Hypertension and Dyslipidemia Overview

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Questions and Answers

What is a common characteristic of hypertension medications for Asian Americans?

They require much smaller doses due to slow metabolism. (correct)

They require larger doses of medication.

They have no risk of toxicity.

They should be taken only once a week.

Which step is NOT recommended to avoid dizziness in patients taking antihypertensive medications?

Avoid hot baths.

Avoid prolonged standing.

Change positions suddenly. (correct)

Wear elastic stockings.

What are triglycerides primarily used for in the body?

As structural components of cell membranes.

In energy metabolism. (correct)

In blood clotting.

As precursors for cholesterol synthesis.

Which lipoprotein is mainly responsible for transporting cholesterol in the body?

Low density lipoproteins (LDL). Signup and view all the answers

What happens to LDL receptor levels when serum cholesterol levels are high?

The body decreases LDL receptor production. Signup and view all the answers

What is dyslipidemia commonly associated with?

Imbalance of lipid components in the blood. Signup and view all the answers

Which component of blood lipids has the least amount of fat?

High density lipoproteins (HDL). Signup and view all the answers

What are lipoproteins primarily composed of?

Cholesterol combined with water-soluble proteins. Signup and view all the answers

What is the primary cause of endothelial dysfunction/injury in atherosclerosis?

Increased LDL and smoking Signup and view all the answers

Which of the following describes the role of macrophages in atherosclerosis?

They engulf LDL and transform into foam cells. Signup and view all the answers

What is a likely consequence of the rupture of an atherosclerotic plaque?

Endothelial injury and thrombus formation Signup and view all the answers

What clinical manifestation is most characteristic of stable angina?

Chest pain with radiation typically to the left arm Signup and view all the answers

Which factor is known to precipitate stable angina?

Emotional upset or stress Signup and view all the answers

What does elevated hs-CRP indicate in relation to cardiovascular health?

Increased risk for myocardial infarction Signup and view all the answers

How does the presence of numerous foam cells affect the artery?

It contributes to lesion progression and narrows the lumen. Signup and view all the answers

In comparison to men, how do women typically present symptoms of stable angina?

May not exhibit chest pain and delay seeking care Signup and view all the answers

What happens to LDL receptors when there is an excess amount of cholesterol in the liver?

They decrease in number. Signup and view all the answers

Which of the following factors contributes to secondary dyslipidemia?

Obesity caused by inflammation. Signup and view all the answers

What is a primary treatment goal for dyslipidemia management?

Increase HDL levels. Signup and view all the answers

Which of the following is NOT part of the dyslipidemia diagnostic criteria?

Decreased triglycerides. Signup and view all the answers

What is the relationship between dietary saturated fat intake and hypercholesterolemia?

It is strongly related to the amount of cholesterol in the blood. Signup and view all the answers

Which lifestyle change can help increase HDL levels?

Smoking cessation. Signup and view all the answers

What is characterized by a reduction of blood flow to the heart due to atherosclerotic plaque build-up?

Coronary Artery Disease (CAD). Signup and view all the answers

Which of the following treatments is NOT recommended for managing dyslipidemia?

Avoid weight reduction in overweight patients. Signup and view all the answers

Which of the following risk factors is NOT associated with atherosclerosis?

Increased HDL levels. Signup and view all the answers

What is the role of HDL in cholesterol metabolism?

Transfers cholesterol from arteries to the liver. Signup and view all the answers

What differentiates variant angina from stable angina?

Variant angina may occur at rest and is not always associated with exertion. Signup and view all the answers

What is a significant characteristic of unstable angina?

It typically occurs at rest and can last more than 20 minutes. Signup and view all the answers

Which ECG finding is associated with a myocardial infarction (STEMI)?

ST segment elevation. Signup and view all the answers

What typically happens to cardiac output (CO) as a myocardial infarction progresses?

CO decreases. Signup and view all the answers

What is the primary goal of pharmacological management in coronary heart disease (CHD)?

To improve perfusion to the heart. Signup and view all the answers

Which symptoms would typically indicate the first phase of a myocardial infarction?

Pallor, dyspnea, and chest pain. Signup and view all the answers

What can the elevation of troponins indicate in a patient suspected of having a myocardial infarction?

It may indicate myocardial injury. Signup and view all the answers

How long after the onset of a myocardial infarction might troponin levels remain elevated?

7-10 days. Signup and view all the answers

What is a common recommendation regarding the use of sublingual nitroglycerin?

Keep in its original container and avoid heat exposure. Signup and view all the answers

Which of the following changes in metabolism occurs in myocardial cells during ischemia?

Shift from aerobic to anaerobic metabolism. Signup and view all the answers

What is the primary consequence of decreased cardiac output (CO) in heart failure?

Activation of catecholamines Signup and view all the answers

Which type of hypertrophy is characterized by an increase in muscle mass without a change in chamber size?

Concentric hypertrophy Signup and view all the answers

What initiates the release of B-type natriuretic peptide (BNP)?

Ventricular wall stress and stretch Signup and view all the answers

Which condition is most commonly associated with left-sided heart failure due to impaired relaxation?

Hypertensive heart disease Signup and view all the answers

What is a common symptom of right heart failure?

Peripheral edema Signup and view all the answers

In left heart failure with preserved ejection fraction (HFpEF), what is primarily affected?

Ventricular relaxation Signup and view all the answers

What is a significant risk factor that can exacerbate left heart failure?

Diabetes mellitus Signup and view all the answers

What physiological effect does natriuretic peptide have on the kidneys?

Promotes natriuresis and diuresis Signup and view all the answers

How does high-output heart failure primarily differ from other types of heart failure?

It is characterized by normal contractility and blood volume but ineffective output. Signup and view all the answers

What leads to right heart failure as a progression of left heart failure?

Increased left ventricular pressure leading to pulmonary congestion Signup and view all the answers

Which heart sound is indicative of left heart failure often due to fluid overload?

S3 heart sound Signup and view all the answers

Which of the following is a primary treatment focus for heart failure management?

Decrease preload Signup and view all the answers

What causes myocardial fibrosis in heart failure?

Fibroblast growth initiated by nonmyocytes Signup and view all the answers

Which hormonal system is activated in response to decreased cardiac output, leading to fluid retention?

Renin-angiotensin-aldosterone system (RAAS) Signup and view all the answers

Study Notes

Hypertension

Asian Americans generally require smaller doses of beta blockers due to slow metabolism and excretion.
Patients may need several visits with providers to figure out the best medication and dosage combinations.
Do not stop taking hypertension medications abruptly unless angioedema occurs.
Routinely monitor blood pressure at home at the same time of day.
Steps to avoid dizziness include: changing positions slowly, wearing elastic stockings, avoiding prolonged standing and hot baths, and discussing persistent dizziness with the provider.

Dyslipidemia

Dyslipidemia is an imbalance of lipid components in the blood.
Triglycerides are used in energy metabolism and consist of three fatty acids and one glycerol molecule.
Phospholipids are structural lipids important for lipoproteins, blood clotting, myelin, and cell membranes.
Cholesterol is created from fatty acids and has similar activities to other lipids.
Hyperlipidemia is interchangeable with dyslipidemia and refers to elevated levels of triglycerides, phospholipids, or cholesterol.
Lipoproteins are a combination of cholesterol, triglycerides, and water-soluble proteins that travel through plasma.
Chylomicrons carry triglycerides to the GI tract for absorption.
Very low-density lipoproteins (VLDL) carry large amounts of triglycerides and cholesterol and have higher protein content than chylomicrons.
Low-density lipoproteins (LDL) are the main carrier of cholesterol, with 50% cholesterol and 10% triglycerides.
High-density lipoproteins (HDL) consist of 50% protein and the least amount of fat.
LDL transports 75% of cholesterol to tissues and the liver.
LDL removal is accomplished by receptor and non-receptor mechanisms.
Most LDL receptors are found in the liver and cells regulate cholesterol intake by adding or removing LDL receptors.
Conditions that decrease LDL receptors include high dietary intake of cholesterol and saturated fat.
Non-receptor removal involves macrophages in arterial cell walls attaching to LDL, which promotes cholesterol accumulation and atherosclerosis development.
HDL facilitates the reverse transport of cholesterol back to the liver.
Behavior modification can increase HDL and lower cholesterol.
Dyslipidemia criteria includes elevated triglycerides, total serum cholesterol, and LDL, as well as decreased HDL.
A 12-hour fast is required for accurate test results.
Hypercholesterolemia, or high blood cholesterol, is strongly related to dietary intake of saturated fat.
Serum cholesterol levels of 240 mg/dL or greater are considered high.
High cholesterol levels contribute to heart attacks and other cardiovascular events associated with atherosclerosis.

Types of Dyslipidemia

Primary dyslipidemia is genetic and can be caused by defective synthesis of apoproteins, lack of defective receptors, or cellular deficits in handling cholesterol.
Secondary dyslipidemia is behavioral and can result from dietary factors, excess alcohol, obesity, hypothyroidism, or metabolic changes associated with type 2 diabetes.
Elevated adipokines and macrophages are linked to systemic chronic inflammation.

Metabolic Syndrome

Metabolic syndrome is a group of cardiovascular risk factors linked to obesity.
Elevated triglycerides, decreased HDL cholesterol, elevated blood pressure, and elevated fasting blood glucose all increase cardiovascular risk.

Dyslipidemia Treatment

Assess and treat conditions known to elevate blood lipids.
Start a low-fat diet.
Eat a Mediterranean diet.
Increase dietary intake of soluble fiber.
Consider dietary supplements and cholesterol-lowering margarines.
Start a weight-reduction diet if the patient is overweight or obese.
Emphasize regular aerobic exercise.
Encourage smoking cessation.
Consider postmenopausal hormone replacement therapy.

Dyslipidemia Medication Goals

Decrease blood lipids.
Prevent or delay atherosclerotic plaque development.
Promote regression of existing atherosclerotic plaque.
Reduce morbidity and mortality from cardiovascular disease.
Pharmacotherapy is initiated when six months of dietary and lifestyle changes fail to decrease dyslipidemia to acceptable levels.

Coronary Heart Disease

Coronary heart disease consists of two categories: coronary artery disease (CAD) and acute coronary syndromes (ACS).
CAD is a reduction of blood flow to the heart due to atherosclerosis buildup, which can lead to ischemia and myocardial infarction (MI).
ACS includes unstable angina and myocardial infarction.
Atherosclerosis is damage to the intimal arterial lining, resulting in buildup of lipids and fibrous materials.

Atherosclerosis Risk Factors

Hypercholesterolemia.
Elevated LDL.
Family history.
Advanced age.
Male sex.
Hypertension.
Diabetes.
Obesity.
Smoking.
Physical inactivity.
Stress.
Elevated high-sensitivity C-reactive protein (hs-CRP).

Pathogenesis of Atherosclerosis

Endothelial dysfunction/injury: Caused by elevated LDL, smoking, immune mechanisms, and mechanical stress, leading to adhesion of monocytes and platelets and initiating inflammation.
Inflammatory cell migration: Macrophages engulf LDL and transform into foam cells, releasing toxic oxygen species that oxidize engulfed LDL.
Lipid buildup + smooth muscle cell proliferation: Accumulation of foam cells progresses the lesion (fatty streak), while growth factors increase smooth muscle cell proliferation, narrowing the lumen.
Plaque structure: Formation of a fibrous cap. Rupture may lead to thrombotic occlusion of the vessel lumen.

C-Reactive Protein

hs-CRP is elevated during MI and indicates inflammation.
It is an acute phase reactant protein of the inflammatory process and can serve as a marker of risk for atherosclerotic vascular disease.

Progression of Atherosclerosis

Inflammation: A key determinant of plaque vulnerability, related to increased macrophage numbers at the site.
Rupture of plaque: Results in endothelial injury, causing platelet aggregation and thrombus formation. The thrombus may remain or detach and travel.
Thrombus occlusion: Occludes the artery or detaches and occludes smaller, distal branches.

Stable Angina

O2 demand exceeds O2 supply, resulting in ischemia.
Precipitated by factors that increase myocardial workload, such as exercise, cold weather, and emotional upset.
Clinical manifestations include substernal chest pain, pain radiation (often to the left arm), nausea, vomiting, dizziness, and dyspnea.
Men and women may present with different symptoms.
People with diabetes may also exhibit different presentations.
Stable angina is usually characterized by pain lasting five minutes or less.

Variant Angina

Also known as Prinzmetal or vasospastic angina.
Occurs at rest or with minimal exertion.
Often occurs at night and frequently at the same time each day.
May be linked to dysrhythmias or progress to MI.

Acute Coronary Syndromes

Stable Angina and MI.

Unstable Angina

Occurs at rest and lasts longer than 20 minutes.
Clinical manifestations are similar to stable angina, but the intensity, timing, and characteristics are more severe.
Ischemia is not severe enough to cause significant myocardial damage.
Often occurs hours or days before an acute MI.

Electrocardiogram Basics

P wave: Atrial depolarization.
QRS complex: Ventricular depolarization.
ST segment: Ventricular repolarization.
T wave: Ventricular relaxation.
ST segment is used to identify indications of MI.

Myocardial Infarction: NSTEMI

Thrombus formation from plaque disruption partially occludes the vessel.
ST depression, T wave inversion, or no ECG changes.

Myocardial Infarction: STEMI

Thrombus formation from plaque disruption fully occludes the vessel.
ST elevation.

MI: Symptoms

Manifestations depend on stage and progression.
Phase one: Classic symptoms of chest pain and dyspnea, generalized discomfort, increased heart rate and blood pressure due to sympathetic nervous system activation.
As MI progresses with treatment, decreased cardiac output leads to decreased heart rate and blood pressure.
MI progression: Stroke volume decreases, and heart rate increases, but overall cardiac output decreases, leading to further decreases in stroke volume and heart rate.
Other symptoms: Pallor, duskiness, coolness, diaphoresis, pain, shortness of breath, and sense of impending doom.

Serum Biomarker: Troponin

Troponin levels may be elevated during MI, but profound elevation suggests MI.
Troponin assays (TnI or TnT) are highly specific for diagnosing ACS.
Troponin levels rise within three hours of MI onset and may remain elevated for 7-10 days.

Goals of Pharmacological Management

Increase perfusion to the heart:
- Coronary artery dilation.
- Decrease oxygen demand.

General Teaching Guidelines for CHD Medications

Take medications as prescribed. Do not increase dosage or stop taking without consulting a provider.
Keep sublingual nitroglycerin in its original container, within reach but not exposed to body heat.
Replace nitroglycerin every six months.
Maintain a chest pain journal and record nitroglycerin use.
Avoid over-the-counter decongestants, cold remedies, and diet pills, as they stimulate the sympathetic nervous system, causing angina and increasing oxygen demands.
Remove nitroglycerin patches or paste at night to prevent tolerance.
Take blood pressure before self-administering nitroglycerin sublingually.
Apply nitroglycerin patches or paste at the same time each day to clean, dry, and hairless areas on the upper body.
Dispose of used patches and paste properly.

Heart Failure

Heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs.
It is a leading cause of death in the United States and globally.
Causes of Heart Failure: Hypertension, cardiomyopathy, myocardial infarction, heart valve disorders, cocaine or methamphetamine use, dysrhythmias, renal failure, hypo/hyper metabolic states.
Compensation Mechanisms for Decreased Cardiac Output:
- Neurohumoral System: Release of catecholamines (epinephrine/norepinephrine) leading to increased heart rate and vasoconstriction
- RAAS Activation: Renin-angiotensin-aldosterone system activation, resulting in vasoconstriction and fluid retention.
- Natriuretic Peptide System:
  - Atrial Natriuretic Peptide (ANP): Released by the atria in response to atrial wall stress.
  - Brain Natriuretic Peptide (BNP): Released by the ventricles in response to ventricular wall stress.
  - Both ANP and BNP promote sodium excretion, vasodilation, increased glomerular filtration rate, and decreased renin activity.
  - Elevated BNP is a diagnostic indicator of heart failure.
  - This system can be overwhelmed, leading to ineffective compensation.
Endothelins: - Released by endothelial cells - Contribute to vasoconstriction, smooth muscle cell proliferation, cardiac myocyte hypertrophy, and aldosterone/catecholamine release. - Antinatriuretic effects on the kidneys.
Ventricular Hypertrophy & Remodeling:
- Elevated ventricular wall stress leads to myocardial hypertrophy.
- Types of Hypertrophy:
  - Symmetric: Width and length increase proportionally (seen in athletes)
  - Concentric: Growth predominately from outside to inside, smaller chamber size, thicker muscle
  - Eccentric: Continued growth, enlargement of chamber size, thinning of muscle, increased volume and stretch
- Remodeling:
  - Nonmyocytes stimulate fibroblast growth, which leads to increased collagen synthesis and myocardial fibrosis. This reduces contractility and increases stiffness.

Left Heart Failure (Systolic) → HFrEF

Reduced Ejection Fraction (<40%) due to decreased contractility.
Increased Preload: The heart stretches due to increased workload, leading to BNP release.
Eccentric hypertrophy.
Diagnostics:
- Echocardiogram
- Elevated BNP levels
Patient Presentation:
- High or decreased blood pressure.
- Third heart sound (S3) indicating volume overload.
- Pulmonary vascular congestion: Pulmonary edema, dyspnea, orthopnea.
- Decreased urine output due to reduced cardiac output and decreased blood flow to the kidneys.
- Inspiratory crackles (from edema).
- Cyanosis (decreased oxygen saturation).
- Pleural effusion (from edema).

Left Heart Failure (Diastolic) → HFpEF

Preserved or normal ejection fraction (55%-70%).
Impaired ventricular relaxation leading to pulmonary congestion.
Major causes:
- Hypertension-induced hypertrophy or prior myocardial infarction
- Impaired calcium removal from left ventricular myocytes: Reduced relaxation
- Concentric hypertrophy: smaller ventricular lumen, leading to increased chamber pressure and backflow into the pulmonary circuit.
Exacerbated by activity: Increased heart rate shortens ventricular filling time.
Diabetes increases the risk of HFpEF.
Patient Presentation:
- Fourth heart sound (S4)
- Dyspnea on exertion (DOE)
- Fatigue
- Pulmonary edema: Inspiratory crackles
Treatment: Focuses on improving ventricular relaxation, increasing diastolic filling times, and reducing myocardial demand.

Right Heart Failure

Inadequate blood flow to the pulmonary circulation.
Commonly associated with:
- Pulmonary hypertension
- Hypoxic pulmonary diseases (COPD)
- Hypoxic vasoconstriction of the pulmonary vasculature (leads to increased right ventricular afterload)
- Remodeling of the pulmonary endothelium
Leads to:
- Cor pulmonale
Progression of left heart failure to right heart failure:
- Increased left ventricular filling pressure.
- Backflow into the lungs (pulmonary congestion).
- Increased pressure in the pulmonary circuit (increased right ventricular afterload).
- Decreased right ventricular emptying (increased preload).
- Right ventricular dilation and failure due to elevated pressure.
Patient Presentation:
- Venous congestion
- Peripheral edema
- Hepatosplenomegaly
- Dyspnea
- Fatigue
- Chest pain/palpitations

High-Output Heart Failure

Adequate blood volume and contractility, but ineffective tachycardia leads to unmet metabolic needs.
Causes:
- Anemia: Decreased red blood cell count
  - Chronic condition
  - Decreased oxygen carrying capacity
  - Anaerobic metabolism and metabolic acidosis.
  - Increased heart rate and stroke volume to maintain cardiac output.
  - Left ventricular fatigue and failure over time.
- Sepsis: Profound inflammation
  - Acute condition
  - Bacterial toxins trigger inflammation.
  - Profound vasodilation and fever
  - Elevated metabolic needs
  - Anaerobic metabolism and metabolic acidosis
  - Increased heart rate and stroke volume to maintain cardiac output
  - Left ventricular fatigue and failure over time.
If elevated heart rate persists for days, left ventricular failure may occur.

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This quiz covers essential concepts related to hypertension and dyslipidemia, including medication management and lipid metabolism. Learn about the roles of various lipids, strategies to manage blood pressure, and the importance of monitoring health conditions. Perfect for medical students or healthcare professionals looking to refresh their knowledge.