Ambulatory Medicine - Step UP Flashcards
MCC of secondary HTN
renal artery stenosis
what types of medications can cause secondary HTN?
OCPs, decongestants, estrogen, appetite suppressants, chronic steroids, TCAs, NSAIDs
mechanism of action of OCPs in causing HTN
estrogen-mediated increase in synthesis of angiotensinogen in the liver
who should be screened for secondary HTN
- pts with HTN before age 25 or greater than 55 yo
- key features in hx/PE
- pts. refractory to standard tx
features of Conn syndrome
HTN and hypokalemia due to increased aldosterone
tx. of Conn syndrome
K+ sparing diuretics, surgery
malignant HTN
sufficient elevation of BP to cause papilledema and other manifestations of vascular damage (encephalopathy, nephropathy)
which hypertensive drugs are contra-indicated in pregnancy?
ACEi/ARBs
thiazides
CCBs
what HTN drugs are safe in pregnancy?
B-blockers
hydralazine
best initial HTN drug choice for African-American patients
thiazide diuretics
who should BB be avoided in?
pts with hx. of asthma, COPD, heart block and depression
what anti-HTN drug is preferred among diabetics?
ACEi
when are alpha-blockers considered in tx. of HTN
in pt with concurrent BPH
when are vasodilators like hydralazine and minoxidil used to tx. HTN
in combo with BB and diuretics in pts with refractory HTN
what drug is used for tx of HTN in pts post-MI
beta blocker
which HTN drugs can decrease LV systolic function in CHF
ACEi and/or BB
what drugs are least effective in african americans
ACEi
ACCOMPLISH trial
tx. with ACEi benazepril PLUS CCB amlodipine was more effective than tx. with ACEi + diuretic
endocrine secondary causes of hyperlipidemia
hypothyroidism
DM
Cushing’s syndrome
renal causes of hyperlipidemia
nephrotic syndrome
uremia
medications that can cause hyperlipidemia
steroids estrogen thiazide diuretics B-blockers HIV protease inhibitors
what levels of LDL significantly predispose to increased CAD risk
> 160 mg/dL
how can you calculate LDL cholesterol
total cholesterol - HDL - TG/5
goal for total cholesterol levels
< 200 mg/dL
goal for LDL in a diabetic? for diabetic and CAD?
1) < 100 mg/dL
2) < 70 mg/dL
effect of HDL on cholesterol
every 10 mg/dL increase in HDL, reduces CAD risk by 50%
which lipid lowering drugs can induce transient elevations in LFTS
statins and fibrates
what other tests should you order if a patient has hyperlipidemia?
TSH - hypothyroidism
LFTs - chronic liver disease
BUN, Cr, urinary proteins
glucose levels
effects of Statins
lower LDL levels
- reduce mortality from cardiovascular events and significantly reduce total mortality
side effects of statins
monitor LFTs - monthly for first 3 months, then every 3-6 months
monitor CPK- decrease CoQ in muscle cells= myopathy
side effects of niacin
lower TG levels, lowers LDL levels, increases HDL
note about use of niacin
- do not use in diabetics (may worsen glycemic control)
- most potent agent for increasing HDL
- flushing effect
- check LFTs and CPK levels
effects of bile-acid binding resins
lower LDL and increase TG levels
- effective when used in combo with statins or niacin in high risk pts
effects of fibrates (gemfibrozil)
lower VLDL and TG
increase HDL
- primarily for lowering TG
side effects of fibrates
gynecomastia gallstones mild GI side effects weight gain myopathies
first line therapy for high TG levels
weight loss, aerobic exercise, glycemic control in DM and low fat-diet
medications to lower TG levels
fibrates
fish oils
nicotinic acid
what kind of headache causes pain that is tight and a band-like pattern around the head most intense in the neck or back of head and can be accompanied by tight posterior neck muscles?
tension headache
what are tension headaches commonly associated with?
anxiety, depression and stress
tx of tension headaches
eliminate causal factor
NSAIDS, acetaminophen and aspirin
man experiences excruciating periorbital pain unilaterally along with ipsilateral lacrimation, facial flushing and nasal stuffiness/discharge - dx?
cluster headache
characteristics of pain in cluster headache
usually awakens the patient form sleep and attacks can occur nightly for 2-3 months and then disappear; worse with alcohol and sleep
DOC for acute cluster headache attack
sumatriptan (Imitrex)
- O2 inhalation can be beneficial
prophylaxis of cluster headaches
verapamil -daily
alternate agents for prophylaxis of cluster headaches
ergotamine,methysergide, lithium, prednisone
classic presentation of a visual aura in migraine
bilateral homonymous scotoma
- bright, flashing crescent-shaped images with jagged edges that often appear on a page obscuring the underlying print
characteristic pain in a migraine
severe, throbbing, unilateral headache that is aggravated by coughing, physicial activity and bending down; may be accompanied by photophobia, NV or increased sensitivity to smell
first line therapy for a migraine
NSAIDs - ibuprofen, naproxen
2nd line therapy for moderate-severe migraines
triptans or dihydroergotamine
contraindications of dihydroergotamine
CAD pregnancy TIAs PVD sepsis
contraindications of sumatriptan
CAD, pregnancy, uncontrolled HTN, MAOIs, SSRIs, lithium, basilar artery migraine, hemiplegic artery
what is the best drug for tx. of migraine severe migraine symptoms
sumitriptan
- should not be used > 1-2x/week
best drug for prophylaxis of a migraines
propranolol
- TCAs are also first line
second-line agents for migraine prophylaxis
methysergide
verapamil
valproic acid
