Hypertension
Lifestyle modificatons for HTN
DASH diet - 2 gram Na, low far diet, low unsaturated fat, use olive oil
Exercise at least 30 min 5x week
Weight reduction
Moderate alcohol daily intake
reduce stress
HTN interventions
ICU to monitor VS, antihypertensive meds/IV vasodilators (nitroprusside), obtain MAP (initial goal to decr. 10-20% first 1-2 hrs, observe for arrhythmias, obtain hrly urine output to check renal funx, neuro checks caution with elderly
What class are they? / MOA, S/E, Nsg, Ed
Thiazide HCTZ -
furosemide -
spirinolactone -
hydrochlorathiazide - first line, causes direct relax of arterioles, reduce PVR, preload/afterload. Used in combo with antihypertensive, also effective for HF (watch potassium!)
furosemide- most common- remove fluid, decr. preload, pulmonary edema, HF, HTN. S/E-concern w elderly, loop diuretic-electrolyte loss, especially potassium. Neurotoxic or ototoxic, give over 2-3min
spironolactone- K-sparing removes fluid- do not need K replaced, can be given with loop diuretic to avoid K supplement
Risk factors
Age/gender
ethnicity
genetics
elevated serum lipid lvels
obesity
inactivity
HTN
smoking
stress
diabetes
Stable angina vs unstable
Stable: temporary/reversible, infrequent/intermittent, pattern onset/duration/intensity, only lasts few mins, with exertion, alleviated when trigger stops, EKG can reveal ST seg depression (nocturnal, Prinzmetal's:vasospastic, chronic)
UNstable: cx by rupture or thickened plaque, unexpected, occurs at rest or minimal exert, new onset/more severe and prolonged, increasing frequency/duration or severity, "pre-infarction angina"
Unmodifiable risk factors for HTN
age (older than 60)
women - postmenopausal - younger at even higher risk with hormone therapy
Gender
Family hx of premature CVD onset less than 55 years of age
Race
Pre-hypertension of gestational HTN
What drug class are they? What do they do?
clonidine (catapress)
Alpha 2 adrenergic agonists
Central acting, decreases SNS activity
leads to lower BP/HR, has unwanted S/E, ortho hypotension
Used for ADHD, menopause, opoid withdrawal
What class are they? What do they do?
Captopril, lisinopril, "pril"
ACE inhibitors - Prevents A-1 from converting to A-2& aldosterone, prevent rise in BP. Aldosterone respons for K excretion (decreased aldost can incr serum K)
Decreases preload/workload of heart, TX HTN and CHF May cause *angioedema, educate if swelling tongue, mouth, SOB, tight throat, call 911/HCP
SE - dry annoying COUGH, hyperkalemia may occur - check K levels
Lipid management + values
Total cholesterol? Optimal LDL level? Optimal HDL? Triglycerides?
total cholesterol <200, LDL<100, HDL 40-60, higher is better, Triglycerides <150
MI - what is it? S/S
risk factors?
prolonged ischemia/not immediately reversible, result of sustained ischemia<20mins, causes cell death - results from plaque rupture and/or thrombus form
S/S: chest pain, heaviness, pressure, tightness, indigestion, SOB, diaphoretic, cold/clammy/ashen, N/V, lightheaded, fatigue/wkness, "impending doom", dysrhythmias
RF: smoking, ^lipids, obesity, inactivity, HTN, DM
Modifiable risk factors for HTN
elevated LDL or HDL
obesity, BMI >30
physical inactivity
tobacco use
substance abuse
sodium use
stress
Estimated GFR <60
Microalbuminuria
Diabetes mellitus
What drug class are they? What do they do? TEACHING
hydralazine
nitroglycerine
IV sodium nitroprusside
direct vasodilators
hydralazine- HTN and HTN crisis peripheral vasodilation, reduces SVR, hypotensive effect
nitroglycerin-
IV sod. nitroprusside- HTN crisis, titrate, rapid onset, can lower BP fast, monitor closely, concern w/ cyanide tox, protect from light, don't keep on it for long periods
TEACHING: take as ordered, lifetime, don't stop suddenly, change position slowly, avoid hot tub, alcohol, herbal supps, monitor labs as ordered, report S/E, eye exam q 6 mos
What drug class are they? WHat do they do?
losartan, valsartan, "tan"
ARB blockers - similar action of ACE 1, 2nd line for HF
Potent vasodilator, also for HTN. less likely to cause cough or hyperkalemia
What drug class tx CAD/hyperlipidemia?
What do they do?
simvastatin (zocor)
Statins! HMG CoA inhibitors- FIRST LINE MED - inhibits synth of cholesterol by blocking LDL increasing enzyme in liver and remove LDL from blood
usually well tolerated, S/E: liver dmg/myo breakdown, myo aches, tenderness, rhabdomyelosis
tkae at HS to decr S/E
check baseline LFT and monitor
TX of angina
Invasive tx
12 lead EKG (within 5mins), O2 (1st and fast), cardiac monitor, ASA for antiplatelet aggregate, baseline vitals, IV, nitro, analgesia (morphine for vasodilate effect to improve coronary circ), blood tests (isoenzymes), phys exam(listen to heart sounds), MONA
Invasive: 1st line- PCI (percutaneous intervent)- PTCA
2nd line- thrombolytic therapy- unless contra
acute surgical reperfusion (CABG) when PCI unsuccessful or recurrent ischemia
CARDIAC MARKERS- help to determine degree of damage to heart tissue
S/s of HTN
asymptomatic "silent killer"
fatigue, reduced activity tolerance, dizziness, palpitations, angina, dyspnea, HA, nosebleed if BP very high
Goal of 130/80
Antiarrhythmic meds/what they do
P-atrial depolarize- squeeze
QRS- Vent depolarize- squeeze
QT- vent refractory period- pause - most dangerous time to initiate arrhythmia, can be prolonged by meds
T- vent repolarize - RESET
Epinephrine: stimulant, raise HR, short acting
Atropine: stimulant, raise HR, short acting
Adenosine: restore rapid rate to normal- IV only- short half life, push rapid, causes short pause (scary), only give with HCP and on bedside monitor - try to cardiovert first or unstable
Digoxin
What drug class are they? What do they do?
amlodopine, nifedipine
diltiazem, verapamil
Calcium channel blockers - first 2 relax smooth myo in coronary arterioles - vasodilatory effect
last 2 - slow conduction velocity - slow HR and reduces afterload
Normal sodium level
BNP
Potassium
Hgb
Sodium- 135-145
BNP- <100
Potassium- 3.5-5.2
Hgb- 14-18 males, 12-16 females
Pharm for MI
Nitroglycerin
Beta blockers (metoprolol)
ACE inhibitors
What is it for? what does it do?
Nitro-used for CP, vasodilators, decr workload on heart, help reduce "pre&after load"
S/E: lowers BP, may cause flushing, HA, orthohypotension, rebound tachy
Give one, no relief? Call 911- can give up to 3, five minutes apart- check BP in between
Keep in glass, away from light, sting on tongue, no moisture
Beta blockers- blocks SNS "fight/flight" to ease workload of heart, reduce HR/BP, prevent cardiac remodeling
decreased repeat MI
ACE Inhibitors- help heart contract efficiently, lowers HR, incr SV and improves CO
define HTN crisis/emergency and what defines each
crisis: severe/abrupt elevationg in BP, systolic >180 and diastolic >120
emergency: severely elevated BP, with evidence of acute organ damage and decreased function, threat to life
Urgency: elevated BP - without evidence of organ damage
Rhythm/intervention
(LOOK AT STRIPS!)
NSR - check vitals, normal
Bradycardia- HR<60, check drug levels, consider pacemaker
Pacemaker rhythm- spike before P (A paced) or QRS (V paced) or both
A-Fib - irregularly irregular, reduce HR<100, return to NSR, anticoag (apixiban) to reduce stroke risk, cardiovert, must be monitor and synchronize shock
A flutter- sawtooth, reduce HR<100, return to NSR, consider anticoagulant
V-tach- little to no CO, fast and wide, check pt, Defib if pulseless, CPR
V-fib- No CO, check pt, defib! CPR
Asystole- check pt, CPR, epinephrine, pacemaker
SVT- vasovagal if unsymptomatic/stable, adenosine/cardiovert if symptomatic/unstable
What drug class are they? What do they do?
"lol"
metoprolol (lopressor), atenolol
propanolol
carvedilol
Beta blockers
metoprolol/atenolol- blocks "fight/flight", slows HR/lowers BP. Post AMI, CAD, HF and arrhythmias check apical HR/BP before - hold if <60
propanolol - non-cardioselective - older, blocks both Beta 1&2 receptors
carvedilol- Alpha/Beta Blocker- relaxes smooth myo, lower HR and BP
mow to measure CO, MAP, pulse pressure
CO = HR + SV (normal 4-8 L)
MAP = systolic - diastolic /3 (mut be 60 or higher to perfuse organs)
pulse pressure- difference between systolic and diastolic
Cardiac Cath Info:
nsg, follow-up, complications, interventions
Pre: check iodine allergy, NPO, pre-op meds, educate- dye makes warn sensation, lie still, may be asked to cough/hold breath/deepbreath
Post: assess site for bleeding/bruising, VS/Neuros every 15 mins, EKG, pressure w/ device, assess distal to site (circ, pulse, sensation, color, temp/movement), femoral- flat, extended leg, bedrest <6hrs, complication : arterial bleed occlusion/bruisin blocks circulation
Complications: arrhythmias (80%) - call code, defib CHF- fluid overload edema, tx w/ meds- (assess - hear S3/S4, murmurs, lung crackles)
cardiogenic shock- tx with fluids, IV Nitroprusside, dobutamine, ICU, may need vent or ECMO
Ventric aneurysm/rupture- immediate surgery
acute pericarditis- friction rub- anti-inflammatories, steroids
pulmonary embolism- anticoagulation
dressler syndrome- anti-inflammatory, tx symptoms