Hypertension - Final Flashcards
1
Q
In a blood pressure, systolic number is when the heart ____, diastolic number is when the heart ____
A
Contracts
Rest
2
Q
HTN is defined as a sustained SBP >____ or DBP >____
A
130
80
Effects >100 million people (1/2 adults), 40% of African Americans, 30% of Whites, 29% of Asians, 27% of Hispanics
3
Q
Classification of systemic BP in adults picture
A
4
Q
Chronic HTN leads to what?
A
ischemic heart disease, stroke, renal failure, retinopathy, PVD, and an overall increased mortality
5
Q
In the surgical population, ___ is as common risk factor for perioperative morbidity & mortality, particularly if undiagnosed/untreated
A
HTN
Widened pulse pressure is alsoa risk factor for cardiovascular morbidity as it correlates withvascular remodeling and “stiffness”
6
Q
Describe the spectrum of elevated BP to severe disease
A
- isolated systolic HTN (SBP >130 mm Hg and DBP <80 mm Hg)
- isolated diastolic HTN (SBP <130 mm Hg with DBP >80 mm Hg)
- combined systolic and diastolic HTN (SBP >130 mm Hg and DBP >80 mm Hg)
7
Q
HTN can result from increased _____ ____, ____ ____, or both
A
Cardiac output
Vascular resistance
8
Q
The cause of primary HTN is unclear, but contributing factors include:
A
SNS hyperactivity, dysregulation of the RAAS, anda deficiency in endogenous vasodilators
9
Q
______ HTN is more rare, but the cause is potentially correctable
A
Secondary
10
Q
Common causes of secondary HTN in adults
A
hyperaldosteronism, thyroid dysfunction, OSA, Cushings, and pheochromocytoma
11
Q
Children w/ HTN generally have secondary HTN d/t:
A
renal disease or coarctation of the aorta
12
Q
Drugs that elevate BP chart
A
13
Q
Secondary HTN causes by age chart
A
14
Q
Chronic HTN leads to:
A
remodeling of small & large arteries, endothelial dysfunction, and potentially irreversible end-organ damage
15
Q
Disseminated vasculopathy plays a major role in:
A
ischemic heart dz, LVH, CHF, CVA, PAD, aortic aneurysm, and nephropathy
16
Q
What can vasculopathy be detected with?
A
Ultrasound with measurement of common carotid intimal-to-medial thickness and arterial pulse-wave velocity
17
Q
What is the general therapeutic goal in HTN?
A
general therapeutic goal is <130/<80
18
Q
End organ damage in HTN chart
A
19
Q
What is resistant HTN?
A
above-goal BP despite 3+ antihypertensive drugs @ max dose
Tx usually includes a LA CCB, an ACI-I or ARB + a diuretic
20
Q
What is controlled resistant HTN?
A
controlled BP requiring 4+medications
21
Q
What is refractory HTN?
A
uncontrolled BP on 5+ drugs
22
Q
What is pseudo-resistant HTN?
A
often d/t BP inaccuracies (i.e. white-coat syndrome) or medication noncompliance
23
Q
Lifestyle modifications for HTN
A
weight loss,↓ETOH, exercise, and smoking cessation
24
Q
___ mmhg reduction in BP for every ___ kg of weight loss
A
1 mmhg
1 kg
25
Dietary potassium and calcium intake are inversely related to:
HTN and cerebrovascular disease
26
ACC/AHA guidlines for BP management (this card sucks)
1. Out-of-office BP's are recommended for dx and titration of BP meds
2. Evidence supports treating pts with ischemic heart dz, cerebrovascular dz, CKD, or atherosclerotic cardiovascular dz w/ BP meds if SBP >130 mmHg
3. There is limited data to support treating pts w/o cardiovascular or cerebrovascular nonpharmacologically if SBP >130 or DBP >80
4. The same goals are recommended for HTN pts w/DM or CKD as for the general HTN population
5. ACE-I’s, ARBs, CCBs, or thiazide diuretics are effective in nonblack HTN pts
6. In black adult HTN pts w/o heart failure or CKD, there is moderate evidence to support initial therapy with a CCB or thiazide diuretics
7. Moderate evidence supports antihypertensive therapy with an ACE-I or ARB in those with CKD to improve kidney outcomes
8. Nonpharmacologic interventions are important components of comprehensive BP management
27
New treatment approaches for HTN chart
28
Notably absent from 1st line therapy are ______, which are reserved for pts w/ what?
β blockers
CAD or tachydysrhythmia, or as a component of multidrug tx in resistant HTN
29
Treatment of secondary HTN
often interventional, including surgical correction of renal artery stenosis, adrenal adenoma or pheochromocytoma
If renal artery repair not possible, BP can be controlled w/ACE-I’s +/- diuretics
30
Primary hyperaldosteronism can be treated w/ what?
aldosterone antagonist such as spironolactone
31
T/F
Pts are often instructed to pause BP meds on the day of surgery
True
32
What do guidelines currently state that is necessary for diagnosis of HTN?
multiple elevated BP readings over time
33
T/F
Elevated BP is a direct prompt to delay surgery in asymptomatic pts w/o risk factors
False
## Footnote
Surgery should not be delayed d/t a transient HTN, unless the pt is experiencing extreme HTN (SBP >180 or DBP >110) or end-organ injury that could be reversed w/BP control
34
The cause of secondary HTN may be indicated by what symptoms?
flushing, sweating & palpitations suggestive of pheochromocytoma
renal bruit may suggest renal artery stenosis
hypokalemia may suggest hyperaldosteronism
35
Stopping BBs or clonidine can be associated with:
Stopping CCBs is associated with:
Rebound HTN
Increased periop CV check
36
Guidelines don’t support delaying surgery for poorly controlled BP; however, perioperative HTN increases what?
blood loss and the incidence of MI & CVA
37
Flow chart for HTN
PWV is pulse wave velocity
38
Poorly controlled HTN is often accompanied by:
hypovolemia, esp if pt is on diuretics
38
Vasoactive drug considerations should take into account:
the pt's age, functional reserve, medications, and the planned surgery
39
HTN crisis is categorized by ____ or ____, based on what?
Urgent or emergent
Prescence of end organ damage
40
Women w/PIH may experience end-organ dysfunction (such as encephalopathy) with a DBP >____
100
41
Current guidelines for peripartum HTN recommend immediate intervention for SBP >___ / DBP>___
160
110
42
What is the 1st line drug for peripartum HTN?
Other options?
Labetalol
Clevidipine: a 3rd-generation dihydropyridine CCB with an ultrashort DoA (1 min half life)
Nicardipine
a second-generation dihydropyridine CCB
43
Treatment for HTN emergency chart
44
For rapid arterial dilation, ______ is the gold standard d/t fast onset and titratability
SNP infusion
45
Classification of pulmonary HTN chart
46
Pulm. HTN is defines as mean PA pressure of what?
(mPAP) >20 mmHg
47
Symptoms of pulm. HTN
Accentuated S2 & S4 "gallop" heart sounds, LE swelling
48
Pulmonary HTN is further divided into 3 hemodynamic profiles based on PA wedge pressure (PAWP) and pulmonary vascular resistance (PVR)
What are they?
isolated precapillary PH
isolated postcapillary PH
combined pre & postcapillary PH
49
What is pre capillary PH?
Primary issue lies in the pulmonary arterial circulation.
- Pulmonary vasc resistance (PVR) ≥3.0 wood units w/ normal LAP or PAWP(<15mmHg)
50
What is post-capillary PH?
increased pulmonary venous pressure d/t elevated LAP usually c/b left heart disease
- Elevated PAWP (>15mmHg), Normal PVR
51
What is combine pre/post-capillary PH?
chronic pulmonary venous HTN with secondary pulmonary arterial vasoconstriction and remodeling
- Characterized by a PVR > 3.0 WU and PAWP >15mmHg
## Footnote
Can be subcategorized as fixed or vasoreactive d/o the response to vasodilators, diuretics, or mechanical assistance
52
What is 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
53
Hemodynamic definitions of PH chart
54
How do you diagnosis pulmonary artery HTN?
Right heart catheterization
55
mPAP can be increased by a variety of mechanisms. What are these?
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
56
PVR equation
(mPAP − PAWP)/COP
57
_____ reveals RA & RV enlargement and elevated tricuspid-regurgitation velocity
TTE
58
Echo is commonly used to estimate what?
pulmonary arterial systolic pressure (PASP) as a screening tool for PH
59
List the mPAPs associated with degree of PH severity from a heart Cath
Mild PH (mPAP = 20–30 mmHg)
Moderate PH (mPAP = 31–40 mmHg)
Severe PH (mPAP >40 mmHg)
60
What is idiopathic PAH?
No identifiable risk factor
- 3% of PAH cases are genetic, with mutations in bone morphogenetic protein receptor type 2 (BMPR2)
- The remaining cases are “associated PAH,” since they can be attributed to disease processes, drugs or toxins
61
Nearly 1: 8 PAH pts with idiopathic PAH have long-term improvements w/ ____
CCB
62
What are the 3 main classes of pulmonary vasodilator drugs for PAH?
Prostanoids
Endothelin receptor antagonists (ERAs)
Drugs that enhance nitric oxide/guanylate cyclase pathways
63
What are prostanoids?
Examples?
mimic the effect of prostacyclin to produce vasodilation while inhibiting platelet aggregation. They also have anti-inflammatory effects and may reduce proliferation of vascular smooth muscle cells.
epoprostenol (IV)
iloprost (inhaled)
treprostinil (SQ, IV, INH, PO)
beraprost(PO)
64
What are endothelia receptor antagonists?
vascular endothelial dysfunction associated with PAH involves an imbalance btw vasodilating (nitric oxide) and vasoconstricting (endothelin) substances. ERAs improve hemodynamics and exercise capacity.
65
nitric oxide produces ____ _____ by stimulating ____ _____ and ____ in smooth muscle cells
pulmonary vasodilation
guanylate cyclase
cGMP
## Footnote
The effect is transient because nitric oxide is quickly bound by hgb and degraded by phosphodiesterase type 5
66
PAH often presents with nonspecific sx s/a:
Severe sx include:
fatigue, dyspnea, and cough
angina and syncope, which can occur with exercise if coronary blood flow doesn’t meet the demands of a hypertrophied RV
67
Describe how a PAH pt might look on assessment
pts may exhibit a parasternal lift, accentuated S2, S3, or S4 gallop, JVD, peripheral edema, hepatomegaly, and ascites
Rarely, compression of a dilated PA may lead to RLN damage and hoarseness
68
For pts with moderate/severe PH, a ______ is recommended prior to moderate-high risk surgery
Right heart Cath
69
Due to potential discrepancies btw PAWP and LVEDP, a ______ is indicated in pts with left heart dz, because inaccurate LVEDP may lead to misclassification of PH and inappropriate treatment
Left heart Cath
70
During right heart cath, vasoreactivity testing with inhaled ___ ____, is performed to determine responsiveness to vasodilator therapy
Nitric oxide
71
PAH flow chart
72
Risk factors for pts with PAH chart
73
Added perioperative complexities can increase risks of what complications?
transient HoTN
mechanical ventilation
modest hypercarbia
small bubbles in IV
T-burg position
Pneumoperitoneum
single-lung ventilation
74
A hallmark of PAH is what?
What does this lead to?
Increased RV after load
leading to RV dilation, increased wall stress, and RV hypertrophy
75
What vent settings can affect RV afterload?
PEEP, hypoventilation, hypercarbia, acidosis, and atelectasis
76
In contrast to the LV, the thinner-walled RV is subject to _____ ____ ____ for the same degree of end-diastolic volume, leading to what?
Greater wall tension
increased RV 02 demand
77
Under normal circumstances the RV intramyocardial pressure is lower than the ____ _____ ____, and ____ ____ perfusion occurs throughout the cardiac cycle
aortic root pressure
RV coronary
78
In PAH, the elevated RV pressure leads to increased coronary flow during ______, making the RV more vulnerable to ______ ______, worsening the 02 supply/demand mismatch and potentially causing myocardial ischemia
Diastole
Systemic hypotension
79
What is the lethal combination that can lead to RV ischemia?
RV dilatation, insufficient LV filling, reduced stroke volume, and systemic hypotension
80
studies show increased perioperative morbidity and mortality in pts with PH undergoing ____ and ____ replacement
Hip
Knee
81
Pneumoperitoneum impacts biventricular load and pump function.
The combination of what 3 things increases RV pressures and afterload?
pneumoperitoneum, head-down position, and increased AW pressures
82
Thoracic procedures involve _____ and _____ of the operative lung
Nonventilation
Atelectasis
83
What 3 features of lung collapse are particularly relevant?
(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
## Footnote
PAH pts are often converted from oral to inhaled or pulmonary vasodilators
inhaled pulmonary vasodilators are recommended during single-lung ventilation
