AAFP Flashcards
Caution is necessary when prescribing TZDs in patients with:
known heart failure or other heart diseases, those with preexisting edema, and those on concurrent insulin therapy (SOR C).
Metformin is often contraindicated because of:
renal insufficiency or heart failure
Danger of sulfonylureas and other insulin secretagogues
hypoglycemia
The 2002 joint guidelines of the American College of Cardiology, the American Heart Association (AHA), and the North American Society of Pacing and Electrophysiology endorse the use of cardiac resynchronization therapy (CRT) in patients with:
medically refractory, symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55 mm, and a left ventricular ejection fraction (LVEF) ≤30%.
What is CRT?
Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously, for example overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block.
The American Heart Association recommends a goal blood pressure of 130/80 mm Hg or less for the treatment of hypertension in patients with:
diabetes mellitus, chronic kidney disease, or coronary artery disease.
Management of dissecting aortic aneurysm
Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added.
Most common cause of HTN in children under 6 yo
renal parenchymal disease
When is surgery indicated?
Dissecting aortic aneurysm
only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture
Who should get screened for AAA?
men 65-75 yo who have ever smoked
Management of SVT
If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia.
Monotherapy for hypertension in African-American patients is more likely to consist of:
diuretics or calcium channel blockers than β-blockers or ACE inhibitors. It has been suggested that hypertension in African-Americans is not as angiotensin II-dependent as it appears to be in Caucasians.
Still’s murmur
systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall.
Venous hum
continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole.
Murmur of physiologic peripheral pulmonic stenosis
The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age.
Metoprolol and carvedilol are metabolized by the __.
liver; therefore do not need renal dosage adjustment
Which needs renal dosage adjustment? Enoxaparin vs clopidogrel
enoxaparin; clopidogrel can be given at standard dosage
What about tPA?
Renal dosing
can be given at standard dosage in renal failure, although hemorrhagic complications are increased
Most useful diagnostic tool for evaluating patients with heart failure
2-D echocardiography w/ Doppler
Diagnosis of MI on EKG
Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads.
New left bundle branch block suggests occlusion of:
left anterior descending artery
Isolated systolic HTN in the elderly responds best to:
diuretics, and to a lesser extent, beta blockers
Benefits of thiazides
highly effective at preventing CVA >> MI improved BP control in African-Americans inexpensive, widely available kidney stone risk reduction preservation of calcium stores (could help w/ osteoporosis) loss of "water weight"
Most common associated etiologic factor of spontaneous axillosubclavian vein thrombosis (ASVT)
compressive anomaly in the thoracic outlet, usually bilateral
Budd-Chiari syndrome refers to thrombosis in which vessels?
intrahepatic, suprahepatic, or hepatic veins
Ankle-brachial index (ABI) of __ is considered normal.
0.9 to 1.2
The INR therapeutic range of 2.5-3.5 is reserved for which patients?
those with mechanical heart valves
Therapeutic INR should be maintained for how long in a pt w/ a first DVT related to travel?
3-6 months
Which patients with DVTs can get outpatient care?
good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding
Symptoms of congestive heart failure in infants are often related to:
feedings
How does hypertrophy in patients with HCM change w/ age?
usually stays the same or worsens
Lifespan in pts w/ HCM
normal in most cases; mortality rate is 1%
Are beta blockers useful in tx of HCM?
no; do not alter disease progression
Inheritance pattern of HCM
autosomal dominant
You should recommend surgical intervention when the diameter of a AAA approaches:
5.5 cm
Aortic stenosis becomes symptomatic when the mean transvalvular gradient exceeds __ and the aortic valve area is smaller than __.
50 mmHg; 1 cm2
Tx for symptomatic aortic stenosis
valve replacement
Patients w/ AS who present w/ dyspnea have a __ chance of being alive in 2 yrs unless the valve is promptly replaced.
50%
Beta blocker use has been shown to be effective in patients w/ NYHA Class __ or __ heart failure.
II or III
Contraindications to beta blocker use
hemodynamic instability, heart block, bradycardia, and severe asthma
Leading cause of death in women
CV disease
A pre-op resting EKG is recommended for which patients?
men > 45, females > 55, pts w/ diabetes, symptoms of chest pain, or a previous hx of cardiac disease
BNP
100; 400
Initial therapy for CHF should be __.
loop diuretic
Patients with BNP values of __ warrant further investigation. What pulmonary problems can cause elevated BNP?
lung cancer, cor pulmonale, and PE
Statins, haloperidol, and drugs of abuse (cocaine, heroin) can cause __ with the release of __, which causes acute renal injury.
Statins, haloperidol, and drugs of abuse (cocaine, heroin) can cause rhabdomyolysis with the release of myoglobin, which causes acute renal injury.
Thrombotic microangiopathy is a rare mechanism of injury to the kidney, and may be caused by:
clopidogrel, quinine, or certain chemotherapeutic agents.
Initial exercise routines for the elderly can be as short as __ in duration. Even __ per week of exercise has been shown to be beneficial.
6 minutes; 30 minutes
A target HR of __ of the predicted maximum should be set as a ceiling for elderly patients.
60-75%
Patients w/ peripheral neuropathy should NOT perform which types of exercises?
treadmill walking or step aerobics bc of the risk of damage to their feet
Most beneficial tx for pts with WPW syndrome who have episodic symptomatic SVT or afib
radiofrequency catheter ablation of bypass tracts
NSAIDs in pts w/ heart failure
should be avoided if possible; they cause sodium and water retension, as well as an increase in SVR which may lead to cardiac decompensation. Pts w/ heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of CHF. NSAIDs, including high dose aspirin, may decrease or negate entirely the beneficial unloading effects of ACEI.
Which ones are less likely to have negative effects?
NSAID heart failure
sulindac and low-dose aspirin
Most efficacious drugs for rate control in afib:
CCBs and beta blockers
In pts 65 yo or older w/ one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is __.
warfarin
What is cilostazol?
drug w/ phosphodiesterase inhibitor activity; used to treat arterial occlusive disease and intermittent claudication
Cilostazol should be avoided in which patients?
pts w/ CHF
Benefits of cilostazol
beneficial effects on HDL cholesterol and in tx of third degree heart block
First-line therapy for systolic HTN
thiazides and long-acting CCBs
Tx for severe hypertension in pregnant woman
IV hydralazine, IV labetalol, or oral nifedipine
Risk of infusions of nitroprusside lasting more than 4 hours
fetal cyanide toxicity
What are the preferred drugs for CHF due to LV systolic dysfunction (bc they are associated w/ the lowest mortality)?
ACE inhibitors
Reasonable alternative : combination of hydralazine/isosorbide dinitrate
Clinical predictors of increased perioperative cardiovascular risk for elderly patients
major risk factors such as unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease
Intermediate predictors
Clinical predictors of increased perioperative cardiovascular risk for elderly patients
mild angina, previous MI, compensated CHF, diabetes mellitus, and renal insufficiency
Clinical predictors of increased perioperative cardiovascular risk for elderly patients
Minor predictors
advanced age, an abnormal EKG, LV hypertrophy, left BBB, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, hx of stroke, and uncontrolled HTN
Patients with significant arterial occlusive disease will have a prominent __ in the ankle-brachial index from baseline following exercise, and usually a __-mm Hg or greater __ in systolic blood pressure.
Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure.
Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with __.
Baker’s cysts
This type of pain commonly begins immediately upon walking and is unrelieved by rest.
peripheral nerve pain
Criteria for severe preeclampsia
BP of 160/110 mmHg or above on 2 occasions, 6 hours apart
proteinuria > 5g/24hr
platelet count
Is DVT ppx indicated with total knee or hip replacements?
LMWH and adjusted-dose warfarin
What is subclinical thyroid dysfunction?
TSH either below or above the normal range, free T3 or T4 levels are normal, and the patient has no sx of thyroid disease.
Subclinical hypothyroidism: definition? Associated lab abnormality?
TSH > 10; likely to progress to overt hypothyroidism; increased LDL cholesterol
Subclinical hyperthyroidism: definition? Associations?
TSH
Patients taking lithium should have what thyroid values measured and how often?
total free T4 and TSH; yearly
What diuretic can be used w/ saline infusions to lower significantly elevated calcium levels?
furosemide
Lithium can __ calcium levels by __.
elevate; elevating PTH secretion from parathyroid gland
What effect does raloxifene have on elevated calcium levels?
mildly reduces elevated Ca levels
What diabetic meds can cause or exacerbate delayed gastric emptying and should not be given to a patient w/ diabetic gastroparesis?
amylin analogues (eg, pramlintide) and glucagon-like peptide 1 (eg, exenatide)
Characteristic lab findings in secondary hypothyroidism
low serum free T4 and a low TSH
Criteria for diagnosing diabetes mellitus
any one of the following: symptoms of diabetes (polyuria, polydipsia, weight loss) plus a casual glucose level ≥200 mg/dL; a fasting plasma glucose level ≥126 mg/dL; or a 2-hour postprandial glucose level ≥200 mg/dL after a 75 gram glucose load
Criteria for impaired glucose homeostasis
either a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test
Normal values for fasting glucose and for the 2-hour glucose level on an oral glucose tolerance test
Red flags when evaluating a solitary thyroid nodule that indicate possible thyroid cancer
male gender, age 65, rapid growth of nodule, sx of local invasion such as dysphagia, neck pain, and hoarseness, hx of head or neck radiation, FH of thyroid cancer, hard fixed nodule > 4 cm, cervical LAD
How do thiazides affect calcium?
They decrease the renal clearance of Ca by increasing distal tubular calcium reabsorption.
What should you do if pt is on metformin and needs contrast or urgent surgery?
metformin should be withheld and hydration maintained until preserved kidney fxn is documented at 24 and 48 hrs after the intervention (general anesthesia can cause hypotension–>renal hypoperfusion–>peripheral tissue hypoxia–>lactate accumulation
Tx for myasthenia gravis
corticosteroids and anticholinesterase meds such as oral pyridostigmine
What about for generalized myasthenia gravis not responding to meds?
thymectomy
Hypothyroidism is associated with __ bone age relative to height age and chronologic age.
markedly delayed
What about cystic fibrosis?
bone age and height age are equivalent but both lag behind chronologic age
Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO?
Height/bone age
height age that is delayed relative to bone age (also seen in maternal substance abuse)
Excess thyroid hormone replacement can lead to what bone problem?
increased bone mineral resorption–>increased serum calcium–> osteoporosis; decreased PTH
Most reliable indicator of iron deficiency anemia
low serum ferritin
As an acute-phase reactant, serum iron may be decreased in response to inflammation even when total body stores of iron are not decreased
Indications for parathyroid surgery when elevated PTH levels are found
kidney stones, age 1 mg/dL above upper limit of normal, reduced bone density
Rotavirus vaccine schedule
3 doses given at 2, 4, and 6 mo of age (all 3 should be administered by 32 weeks of age)
Why should you avoid foods high in simple sugars in babies w/ diarrhea?
the osmotic load can worsen the diarrhea; also avoid fatty foods
In acute viral gastroenteritis, which comes first, vomiting or diarrhea?
vomiting
Volvulus in babies may present in one of three ways:
- sudden onset of bilious vomiting and abdominal pain in the neonate
- hx of feeding problems w/ bilious vomiting that now apepars to be due to bowel obstruction
- failure to thrive w/ severe feeding intolerance
Sx of necrotizing enterocolitis
seen in NICU in premature infants in first few weeks of life; infants are ill, and signs and sx include lethargy, irritability, decreased PO intake, abdominal distention, and bloody stools.
A plain abdominal film showing __ is diagnostic of NEC.
pneumatosis intestinalis caused by gas in the intestinal wall
Recommended age for testing for seroconversion in baby who got HBIG and Hep B vaccine bc mom was positive for HBsAg
9-12 months
