The "silent killer
-Hypertension
-Many pt. are asymptomatic
Main worry with HTN
-Not so much #'s, but their effect on target organs like brain, heart, kidneys, etc.
HTN Emergency
BP >220/40
-develops over hours to days
-EVIDENT acute target organ damage
HTN Urgency
-develops over days or weeks
-BP severely high, but no evidence of target organ damage yet.
Misc. causes of HTN crisis
-noncompliance
-crack cocaine use
-tumor of adrenal medulla, etc.
HTN is significant risk factor for:
1. CVA
2. MI (major)
3. Renal Failure
BP
force exerted by blood against walls of blood vessels
BP=
CO x SVR (systemic vascular resistance)
CO
amount of blood pumped out of heart each minute
SVR
arteries' resistance to blood flow
-Think of aferload
C
hr
onotropic
heart rate
Inotropic
contactility
Sympathetic N.S. effect on BP
-Increases HR & cardiac contractility
-net effect is increase in arterial pressure by increasing CO & SVR
-Epi & norepi
Arterial Baroreceptors
-Found in carotid, aorta, & walls of Left Ventricle
-monitors level of arterial pressure
Renal System's Effect on BP
-Control sodium excretion & ECV
-RAAS
Endocrine System's Effect on BP
-Release of epi & norepi
-Release of aldosterone
-Release of ADH
Primary HTN
-most common
-Essential/Idiopathic
-Examine contributing factors
Secondary HTN
-non-essential
-elevated BP w/specific cause that can be corrected
-EX. pheochromocytoma (tumor of adrenal medulla)
Hypertensive Patient Presentation
-Asymptomatic in itself but presents effects on target organs:
-CAD
-CVA
-PVD
-Retinal damage
-Renal Failure
Diagnostic Studies
-check BP both arms (use higher reading)
-Follow-up is to take it twice (5 min apart)
-Metabolic panel w/creatinine
-CBC
-Cardiac work-up
-U/A or urine test to assess 2ndary causes
Cardiac Work-Up
-EKG
-Echo
-Stress test
First Line HTN Drugs
-Thaizide diuretics
-Ca Channel Blockers
-ACE Inhibitors
-ARBs (angiotensin Receptor Antagonists)
HTN Drugs Side Effect Management
-gum/hard candy for dry mouth
-slow position chgs for orthostatic hypotension
-discuss sex dysfunction
-schedule diuretics to avoid nocturia
Heart Failure
-impaired cardiac pumping and/or filling which leads to lowered cardiac output
-CO = HR x SV
Systolic HF
-Inability to pump effectively
HALLMARK
: decrease in LV ejection
Diastolic HF
-inability of ventricles to relax and fill during diastole (stiff ventricles)
-normal ejection fraction though
Compensations to improve CO when heart fails....
-Sympathetic N.S.
-Dilation
-Hypertrophy
-Neuro-hormonal response (RAAS)
**All increase O2 demand of heart which is already struggling, so a little is good, but too much is a bad thing
HF Clinical Manifestations
-dominant feature: increased intravascular volume
-depend on extent of failure & which ventricle is affected though
Left & Right Sided Failure
-Can fail separately
-Left usual precedes Right
Acute Decompensated HF (ADHF)
-Manifest as acute pulm. edema
-pulm venous pressure increases R/T decreased efficiency of LV
Left Sided HF S/S
-All have to do w/ lack of blood flow to system & backing up into lungs
PND (Paroxysmal nocturnal dyspnea)
-Seen in L. Failure
-fluid accumulating around heart and pulm. circulaton when pt. lying down
-pt will feel suffocated and want to sit up.
Nocturia in L-sided HF
-caused by fluid sitting still in areas and getting absorbed into vascular compartment and kidneys are stimulated to excrete it
R-sided HF S/S
all R/T systemic fluid back-up
-Edema
-Hepatomegaly
-JVD
-Ascites
-Anorexia & nausea
-Weakness
Medications used for HF
-Diuretics (watch K+)
-ACE/ARBs (interfere w/ RAAS)
-Inotropic Drugs (increase contractility and CO)
-Beta blockers (reduce workload of heart/HR)
-EX: DIGOXIN (lowers HR but increases contractility)
Digoxin Toxicity
FIRST SIGN
=N/V
-be careful when giving Digoxin & Lasix (which causes you to lose K+)
3 meds used for HF
1. Diuretics: decrease preload & circulating B.V.
2. Beta Blockers: decrease HR & force of contraction (so lower cardiac O2 demand)
3. ACE-I: vasodilation decreases afterload, increases preload, prevents ventricular remodeling
Why would someone be taken off Ace-I's?
Angioedema & cough (caused by bradykinin)