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Cardiology (Fall 2023) > Hypotension > Flashcards

Hypotension Flashcards

1
Q

what is considered hypotension

A

<90/60

treat the patient not the number! consider what is normal for the patient

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2
Q

what is the pathophysiology of hypotension

A
  • Hypotension reduces blood flow
  • Decreasing oxygen delivery to organs and tissues
  • Causing cellular damage and dysfunction.
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3
Q

what is circulatory shock

A

when oxygen delivery is insufficient to support tissue metabolic requirements

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4
Q

what three factors determine arterial pressure

A

1)cardiac output
2)venous pressure
3)systemic vascular resistance

any reduction in these variables can lead to hypotension

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5
Q

what are possible causes of hypotension

A
  • arrhythmias
  • structural disease (HF, valve disease)
  • hypovolemia
  • systemic vasodilation (sepsis, anaphylaxis)
  • obstructive (PE)
  • endocrine (hypothyroid, adrenal insufficiency)
  • drug induced

(by the end of this course youll be able to intuitively know these)

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6
Q

what are the 5 history questions to ask a patient with hypotension

A
  • Acute change in BP?
  • Precipitating events/symptoms?
  • Medications, including any recent changes?
  • Pre-existing medical conditions?
  • Are they symptomatic?
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7
Q

what are symptoms of hypotension

A
  • Lightheadedness, dizziness
  • Syncope
  • Nausea
  • Confusion
  • Fatigue

Depends on the patient, underlying cause, existing comorbidities, age, etc.

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8
Q

what are the signs of hypotension

A
  • bradycardia/tachycardia
  • pallor, diaphoresis, cool/clammy, prolonged cap refill
  • Altered LOC
  • other signs depend on underlying mechanism
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9
Q

what is diagnostic testing for hypotension

A
  • EKG
  • CBC, CMP, UA
  • Echo
  • UDS
  • CT head

note: testing should reflect your diagnosis

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10
Q

what is the management used for the majority of hypotensive patients? Who would we NOT want to treat this way?

A

IV bolus of normal saline

Careful in patients with heart failure due to fluid overload

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11
Q

what is orthostatic hypotension

A

a drop in BP upon standing, leading to symptoms of hypotension.

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12
Q

what are causes of orthostatic hypotension

A
  • impairment of autonomic reflexes
  • volume depletion
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13
Q

what is the criteria for orthostatic hypotension

A

A 20 mmHg fall in SBP
OR
A 10 mmHg fall in DBP

after standing from a lying position

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14
Q

how long after standing does orthostatic hypotension typically occur

A

within 2-5 minutes of standing (delayed orthostasis may occur after 5 or even 10 minutes)

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15
Q

What is the normal BP response to standing

A

rapid decrease in venous return and cardiac output which causes stimulation of the SNS
1. increase in HR
2. increase in PVR
3. therefore increasing CO and limiting

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16
Q

What detects change in position of the body (such as from lying to standing up)

A

baroreceptors in the carotids

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17
Q

what are things could lead to orthostatic hypotension

A
  • Prolonged lying or sitting
  • Volume depletion
  • Autonomic failure
  • Neurodegenerative disease, such as Parkinson’s
  • Neuropathies, as a result of DM, B12 deficiency, amyloidosis, sarcoidosis, Lyme disease
  • Medication SE
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18
Q

what medication classess can cause orthostatic hypotension

A
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19
Q

what are the classic symptoms for orthostatic hypotension

A

Generalized weakness
Dizziness or lightheadedness
Blurry vision or darkening of the visual fields
Syncope

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20
Q

what are atypical presentations of orthostatic hypotension

A

fatigue
cognitive slowing
nausea

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21
Q

what are the diagnostic studies that can be done to evaluate for orthostatic hypotension

A

bedside tilt test
formal tilt table test

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22
Q

what is bedside tilt test or orthostatic BP measurement

A

have patient lie down for 5 minutes , then sit up for 2 minutes, then stand and take BP immediatly after standing, then at 2 minutes, then at 5 minutes.

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23
Q

describe tilt table testing

A
  • pt lies down and is strapped into bed
  • IV in for PRN fluids
  • ECG and BP are monitored
  • pt lies flat then raised to standing angle.
  • note symptoms for the next 45 mintues
  • if no symptoms, lie flat and give meds to increase HR
  • tilt patient upright and monitor for symptoms
  • lower flat and get back to baseline. once normal, test is complete
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24
Q

how many patients have no identifiable cause of orthostatic hypotension

A

1/3

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25
Q

what tests should be don after tilt testing to focus on treatable conditions

A

CBC
CMP
EKG
EMG

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26
Q

how do you treat acute orthostasis d/t volume depletion

A

IV fluids

27
Q

how do you treat chronic orthostasis

A

symptoms are managed initially with nonpharmacologic measures, which the patient must strictly adhere to

pharm therapy is added if there are severe symtpms or symptoms refractory to nonpharm therapy

28
Q

what are options for nonpharm management of chronic orthostasis

A
  1. rmeove causative medication if possible
  2. lifestyle modifications
  3. physical maneuvers
29
Q

what are the lifestyle modifications used to treat orthostasis

A
  • Get up slowly
  • Straining, coughing and exertion in hot weather can exacerbate sx’s
  • Elastic compression stockings
  • 6 to 10 g of sodium per day
  • At least 3 liters of water a day
30
Q

what are the physical maneuvers used to treat orthostasis

A
  • Tensing leg muscles while standing; crossing legs tightly while standing
  • Isometric handgrip when standing
31
Q

what are the medications used to treat orthostasis

A

Fludrocortisone (Florinef)
Midodrine (ProAmatine)

not first line. only used if symptoms are severe or if pt is refractory to non-pharm treatment

32
Q

What should be watched for closely in a patient who is using pharmacologic measures to manage orthostatic hypotension

A
  • supine HTN!!
  • have pts monitor BP mulitple times/day while sitting/standing and lying
  • elevate head of bed 20-30 degrees while sleeping to protect brain from supine HTN
33
Q

what drug class is fludrocortisone

A

Potent mineralocorticoid with high glucocorticoid activity

34
Q

what is the MOA of fludrocortisone

A

Promotes increased sodium reabsorption and potassium excretion from renal distal tubules

35
Q

what is the Dosage of fludrocortisone

A

Initiated at 0.1mg/day and may be increased in weekly increments to 0.3mg/day

36
Q

what are possible SE of fludrocortisone

A

edema
supine/sitting HTN

37
Q

what is the possible electrolyte abnormality with fludrocortisone use?

A

hypokalemia

38
Q

what lab study should be done after starting a patient on fludrocortisone

A

BMP after a week

39
Q

what drug class is midodrine

A

Alpha-1 selective adrenergic agonist

40
Q

what is the MOA of midodrine

A

Increases peripheral vascular resistance, which increases arteriolar and venous tone, resulting in increased SBP and DBP
Does not cross the blood-brain barrier

41
Q

why is fludrocortisone usually used over midorine

A

midodrine has a short half life and therefore must be dosed TID

42
Q

what is the dosage of midodrine

A

Initiate dose of 2.5mg TID, then titrate weekly to 10mg TID for desired response

43
Q

what are the SE of midodrine

A

supine HT
paresthesias
piloerection
pruritus
GI upset
urinary retention or urgency.

44
Q

what is the usual cause of discontinuation of midodrine

A

Supine HTN

45
Q

what is POTS

A

Another form of orthostatic intolerance, but the hallmark response to standing is an exaggerated increase in heart rate

46
Q

what is the common demographic for POTS

A

young female patients (14-45)

47
Q

what is the possible etiology of POTS

A

Distal denervation
Hypovolemia
Venous dysfunction
Cardiovascular deconditioning
Baroreflex abnormalities
Increased sympathetic activity
Genetic abnormalities

48
Q

what is the clinical presentation of POTS

A

Dizziness / Lightheadedness
Syncope
Weakness and fatigue
Blurry vision

49
Q

what is diagnostic criteria for pots

A

●History of symptoms of orthostatic intolerance
●Correlation of symptoms with a sustained increase in upright heart rate by at least 30 beats/minute (40 beats/minute for patients under the age of 20 years) within 10 minutes of standing or head-up tilt, without orthostatic hypotension

●Autonomic testing to correlate symptoms with heart rate changes, confirm the diagnosis, and assess the degree of objective signs of orthostatic intolerance

●Other diagnostic testing as needed to exclude alternative diagnoses or confounding concomitant conditions

50
Q

what is the gold standard for POTS diagnosis? what is considered a positive test?

A

formal tilt table test

Must see a sustained increase in HR of greater than 30 bpm OR
An increase to 120 bpm or higher in the first 10 minutes of the test

There should be no drop in blood pressure

51
Q

what should INITIAL evaluation of POTS include

A

CBC
CMP
EKG
TFTs

52
Q

what is nonpharmacological treatment for POTS

A
  • Avoid any exacerbating factors
  • Increase water intake (2 liters per day)
  • Increase salt intake (3 to 5 grams per day)
  • Aerobic exercise of the lower extremities / compression stockings
53
Q

what is pharmacologic treatment for POTS

A

Fludrocortisone
Midodrine
Beta blockers, such as Propranolol (20 to 30 mg tid or qid)
SSRI/SNRI – rarely used but have been shown to be beneficial in some

54
Q

what is the survival rate of cardiogennic shock

A

50%

55
Q

what is the definition of cardiogenic shock

A

Result of the failure of the heart in its function as a pump, resulting in inadequate cardiac output.

56
Q

what is the MCC of cardiogenic shock

A
  • Extensive myocardial damage from an acute MI
  • Mechanical complications of an acute MI (such as valve lesions, arrhythmias, cardiomyopathies)
57
Q

what are the causes of cardiogenic shock

A
58
Q

what is the principle feature of cardiogenic shock

A

hypotension with evidence of end-organ hypoperfusion

(occurs as consequence of inadequate cardiac function)

59
Q

what is the classic presetation of cardiogenic shock

A

peripheral vasoconstriction (cool, moist skin)
tachycardia

60
Q
A
61
Q

what are lab findings in patients with recent or acute MIs

A

elevations in cardiac-specific enzymes (CK-MB, troponin)

62
Q

what are lab findings in pateitns with renal and hepatic hypoperfusion

A

elevations in serum ceratinine and AST, ALT

63
Q

what are lab findings in pateints with hepatic congestion or hepatic hypoperfusion

A

Coagulation abnormalities may be present. An anion gap acidosis may be present, and the serum lactate level may be elevated.

64
Q

“youll go more into this later in the semester but i just wanted you to know the overview”

A

Cardiology (Fall 2023) (45 decks)

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