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Cardiovascular > Hypotension > Flashcards

Hypotension Flashcards

1
Q

What does hypotension typically refer to?

A

BP <90/60

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2
Q

When is hypotension considered pathologic?

A

If symptomatic (may be physiologic ie athletes)

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3
Q

What is the pathophysiology of hypotension?

A
  • Reduced blood flow
  • Decreased oxygen delivery to organs and tissues
  • cellular damage and dysfunction
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4
Q

When oxygen delivery is insufficient to support metabolic requirements, a patient is said to be in what?

A

circulatory shock

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5
Q

What is arterial pressure determined by?

A
  1. Cardiac output
  2. Venous pressure
  3. Systemic vascular resistance

A decrease in any of these can lead to hypotension

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6
Q

What are hypovolemia causes of hypotension?

A
  • hemorrhage
  • dehydration
  • dialysis
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7
Q

what are endocrine causes of hypotension?

A
  • adrenal insufficiency
  • diabetes (orthostatic mainly due to ANS dysfunction)
  • hypothyroidism
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8
Q

What are vascular causes of hypotension?

A
  • Aortic dissection or rupture
  • peripheral vascular disease
  • pulmonary embolism
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9
Q

what are drug-induced causes of hypotension?

A
  • alcohol
  • antidepressants
  • antihypertensives
  • antipsychotics
  • anxiolytics
  • general anesthesia
  • narcotics
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10
Q

what are neurogenic causes of hypotension?

A
  • age-related
  • medullary stroke
  • parkinsonism
  • postprandial
  • peripheral neuropathy
  • syphilis
  • vasomotor: emotional or micturition
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11
Q

What is important historical information to gather about 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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12
Q

what are symptoms of hypotension?

A
  • lightheadedness, dizziness
  • syncope
  • nausea
  • confusion
  • fatigue
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13
Q

what are signs of hypotension?

A
  • bradycardia or tachycardia
  • skin: pallor, diaphoresis, cool, clammy, prolonged capillary refill
  • altered LOC
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14
Q

what clinical presentation can be present in both hypertension or hypotension?

A
  • dizziness
  • blurred vision
  • nausea
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15
Q

What diagnostic testing can be helpful for hypotension?

A
  • EKG
  • CBC, CMP, UA
  • Echocardiogram
  • Urine drug screen
  • CT head
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16
Q

The majority of patients with hypotension can be resuscitated with what?

A

IV bolus of normal saline

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17
Q

If a patient is hypovolemic, what is the treatment?

A

Fluid resuscitation

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18
Q

Who do we need to avoid giving fluids to?

A

heart failure

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19
Q

drop in blood pressure upon standing, leading to symptoms of hypotension

A

orthostatic hypotension

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20
Q

what can cause orthostatic hypotension?

A
  • impairment of autonomic reflexes
  • volume depletion
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21
Q

who is more commonly impacted by orthostatic hypotension?

A
  • elderly
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22
Q

what is classified as orthostatic hypotension?

A
  • drop of either 20 mmHg in SBP
  • or 10 mmHg in DBP

usually within 2-5 minutes

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23
Q

what is normal response to standing?

A
  • rapid decrease in venous return and CO
  • detected by baroreceptors in carotid
  • SNS increases HR and peripheral vascular resistance –> increased CO and limited drop in SBP
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24
Q

what are causes of 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
  • SE of medications of peripheral vasodilation, autonomic dysfunction, and volume depletion
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25
Q

what are medications that cause orthostatic hypotension?

A
  • alpha-1 antagonists (terazosin, prazosin, doxazosin)
  • ACEI, BB, clonidine
  • diuretics (HCTZ, loops)
  • PDE-5 (sildenafil, vardenafil)
  • Antidepressants (TCAs, trazodone, MAOIs)
  • Opioids (morphine, oxycodone, tramadol)
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26
Q

What are additional causes of orthostatic hypotension?

A
  • aging
  • adrenal insufficiency
  • cardiogenic: CHF, AS, arrhythmias
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27
Q

why can aging cause orthostatic hypotension?

A
  • decrease in baroreceptor sensitivity
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28
Q

what are symptoms of orthostatic hypotension?

A
  • generalized weakness
  • dizziness or lightheadedness
  • blurry vision or darkening of visual fields
  • syncope
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29
Q

what are atypical presentations of orthostatic hypotension?

A
  • fatigue
  • cognitive slowing
  • nausea
30
Q

how can orthostatic hypotension be evaluated?

A
  • bedside tilt test/orthostatic BP measurement (take BP on standing, at 2 mins, at 5 mins)
  • Formal tilt table test
31
Q

What happens during a tilt table test?

A
  • Patient lies down on table
  • IV
  • ECG, BP cuff, and straps on chest/legs
  • Pt lies flat then is raised to almost standing angle
  • Stays upright for 45 mins to determine symptoms
  • If no reaction, medication (NTG) is given to increase HR while flat
  • Pt tilted upright and symptoms measured
  • Pt lowered to flat and allowed to rest. HR/BP measured
32
Q

How is orthostatic hypotension worked up in addition to tilt table testing and orthostatic hypotension measurement?

A
  • CBC, BMP
  • EKG
  • EMG

Over 1/3 of patients will have no identifiable cause discovered, even after extensive work-up :(

33
Q

How is orthostatic hypotension treated?

A
  • Acute orthostasis due to volume depletion- IV fluids
  • Chronic- initially nonpharm, pharm added with severe symptoms or refractory
34
Q

what is nonpharm management of orthostatic hypotension?

A
  • Removal of causative medication
  • Get up slowly
  • Straining, coughing, and exertion in hot weather can exacerbate
  • Maintain hydration
  • Elastic compression stockings
  • Increase salt and water intake
  • physical maneuvers
35
Q

how much salt and water should a patient with orthostatic hypotension consume per day?

A

6-10 g of sodium per day
at least 3 liters of water a day

36
Q

What are physical maneuvers for orthostatic hypotension?

A
  • tensing leg muscles while standing; crossing legs tightly while standing
  • isometric handgrip when standing
37
Q

what is pharmacological management of orthostatic hypotension?

A
  • fludrocortisone
  • midodrine
38
Q

what should be kept in mind when giving pharmacoligic treatment for orthostatic hypotension?

A
  • close patient monitoring
  • should monitor BP at home several times a day
  • supine hypertension can occur
  • elevate head of bed 10-20 degrees to protect brain while sleeping
39
Q

what is the drug class of fludrocortisone?

A
  • potent mineralcorticoid with high glucocorticoid activity
40
Q

what is the mechanism of action of fludrocortisone?

A
  • promotes increased sodium reabsorption and potassium excretion from renal distal tubules
41
Q

What are considerations when using fludrocortisone for orthostatic hypotension?

A
  • patients must be monitored for edema, sitting/supine hypertension
  • BMP in a week to monitor for hypokalemia
  • Discontinuation is common due to side effects, predominantly HTN and edema
42
Q

what is the drug class of midodrine?

A
  • alpha-1 selective adrenergic agonist
43
Q

what is the moa of midodrine?

A
  • increased peripheral vascular resistance, which increases arteriolar and venous tone, resulting in increased SBP and DBP
  • does not cross BBB
44
Q

what are considerations when using midodrine?

A
  • supine hypertension is most common cause of discontinuation
45
Q

what are side effects of midodrine?

A
  • paresthesias
  • piloerection
  • pruritis
  • GI upset
  • urinary retention or urgency
46
Q

what is the hallmark response to standing with POTS?

A

exaggerated increase in HR

47
Q

What are cardiogenic causes of hypotension?

A
  • Acute coronary syndrome
  • Arrhythmias
  • Cardiomyopathy
  • Congestive heart failure
  • Valvulopathy
  • Pulmonary embolism
  • Pulmonary hypertension
  • Cardiac tamponade
  • Tension pneumothorax
48
Q

What are general causes of hypotension?

A
  • Cardiogenic
  • Hypovolemia
  • Orthostatic
  • Sepsis
  • Endocrinologic
  • Vascular
  • Drug-induced
  • Neurogenic
49
Q

Who most commonly gets POTS?

A
  • young patients (14-45)
  • more common in females than males
50
Q

What are possible causes of POTS?

A
  • Distal denervation
  • Hypovolemia
  • Venous dysfunction
  • Cardiovascular deconditioning
  • Baroreflex abnormalities
  • Increased sympathetic activity
  • Genetic abnormalities
  • Can be triggered by infectious illness or post-surgical
51
Q

What are the most common symptoms of POTS?

A
  • Dizziness/lightheadedness
  • Syncope
  • Weakness and fatigue
  • Blurry vision
52
Q

What are possible symptoms of POTS?

A
  • Nausea
  • Abdominal cramping
  • Diarrhea or constipation
53
Q

What can worsen symptoms of POTS?

A
  • Dehydration
  • Menstruation
  • Prolonged standing
54
Q

What is the diagnostic criteria for POTS?

A
  • History of symptoms of orthostatic intolerance with or without systemic symptoms
  • Correlation of symptoms with increase in upright heart rate by at least 30 bpm (40 under 20 yo) within 10 minutes of standing, or head-up tilt, without orthostatic hypotension
  • Autonomic testing to correlate symptoms with hr changes, confirm the diagnosis, and assess degree of objective signs of orthostatic intolerance
  • Exclusion of alternative diagnoses or confounding concomitant conditions
55
Q

What is the gold standard diagnostic evaluation of POTS?

A
  • Formal tilt table test
  • Increase in HR of greater than 30 bpm or increase to 120 bpm or higher in first 10 mins of test
  • No drop in BP
56
Q

How would you initially evaluate a patient with POTS?

A
  • CBC
  • CMP
  • EKG
  • Thyroid function tests
57
Q

How is POTS treated?

A

Nonpharmacologic treatment and pharmacologic treatment

58
Q

What is nonpharmacological treatment for POTS?

A
  1. Avoid any exacerbating factors
  2. Increase water intake (2 L per day)
  3. Increase salt intake (3 to 5 g per day)
  4. Aerobic exercise of the lower extremities/compression stockings
59
Q

What is pharmacological treatment for POTS?

A
  • Fludricortisone
  • Midodrine
  • Beta blockers, such as propranolol (not well tolerated but blunts response)
  • SSRI/SNRI- rarely used but have been shown to be beneficial in some
60
Q

What is the prognosis of POTS?

A

Most patients have improved symptoms after 1-2 years

61
Q

What is the underlying cause of cardiogenic shock?

A
  • Failure of the heart in its function as a pump, resulting in inadequate cardiac output
62
Q

What is the prognosis of cardiogenic shock?

A

50% do not survive, extremely morbid

63
Q

What is the MC cause of cardiogenic shock?

A
  • Extensive myocardial damage from an acute MI
  • Mechanical complications of an acute MI: valve lesions, arrhythmias, and cardiomyopathies
64
Q

What are possible causes of cardiogenic shock?

A
  • Acute MI complications
  • End-stage, severe cardiomyopathies (secondary to valvular disease, chronic ischemic disease, restrictive/infiltrative, idiopathic)
  • Acute myocarditis
  • Stress cardiomyopathy
  • Endocrine disease (hypothyroidism, pheochromocytoma)
  • Medications
  • Posttraumatic
65
Q

What is the principle feature of shock?

A

Hypotension with end-organ hypoperfusion

66
Q

What is the presentation of the classic patient with cardiogenic shock?

A

Evidence of peripheral vasoconstriction (cool, moist skin) and tachycardia

67
Q

What is the vicious cycle of cardiac injury?

A

Myocardial cell death –> decreased cardiac output –> hypotension –> decreased coronary perfusion –> ischemia and/or occlusion of coronary artery –> myocardial cell death

68
Q

What are lab findings of cardiogenic shock?

A
  • Recent MIs: Elevations in cardiac-specific enzymes (CK-MB, troponin)
  • Renal and hepatic hypoperfusion: elevations in serum creatinine and in AST, ALT
  • Hepatic congestion or hepatic hypoperfusion: coagulation abnormalities, anion gap acidosis may be present, serum lactate level may be elevated
69
Q

What are diagnostic studies for cardiogenic shock?

A
  • Electrocardiogram
  • Chest radiography
  • Laboratory tests
  • Echocardiography
  • Pulmonary artery catheterization
  • Cardiac catheterization
70
Q

What is treatment for cardiogenic shock?

A
  • Oxygen supplementation; intubation; ventilation
  • Vasopressors/inotropes; consider careful IV fluids, arterial line and pulmonary artery catheter insertion; correct underlying causes of acidemia
  • Intra-aortic balloon pump, if needed
  • For suspected acute MI: aspirin, heparin, urgent cardiac catheterization, revascularization; fibrinolysis?

Cardiovascular (17 decks)

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