SM 145a - Cases in Hypertension and Heart Failure Flashcards
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Which blood pressure medications are most likley to cause depression and decreases in energy?
Centrally acting agents: work to inhibit sympathetic outflow from the presynaptic neuron
- Methyldopa
- Clonidine (alpha-2 receptor agonist)
- Guanabenz
- Guanfacine
What is a rare but serious side effect of sodium nitroprusside?
Cyanide toxicity
Which of the following medications are NOT shown to have a mortality benefit in patients with HFrEF?
A.Amlodipine (calcium channel blocker)
B.Metoprolol succinate (beta-blocker)
C.Lisinopril (ACE-inhibitor)
D.Spironolactone (mineralocorticoid receptor antagonist)
A: Amlodipine (and other Ca2+ channel blockers)
Not shown to reduce mortality in patients with HFrEF
A patient is in cardiogenic shock with low flow and high resistance
Which of the following medications would be appropriate?
A. (oral) Hydralazine
B. Amlodipine
C. Intravenous Nitroglycerin
D. Minoxidil
E. Nitroprusside
E. Nitroprusside
Results in immediate vasodilation; useful in hypertensive emergency, acute decompensated heart failure
If a patient’s blood pressure is 115/75, what is their estimated mean arterial pressure?
~88
Mean arterial pressure = (2*DBP + SBP)/3
A patient on an ACE-inhibitor complains of thick/heavy tongue, swollen lips, and hoarseness.
What is happening?
Is it serious?
Who is most likley to have this side effect
Angioedema
Very serious
Women and African Americans
Which letter represents the site of action of chlorthalidone?
E: The distal convoluted tubule
Which NYHA classification of heart failure is described below?
“Marked limitation of physical activity, comforable at rest, but less than ordinary activity causes symptoms”
Class III
__________ is the only food that decreases the amount of biliary choloseterol that is produced by the body
Fiber is the only food that decreases the amount of biliary choloseterol that is produced by the body
Which NYHA classification of heart failure is described below?
“No limitation of physical activity - ordinary physical activity does not cause symptoms”
Class I
Which letter correctly labels the site of action of furosemide?
D: Thick ascending limb
Furosemide is a loop diuretic
(Also Torsemide and Bumetanide)
What electrolyte abnormalities are associeated with thiazide-type diuretics?
Act on distal convoluted tubule
- Hyponatremia
- Hypokalemia
- Hypomagnesemia
- Hypercalcemia
- Hyperuricemia
A patient is showing signs of acute decompensated heart failure.
You order furosemide 80 mg intravenously x 1. The patient feels better almost immediately. What is the mechanism underlying the beneficial effect of furosemide within minutes?
Acute pulmonary venodilation
Increased venous capacitance immediately. This reduces venous return -> reduces LV filling -> reduces pulmonary edema
Which blood pressure measurement (systolic or diastolic) is most indicative of CVD risk?
Systolic
Diastolic can inform us of risk of renal disease, but in treating hypertension cardiologists mostly focus on systolic BP
What LDL level (mg/dL) constitutes the upper limit of acquired hypercholesterolemia?
160 mg/dL
Anything above this likely indicates familial hypercholesterolemia
Which of the following medications, would serve to partially correct hypokalemia and may be of modest benefit for heart failure with preserved ejection fraction (HFpEF)?
A. Diltiazem
B. Hydralazine
C. Spironolactone
D. Prazosin
C. Spironolactone
A patient has left ventricular hypertrophy, an LVEF of 65%, and grade II diastolic dysfunction
Which of the following best depicts the changes in this patient’s pressure-volume loop? (black line: normal; red line: patient)
C
Increased filling pressure
A 75-year-old woman has a lifelong history of poorly controlled hypertension along with obesity and diabetes. S4 was auscultated on her physical exam. She notes progressive shortness of breath with 1 block exertion, episodes of breathlessness at night, weight gain, and lower extremity edema. Symptoms have been intermittently present for 2-3 years.
What stage of heart failure does this patient have?
What symptom status?
Stage C: Structural heart disease with prior or current symptoms of HF
NYHA Class III: Marked limitation of physical activity, comfortable at rest, but less than ordinary activity causes symptoms
Which NYHA classification of heart failure is described below?
“Severe limitation and discomfort with any phsyical activity, symptoms present even at rest”
Class IV
Which NYHA classification of heart failure is described below?
“Slight limitation of physical activity, comfortable at rest, ordinary physical activity causes symptoms”
Class II
An obese patient with a family history of smoke and a social history of 15 pack years of smoking has home blood pressures of 144/76, 136/84, 140/92, 139/83
What should your next step be?
Recommend pharmacologic therapy and lifestyle modification
What is the benefit of weight loss in a patient who is hypertensive?
For every kilogram of weight loss, BP decreases by 1 point
Weight loss lowers systemic vascular resistance
How does amlodipine exert its antihypertenisve effect?
Amlodipine (and other -dipine drugs): dihydropyridine Ca2+ channel blocker
Decreases peripheral vascular resistance
- Block L-type Ca2+ channels to decrease intracellular Ca2+ concentration
- Less calcium = decreased smooth muscle constriction = vasodilation
A blood pressure of 140/94 is classified as…
Stage II hypertension
Which anti-hypertensive medication may cause a loss of libido in women and gynecomastia in men?
Spironolactone
(Not eplerenone)
A patient has left ventricular hypertrophy, an LVEF of 65%, and grade II diastolic dysfunction
Which curve best depicts this patient’s end-diastolic pressure volume relationship? (Red = normal)
Curve A
LV hypertrophy = less compliant ventricle; increased pressure at every volume, more pronounced at higher volumes
A patient has left ventricular hypertrophy, an LVEF of 65%, and grade II diastolic dysfunction.
They are given forsemide, a loop diuretic
Which of the following arrows best depicts the direction in which the patient’s left ventricular end-diastolic pressure will move after administration of diuretic from the point shown?
A
Diruretics will decrease the amount of volume in the body, decreaseing LV end diastolic volume
What is the mechanism of an ACE-inhibitor induced cough?
Increased bradykinin
Which hypertensive patients would be good candidates for peripheral vasodilators, such as hydralazine, minoxidil, and nitroprusside?
- Patients with difficult to control blood pressure
(Stage 2 hypertension)- taking other agents without control, or adverse side effects to those agents
- Patients in a hypertensive emergency
For every kilogram of weight loss, systolic blood pressure decreases by ________
For every kilogram of weight loss, systolic blood pressure decreases by 1 point
_(_In treating blood pressure, we care most about systolic because this measurement correlates most with CVD risk; diastolic only has implications for renal failure)
How successful is blood pressure control in an at-risk patient to prevent the onset of a first episode of heart failure?
Significant: ~40% risk reduction
