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Prodigy Quick Review > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is ‘pre-hypertension’?

A

Prehypertension is defined as a systolic blood pressure
between 120-139 or a diastolic blood pressure between 80-89.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 104.

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2
Q

How common is hypertension in the United States?

A

Approximately 70 million Americans are diagnosed with
hypertension.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 5418.

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3
Q

How is the diagnosis of hypertension made in the

adult patient?

A

Hypertension is diagnosed when the blood pressure is
determined to be at least 140/90 on two successive occasions
that are at least 1-2 weeks apart.
Stoelting RK, Dierdorf SF. Anesthesia & Co-Existing Diseases.
5th ed. New York, NY: Churchill-Livingston; 2008: 87.

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4
Q

What is the difference between essential
hypertension and remedial (secondary)
hypertension?

A

Secondary hypertension is an increase in blood pressure due to
a cause that can be identified and cured such as
pheochromocytoma, renal artery stenosis, coarctation of the
aorta, Conn’s syndrome, or Cushing disease. Essential
hypertension is an increased blood pressure for which there is
no identifiable cause and is diagnosed based on the exclusion
of causes such as those listed above. Approximately 95% of
patients with hypertension are diagnosed with essential
hypertension.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 491.

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5
Q

What is the most common cause of secondary

hypertension?

A

Renal artery stenosis
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 105.

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6
Q

What lifestyle modifications have been shown to be

effective in the treatment of hypertension?

A

Smoking cessation, weight loss, exercise, maintenance of
normal calcium and potassium levels, and limiting sodium
intake.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 106-107.

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7
Q

What are the positive effects of sodium restriction?

A

Decreasing sodium intake has been shown to reduce blood
pressure, minimize hypokalemia due to diuretic use, protect
from osteoporosis, and enhance ventricular contractility as a
result of decreased calcium excretion.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 107.

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8
Q

How is the determination made to institute lifestyle
modification changes versus placing a patient on
antihypertensive drugs?

A

If the patient exhibits any signs of end-organ damage due to
hypertension such as renal disease, coronary artery disease,
cerebrovascular disease, retinopathy, etc,) the patient will be
placed on antihypertensive therapy as soon as possible. If no
evidence of end-organ damage is present and the patient is
otherwise asymptomatic, lifestyle modification therapy is often
effective.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 106-107.

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9
Q

What concomitant disorders are often seen with

hypertension?

A

Hypertension is often seen with diabetes mellitus, insulin
resistance, dyslipidemia, and obesity. Approximately 40% of
patients with hypertension have elevated cholesterol levels.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 104-105.

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10
Q

How is the degree of hypertension related to

cardiovascular risk?

A

For every increase of 20/10 mmHg over a 115/75, the risk of
cardiovascular disease doubles.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 491.

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11
Q

How does the institution of antihypertensive
medication in patients with essential hypertension
affect their cardiovascular risk?

A

The implementation of antihypertensive therapy reduces the
risk of cardiovascular complications by 25% and reduces the
risk of stroke by 38%.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 491.

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12
Q

How is alcohol ingestion related to hypertension and

cardiovascular risk?

A

Alcohol ingestion is associated with an increase in blood
pressure, but the moderate consumption of alcohol has been
shown to decrease overall cardiovascular risk.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 105.

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13
Q

How does chronic hypertension affect the left

ventricular oxygen supply and demand?

A

As the left ventricle undergoes compensatory concentric
hypertrophy, the increased myocardial mass has a higher
oxygen demand while the contraction of the hypertrophied
muscle can reduce subendocardial oxygen supply, placing the
myocardium at greater risk for ischemia.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 492.

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14
Q

How does the left ventricle respond to the increased

demands made on it by hypertension?

A

Faced with the increased afterload associated with chronic
hypertension, the left ventricle increases its myocardial mass
(concentric hypertrophy).
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 492.

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15
Q

What is the relationship between hypertension and

atherosclerotic disease?

A

Hypertension accelerates the development of atherosclerotic
changes in the arterial vessels.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 491.

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16
Q

What is the standard goal of therapy in the medical
management of hypertension? How is this
influenced by a concomitant diagnosis of diabetes
mellitus or renal disease?

A

The standard goal is the reduction of the blood pressure to less
than 140/90. In patients with diabetes mellitus or renal disease,
the goal is to reduce the blood pressure to less than 130/80
mmHg.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 105

17
Q

How is obstructive sleep apnea linked to

hypertension?

A

Obstructive sleep apnea results in paroxysmal hypoxemia,
arousal, and activation of the sympathetic nervous system with
resulting increases in blood pressure. Approximately 30% of
patients with OSA are also diagnosed with hypertension.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 105.

18
Q

How can hypertension lead to congestive heart

failure?

A

The chronic increase in afterload can result in cardiomyopathy
and left ventricular failure with resultant congestive heart failure.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 491.

19
Q

How is the renal juxtoglomerular apparatus

implicated in the pathophysiology of hypertension?

A

In the face of chronic vasoconstriction, the response of the
juxtaglomerular apparatus is to increase intravascular volume.
It releases renin. The end result of renin release is the
conversion of angiotensin I to angiotensin II. Angiotensin II is
the primary stimulus for the release of aldosterone by the
adrenal cortex. Aldosterone results in increased sodium and
water retention.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 492.

20
Q

Within what range should you maintain blood
pressure during the anesthetic for a patient with
chronic hypertension?

A

The goal is maintenance of the mean arterial blood pressure
within 20% of their normal mean pressure.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 493.

21
Q

What medications may be used to treat
intraoperative hypertension in the chronically
hypertensive patient?

A

Volatile anesthetics and opioids may be used to control blood
pressure, as may beta-blockers, ACE inhibitors, nitroprusside,
alpha-2 agonists such as clonidine, alpha-1 blockers such as
droperidol, and calcium-channel blockers.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 494.

22
Q

What are methods that can be employed to reduce
the exaggerated blood pressure response to
laryngoscopy seen in many hypertensive patients?

A

Continuing their regularly scheduled antihypertensive
medication, achieving a deeper level of anesthesia than typical
for non-hypertensive patients prior to laryngoscopy, pre-treating
with lidocaine intravenously or administration of 2-3 mcg/kg of
fentanyl, and reducing the duration of laryngoscopy to less than
15 seconds.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 493.

23
Q

What is the most effective means of preventing the
postinduction hypotension commonly seen in
hypertensive patients?

A

Because the chronically hypertensive patient is volume
contracted, adequate hydration prior to induction will usually
attenuate the drop in blood pressure seen after induction of
anesthesia.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 493.

24
Q

How can antihypertensive medical therapy affect
homeostatic compensatory mechanisms and how
can this affect the anesthetic management of the
patient?

A

Antihypertensives can block the body’s ability to compensate for
changes in sympathetic tone. As a result, the normal reflexes
such as increased heart rate or vasoconstriction that may
normally occur during induction of anesthesia or in response to
blood loss may not occur, making the anesthetic management
of the patient more difficult.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 492.

25
Q

How rapidly should the blood pressure be decreased

in patients with hypertensive emergency and why?

A

The goal is reduction of the diastolic pressure by about 20%
over the first 60 minutes and then more gradually after that.
Reducing the diastolic pressure too rapidly can result in
coronary or cerebral ischemia.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 109.

26
Q

What are the most commonly used methods of
treating intraoperative hypotension in the chronically
hypertensive patient?

A

Prolonged hypotension in the hypertensive patient is associated
with poor outcomes and must be treated aggressively. If
reducing the amount of volatile agent used and ensuring
adequate volume expansion do not treat the problem rapidly,
then fast-acting vasopressors such as phenylephrine or
ephedrine may be necessary until the cause of the hypotension
can be identified.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 494.

27
Q

At what blood pressure does encephalopathy usually

appear? What is the exception to this rule?

A

Encephalopathy usually does not present until the diastolic
blood pressure reaches 150 mmHg. The exception is
parturients who may exhibit signs of encephalopathy with
diastolic pressures at 100 mmHg.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 109.

28
Q

Why should nitroprusside be used with caution in the

hypertensive patient exhibiting encephalopathy?

A

Nitroprusside’s use can be complicated by lactic acidosis and
cyanide toxicity. Nicardipine (which offers both cardiac and
cerebral protection) may be a more suitable option.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 110.

29
Q

What is the difference between hypertensive

emergency and hypertensive urgency?

A

Hypertensive emergency is defined as hypertension with
evidence of end-organ damage such as myocardial ischemia,
dissecting aortic aneurysm, renal insufficiency, pulmonary
edema, encephalopathy, eclampsia, or intracerebral
hemorrhage. Hypertension without signs of end-organ damage
is termed ‘hypertensive urgency’. These patients often present
with hypertension and symptoms such as headache, epistaxis,
or anxiety.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 109.

30
Q

How is the diagnosis of hypertensive emergency

made in parturients?

A

Even if no overt signs of end-organ damage are noted, a
diastolic pressure higher than 109 mmHg in a parturient is
designated as a hypertensive emergency and immediate
treatment is warranted.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 109.

31
Q

How is hypertension due to primary aldosteronism
(Conn’s syndrome) treated differently in males and
females and why?

A

Primary aldosteronism is treated with spironolactone in women.
Amiloride is used as the treatment of choice in males as
spironolactone can result in gynecomastia.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 109.

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