment should be done beacuse….
Blood pressure may be treated differently depending on the patients short-term risk of a life-threatening event
It is essential that a risk assessment be undertaken before treatment is determined
CV Non-modifiable risk factors of hypertension
Age ≥55 years
Male
Family history of premature
cardiovascular disease
(age <55 in men and
<65 in women doubles FRS)
CV Modifiable risk factors include…
Sedentary lifestyle
Poor dietary habits
Abdominal obesity
Dysglycemia (or diabetes)
Smoking (even 2nd hand)
Dyslipidemia
Stress
Hypertension
People at the highest risk for CV events will demonstrate….
Target organ damage
Target Organ Damage Includes
Cerebrovascular disease
Hypertensive retinopathy (would only know if you got an eye exam)
Left ventricular dysfunction (more about function)
Left ventricular hypertrophy (enlarged left ventricle; but, nothing about function – slow change over time )
Coronary artery disease
CKD
Peripheral Artery Disease
Target organ damage is a sign that damage….
Has already occured
When detrming someone’s risk factors for CV disseas ethey should be considered
Together
What is the framingham risk calculator?
A widely used tool to assess overall CV risk in Canada
A simple algorithm estimates an individual’s 10-year risk of experiencing a major CV event (MI, stroke, etc) or death.
What are limitations of the framingham risk score?
Just an estimate (not a crystal ball)
Poor performance in extremes of age (young, old)
10-year risk may not always correlate to lifetime risk
Study absolute risk, relative risk and number to treat
Look at notes
What is a relative risk reduction?
Relative risk reductions are commonly used to convey risk/benefits in health care
What is the absolute risk?
This magnitude of benefit represents approximately 100% of the available risk assuming age and sex cannot be modified
Are high blood pressure readings an emergency? What should we do?
No
Check technique and re-take BP
Ask patient if they are experiencing symptoms
If no signs/symptoms of danger, ask patient to make an appointment within a day or two. Might have to go to walk-in clinic
What are some symptoms of concern in regards to a high blood presusre reading?
1) Neurologic
2) Cardio-repsiratory
3) Any symptoms suggestive of major CV event
Neuroligic sx may include:
Severe headache, numbness, weakness, slurred speech,
Vision problems
Cardio-respiratory sx:
Chest pain, difficulty breathing
A hypertensive urgent situation is when….
Situations where BP should be reduced within hours
BP ≥180 / ≥130 AND
papilledema or other target organ changes
A hypertensive emergency is when….
Situations that require immediate BP reduction
E.g. hypertensive encephalopathy, intracranial bleed, unstable angina/MI, acute heart failure