Cardio 1 Flashcards
What are 3 types of cardio myopathies? What is most common?
Dilated (95%)
Hypertrophic (4%)
Restrictive (1%)
Pathophysiology of a dilated cardiomyopathy
heart becomes weak and unable to empty the ventricles -> leads to dilation of left ventricle
Signs of dilated cardiomyopathy and CHF
Elevated JVP Rales S3 gallop Cardiomegaly Mitral/tricuspid regurg Peripheral edema
Signs of CHF on ECHO
Cardiomegaly
Reduced systolic function
High diastolic pressure
Low cardiac output
Treatment of dilated cardiomyopathy and CHF
ACE inhibitors
Beta Blockers
Diuretics
Aldosterone Inhibitors
Cause of sudden cardiac death in young athletes. Imaging reveals LVH.
Hypertrophic cardiomyopathy
Characteristics of murmur heard with Hypertrophic cardiomyopathy
systolic murmur that decreases with squatting
Causes of Hypertrophic cardiomyopathy
autosomal dominant inheritance
Pathophysiology of Hypertrophic cardiomyopathy
septal wall thickening resulting in left ventricle outflow obstruction and LVH
Hypertrophic cardiomyopathy treatment
BBs or CCBs
Surgical removal of hypertrophic tissue
May need pacemaker
Pathophysiology of Restrictive Cardiomyopathy
good ventricular contractions, but poor diastolic filling
What is primary (essential) HTN?
HTN with no identifiable cause; 95% of cases
What are BP ranges for the following: Normal Pre-HTN Stage 1 HTN Stage 2 HTN HTN urgency
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
Clinical definition of HTN
BP > 140/90 on two or more separate occasions
- BP > 150/90 if 60 or older
Behavior modifications to reduce primary HTN
Weight reduction DASH diet Reduce sodium intake Increase aerobic activity Limit alcohol consumption
Method for most accurate in-office BP reading
Two readings 5 min apart, sitting in chair with feet resting on floor
Confirm elevated reading in contralateral arm
How should BP be eval’d in patient with “white coat HTN?”
ambulatory BP monitoring
BP goals for patients with HTN
less 140/90
less 130/80 with DM or CKD
First line therapy for patients with mild HTN (140-150/90-99)?
thiazide diuretics
MOA of thiazide diuretics
inhibiting Na+/Cl- transporter in distal convoluted tubule -> decrease Na+ resabsorbtion -> loss of NaCl and fluid (also loss in K+)
Long term effects of thiazide diuretics
lower peripheral vascular resistance
Most common thiazide diuretics used and their dosing
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
Side effects of thiazide diuretics
Decrease in serum K, Na, Mg
Increase in serum Ca
Increase Uric acid (think gout)
Increase glucose (pay attention in diabetics)
Powerful diuretic to use ACUTE cases of pulmonary edema, hyperkalemia, and renal failure?
loop diuretics
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!
Side effects of Loop diuretics
Hypotension Ototoxicity (reversible) Hyperuricemia (gout) Decreased serum Na, K, Mg Increased serum Ca
Common examples of Loop diuretics
Furosemide - Lasix
Ethacrynic Acid
MOA of potassium sparing diuretics
block production of key protein for Na/K exchange in collection tube
No loss of K+
What are catecholamines and where do they bind?
Catecholamines (mostly epinephrine and norepinephrine) bind to alpha and beta receptors
What is a secondary agent to use in combo therapy for HTN?
potassium sparing diuretic
Side effects of potassium sparing diuretic
HYPERKALEMIA
Ototoxicity (reversible)
Hyperuricemia (gout)
Decreased Mg
Commonly used potassium sparing diuretics
Spironolactone
Amiloride
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
Beta blockers effect on the heart
prevent sympathetic cardiac stimulation - decrease HR and cardiac output
Indications for beta blockers
HTN, angina, MI, CHF
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)
What drug class prevents sympathetic vasoconstriction?
alpha blockers
Indications for alpha blockers
Secondary med for HTN
1st line for BPH
Where are alpha receptors located?
vascular smooth muscle throughout body
Main side effect of alpha blockers
hypotension
Renin is secreted from ______ in response to low ______.
juxtaglomerular cells
blood volume
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
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)
Indications for ACE inhibitors?
HTN, CHF, DM
Side effects of ACE inhibitors
cough
hyperkalemia
teratogenic
Why would ARBs be used over ACE-I?
patient unable to tolerate cough of ACE
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)
Examples of CCBs
Verapamil
Diltiazem
Amlodipine – less effective on cardiac tissue
Nifedipine – less effective on cardiac tissue
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
MOA of Hydralazine and Nitroprusside
Direct arterial smooth muscle dilators
work by releasing nitric oxide
HTN treatment protocol for patient over 55 or African American
start with CCB or thiazide
HTN treatment protocol for patient under 55 and not African American
start with ACE inhibitor
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
Suggested therapy for pregnant woman with HTN
hydralazine and clonidine
or methyldopa
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
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
How to treat hypotension?
treat underlying cause; i.e. give fluids for fluid depletion, check BP meds
_____ is the inability of the heart to pump enough blood to meet the needs of the body.
CHF
Physiological changes that cause CHF
fluid overload/retention
decreased cardiac contractility
decreased cardiac output
What is pulsus alternans?
alternating strong and weak beats
Characteristics of pulse of patient with CHF
tachycardia, weak, thready, pulsus alternans
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
Kussmaul breathing seen in what conditions?
metabolic acidosis (DM)
diabetic ketoacidosis
hyperapnea
sepsis
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
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
Heart sounds of CHF patient
possible murmurs, S3 or S4 sounds, diminished first heart sound
What lung sound suggests fluid at alveolar level?
rales/crackles
Likely treatment if you hear wheezing on exam
Nebulizer tx
Steroids
Left-sided CHF causes
pulmonary edema
Right-sided CHF cause
Hepatomegaly
Abdominal edema
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
What is batwing or butterfly shadow on CXR?
enlarged hila and alveolar edema
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
How can you asses ejection fraction, ventricular function, and valves of the heart?
ECHO
Which lab is a good indicator of CHF, however maybe not that specific?
elevated BNP
Treatment of CHF
Low sodium diet
Meds:
- Diuretics (thiazide or loop diuretic with ACEI)
- Beta blockers
- Digitalise (inotropic agents)
__________ is the number one cause of cardiac-related death and disability.
Atherosclerosis
Risk factors of atherosclerosis
HTN Dyslipidemia Smoking Diabetes Advancing age Family history Male (4:1)
What allows the visualization of arteries under x-ray?
angiogram
What is an ankle-brachial index used for?
compares systolic BP in upper vs lower extremity; useful in peripheral vascular disease
What is heard over an artery that is partially occluded?
bruit
How is Doppler U/S more advantageous than regular U/S for atherosclerosis eval?
sees changes in blood flow
Medical treatment of atherosclerosis
Blood thinners - Aspirin 81 mg or 325 mg daily
When should routine cholesterol screening be done?
begin at 35 for men and 45 for women
Low and high levels of HDL
low less than 40
high over 60
optimal level of LDL
less than 100
What is high level LDL?
> 160
Optimal total cholesterol level
less than 200
Normal and high triglycerides
normal less than 150
high over 200
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)
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
MOA of statins
Inhibit rate-limiting step in hepatic cholesterol production
Most common side effect of statins
myositis (muscle inflammation)
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
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
Which drug class decreases afterload? How?
ACE inhibitors and hydralazine by arterial dilation
What drug class decreases preload? How?
Nitrates dilate veins and slows amount of blood going into heart, decreasing cardiac work
LDL and HDL transport cholesterol to what areas in the body?
LDL - cholesterol to periphery (bad)
HDL - cholesterol from periphery back to liver (good)
