list of dzs which cause or can be made worse by hypertension (read over)
CKD (chronic kidney dz), HAC (hyperadrenocorticism), Hyperthyroidism, Pheochromocytoma (a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine, leading to attacks of raised blood pressure, palpitations, and headache.), diabetes mellitus, liver dz, Hyperaldosteronism, intracranial lesions
4 diff methods you can use to measure bp?
Oscillometric, Doppler, Pressure plethysmography, High definition oscillometry
What should you remember about using doppler to measure BP?
it only tells you systolic
what is White coat syndrome/ how does it relate to BP
they see someone in a white coat and they freak out because they remember people in white coats= bad things. SO it's basically sympathetic activation leading to inc bp
what is secondary hypertension?
Concurrent with clinical disease or drug administration (basically happening for some reason)
is 1* or 2* hypertension more common?
idiopathic hypertension is aka? what should you think about if you see this in a dog/cat?
aka primary or essential. Consider that it might be 2* to a subclinical dz. However, 1* HT might be more common than previously thought
Evidence of Target Organ Damage--> how would high BP affect kidneys? How should you eval to see if BP is hurting them?
you will see Progression of CKD...Evaluate creatinine, proteinuria, GFR
Evidence of Target Organ Damage--> how would high BP affect eyes? what probs might you see?
will see lots of Retinopathy. Might see Acute blindness, detachment, vessel tortuosity, perivascular edema, papilledema, hyphema, 2° glaucoma
Evidence of Target Organ Damage--> how would high BP affect brain? How should you assess the brain to see if there are probs?
might see Encephalopathy or stroke. Try to Localize to CNS, neuro exam, MRI
Evidence of Target Organ Damage--> how would high BP affect heart/BVs? how would you assess the heath of these organs?
Can see Left Ventricular Hypertrophy or cardiac failure... look at Heart size, rhythm, murmurs, hemorrhage with Auscultation, radiography, ultrasound, ECG
7 types (some categories some specifics, categories in other cards too) of drugs used to treat hypertension?
2 possible reasons there would be inc pulm blood flow?
Congenital L to R shunts, ↑ CO
what are some reasons you might have Increased pulmonary vascular resistance (PVR) leading to pulm hyperT?
it could be ↓ drainage (left heart), or things like Loss vessels PTE, HWD, HAC, IMHA, sepsis, neoplasia, nephrotic syndrome, cor pulmonale, chronic upper airway disease
luminal narrowing can lead to pulm hyperT..what are the two mechanisms which lead to luminal narrowing and give some examples of both of them
(1) ANATOMIC NARROWING can occur because of... Eisenmenger's synddrome (more on this in another card), HWD, or 1* pulmonary hyperT. (2) PULMONARY VASOCONSTRICTION can happen with high altitidues, with cor pulmonale, Hypoventilation, NMD (neuromuscular dz), obesity, chest wall deformities
what's cor pulmonale again?
abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.
what is eisenmenger's syndrome?
the process in which a long-standing left-to-right cardiac shunt caused by a congenital heart defect (typically by a ventricular septal defect, atrial septal defect, or less commonly, patent ductus arteriosus) causes pulmonary hypertension
know how to explain this thingy.
The top is the normal flow and pressure of things. The bottom pic is mitral stenosis. Notice how all the blood pressures behind the mitral stenosis increase significantly. The right heart is not built to take these pressures which causes changes to the structure of the heart (like the R vent thickening to push against these very high pressures)
(not sure if important) so we know that the left heart's (ventricles) pressures are 120/80 because that is what we see in the body which is from the L heart. But what are the pressures in the R heart (ventricle) like?
*HOW DO YOU DX PULM HYPERTENSION?
which setting must you have the echo on to measure pulm hypertension?
what are the two measurements and results of the echo which tell you you have pulm hyperT? (know the numbers!)
A tricuspid regurg of greater than 2.7m/sec, or a pulmonic insufficiency of >2m/sec
but, uh, if you are measuring tricuspid regurg as a way to determine pulmonary hypertension.. what if the dog just has TR, dude?
will have regurg but not fast bc R side of heart slow--so won't be near as fast as in pulmonary hypertension, bro
pulm hyperT if the tricuspid regurg measured on the echo is...
>2.7m/sec (she cares more about TR than PI i think she said)
pulm hyperT if the pulmonic insufficiency is...
what does it meeeean?
anything below that line is blood going in the direction it SHOULDN'T be going in. (hence the "TR" label)
what are two awesome drugs for tx of pulmonary hypertension?
Sildenafil (viagara) and Tadalifil (cialis) which are both Phosphodiesterase 5 inhibitors
which class of drugs do you use to tx pulm hyperT and what are the 2 drugs in this class we're interested in?
Phosphodiesterase 5 inhibitors, Sildenafil (viagara) and Tadalifil (cialis)
Toxic Myocardial Disease is caused by what drug?
Doxorubicin (this is a chemotheraputic)
what kinda damage does doxorubicin do to the heart? (broadly and specifically)
it causes toxic myocardial dz and can cause acute and chronic damage. ↓ CO, arrhythmias, myocyte damage.
toxic myocardial disease presents similarly to what other dz?
what drug MIGHT minimize damage from toxic myocardial dz?
Ventricular, atrial, combination, Tetrology of Fallot
what is the vascular congenital dz?
Persistent Ductus Arteriosus (PDA)
Sub-Aortic Stenosis (SAS) is most common in who? (breeds)
POSTER CHILD IS NEWFIES. can also happen in Goldens, Rottweilers, Boxer, GSD, Bulldogs, Danes, GSHP(German Shorthaired Pointer), Bouvier, cats (so mostly huge dogs and cats)
how would you describe the murmur caused by SAS? (type of murmur, common description for it, is it systolic or diastolic? where is it loudest?)
This is a Systolic crescendo/decrescendo murmur (as is characteristic of stenoses) and is often described as "musical". It is often loudest over the L heart base (aorta on L side) and can radiate anywhere
SAS has what effect on the outflow tract? what probs does this lead to?
outflow tract obstruction--> Fibrous or fibromuscular subvalvular most common --> Pressure overload to LV
how is the heart mm affected by SAS? (is it eccentric or concentric hypertrophy?) what problems does this lead to?
causes Concentric hypertrophy (thicker walls) which causes problems with ventricular filling, Coronary perfusion
sas can cause low output failure, which has what consequences?
Exercise intolerance, syncope, sudden death
although SAS might be present from birth (it is congenital) you might not hear murmur or see clinical signs until..(age).
how might SAS appear on rads?
LV enlargement, post-stenotic dilation
how might SAS appear on echocardiography?
hypertrophy, subaortic narrowing, SAM (systolic anterior motion) of anterior mitral leaflet, aortic dilation, turbulence
**which drug and which lifestyle change are recommended for medical management of SAS?
(1) beta blockers (relax/dec afterload+arrhythmias) (2) exercise restriction (no sudden bursts of activity)
how successful has sx/ballooning to fix SAS been?
what is prog of SAS/ what is prog dependant on?
Depends on gradient (Doppler > 100-125 mmHg). More than 50% die suddenly within 3 years
*****SAS dogs have a predisposition for what other huge problem?
Predisposition for infective endocarditis***
which breeds are prone to pulmonic stenosis? (who is the poster child? is there a gender predisposition?)
BULLDOGS are esp prone, ESP males. Mastiffs, Samoyed, Schnauzer, Westie, Cockers, Beagle, Airedale, Boykins, Chihuahua, Scotties Terriers, more common in smaller breeds
how would you describe a pulmonary stenosis murmur? what word might be used to to describe it? systolic or diastolic? where is it loudest?
Systolic crescendo/decrescendo murmur +/- click. Loudest over left heart base
pulmonic stenosis-> where does the prob usually stem from anatomically?
usually valvular (Dysplastic valve leaflets)
is pulmonic stenosis a problem with preload or afterload? describe the 2* morpho changes of the heart due to it.
it's a pressure overload (so afterload) therefore you will see RV hypertrophy, With 2⁰ dilation and RA enlargement
how will PS appear on rads and ultrasound?
RV enlargement, Post stenotic dilation
what do you do to determine severity of a PS? WHAT is considered severe?
Doppler evaluation for severity--> Severe > 80 mmHg
what are your treatment options for pulmonary stenosis?
Surgical and balloon procedures
are you worried about ballooning and blowing up one of the only 4 valves in the heart?
lol well i mean, it's important and all, but you only need one valve on each side of the heart-- and the AV valves (in this case, tricuspid) is wayyyy more important than the pulmonic. so shred it.
so what is the standard procedure for a Balloon Valvuloplasty?
use Fluoroscopy first to assess (more on this later), thread balloon at end of catheter into the heat, position the deflated balloon in the valve, inflate and shred valve. Often have to balloon 2-3 times
so you get your most common pt for the PS, a male bulldog, and you think you want to do a Balloon Valvuloplasty to treat it. what must you ALWAYS ALWAYS be careful of when doing these procedures?
certain dogs, esp bulldog/boxers, cant do ballooning if there is an aberrant coronary artery (Single anomalous coronary artery)-- that is to say, only one coronary vessel going to the heart and it is in an abnormal location, which includes running right over the pulmonary valve you want to balloon. If you don't check with fluoroscopy to see if that vessel is there, and you balloon, youll shred the ONE vessel to R side of heart--> dead R heart--> dead dog. this is why we have other proc. like patch graft valvuloplasty (use patch + ballooning to inc width of outflow tract)
which two breeds are most likely to have a Single anomalous coronary artery on the right side over the pulmonary valve, just to make your life hell?
bulldogs and boxers
what if you dont catch a PS until later, or decide not to treat it till later, and then balloon the pulmonary valve? WHY might you have waited though?
what if we wait to tx it? dilation might pull apart tricuspid valve-- now if you blow up pulmonic valve have pulmonic and tricuspid insufficiency- two bad valves on R is bbbbaaadddd. some cardiologists wait bc might have to do it again if young growing puppy (but they are monitoring them for 2* changes, then must be more aggressive)... (puppy murmurs are only there when theyre really young, so go away quickly, check back in a few weeks)
(pic) what does PS look like on US?
MPA: Main pulmonary artery, RVOT: right ventricular outflow tract
Pages linking here (main versions and versions by same user)