Cardio Flashcards
Treatment for HTN (general drug classess)
think “CAT”
Calcium channel blockers
Ace/Arbs
Thiazide diuretics
**Remember – BB not first line, unless another more prominent indications such as afib/angina
White coat hypertension vs Masked HTN
WC - BP elevated in presence of medical professional but normal at home
Masked - High BP at home but normal at office
**Ambulatory BP x3months at home, base tx off that
what medication class is chlorthalidone?
thiazide diuretic
What is a good 1st choice medication class for HTN?
Ace/Arbs
** Unless African American with CKD, then no Ace/Arb since HTN not as driven by RAAS system
** any population = good start low dose amlodipine –> can cause feet swelling
*** can start on thiazide diuretic (chlorthalidone or HCTZ) then if needed can add ace/arb on pill
What are the ABCDs of HTN?
A = Ace/Arbs B = Beta blockers C = Calcium Channel blockers D = Diuretics
What do we use ace inhibitors for?
DM /scleroderma –> protects kidneys
CHF/p MI –> caridoprotective
Young pts (caucasian) w/ HTN
Beta blockers used for what DDx?
CHF/p MI –> improves survival (carvedilol/metoprolol for CHF)
young pts (Caucasian) w/ HTN
Calcium Channel blockers used in…
meds do not improve survival
Useful in AA & elderly
SE of Ace/Arbs
Angioedema –> emergency
Cough (Ace) –> switch to Arb
Hyperkalemia
Hyponatremia
Creatine increased in renal artery stenosis (contra)
SE of Beta blockers
bradycardia
Increase lipids/cholesterol
increase depression
worsen asthma/copd –> bronchospasm (contra)
Hyperkalemia
SE of calcium channel blockers
based on category
Dihydropyridines (-pine) nifedipine, amlodipine
- peripheral vasodilation
- HR Increases/stays the same (except for amlodipine which decreases HR)
Non-dihydropyridines; diltiazem, verapamil
-reduction in inotrope (reduces contractility of heart) –> decreased HR
usefull in afib RVR
Other SE
edema, constipation, HF (d/t negative inotrope effects)
SE of Diuretics (loop vs HCTZ)
Loop:
- decreases Ca, K, Na
- Increase Creatine –> AKI
HCTZ: ascending limb
increases: Ca level serum but decreases Ca excretion, uric acid (worsens gout), lipids, glucose
Decreases: K
Ace & Arb MOA
MOA: block conversion of angiotensin I -> II
What is the typical medication suffix for the medication classes ACE/ARBs
Ace: “-pril”
ARB: “-sartan”
What is the first choice medication for tx of HTN in pts with DM or renal disease?
Ace/Arbs —> Unless in black pts (then 1st line is diuretic)
Side effects for Ace/Arbs
Ace — Dry hacking cough 1-2 weeks after tx start –> switch pt to Arb
- First dose hypotension
- Hyperkalemia
- Acute renal failure
- Angioedema
***Do not combine both ACE/ARBS –> increased AE
When should you avoid the use of ACE/ARB ?
Pregnancy
Renal artery stenosis
Acute renal insufficiency
What is the definition of a murmur?
sound detected when there is turbulent blood flow through the great vessels or across a heart
What 2 vavles cause nearly all of the trouble in adults?
Aortic and mitral
Amelies 3 rules for murmurs
- Stenosis vs Regurgitation (where is it heard / check pulse)
- Where is it heard the loudest?
- Are there associated findings (CP, SOB, cyanosis, exercise intolerance, palpitations, BP, thrill, changes with positioning)
Systolic murmurs
Mr. Peyton Manning AS MVP
Mr. = Mitral Regurgitation (SOB/ fatigue, HF)
Peyton Manning = Physiologic Murmur (Asymptomatic, can be normal. Kids & young adults)
AS = Aortic stenosis (angina, syncope, HF) MVP = Mitral valve prolapse (palpitatiosn, CP, "click"
Diastolic Murmurs
Mnemonic: ARMS!
All diastolic murmurs are abnormal!
AR = Aortic regurgitation (Angina, syncope, HF) MS = Mitral stenosis (Dyspnea, Afib) - can be caused by rheumatic heart disease from strept throat
what are associated findings with aortic stenosis?
“ASC” (Aortic stenosis Complications)
Angina, Synocpe, CHF
1 choice for HTN in pregnancy?
Methyldopa
Heart failure (patho)
Not enough forward flow in the heart –> leads to back up and congestion
-Kidney function decreases (reduced perfusion) -> activates RAAS & ADH system -> increased fluid retention –> symptoms
- Pulm system- congestion affects lungs first –> pulm edema
- Liver congestion –> Increased AST/ALT = “nutmeg liver”
- Elevated pulm artery pressures
- Pedal edema
Systole
“Lub”
active contraction –> blood pumped to systemic circulation
closure of AV valves (3-leaf)
Diastole
“dub”
Relaxation - blood enters into the heart and fills
-minimum arterial pressure exerted during relaxation and dilation of the ventricles
Closure of semilunar valves (2-leaf)
systolic dysfunction
heart cant contract
EF will decrease
Diastolic dysfunction (HFpEF)
heart can relax
unchanged EF
Normal EF -> blood cant get in –> Blood cant get pumped out which preserves EF
-Causes: Prolonged HTN –> muscles to thicken preventing relaxation of heart (L ventricular hypertrophy)
What is the most important aspect in controlling CVD?
Controling LDL (bad cholesterol) VLDL (very bad )
*HDL = good cholesterol
what medication class is used to treat hyperlipidemia?
examples of “big guns”
HMG-CoA reductase inhibitors
Atorvastatin (Lipitor) 40-80mg
Rosuvastatin (Crestor) 20-40mg
** these decrease LDL by 50%
What is the #1 of pathogen of endocarditis?
What are the most common causes?
Staph Aureus
Causes: skin lesions, IV drug use, Dental work
what is endocarditis?
inflammation of the endocardium (inner lining of the heart)
affects heart valves - most often Mitral
What are Janeway Lesions? what do they indicate?
non-tender small erythematous lesions (macular, papular, or nodular) on the palms
indicate infective endocarditis!
Pt has chest pain that is relieved by leaning forward… what is a possible DDx?
Endocarditis
What is the mechanism of action of Prostaglandin in a pt with transposition of the great vessel?
to produce vasodilation and provide adequate oxygenation
**prostaglandin slows down the closing of ductus arteriosus and PFO allowing O2 blood to cross from pulm circulation to systemic circulation through congenital pathway
What causes Afib?
Heart failure, Electricity issue, pMI, valve issues
how do we treat afib?
ventricular rate control : Betablocker or non-dihydropyridine calcium channel blocker
rhythm control with antiarrhythmic drug
anticoagulation: warfarin
how long does it take proximal afib to terminate?
7 days
How is peripheral artery disease (PAD) defined?
Ankle-brachial index (ABI) of <0.90
compare BP of lower extremity and upper extremity
Assessment finding for PAD
- Most asymptomatic
- Intermittent Claudication - earliest manifestation. pain in legs with exercise relieves with rest (2-5 mins) . only 10% of pts
- pain, ache, cramp of feeling tired in extremity foot, calf, thigh or buttocks with exercise
- narrow lumen produces characteristic pain distal to site
- lack of hair growth
- thickened toenails
- diminished pulses
- pale, cool extremities
- dependent rubor
- prolonged cap refill
- bruit in abd, fem or popiteal
Gold standard for PAD diagnosis
Contrast angiography - highly sensitive
also do duplex Us & doppler, ABI
Treatment for PAD
Antiplatelet: Petal, Plavix, ASA
Pentoxifylline - decreases blood viscosity
High intensity statin - atorvastatin, rosuvastatin
Varicose Veins physical assessment
Assess by having pt STAND
Trendelenburg Maneuver - assess valves of peripheral veins
supine leg 90degrees
occlude greater saphenous
Have pts stand continuing to occlude saphenous for 20 seconds
then have pt stand to “map” veins ?
Tx for varicose veins
cosmetic
laser therapy/abaltion
sclerotherapy
surgery
when starting coumadin, when should you get your first INR based off of known half life?
3 days
Missed dose for warfarin…. what are next steps?
<12 hours –> take dose and continue on. INR in 1 week
> 12 hours = take next dose at time due. Notify MD. INR in 3-7 days
What is the antidote for warfarin?
Vitamin K
Reversal agents for DOACs (direct oral anticoagulants)
(becoming more prevalent then warfarin, less interaction, but equal therapeutic effect)
- Andexanet alfa (Andexxa) –> reverses effect of Rivaroxabn (xeralot) & Apixaban (Elliquis)
Idarucizumab (Praxbind) –> reverses Dabigatran (Pradaxa)
What is the reversal agent of Dabigatran (Pradaxa)
Med is a Direct oral anticoagulant (DOAC)
Reversal = Idarucizumab (Praxbind)
Normal CV changes in pregnancy
- Systemic Vasodilation (Decrease SVR/BP)
- Renal vasodilation
- increased CO – may causes systolic flow murmur
- Increased total RBC production / Blood volume
- Increased HR
Stenotic vs Regurgitant valves
stenotic = valves dont OPEN properly
Regurgitation = valves dont CLOSE properly
Sick sinus syndrome (patho)
destruction of the SA node and changes in the nerves and ganglia
SA node doesn’t fire to initiate a heartbeat
what type of angina involves nocturnal symptoms?
unstable angina
symptoms at rest and at night!
What causes Prinzmetals angina? aka Variant angina
coronary artery vasospasm
occurs in atypical patterns
can cause ST elevation
Pt experiences chest pressure, heaviness on exertion. what type of angina is this?
Classic/Stable Angina
relieved by rest
What bacteria is responsible for rheumatic fever
Group A streptococcus
What regulates MAP?
Caridac output
Systemic vascular resistance
central venous pressure (pressure exerted by heart)
what are the four defects of tetralogy of Fallot
- large ventricular septal defect
- pulmonary stenosis
- Right ventricular hypertrophy
- overriding aorta
which can cause both a systolic and diastolic timed murmur?
Tricuspid regurgitation
- causes blood to flow backward into R atrium when ventricles contract
- murmur increases intensity with inspiration
Which cardiac rhythm has prolonged QT interval?
Torsades de pointes
what organ synthesized triglycerides?
Liver
pts with ventricular septal defect have which type of murmur?
Holosystolic
heard throughout systole, usually asymptomatic
What peptide hormone causes vasoconstriction and increases blood pressure
Angiotensin
T/F Does Raynaud phenomenon cause reactive hyperemia?
True.
occurs when blood vessel is constricted for a prolonged period then dilates suddenly producing substantially increased blood flow to the area.
What is the name of a condition that is acute, febrile, immune-mediate disease characterized by vasculitis leading to coronary artery aneurysm ?
Kawasaki syndrome
when does the ducus arteriosus close?
1-2 days after birth
which congenital heart defects result in RIght to LEFT shunting and requires emergency surgical intervention?
Tetralogy of Fallot
Pulmonary Atresia
What differentiates unstable angina vs NSTEMI?
elevated troponins
NSTEMI - elevated trops present
Unstable angina - same symptoms but trops negative
what is a cyanotic mixed defect with increased pulm flood flow?
transposition of the great arteries
