Part I: Chapter 23: Alterations of Cardiovascular Function

In HTN, increased levels of ____ (atrial natriuretic peptide) and ____ (brain natriuretic peptide) are linked to an increased risk for ventricular hypertrophy, atherosclerosis, and heart failure.

ANP, BNP

Individuals with heart failure, kidney disease, or who have a history of myocardial infarction or stroke should begin antihypertensive treatment with an ______, ARB, or aldosterone antagonist.

ACE inhibitor

Because onset of SVCS is slow, collateral venous drainage to the _____ vein usually has time to develop.

azygos

The normally increased sympathetic activity during upright posture is mediated through a stretch receptor, or ______ reflex that responds to shifts in volume caused by postural changes. This reflex promptly increases heart rate and constricts the systemic arterioles. Thus, arterial blood pressure is maintained. These mechanisms are dysfunctional or inadequate in individuals with orthostatic hypotension. Consequently, upon standing, blood pools and normal arterial pressure cannot be maintained.

baroreceptor

Increased SNS activity causes increased heart rate and systemic vasoconstriction, thus raising the blood pressure. Additional mechanisms of SNS-induced hypertension include structural changes in blood vessels (vascular remodeling) renal sodium retention (shift in natriuresis curve), insulin resistance, increased renin and _______ levels, and procoagulant effects.

angiotensin

Finally, aldosterone not only contributes to sodium retention by the kidney but also has other deleterious effects on the cardiovascular system. Medications, such as _____________ (ACE) inhibitors and angiotensin receptor blockers (ARBs), oppose the activity of the RAAS and are effective in reducing blood pressure and protecting against target organ damage.

angiotensin-converting enzyme

Because DVT is usually asymptomatic and difficult to detect clinically, prevention is important and includes early ambulation, pneumatic devices, and prophylactic _______.

anticoagulation

Hypertension results from a sustained increase in peripheral resistance (_______ vasoconstriction), an increase in circulating blood _____, or both.

arteriolar, volume

Most thrombi will eventually dissolve without treatment; however, untreated DVT is associated with a high risk of __________ of a part of the clot to the lung, a process known as pulmonary embolism.

embolization

Besides ________, malignant HTN can cause papilledema, cardiac failure, uremia, retinopathy, and CVA.

encephalopathy

The diseases that cause secondary orthostatic hypotension are _____ disorders (e.g., adrenal insufficiency), _____ disorders (e.g., porphyria), or diseases of the central or peripheral ______ system (e.g., intracranial tumors, cerebral infarcts, Wernicke encephalopathy, peripheral neuropathies).

endocrine, metabolic, nervous

Some genetic abnormalities, including ________ mutation, prothrombin mutations, and deficiencies of protein __, protein __, and __________; these abnormalities are commonly found in individuals who develop thrombi in the absence of the usual risk factors.

factor V Leiden, C, S, antithrombin

Primary orthostatic hypotension affects up to 18% of older adults, and it is a significant risk factor for ____ and associated injury.

falls

Risk factors for varicose veins also include age, _____ gender, a family history of varicose veins, obesity, pregnancy, deep venous thrombosis, and previous leg injury.

female

Management of DVT consists of anticoagulation therapy using _____ and warfarin. In selected individuals, thrombolytic therapy or placement of an inferior vena cava filter may be indicted.

heparin

In infants, SVCS can lead to _______.

hydrocephalus

If a vein valve is damaged, a section of the vein is subjected to the pressure of a larger volume of blood under the influence of gravity. The vein swells as it becomes engorged and surrounding tissue becomes edematous because increased _______ pressure pushes plasma through the stretched vessel wall.

hydrostatic

Chronic venous insufficiency symptoms include edema of the lower extremities and _________ of the skin of the feet and ankles.

hyperpigmentation

Chronic _____ can lead to target organ damage in the heart, kidney, brains, and eyes.

hypertension

Evidence of heart disease, renal insufficiency, central nervous system dysfunction, impaired vision, impaired mobility, vascular occlusion, or edema can all be caused by sustained ______.

hypertension

_________ is consistent elevation of systemic arterial blood pressure. It is the most common primary diagnosis in the U.S.

hypertension

The term _________, or primary, orthostatic hypotension implies no known clinical cause. It affects men more often than women and usually occurs between the ages of 40 and 70 years.

idiopathic

Dysfunction of the natriuretic hormones, along with alterations in the RAA system and the SNS, causes an increase in vascular tone and a shift in the pressure-natriuresis relationship. When there is inadequate natriuretic function, serum levels of the natriuretic peptides are _________.

increased

The same sluggish circulation makes post-reparative surgery ______ a significant risk.

infection

Although many cytokines (e.g., histamine, prostaglandins) have vasodilatory actions in acute inflammatory injury, chronic _______ contributes to vascular remodeling and smooth muscular contraction.

inflammation

______ is common in HTN, even in individuals without diabetes.

insulin resistance

___________ is typically defined as a sustained systolic blood pressure reading that is greater than or equal to 140 mmHg systolic and <90 mm Hg dystolic.

isolated systolic hypertension

All stages of HTN are associated with increased risk for target organ disease events, such as myocardial infarction, ____ disease, and stroke.

kidney

Deep venous thrombosis occurs primarily in the _______ extremities.

lower

Venous thrombi are more common than arterial thrombi because flow and pressure are ______ in the veins than in the arteries.

lower

The SVC is a relatively low-pressure vessel that lies in the closed thoracic compartment; therefore, tissue expansion can easily compress the SVC. The right main stem bronchus abuts the SVC so that cancers occurring in this bronchus may exert pressure on the SVC. Additionally, the SVC is surrounded by _____ nodes and lymph chains that commonly become involved in thoracic cancers and compress the SVC during tumor growth.

lymph

___________ is rapidly progressive HTN in which diastolic pressure renders the cerebral arterioles incapable of regulating blood flow to the cerebral capillary beds. If blood pressure is not reduced, cerebral edema and cerebral dysfunction (encephalopathy) increase until death occurs.

malignant hypertension

Obesity, HTN, dyslipidemia, and glucose intolerance often are found together in a condition called the ______ syndrome.

metabolic

The ___________ hormones modulate renal sodium excretion and require adequate potassium, calcium, and magnesium to function properly.

natriuretic

Angiotensin II also mediates arteriolar _______, which is structural change in the vessel wall that results in permanent increases in peripheral resistance.

remodeling

In HTN, subtle _____ injury results, with renal vasoconstriction and tissue ischemia. Tissue ischemia causes inflammation of the kidney and contributes to dysfunction of the glomeruli and tubules, which promotes additional sodium retention.

renal

Microalbuminuria (small amounts of protein in the urine) occurs in 10-25% of individuals with primary hypertension as is an early sign of impending _____ dysfunction.

renal

Most cases (92%-95%) of hypertension are diagnosed as primary hypertension (also called essential or idiopathic hypertension). Secondary hypertension is caused by an underlying factor such as _________ disease and accounts for 5%-8% of cases.

renal

In hypertensive individuals, overactivity of the ________ system contributes to salt and water retention and increased vascular resistance. High levels of angiotensin II contribute to endothelial dysfunction, insulin resistance, and platelet aggregation.

renin-angiotensin-aldosterone

Complications of HTN also extend to the _____ and include retinal vascular sclerosis, exudation, and hemorrhage.

retina

This means that for a given BP, individuals with HTN tend to secrete less ____ in their urine.

salt

Varicose veins are caused by (1) trauma to the ______ veins that damages one or more valves or (2) gradual venous distention caused by the action of ______ on the legs

saphenous, gravity

_________ HTN is caused by an underlying disease process or medication that raises peripheral vascular resistance or cardiac output.

secondary

Low dietary potassium, calcium, and magnesium intakes also are risk factors because without their intake, _______ is retained.

sodium

Factors associated with primary hypertension include (1) family history of HTN (2) advancing age (3) gender (men < 55 years, women > 70 years) (4) black race (5) high dietary ____ intake (6) _____ intolerance (7) smoking (8) obesity (9) heavy _____ consumption (10) low dietary intake of _______, calcium, and magnesium

sodium, glucose, alcohol, potassium

____________ is a progressive occlusion of the superior vena cava (SVC) that leads to venous distention in the upper extremities and head.

superior vena cava syndrome

The ________ has been implicated in both the development and the maintenance of elevated blood pressure and plays a role in hypertensive organ damage.

sympathetic nervous system

In addition, the individual is at increased risk for ________ heart failure as the contractility of the heart is impaired due to higher oxygen demands. Aneurysms and atherosclerosis can also result.

systolic

A detached thrombus is called a ________.

thromboembolus

A ____ is a blood clot that remains attached to a vessel wall.

thrombus

Orthopedic trauma or surgery, spinal cord injury, and obstetric/gynecologic conditions can be associated with up to a ______ likelihood of DVT.

100%

HTN is defined as a sustained sys/dys BP equal to or greater than what value mmHg?

140/90

One in three Americans has HTN, and more than 2/3 of those older than age ____ are affected, as the chance of developing HTN increases with age.

60

If thrombosis does occur, diagnosis is confirmed by a combination of serum _______ measurement and Doppler ___________.

D-dimer, ultrasonography

Three factors (triad of _____) promote venous thrombosis: (1) venous stasis (e.g. immobility, age, CHF), (2) venous endothelial damage (e.g. trauma, intravenous medications) and (3) hypercoagulable states (e.g., inherited disorders, malignancy, pregnancy, use of oral contraceptives or hormone replacement therapy).

Virchow

Insulin resistance is associated with decreased endothelial release of nitric oxide and other vasodilators. It also affects renal function and causes renal salt and water retention. In many individuals with diabetes treated with drugs that increase insulin sensitivity, _______ often declines, even in the absence of antihypertensive drugs.

blood pressure

The early stages of HTN have no clinical manifestations other than elevated _______.

blood pressure

Causes of SVCS include ________ (75% of cases), followed by lymphomas and metastasis of other cancers. Other less common causes include tuberculosis, mediastinal fibrosis, cystic fibrosis, and invasive therapies (pacemaker wires, central venous catheters, and pulmonary artery catheters).

bronchogenic cancer

A specific cause for primary hypertension has not been identified. Genetic predisposition is believed to be polygenic. The inherited defects are associated with renal sodium excretion, insulin and insulin sensitivity, activity of the sympathetic nervous system and the renin-angiotensin-aldosterone system, and cell membrane sodium or _____ transport.

calcium

Clinical manifestations of SVCS are edema and venous distention in the upper extremities and face, including the ocular beds. Affected persons complain of a feeling of fullness in the head or tightness of shirt collars, necklaces, and rings. ________ may cause headache, visual disturbance, and impaired consciousness. The skin of the face and arms may become purple and taut, and capillary refill time is prolonged. Respiratory distress may be present because of edema of bronchial structures or compression of the bronchus by a carcinoma.

cerebral edema

Although usually considered an adult problem, HTN also occurs in ____ and is being diagnosed with increasing frequency.

children

_______ orthostatic hypotension may be secondary to a disease or primary.

chronic

Inadequate venous return over a long period is termed __________. Venous hypertension, circulatory stasis, and tissue hypoxia cause an inflammatory reaction in vessels and tissue leading to fibrosclerotic remodeling of the skin and then to ulceration.

chronic venous insufficiency

Treatment of varicose veins and ____ begins conservatively, and excellent wound healing results have followed noninvasive treatments such as elevating the legs, wearing compression stockings, and performing physical exercise. Invasive management includes sclerotherapy or surgical ligation, conservative vein resection, and vein stripping.

chronic venous insufficiency

HTN is also more prevalent in blacks and ______.

diabetics

Left ventricular hypertrophy results in the heart being less able to relax during ______, leading to diastolic heart failure.

diastole

________ have been show to be the safest and most effective medications for lowering blood pressure.

diuretics

Orthostatic hypotension may be acute or chronic. Acute may occur as a result of (1) altered body chemistry (2) ___ action - anti HTN and anti depressants (3) prolonged immobility caused by illness (4) starvation (5) physical exhaustion (6) any condition that produces ____depletion - dehydration, diuresis, K or Na depletion (7) any condition that results in venous pooling (e.g., _____, extensive varicosities)

drug, volume, pregnancy

Endothelial injury and dysfunction in primary hypertension is further characterized by a decreased production of vasodilators, such as ________, and an increased production of vasoconstrictors, such as endothelin.

nitric oxide

Varicose veins and valvular incompetence can progress to chronic venous insufficiency, especially in ______ individuals.

obese

______ (a risk factor for HTN) is associated with changes in adipokines (i.e., leptin and adiponectin) and increased activity of the SNS and the RAAS.

obesity

______ is linked to inflammation, endothelial dysfunction, and insulin resistance and an increased risk for cardiovascular complications for HTN.

obesity

Because of its slow onset and the development of collateral venous drainage, SVCS is generally not a vascular emergency, but it is an ______ emergency. Oncologic treatments may ensue.

oncologic

_______ hypotension is often accompanied by dizziness, blurring or loss of vision, and syncope or fainting caused by insufficient vasomotor compensation and reduction of blood flow through the brain. Although no curative treatment is available for idiopathic orthostatic hypotension, often it can be managed adequately with a combination of nondrug and drug therapies - increasing fluid and salt intake, wearing thigh-high stockings, and taking mineralocorticoids and vasoconstrictors. Both acute and secondary forms of hypotension resolve when the underlying disorder is corrected.

orthostatic

Accumulation of clotting factors and _____ leads to thrombus formation in the vain, often near a venous valve. Inflammation around the thrombus promotes further platelet aggregation, and the thrombus propagates proximally. This inflammation may cause pain and redness, but because the vein is deep in the leg, it is usually not accompanied by clinical symptoms or signs.

platelets

Persistent venous obstruction may lead to chronic venous insufficiency and _________ with associated pain, edema, and ulceration of the affected limb.

post-thrombotic syndrome

The term ___________ refers to a decrease in systolic BP of at least 20 mm Hg or a decrease in diastolic BP of at least 10 mm Hg within 3 minutes of moving to a standing position.

postural hypotension

Inflammation, endothelial, obesity-related hormones, and insulin resistance also contribute to both increased peripheral resistance and increased blood volume. Increased vascular volume is related to a decrease in renal excretion of salt, often referred to as a shift in the __________________.

pressure-natriuresis relationship

Venous distension can develop over time in individuals who habitually stand for long periods, wear constricting garments, or cross the legs at the knees, which diminishes the action of the muscle ______.

pump

Examples of secondary HTN include renal vascular or parenchymal disease, adrenocortical ________, adrenomedullary tumors, and drugs (oral contraceptives, corticosteroids, antihistamines).

tumors

Diagnosis of HTN requires BP measurement on at least two separate occasions, averaging readings at least ____ minutes apart. Individuals who have elevated blood pressure are assumed to have primary HTN unless other factors indicate secondary hypertension.

two

Diagnosis is made by chest X-ray, Doppler studies, computed tomography (CT), magnetic resonance imaging (MRI), and _____.

ultrasound

The natriuretic hormones include atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), C-type natriuretic peptide (CNP), and _________.

urodilatin

Veins are thin walled, highly distensible vessels with _____ to prevent backflow and pooling of blood.

valves

A ___________ is a vein in which blood has pooled, producing distended, tortuous, and palpable vessels.

varicose vein

Circulation may become so poor that any trauma or pressure can lower the oxygen supply and cause cell death and necrosis, resulting in ________.

venous stasis ulcers

Cardiovascular complications of sustained hypertension include left ______ hypertrophy, angina pectoris, heart failure, coronary artery disease, myocardial infarction, and sudden death.

ventricular

Salt retention leads to ______ retention and increased blood volume, which contributes to an increase in blood pressure.

water