Hypertension Flashcards
1
Q
What is considered high blood pressure/HTN?
A
SBP> 130 and/or DBP>80
2
Q
How many people are affected by HTN in the US?
A
100 million
3
Q
What is the risk of developing HTN in the US?
A
90%
4
Q
What population has the highest risk of HTN?
A
40%
5
Q
Normal BP
A
SBP <120 and/or DBP<80
6
Q
Elevated BP
A
SBP 120-129 and DBP <80
7
Q
Stage 1 HTN
A
SBP 130-139 and/or DBP 80-89
8
Q
Stage 2 HTN
A
SBP>140 and/or DBP >90
9
Q
What complications does chronic HTN lead to?
A
Ischemic heart disease
Stroke
Renal Failure
Retinopathy
PVD
Increased Mortality
10
Q
Differentiate between
Isolated Systolic HTN
Isolated diastolic HTN
Combined HTN
A
SBP>130
DBP>80
SBP>130 AND DBP>80
11
Q
Widened pulse pressure is also a risk factor for _____________ as it correlates with _____________ and _______________
A
cardiovascular morbidity
vascular remodeling
stiffness
12
Q
What can HTN result from?
A
increased cardiac output, vascular resistance, or both
13
Q
What are contributing factors for HTN?
A
SNS Hyperactivity
Dysregulation of RAAS
Deficiency in endogenous vasodilators
14
Q
A
15
Q
Genetic and lifestyle risks
A
Obesity
Alcoholism
Tobacco
16
Q
Is primary or secondary HTN more rare?
A
Secondary
17
Q
Common causes of secondary HTN
A
Hyperaldosteronism
Thyroid dysfunction
OSA
Cushings
Pheochromocytoma
18
Q
What normally causes HTN in children?
A
Generally secondary HTN d/t renal disease or coarction of the aorta
19
Q
Drug Classes that increase BP
A
20
Q
What are the most common causes of secondary HTN in children (birth-12yr)?
A
Renal Parenchymal disease
Coarctation of the aorta
21
Q
What are the most common causes of secondary HTN in adolescents (12-18yr)?
A
Coarction of the aorta
22
Q
What are the most common causes of secondary HTN in young adults?
A
Thyroid dysfunction
Fibromuscular dysplasia
Renal Parenchymal disease
23
Q
What are the most common causes of secondary HTN in middle-aged adults?
A
Hyperaldosteronism
Thyroid dysfunction
OSA
Cushings
Pheochromocytoma
24
Q
What are the most common causes of secondary HTN in older adults?
A
Renal failure
Hypothyroidism
Atherosclerotic renal artery disease
25
Which age group most likely has underlying disease causing secondary HTN?
Least?
Children (70-85%)
Young adults (5%)
26
What can chronic HTN lead to?
Remodeling of small & larger arteries, endothelial dysfunction, and potentially irreversible end-organ damge
27
How can vasculopathy be detected?
on U/S with measurement of the common carotid intimal-to-medial thickness and arterial pulse wave velocity
28
What can track progression of LVH?
EKG and Echo
29
What does an MRI track?
microvascular changes with cerebrovascular damage
30
What can disseminated vasculopathy lead to?
Ischemic heart disease
LVH
CHF
CVA
PAD
Aortic aneurysm
Nephropathy
31
What are results of vasculopathy end-organ damage?
Endothelial dysfunction
Remodeling
Generalized atherosclerosis
Atherosclerotic stenosis
Aortic aneurysm
32
What are results of Cerebrovascular damage end-organ damage?
Acute hypertensive encephalopathy
Stroke
ICH
Lacunar infarction
Vascular dementia
Retinopathy
33
What are results of heart disease end-organ damage?
LVH
A fib
Coronary microangiopathy
Myocardial infarction
HF
34
What are results of Nephropathy end-organ damage?
Albuminuria
Proteinuria
Renal failure
35
What is therapeutic BP goal?
<130/<80
36
Resistant HTN
BP above goal despite 3+ antihypertensives at max dose
-Usually includes CCB, ACEi or ARB, & diuretic
37
Controlled resistant HTN
controlled BP requiring 4+ medications
38
Refractory HTN
uncontrolled HTN on 5+ drugs
present in 0.5%
39
Pseudo-resistant HTN
Appears resistant to drugs, often due to BP inaccuracies (white coat syndrome) or medication noncompliance
40
Lifestyle modifications for HTN
weight loss
decrease ETOH
exercise
smoking cessation
41
True or False: There is a continuous relationship b/t increased BMI and HTN
True
42
How much is BP reduced with weight loss?
1mmHg per 1kg of weight loss
43
True or False: Excessive ETOH is associated with HTN and resistance to antihypertensive drugs
True
44
Dietary potassium and calcium are __________related to HTN and cerebrovascular disease
Salt is ________related
Inversely
directly
45
How many drug classes are approved for HTN?
15
46
Why are Beta blockers not part of 1st line therapy?
Reserved for patients with CAD, tachyarrhythmia, or resistant HTN
47
What is primary treatment for secondary HTN?
Surgical correction of renal artery stenosis, adrenal adenoma, or pheochromocytoma
48
What class do we use in secondary HTN if renal artery repair isn't possible?
ACEi +/- diuretics
49
When are ACEi, ARBs, and direct renin inhibitors contraindicated in secondary HTN?
bilateral renal artery stenosis b/c they can accelerate renal failure
50
What can primary hyperaldosteronism be treated with?
aldosterone antagonist
ex: spironolactone
51
What is recommended for the diagnosis and titration of BP medications?
Out-of-office BP measurements
## Footnote
This includes methods such as home BP monitoring or ambulatory BP monitoring.
52
Which patients should be treated with BP medications if SBP >130 mmHg?
Patients with ischemic heart disease, cerebrovascular disease, CKD, or atherosclerotic cardiovascular disease
## Footnote
This recommendation is based on evidence supporting the treatment of these specific conditions.
53
Is there sufficient data to support nonpharmacological treatment for patients without cardiovascular or cerebrovascular conditions if SBP >130 or DBP >80?
No, there is limited data
## Footnote
This indicates a need for careful consideration of treatment approaches in these patients.
54
What treatment goals are recommended for hypertensive patients with diabetes or CKD?
The same goals as for the general hypertensive population
## Footnote
This emphasizes the importance of consistent management strategies across different patient groups.
55
Which medications are effective in nonblack hypertensive patients?
ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics
## Footnote
These classes of medications are commonly used in the management of hypertension.
56
What initial therapy is supported for black adult hypertensive patients without heart failure or CKD?
CCB or thiazide diuretics
## Footnote
This recommendation is based on moderate evidence favoring these treatments for this demographic.
57
What type of therapy is supported for patients with CKD to improve kidney outcomes?
Antihypertensive therapy with an ACE inhibitor or ARB
## Footnote
This highlights the renal protective effects of these medications in CKD patients.
58
What role do nonpharmacologic interventions play in BP management?
They are important components of comprehensive BP management
## Footnote
This includes lifestyle changes such as diet, exercise, and weight management.
59
True or False: Assessing BP in a single moment in time gives an accurate picture of overall BP trends
False. BP can be affected by anxiety and other factors. Multiple BP readings over time are necessary for a diagnosis.
60
True or False: Beta blockers meds should be discontinued the morning of surgery
False
61
When should surgery be delayed because of HTN?
Extreme HTN (SBP>180 or DBP>110) or end-organ injury that could be reversed w/BP control
62
Which symptoms may indicate the cause of secondary HTN?
Pheochromocytoma: flushing, sweating, palpitations
Renal artery stenosis: renal bruit
Hyperaldosteronism: Hypokalemia
63
What is the risk of suddenly stopping beta blockers or CCB?
BB: rebound HTN
CCB: increased periop CV events
64
True or False: Patients with organ damage from chronic HTN are resilient to periods of hypotension and have decreased risk of AKI and myocardial injury
False. They are at higher risk
65
Poorly controlled periop HTN places patient more at risk for____?
blood loss, MI, CVA
66
Induction Consideration for HTN
- Hemodynamically vulnerable
- Drugs may cause hypotension while direct laryngoscopy and induction cause inc. BP and HR
- Consider esmolol and preinduction ALine
-At risk for hypovolemia (esp. if on diuretics)---consider modest volume loading unless LVH
67
Peripartum HTN Considerations
-May experience end-organ dysfunction with DBP>100
- Immediate intervention recommended for SBP>160 or DBP>110
68
What is the 1st line drug for peripartum HTN?
Labetolol
69
Gold standard drug for arterial dilation
sodium nitroprusside
70
Clevidipine
ultra short acting (1 min 1/2 life) dihydropyridine CCB that has selective arteriolar vasodilating properties
*expensive
71
Nicardipine
dihydropyridine CCB with longer half life (~30min)
*less titratable than clevidipine
72
What antihypertensives are contraindicated in peripartum HTN?
ACEi and ARBs
73
What is the goal of BP control in HTN crisis including aortic dissection?
Lessening pulsatile force of left ventricular contraciton
74
What is a risk of nitroprusside administration?
cyanide toxicity
75
Cautions in controlling BP of HTN crisis with pheochromocytoma and cocaine
unopposed alpha-adrenergic stimulation following Beta blockade worsens HTN (give alpha blocker first)
76
What are the types of pulmonary hypertension (PH)?
1. Pulmonary arterial hypertension (PAH)
2. PH due to left heart disease
3. PH due to lung disease and/or hypoxia
4. Chronic thromboembolic PH
5. PH with unclear multifactoral mechanisms
77
What mean PA pressure is considered hypertensive?
mPAP>20mmHg
78
Symptoms of PH
S2 &S4 gallop heart sounds
LE swelling
79
Precapillary PH
Primary issue lies in the pulmonary arterial circulation.
PVR>3 and normal PAWP
80
Normal PAWP
<15mmHg
81
Postcapillary PH
increased pulmonary venous pressure d/t elevated LAP usually c/b left heart disease
-PAWP>15, normal PVR
82
Combined pre- and postcapillary PH:
chronic pulmonary venous HTN with secondary pulmonary arterial vasoconstriction and remodeling
- PVR>3 AND PAWP >15
83
High Flow PH
occurs w/o an elevation in PAWP or PVR and results from increased pulmonary blood flow c/b systemic-to-pulmonary shunt or high cardiac output states
84
What groups of PH are isolated precapillary?
1,3, 4, 5
85
What groups are isolated post capillary and combined?
2,5
86
What is required for PAH diagnosis, classification, and treatment plan?
Right heart cath
87
What can increase mPAP?
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
88
Formula for PVR
PVR = (mPAP − PAWP)/COP
89
Mild PH
mPAP 20-30
90
Moderate PH
mPAP 31-40
91
Severe PH
mPAP>40
92
Idiopathic PH
no identifiable risk factor
93
What are the 3 main classes of pulmonary vasodilator drugs?
1. Prostanoids
2. Endothelin receptor antagonists (ERAs)
3. Drugs that enhance nitric oxide/guanylate cyclase pathways
**Combination therapy is often required
94
What is the only prostanoid proven to reduce mortality?
epoprostenol (IV)
95
Prostanoid Effects
mimic the effect of prostacyclin to produce vasodilation while inhibiting platelet aggregation. They also have anti-inflammatory effects and may reduce the proliferation of vascular smooth muscle cells.
96
Endothilin Receptor antagonists (ERAs)
Vascular endothelial dysfunction associated with PAH involves an imbalance btw vasodilating (nitric oxide) and vasoconstricting (endothelin) substances. ERAs improve hemodynamics and exercise capacity.
97
Nitric oxide/guanylate cyclase:
nitric oxide produces pulmonary vasodilation by stimulating guanylate cyclase and cGMP in smooth muscle cells. The effect is transient because nitric oxide is quickly bound by hgb and degraded by phosphodiesterase type 5
98
PAH symptoms
fatigue, cough, dyspnea
Severe: angina, syncope,
may exhibit: parasternal lift, S2, S3, S4 gallop, JVD, peripheral edema, hepatomegaly, ascites
99
What does chronic treatment of PAH include?
PD-5 inhibitors to prolong half life of nitric oxide
100
When is a left heart cath indicated?
to differentiate between PAWP and LVEDP in pts with left heart disease because inaccurate LVEDP may lead to misclassification and improper treatment
101
What does PAH responsiveness to inhaled nitric oxide indicate?
That they will also respond to CCB
***only about 10-15% respond
102
What are patient risk factors for morbidity and mortality in surgical patients with PAH?
-Hx of PE, CAD, CRD
-NYHA/WHO FC>II
-Higher ASA class
-RAD on ECG
-Echo parameters: RVH, RVMPI>.75
-Hemodynamics: Inc. PAP, RSVP/SBP>0.6
103
What are operative risk factors for morbidity and mortality in surgical patients with PAH?
-Emergent
-Intermediate or high risk
-High risk for venous embolism
-Elevation in venous pressure (trendelenburg, insufflation)
-Reduction in lung vascular volume
-Longer duration of anesthesia
-Intraop vasopressors
-Induction of severe systemic inflammatory resposne
104
What is the primary intraopertive goal of managing PAH?
maintaining optimal “mechanical coupling” btw the right ventricle and pulmonary circulation to promote adequate left-sided filling and systemic perfusion
105
What is a hallmark sign of PAH?
increased RV afterload, leading to RV dilation, increased wall stress, and RV hypertrophy
106
What respiratory effects can affect RV afterload?
PEEP
Hypoventilation
Hypercarbia
Acidosis
Atelectasis
107
What can lead to RV ischemia?
The “lethal combination of RV dilatation, insufficient LV filling, reduced stroke volume, and systemic hypotension
108
What orthopedic surgies have increased mortality and morbidity in PH patients?
hip and knee replacements
109
How does HPV affect RV afterload?
Increases it....inhaled pulmonary vasodilators are recommended and often used during single lung ventilation
110
What is the only class of PH to have benefit from pulmonary vasodilators?
PAH
111
Do we need to continue pulmonary vasodilators introp?
Yes, need to give IV or inhaled if on PO
112
What herbal supplements raise BP?
Ephedra
Ginseng
Ma Huang
113
What immunosuppressive agents raise BP?
Cyclosporine
Sirolimus
Tacrolimus
114
Do oral contraceptives and andgrogens raise BP?
Yes
115
What examples of sympathomimetics were given that raise BP?
Decongestants
Diet pills
116
What anti inflammatory meds raise BP?
COX-2, NSAIDs
117
What anti-infective agent raises BP?
Ketoconazole
118
Do vascular endothelial growth factor inhibitors raise BP?
Yes
