Hypertension- (Final, Mordecai)

Question 1

What defines hypertension (HTN)?

Answer 1

Sustained SBP > 130 mmHg and/or DBP > 80 mmHg.

Question 2

What percentage of adults in the US have hypertension?

Answer 2

Nearly 50%, affecting over 100 million people.

Question 3

What is the lifetime risk of developing hypertension in the US?

Answer 3

90%.

Question 4

What are the three subtypes of hypertension?

Answer 4

Isolated systolic HTN, isolated diastolic HTN, and combined systolic-diastolic HTN.

Question 5

What causes HTN pathophysiologically?

Answer 5

Increased cardiac output, increased vascular resistance, or both.

Question 6

What are key contributors to primary HTN?

Answer 6

SNS hyperactivity, RAAS dysregulation, and deficient vasodilators.

Question 7

Name three modifiable risk factors for primary HTN.

Answer 7

Obesity, alcohol use, and tobacco.

Question 8

What are common causes of secondary HTN in adults?

Answer 8

Hyperaldosteronism, thyroid dysfunction, OSA, Cushing’s, pheochromocytoma.

Question 9

What should be suspected in a child with HTN?

Answer 9

Secondary HTN, commonly due to renal disease or aortic coarctation.

Question 10

What are some complications of chronic HTN?

Answer 10

Ischemic heart disease, LVH, CHF, stroke, PVD, nephropathy, retinopathy.

Question 11

How is early vasculopathy detected?

Answer 11

Ultrasound (intimal-to-medial thickness) and pulse-wave velocity.

Question 12

What is the general BP goal in HTN treatment?

Answer 12

<130/<80 mmHg.

Question 13

What defines resistant hypertension?

Answer 13

BP above goal despite 3+ antihypertensives at max doses.

Question 14

What is pseudo-resistant HTN?

Answer 14

Apparent resistance due to measurement errors or noncompliance.

Question 15

How much does BP reduce per 1 kg of weight loss?

Answer 15

~1 mmHg.

Question 16

Which minerals are inversely related to BP?

Answer 16

Potassium and calcium.

Question 17

What first-line antihypertensives are recommended for non-Black patients?

Answer 17

ACE-I, ARBs, CCBs, or thiazide diuretics.

Question 18

What are β-blockers reserved for?

Answer 18

CAD, tachydysrhythmia, or part of multidrug therapy in resistant HTN.

Question 19

When should surgery be delayed for HTN?

Answer 19

If SBP >180 mmHg or DBP >110 mmHg with end-organ damage.

Question 20

Which antihypertensives should not be stopped pre-op?

Answer 20

β-blockers and clonidine.

Question 21

Why are HTN patients vulnerable at induction?

Answer 21

Prone to hypotension from drugs and hypertension from DL/intubation.

Question 22

What helps stabilize BP in hypertensive patients before induction?

Answer 22

Modest fluid loading and pre-induction β-blockers (e.g., esmolol).

Question 23

What defines hypertensive urgency vs emergency?

Answer 23

Presence of end-organ damage.

Question 24

What are first-line drugs for acute HTN control?

Answer 24

Labetalol, SNP, clevidipine, nicardipine.

Question 25

What defines pulmonary hypertension (PH)?

Answer 25

Mean pulmonary artery pressure (mPAP) > 20 mmHg.

Question 26

What are the three classifications of PH?

Answer 26

Precapillary, postcapillary, and combined.

Question 27

What is the gold standard for PH diagnosis?

Answer 27

Right heart catheterization.

Question 28

What is idiopathic pulmonary arterial hypertension (PAH)?

Answer 28

PAH without an identifiable cause.

Question 29

What are the three main PAH drug classes?

Answer 29

Prostanoids, endothelin receptor antagonists, and nitric oxide pathway enhancers.

Question 30

Which PAH drug reduces mortality?

Answer 30

Epoprostenol (IV prostanoid).

Question 31

What is the primary intraop goal in PAH patients?

Answer 31

Maintain RV-pulmonary artery coupling to ensure LV filling and systemic perfusion.

Question 32

What factors increase RV afterload during surgery?

Answer 32

PEEP, hypercarbia, acidosis, hypoxia, T-burg position, and pneumoperitoneum.

Question 33

Why is the RV at higher ischemic risk in PAH?

Answer 33

Elevated wall tension increases O2 demand, and systemic hypotension impairs coronary perfusion.

Question 34

What diagnostic test is required for definitive diagnosis and classification of PH?

Answer 34

Right heart catheterization.

Question 35

What does the pulmonary vascular resistance (PVR) equation look like?

Answer 35

PVR = (mPAP − PAWP) / Cardiac Output.

Question 36

What can transthoracic echocardiogram (TTE) show in PH?

Answer 36

RA & RV enlargement, elevated tricuspid-regurgitation velocity, and estimated PASP.

Question 37

How is the severity of PH graded by mPAP?

Answer 37

Mild: 20–30 mmHg Moderate: 31–40 mmHg Severe: >40 mmHg

Question 38

What is a normal physiologic response of pulmonary circulation to increased CO?

Answer 38

It accommodates a fourfold increase in cardiac output without a major rise in mPAP.

Question 39

What are common causes of PAH?

Answer 39

Genetic mutations (e.g., BMPR2), connective tissue disease, toxins/drugs, idiopathic cases.

Question 40

What is the prognosis for PAH despite treatment?

Answer 40

1-year mortality remains ~15%, with generally poor long-term outcomes.

Question 41

What are the three main classes of drugs used to treat PAH?

Answer 41

Prostanoids Endothelin receptor antagonists (ERAs) Nitric oxide/guanylate cyclase pathway drugs

Question 42

What do prostanoids do in PAH?

Answer 42

Mimic prostacyclin to vasodilate, inhibit platelet aggregation, reduce inflammation, and limit vascular remodeling.

Question 43

Which prostanoid has been shown to reduce mortality in PAH?

Answer 43

Epoprostenol (IV).

Question 44

How does nitric oxide cause pulmonary vasodilation?

Answer 44

By activating guanylate cyclase and increasing cGMP in smooth muscle cells.

Question 45

Why is the effect of inhaled nitric oxide short-lived?

Answer 45

It is rapidly bound by hemoglobin and degraded by phosphodiesterase type 5 (PDE5).

Question 46

What drugs prolong nitric oxide's effect in PAH treatment?

Answer 46

PDE5 inhibitors.

Question 47

What clinical symptoms raise suspicion for PAH preoperatively?

Answer 47

Fatigue, dyspnea, angina, syncope, accentuated S2, parasternal lift, JVD, and peripheral edema.

Question 48

What test is recommended before moderate-high risk surgery in PAH patients?

Answer 48

Right heart catheterization.

Question 49

What is the purpose of vasoreactivity testing during right heart cath?

Answer 49

To determine responsiveness to vasodilator therapy like inhaled nitric oxide or CCBs.

Question 50

What is the main intraoperative goal in PAH patients?

Answer 50

Maintain mechanical coupling between RV and pulmonary circulation.

Question 51

What factors increase RV afterload during surgery?

Answer 51

PEEP, hypoventilation, hypercarbia, hypoxia, acidosis, surgical stimulation.

Question 52

Why is the RV more vulnerable to ischemia in PAH?

Answer 52

Increased wall tension and pressure demand compromise coronary perfusion during hypotension.

Question 53

Why is orthopedic surgery high risk for patients with PH?

Answer 53

Studies show increased perioperative morbidity and mortality, particularly with hip and knee replacements.

Question 54

What are the main concerns with laparoscopy in PH patients?

Answer 54

Pneumoperitoneum, increased airway pressure, and head-down position increase RV pressure and afterload.

Question 55

What makes thoracic surgery particularly risky in PH?

Answer 55

It often involves lung collapse, systemic hypoxia, and hypoxic pulmonary vasoconstriction, all of which increase RV afterload.

Question 56

What inhaled therapy is often initiated during thoracic surgery in PAH patients?

Answer 56

Inhaled pulmonary vasodilators.

Question 57

What is the primary anesthetic concern for patients with PAH?

Answer 57

Preserving right ventricular function and preventing increases in pulmonary vascular resistance.

Question 58

Why are small air bubbles in IV lines dangerous for PAH patients?

Answer 58

They can travel to the pulmonary circulation and exacerbate pulmonary hypertension or cause embolic complications.

Question 59

What ventilation strategies should be avoided in PAH patients?

Answer 59

High PEEP, hypoventilation, hypercarbia, and acidosis, as they all increase PVR and RV strain.

Question 60

What is the consequence of systemic hypotension in PAH?

Answer 60

It reduces coronary perfusion pressure, worsening RV ischemia and potentially causing cardiovascular collapse.

Question 61

What positioning should be used cautiously in PAH patients?

Answer 61

Trendelenburg position, due to effects on venous return and RV afterload.

Question 62

Should PAH medications be continued perioperatively?

Answer 62

Yes — especially vasodilators. Oral drugs may need conversion to IV or inhaled forms intraoperatively.

Question 63

What anesthetic technique may help with pulmonary vasodilation in PAH?

Answer 63

Inhaled nitric oxide or prostacyclin analogs during periods of increased PVR.