Cardio 1 Flashcards
1
Q
What are 3 types of cardio myopathies? What is most common?
A
Dilated (95%)
Hypertrophic (4%)
Restrictive (1%)
2
Q
Pathophysiology of a dilated cardiomyopathy
A
heart becomes weak and unable to empty the ventricles -> leads to dilation of left ventricle
3
Q
Signs of dilated cardiomyopathy and CHF
A
Elevated JVP Rales S3 gallop Cardiomegaly Mitral/tricuspid regurg Peripheral edema
4
Q
Signs of CHF on ECHO
A
Cardiomegaly
Reduced systolic function
High diastolic pressure
Low cardiac output
5
Q
Treatment of dilated cardiomyopathy and CHF
A
ACE inhibitors
Beta Blockers
Diuretics
Aldosterone Inhibitors
6
Q
Cause of sudden cardiac death in young athletes. Imaging reveals LVH.
A
Hypertrophic cardiomyopathy
7
Q
Characteristics of murmur heard with Hypertrophic cardiomyopathy
A
systolic murmur that decreases with squatting
8
Q
Causes of Hypertrophic cardiomyopathy
A
autosomal dominant inheritance
9
Q
Pathophysiology of Hypertrophic cardiomyopathy
A
septal wall thickening resulting in left ventricle outflow obstruction and LVH
10
Q
Hypertrophic cardiomyopathy treatment
A
BBs or CCBs
Surgical removal of hypertrophic tissue
May need pacemaker
11
Q
Pathophysiology of Restrictive Cardiomyopathy
A
good ventricular contractions, but poor diastolic filling
12
Q
What is primary (essential) HTN?
A
HTN with no identifiable cause; 95% of cases
13
Q
What are BP ranges for the following: Normal Pre-HTN Stage 1 HTN Stage 2 HTN HTN urgency
A
Normal BP: less 120/80 Pre-HTN: less 140/90 Stage 1: less 160/100 Stage 2: > or = 160/100 Severe: >180 / >110 Urgency: >220 / > 125
14
Q
Clinical definition of HTN
A
BP > 140/90 on two or more separate occasions
- BP > 150/90 if 60 or older
15
Q
Behavior modifications to reduce primary HTN
A
Weight reduction DASH diet Reduce sodium intake Increase aerobic activity Limit alcohol consumption
16
Q
Method for most accurate in-office BP reading
A
Two readings 5 min apart, sitting in chair with feet resting on floor
Confirm elevated reading in contralateral arm
17
Q
How should BP be eval’d in patient with “white coat HTN?”
A
ambulatory BP monitoring
18
Q
BP goals for patients with HTN
A
less 140/90
less 130/80 with DM or CKD
19
Q
First line therapy for patients with mild HTN (140-150/90-99)?
A
thiazide diuretics
20
Q
MOA of thiazide diuretics
A
inhibiting Na+/Cl- transporter in distal convoluted tubule -> decrease Na+ resabsorbtion -> loss of NaCl and fluid (also loss in K+)
21
Q
Long term effects of thiazide diuretics
A
lower peripheral vascular resistance
22
Q
Most common thiazide diuretics used and their dosing
A
Hydrochlorothiazide – HCTZ
Dose – 12.5 mg or 25 mg po daily
Chlorthalidone (Longer acting with better 24 hour BP control than HCTZ)
Dose – 12.5 mg or 25 mg po daily
23
Q
Side effects of thiazide diuretics
A
Decrease in serum K, Na, Mg
Increase in serum Ca
Increase Uric acid (think gout)
Increase glucose (pay attention in diabetics)
24
Q
Powerful diuretic to use ACUTE cases of pulmonary edema, hyperkalemia, and renal failure?
A
loop diuretics
25
How do loop diuretics decrease renal vascular resistance?
Inhibit Na/K/Cl transporter in ascending Loop of Henle where most Na is reabsorbed making this medication very powerful!
26
Side effects of Loop diuretics
```
Hypotension
Ototoxicity (reversible)
Hyperuricemia (gout)
Decreased serum Na, K, Mg
Increased serum Ca
```
27
Common examples of Loop diuretics
Furosemide - Lasix
| Ethacrynic Acid
28
MOA of potassium sparing diuretics
block production of key protein for Na/K exchange in collection tube
No loss of K+
29
What are catecholamines and where do they bind?
Catecholamines (mostly epinephrine and norepinephrine) bind to alpha and beta receptors
30
What is a secondary agent to use in combo therapy for HTN?
potassium sparing diuretic
31
Side effects of potassium sparing diuretic
HYPERKALEMIA
Ototoxicity (reversible)
Hyperuricemia (gout)
Decreased Mg
32
Commonly used potassium sparing diuretics
Spironolactone
| Amiloride
33
Where are beta 1 and beta 2 receptors located?
beta-1 in heart and kidneys
beta-2 in lungs, GI, liver, vascular smooth muscle, and skeletal muscle
34
Beta blockers effect on the heart
prevent sympathetic cardiac stimulation - decrease HR and cardiac output
35
Indications for beta blockers
HTN, angina, MI, CHF
36
Why should BBs be avoided in asthma patients? If need to use BB which one?
Common side effect of BB is asthma exacerbation due to Beta-2 blockage increasing airway resistance
If BB necessary use one with high affinity to Beta-1 receptor in heart (metoprolol, atenolol)
37
What drug class prevents sympathetic vasoconstriction?
alpha blockers
38
Indications for alpha blockers
Secondary med for HTN
| 1st line for BPH
39
Where are alpha receptors located?
vascular smooth muscle throughout body
40
Main side effect of alpha blockers
hypotension
41
Renin is secreted from ______ in response to low ______.
juxtaglomerular cells
blood volume
42
Describe process of how renin increases blood volume?
RAAS vasoconstricts and increases plasma volume
Renin -> Angiotensin I -> Angio I + ACE -> Angio II -> vasoconstriction and stimulates aldosterone -> kidneys reabsorb more Na and water
43
How do ACE inhibitors reduce BP?
inhibit enzyme that produces angiotensin II
reduces vasoconstriction (lower resistance)
reduces aldosterone secretion and thus Na and water reabsorption (lower blood volume)
44
Indications for ACE inhibitors?
HTN, CHF, DM
45
Side effects of ACE inhibitors
cough
hyperkalemia
teratogenic
46
Why would ARBs be used over ACE-I?
patient unable to tolerate cough of ACE
47
How do CCBs treat HTN and arrhythmias?
block voltage gated calcium channels in blood vessels and cardiac muscles, decreasing muscle tone and vasoconstriction
Reduce HR and contractility
Reduce AV node conduction to treat arrhythmias (esp. SVT)
48
Examples of CCBs
Verapamil
Diltiazem
Amlodipine – less effective on cardiac tissue
Nifedipine – less effective on cardiac tissue
49
How do central sympatholytic acting drugs work (Clonidine, Methyldopa)?
centrally working alpha-2 agonist decrease sympathetic activity - decrease HR and BP
* work same as BBs
50
MOA of Hydralazine and Nitroprusside
Direct arterial smooth muscle dilators
work by releasing nitric oxide
51
HTN treatment protocol for patient over 55 or African American
start with CCB or thiazide
52
HTN treatment protocol for patient under 55 and not African American
start with ACE inhibitor
53
What is used for dual therapy for HTN? When is it used?
ACE + CCB or thiazide
used in stage 2 HTN or if BP goal not met with mono therapy
54
Suggested therapy for pregnant woman with HTN
hydralazine and clonidine
| or methyldopa
55
You are looking to add a second medication to help a patient better control their blood pressure. The patient has a history of asthma and benign prostatic hypertrophy. Which anti-hypertensive would be a poor choice?
beta blocker due to possible asthma exacerbation
56
Clinical definition of orthostatic hypotension?
decrease in systolic BP of 20 mm Hg or decrease in diastolic blood pressure of 10 mm Hg when going from lying to sitting or sitting to standing
57
How to treat hypotension?
treat underlying cause; i.e. give fluids for fluid depletion, check BP meds
58
_____ is the inability of the heart to pump enough blood to meet the needs of the body.
CHF
59
Physiological changes that cause CHF
fluid overload/retention
decreased cardiac contractility
decreased cardiac output
60
What is pulsus alternans?
alternating strong and weak beats
61
Characteristics of pulse of patient with CHF
tachycardia, weak, thready, pulsus alternans
62
Cheyne-Stokes respiration seen in CHF
abnormal breathing pattern of progressively deeper and faster breathing, followed by gradual decrease in breathing
hyperapnea-hypopnea separated by periods of apnea
63
Kussmaul breathing seen in what conditions?
metabolic acidosis (DM)
diabetic ketoacidosis
hyperapnea
sepsis
64
How to determine elevated venous pressure seen in CHF?
Jugular Venous Distention test
patient sitting at 45 deg; jugular vein pulsation higher than 4 cm above sternal angle is elevated
65
Hepatojugular reflex
patient sitting at 45 deg; pressure applied to abdomen for about a minute and if the neck vein height increases by 3 cm the test is positive
66
Heart sounds of CHF patient
possible murmurs, S3 or S4 sounds, diminished first heart sound
67
What lung sound suggests fluid at alveolar level?
rales/crackles
68
Likely treatment if you hear wheezing on exam
Nebulizer tx
| Steroids
69
Left-sided CHF causes
pulmonary edema
70
Right-sided CHF cause
Hepatomegaly
| Abdominal edema
71
Signs of CHF
```
Cyanosis
Dyspnea
Tachycardia
Weak/thready pulse
Cheyne-Stokes breathing
JVD
Displaced apical impulse
Dullness to percussion of lung bases
Possible S3 or S4 heart sounds
Rales or wheezing
Hepatomegaly
Hepatojugular reflex
Lower leg edema
```
72
What is batwing or butterfly shadow on CXR?
enlarged hila and alveolar edema
73
Findings on chest x-ray that suggest CHF
Cardiomegaly
Pleural effusion = ground glass appearance from fluid build up
Kerley B lines = short parallel lines at lung periphery near bases
Peribronchial cuffing
Batwing or Butterfly shadow
Water bottle or boot shaped heart
74
How can you asses ejection fraction, ventricular function, and valves of the heart?
ECHO
75
Which lab is a good indicator of CHF, however maybe not that specific?
elevated BNP
76
Treatment of CHF
Low sodium diet
Meds:
- Diuretics (thiazide or loop diuretic with ACEI)
- Beta blockers
- Digitalise (inotropic agents)
77
__________ is the number one cause of cardiac-related death and disability.
Atherosclerosis
78
Risk factors of atherosclerosis
```
HTN
Dyslipidemia
Smoking
Diabetes
Advancing age
Family history
Male (4:1)
```
79
What allows the visualization of arteries under x-ray?
angiogram
80
What is an ankle-brachial index used for?
compares systolic BP in upper vs lower extremity; useful in peripheral vascular disease
81
What is heard over an artery that is partially occluded?
bruit
82
How is Doppler U/S more advantageous than regular U/S for atherosclerosis eval?
sees changes in blood flow
83
Medical treatment of atherosclerosis
Blood thinners - Aspirin 81 mg or 325 mg daily
84
When should routine cholesterol screening be done?
begin at 35 for men and 45 for women
85
Low and high levels of HDL
low less than 40
| high over 60
86
optimal level of LDL
less than 100
87
What is high level LDL?
> 160
88
Optimal total cholesterol level
less than 200
89
Normal and high triglycerides
normal less than 150
| high over 200
90
Ways to manage dyslipidemia without medication?
- Weight reduction
- Reduce dietary fats to 30% and saturated fats to less than 10%
- Mediterranean diet
- Increase aerobic exercise (increase HDL)
91
Medications for elevated cholesterol?
81 mg or 325 mg of Aspirin daily to lower LDL
Statins (HMG-CoA inhibitors): lovastatin, pravastatin, simvastatin, atorvastatin
Postmenopausal estrogen replacement helps lower LDL and raise HDL
Niacin is effective but not well tolerated
Bile acid binding resins: Cholestyramine, Colestipol
Fibric acid derivatives: Gemfibrozil, Fenofibrate
92
MOA of statins
Inhibit rate-limiting step in hepatic cholesterol production
93
Most common side effect of statins
myositis (muscle inflammation)
94
A 68 yo female presents to your office c/o worsening SOB with stairs. When questioned you find she sleeps up on three pillows. On PE where might you find her apical impulse? What is the most common location of the apical impulse?
hers likely at 6th intercostal space between midclavicular line and axillary line (LVH)
common location of apical pulse is 5th intercostal space in the midclavicular line
95
A 79 yo male presents to your office with his daughter. She is concerned because he seems to be light headed and dizzy more frequently and even passed out for a short period of time yesterday after getting up from his chair. You suspect he is fluid depleted. If that is the case, what should his BP and HR do when going from sitting to standing?
orthostatic hypotension
systolic BP down at least 20 and diastolic at least 10 mmHg
HR increase 15 BPM
96
Which drug class decreases afterload? How?
ACE inhibitors and hydralazine by arterial dilation
97
What drug class decreases preload? How?
Nitrates dilate veins and slows amount of blood going into heart, decreasing cardiac work
98
LDL and HDL transport cholesterol to what areas in the body?
LDL - cholesterol to periphery (bad)
| HDL - cholesterol from periphery back to liver (good)
