Cardio Flashcards
Acute coronary syndrome
Can be STEMI, NSTEMI, angina
S&S: Chest pain/tightness, can radiate to back, shoulder and jaw. More likely with older men. Lasts more than 15 min. “Elephant sitting on chest.” Other symptoms: diaphoretic, palpitations, SOB, N/V. Some women, elderly and diabetics present with GI symptoms only
Aggravating factors: large meal, physical exertion, emotional upset
Dx: EKG is best tool
Tx: Aspirin 162-325 to chew, go to ED
Stable & Unstable Angina
Typically lasts 2-5 min
Can be brought on with exertion, heavy meal, stresss
Stable: relieved by rest or nitro
Unstable: occurs at rest, nitro does not help. Episodes are more frequent, severe or prolonged. May be ACS if myocardial ischemia
Abdominal Aortic Aneurysm
Typically asymptomatic
Risk factors: smoker, HTN
S&S: If not ruptured, can have abd, back or flank pain. If ruptured, can have severe, sharp pain in abd, flank and back w/ pulsatile mass (only 50% cases)
Dx: Ultrasound
Can have incidental finding on x-ray: deviated trachea, widening mediastinum, obliteration of aortic knob
What ventricle is closest to the sternum and generates the apical impulse?
Right ventricle
What disorder causes a displacement of the point of maximal impulse?
Severe left ventricular hypertrophy and cardiomyopathy
Can also be caused by pregnancy in the third trimester
Describe the path of Deoxygenated Blood
Enters the heart through the superior vena cava and inferior vena cava
Right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → the lungs → alveoli
Describe the path of oxygenated Blood
Exits the lungs through the pulmonary veins and enters the heart
Left atrium → mitral valve → left ventricle → aortic valve → aorta → general circulation
What can cause an S3 murmur?
HF or CHF
Always abnormal if occurs after age 40
Can be normal in children, pregnancy and athletes <35
What can cause an S4 murmur?
Increase resistance of stiff left ventricle, LVH
Can be normal finding in elderly
Is an S2 split normal?
Normal if present during inspiration and disappears during expiration
What can cause a systolic murmur?
MR, ASS
Mitral regurgatation
Aortic stenosis
What can cause a diastolic murmur?
MS. ARD
Mitral stenosis
Aortic regurgitation
Which murmurs radiate?
Systolic
to the axilla in mitral regurgitation and to the neck with aortic stenosis
Which murmurs cannot be benign?
Diastolic
Where are mitral murmurs heard?
On the apex (or apical area) of the heart or
On the fifth ICS on the left side of the sternum medial to the midclavicular line
S3 is a sign of ___; S4 is a sign of ___.
S3 is a sign of CHF; S4 is a sign of LVH.
Grading murmurs: Be aware that the first time a thrill is palpated is at grade __
Grade IV
Atrial Fibrillation and flutter
Fibrillation- major cause of stroke, SVT
Flutter - atria contracts regularly but faster than ventricle
S&S: palpitations “a fish is flopping in my chest” or “drums are pounding in my chest”
Weakness, dizzy, dyspnea, presyncope
Dx: EKG
No discrete p waves, irregular rhythm
Consider holter monitor for paroxysmal AF
Tx: use CHA2DS2-VASc to eval for anticoagulation
warfarin for value involvement
Direct-acting anticoagulants (DOACs) first-line agents for nonvalvular AF.
Cardioversion in first 48hr
Rate control: Use beta-blockers, calcium channel blockers (CCBs), digoxin.
Amiodarone (Cordarone; antiarrhythimic)
CHA2DS2-VASc
C (CHF), H (HTN), A (age >75 years), D (diabetes), S2 (stroke/transient ischemic attack [TIA]), V (vascular disease), A (age 65–74 years), S (sex: female gender is at higher risk).
Score of 0 is low risk. Score of 2 or more requires anticoagulation
DOAC-associated life-threatening bleeding episode reversal agents
Life-threatening bleeding caused by rivaroxaban (Xarelto) and apixaban (Eliquis) can be treated with andaxanet alfa (Andexxa). Bleeding caused by dabigatran (Pradaxa) is treated with idarucizumab (Praxbind).
Anticoagulation Guidelines
INR goals
Atrial Fibrillation: INR 2.0 to 3.0
Synthetic/Prosthetic Valves: INR 2.5 to 3.5
Paroxysmal Supraventricular Tachycardia
EKG shows tachycardia with peaked QRS complex with P waves present. When having an episode, has regular but rapid heartbeat, which starts and stops abruptly (intermittent episodes).
Narrow QRS complex
Types: Wolff-Parkinson-White
S&S: palpitations, SOB, anxiety, weak, fatigue
Dx: EKG
TX: If WPW or symptomatic, refer to cardio
It hemodynamically stable, may need cardioversion, 911
Can try vagal maneuvers or valsalva
Pulsus Paradoxus
fall in systolic BP (SBP) of more than 10 mmHg during the inspiratory phase
Sign of cardiac tamponade
Other causes: asthma, emphysema, pericarditis
What is a normal PR interval?
The PR interval (atrial depolarization) duration is 0.12 to 0.20 seconds (3–5 small boxes).
Hypertension
BP above 130/80
Confirm at 2 office visits 1-4 weeks apart
Nonpharm treatment for most pts
If risk factors present, pharm and lifestyle changes
Blood pressure stages
Normal <120 mmHg and <80 mmHg
Elevated 120–129 mmHg and <80 mmHg
Stage 1 130–139 mmHg or 80–89 mmHg
Stage 2 140 mmHg or higher or 90 mmHg or higher
When do you screen for HTN?
Starting at age 18 years, screen BP every year. If normal BP, recheck in 1 year.
If presence of risk factors for HTN, screen at least semiannually (twice a year).
Target organ damage of HTN
Eyes: hypertensive retinopathy
Kidneys: microalbuminuria and proteinuria
Heart: murmurs, MI
Brain: TIA, stroke
What are the three major causes of secondary hypertension?
- Renal (renal artery stenosis, polycystic kidneys, CKD)
- Endocrine (hyperthyroidism, hyperaldosteronism, pheochromocytoma)
- Other causes (obstructive sleep apnea, coarctation of the aorta)
What are the risk factors for secondary HTN?
Age younger than 30 years
Severe HTN or acute rise in BP (previously stable patient)
Resistant HTN despite treatment with at least three antihypertensive agents
Malignant HTN (severe HTN with end-organ damage such as retinal hemorrhages, papilledema, acute renal failure, and severe headache)
What is the difference between hypertensive urgency and emergency
SBP >180 mmHg and/or DBP >120 mmHg
Urgency = no target organ damage
Emergency = target organ damage (such as nausea and vomiting, increased intracranial pressure (ICP), cerebrovascular accident (CVA)/TIA, MI, acute PE, acute renal failure, retinopathy (flame-shaped hemorrhages), papilledema, or acute severe low-back pain (dissecting aorta).) Call 911
Masked HTN
office SBP 120 to 129 mmHg with normal DBP <80 mmHg after 3-month lifestyle modification trial, while daytime home measurement BP is 130/80 mmHg or higher.
Isolated Systolic Hypertension in the Elderly
Loss of recoil in the arteries (atherosclerosis) increases PVR.
Pulse pressure (SBP – DBP) increases
Nonpharm: dietary salt restriction and weight loss in the obese
Pharm: Initial monotherapy with a low-dose thiazide diuretic, a CCB (long-acting dihydropyridine), or an ACEI or ARB. (low and slow w/ elderly)
Orthostatic Hypotension
Who is at risk?
How do you check?
Elderly at higher risk bc less active autonomic nervous system and slower metabolism of drugs by the liver
Check BP in supine and standing, see if symptomatic with position changes (dizzy)
How do we use the ASCVD score in HTN management
- assess 10 year risk
- Reassess in 1 month after medication implimentation
- If goal met, reassess in 3 and 6 months
- If goal not met, consider different meds or titration, continue monthly until goals met
What is the goal BP for Stage 1 and Stage 2 HTN
<130/80 mmHg
When do you begin introducing HTN medication
At stage 1 if ASCVD risk >10%
Any time at stage 2
Lifestyle modifications for HTN
-Lose weight if overweight (body mass index [BMI] 25–29.9) or obese (BMI 30 or higher).
-Normal weight is a BMI of 18.5 to 24.9.
-Stop smoking. Reduce stress level.
-Reduce dietary sodium: <1.5 g per day (1,500 mg/d)
-Maintain adequate dietary intake of potassium (>3,500 mg/day) in patients with normal kidney function.
-Limit alcohol intake:
–For men: 1 ounce (30 mL); up to two drinks or less per day
–For women: 0.5 ounce; up to one drink or less per day
-Eat fatty cold-water fish (salmon, anchovy) three times a week.
What is the DASH diet?
Increase potassium, magnesium, and calcium. Reduce red meat and processed foods. Eat more whole grains and legumes. Eat more fish and poultry.
This diet is high in fruits and vegetables, has moderate low-fat dairy, and is low in animal protein.
Antihypertensive Medications: Diuretics
Decrease blood volume, venous pressure, and preload
Types:
Thiazides
Loop diuretics
Aldosterone receptor antagonist
Thiazide diuretic
Inhibiting reabsorption of sodium and chloride ions in the distal tubules of the kidneys
Hydrochlorothiazide 12.5 to 25 mg PO daily
Chlorthalidone (Hygroton) 12.5 to 25 mg PO daily
Indapamide (Lozol) PO daily
Chlorothiazide (Diuril) daily or divided dose
Favorable effect with osteopenia/osteoporosis –> slows down calcium excretion by the kidneys
Contain Sulfa - avoid with allergy
SE:
“Hyper”
Hyperglycemia (be careful with diabetics)
Hyperuricemia (can precipitate a gout attack; contraindicated in gout)
Hypertriglyceridemia and hypercholesteremia (check lipid profile)
“Hypo”
Hypokalemia (potentiates digoxin toxicity, increases risk of arrhythmias)
Hyponatremia (hold diuretic, restrict water intake, replace K+ loss)
Hypomagnesemia
Loop diuertics
Inhibit the sodium–potassium–chloride pump of the kidney in the loop of Henle.
Furosemide (Lasix) PO BID
Bumetanide (Bumex) PO BID
SE: “hypo”
Hypokalemia (potentiates digoxin toxicity, increases risk of arrhythmias)
Hyponatremia (hold diuretic, restrict water intake, replace K+ loss)
Hypomagnesemia
Possibly altered excretion of lithium and salicylates
If people are allergic to sulfa, they may have cross-sensitivity to _____ diuretics.
thiazides and loop diuretics
Aldosterone Receptor Antagonist Diuretics
Increases elimination of water in the kidneys and conserves potassium.
Spironolactone (Aldactone) daily
Eplerenone (Inspra) daily
Side Effects:
Gynecomastia, galactorrhea
Hyperkalemia - Very high risk of hyperkalemia if used with ACEIs, ARBs, potassium supplements, or NSAIDS.
Gastrointestinal (GI; vomiting, diarrhea, stomach cramps), postmenopausal bleeding, erectile dysfunction
Beta-blockers
Decreases vasomotor activity, decreases CO, and inhibits renin (kidneys) and norepinephrine release.
Asthma, COPD, chronic bronchitis, emphysema, sinus brady
Cardioselective beta-blockers (B1 receptors):
Atenolol (Tenormin)
Metoprolol (Lopressor)
Bisoprolol
Nonselective beta-blockers (inhibits both B1 and B2 receptors):
Propranolol (Inderal)
Timolol
Pindolol
Beta-blockers with alpha- and beta-blocking action: Labetalol (Normodyne) and carvedilol
Calcium Channel Blockers
Blocks voltage-gated calcium channels in cardiac smooth muscle and the blood vessels. Results in systemic vasodilation
Side Effects
Headaches (due to vasodilation)
Ankle edema (caused by vasodilation and considered benign)
Heart block or bradycardia (depresses cardiac muscle and AV node)
Reflex tachycardia (seen with dihydropyridines such as nifedipine)
Contraindications
Bradycardia
CHF
Dihydropyridine CCBs (-pine ending): less potent
Nifedipine (Procardia XL) daily
Amlodipine (Norvasc) daily
Felodipine (Plendil) daily
Nondihydropyridine CCBs:
Verapamil (Calan SR) daily or BID
Diltiazem (Cardizem CD) daily
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers
ACEIs: Inhibit activity of angiotensin-converting enzyme, which decreases conversion of angiotensin I to II (more potent vasoconstrictor)
-pril
ARBs: Block the effect of angiotensin II
-sartan
Dry hacking cough (up to 10% with ACEIs; less with ARBs)
Hyperkalemia, angioedema (rare but may be life-threatening)
Contraindicated: Moderate-to-severe kidney disease
Alpha-1 Blockers/Antagonists
Potent vasodilators. Also relax smooth muscle found on the bladder neck and prostate gland and relieves obstructive voiding
-zosin
Not first-line unless comorbid BPH
Side effects: Dizziness and hypotension.
Commonly orthostatic hypotension
Take at bedtime
Direct Renin Inhibitors
Inhibits RAS
Do not combine aliskiren with ACEI or ARB (higher risk hyperkalemia).
Aliskiren (Tecturna) once a day
Aliskiren and hydrochlorothiazide once a day
Angiotensin Receptor-Neprilysin Inhibitors
New drug class for the treatment of HFrEF
Combination of neprilysin inhibitor (sacubitril) with ARB (valsartan)
Sacubitril/valsartan (Entresto)
Heart Failure
EF <40% is systolic heart failure (or HFrEF)
EF >40%, is diastolic failure (or HFpEF)
Left: lungs - crackles, rales, sough, paroxysmal nocturnal dyspnea (also right), orthopnea (also right)
Right: body - JVD, enlarged spleen/liver can cause anorexia, nausea and abd pain. Lower extremtiy edema
Dx: BNP (can be elevated by renal failure and CKD), ECHO, chest x-ray, daily weight for fluid fluctuations
Tx: Diurectics, beta-blocker if HFrEF
First line for stable is ACE or ARB
Best managed by cardiologist
ED if acute decompensated HF
Restrict sodium to 2 to 3 g/d.
Fluid restriction (1.5–2 L/d)
New York Heart Association Functional Capacity Ratings
Class I No limitations on physical activity
Class II Ordinary physical activity results in fatigue, exertional dyspnea
Class III Marked limitation in physical activity
Class IV Symptoms are present at rest, with or without physical activity
Deep Vein Thrombosis
Causes
Stasis: Prolonged travel/inactivity (more than 3 hours), bed rest, CHF
Inherited coagulation disorders: Factor C deficiency, Leiden, and so forth
Increased coagulation due to external factors: Oral contraceptive use, pregnancy, bone fractures especially of the long bones, trauma, recent surgery, malignancy
S&S: gradual onset, swelling of lower extremity, red and warm, painful
If PE, may have chest pain, dyspnea, dizziness
Dx: Homan’s sign, lower leg pain on dorsiflexion
Ultrasound
Tx: Hospital admission
Heparin drip, then PO warfarin
Superficial thrombophlebitis
Inflammation of a superficial vein d/t trauma
Risk factors: IV, IV drug use
S&S: indurated vein, redness, tender. Warm to touch, cord like. No swelling to extremity. Afebrile
Tx: NSAIDs, warm compress, elevation
Peripheral Arterial Disease
Gradual narrowing of arteries in lower extremities, can lead to permanent ischemic damage
Higher risk: smoker, HTN, DM, HLD
S&S: pain with ambulation (intermittent claudication) and relieved by rest. Atrophic skin changes (shiny, hyperpigmented), may have gangrene. Legs hairless, cool to touch. Decreased or absent pedal pulse. May have bruits.
Dx: Use ABI to eval severity
Tx: daily ambulation
Cilostazol (Pletal) is a phosphodiesterase inhibitor (direct vasodilator
Ankle-bradial index (ABI)
Used to evaluate severity of PAD. A score of ≤0.9 is diagnostic for PAD, and a score of ≤0.5 indicates severe arterial disease; refer to vascular specialist. ABI score of 0.91 to 1.3 is normal.
Divide the highest systolic BP (measure each arm and choose the higher BP) by the highest systolic BP of each ankle
Raynaud’s Phenomenon
Reversible vasospasm of the peripheral arterioles on the fingers and toes due to an exaggerated response to cold temperature or emotional stress.
Associated with an increased risk of autoimmune disorders
S&S: color changes on fingers and toes in symmetric pattern (Think of the colors of the American flag), recurrent episodes. Numbness and tingling. Can have livedo reticularis (violaceous mottling or reticular pattern of the skin of the arms and legs). Can get shallow ulcers
Tx: Maintain body warmth, avoid stimulants, smoking cessation
Do not use any vasoconstricting drugs (e.g., Imitrex, ergots, pseudoephedrine/decongestants, amphetamines)
Can use CCBs, vasodilators
Bacterial Endocarditis
Pathogen: gram positive (e.g., viridans streptococcus, S. aureus).
Risk factors: IV drug use, recent dental work, prosthetic valve
S&S: fever, chills, and malaise, subungual hemorrhages (splinter hemorrhages on nail bed) and tender violet-colored nodules on the fingers and/or on toes (Osler’s nodes). Palms and soles may have tender red spots (Janeway lesions).
Tx: Refer to cardio or ED
IV antibiotics
Prophylaxis reconmended for high risk populations in dental and respiratory procedures
Amoxicillin 2g PO 1 hr before procedure
Use clindamycin for penicillin allergy
Mitral valve prolapse
S&S: midsystolic click accompanied by a late systolic murmur. Faitgue, palpitations, lightheadedness, aggravated by heavy exertion. May have chest pain. Dyspnea is most common symptom. Rule out Marfan’s
Dx: Transthoracic 3D echo (3D-TEE)
Tx:
Asymptomatic = no treatment, MVP usually benign
Palpitations = beta-blockers
Can cause mitral regurgitation, afib, stroke
Lipid panel values:
Total cholesterol
HDL
LDL
Triglycerides
Total Cholesterol
Normal: <200 mg/dL
Borderline high: 201 to 239 mg/dL
High: >240 mg/dL
High-Density Lipoprotein Cholesterol
Men: >40 mg/dL
Women: >50 mg/dL
Low-Density Lipoprotein Cholesterol
Optimal: <100 mg/dL
Triglycerides
Normal: <150 mg/dL
Hyperlipidemia
Typically asymptomatic
Screening:
Men aged 35 years or older
Women aged 45 years and older
> 76 years with no history of CVD: do not screen
Tx:
If triglycerides >500, treat first bc risk of acute pancreatitis.
Avoid alcohol, review meds
First line meds: fibrates (fenofibrate, gemfibrozil, benzafibrate)
OTC Vit B3
Statins
Lifestyle modifications: Decrease sugar and simple carbohydrates (junk food), avoid alcoholic drinks, follow low-fat diet, eat fish with omega-3 (salmon, sardines) twice a week, lose weight, and increase aerobic-type physical activity.
Next, treat LDL -> encourage fiber
Secondary Prevention (Presence of ASCVD)
Start statin with:
-Patients with any form of clinical ASCVD (history of MI, CAD, angina, stroke/TIA, PAD, coronary revascularization)
-Very high risk ASCVD (defined as a history of multiple major ASCVD events or one major ASCVD event with multiple high-risk conditions)
-Diabetic patients with LDL of ≥70 mg/dL
-Severe primary hypercholesterolemia (LDL of 190 mg/dL or higher)
extensor tendon xanthomas
Lipid deposits in tendons
Achilles, subpatellar, or hand extensor tendons
Refer to cardio(?) to rule out familial hypercholesterolemia (FH)
Statins
HMG-CoA reductase is the enzyme in the liver that is responsible for cholesterol synthesis. Statins inhibit this enzyme. They are best at lowering LDL.
-risk of rhabdomyolysis
-Check liver function labs
-Can cause cognitive effects (memory loss and confusion) that are reversible once statin DC. BC brain and nerves mostly fat
-Patients on simvastatin and lovastatin should avoid grapefruit juice. Also, they should not mix these two statins with macrolides.
Fibrates:
Gemfibrozil (Lopid), fenofibrate (Tricor), benzafibrate (Bezalip).
Do not use with severe renal disease.
Action: Reduces production of triglycerides by the liver and increases production of HDL.
Bile Acid Sequestrants
Cholestyramine (Questran Light), colestipol (Colestid), colesevelam (Welchol)
Action: Work locally in the small intestine; interfere with fat absorption, including fat-soluble vitamins (vitamins A, D, E, and K)
-Good alternative if cannot tolerate statin and fibrates
-No hepatotoxicity
SE:
Bloating, flatulence
Cholesterol-Absorption Inhibitors
Ezetimibe (Zetia)
Absorbs cholesterol from the small intestines
Contraindications: Active liver disease, elevated ALT/AST
Can be taken alone or combined with a statin or fibrate
Side effects: Diarrhea, joint pains, tiredness
Rhabdomyolysis
Acute breakdown and necrosis of skeletal muscle > causes renal failure
High risk with statins
S&S: trifecta of muscle pain (myalgia), weakness, and red-to-brown urine
DX: CK, UA
TX: DC statin
Stop alcohol (dont prescribe statins to alcoholics)
Go to ED
Memorize these statin case scenarios
An adult (21–75 years) with any type of ASCVD (e.g., CAD, PAD, stroke, TIA) is given high-intensity statins such as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg.
An adult with LDL >190 mg/dL (without ASCVD or DM) is a candidate for high-intensity statin dosing.
What should you do with pt triglycerides >500?
What are they at risk for?
Start niacin or fibrates
At risk for pancreatitis
dietary sources of magnesium, potassium, and calcium.
Magnesium:
Potassium: potatoes, bananas
Calcium: dairy
BMI
Underweight <18.5
Normal weight 18.5–24.9
Overweight 25–29.9
Obese 30–39.9
Grossly obese >40
Waist circumference & Waist to hip ratio
Waist Circumference
Males: >40 inches (102 cm); South Asians, >35 inches (90 cm)
Females: >35 inches (88 cm); South Asians, >31 inches (80 cm)
Waist-to-Hip Ratio
Males: 1.0 or higher
Females: 0.8 or higher
Metabolic syndrome
At higher risk for type 2 DM, cardiovascular disease, and stroke
At least three characteristics (out of five) must be present to diagnose metabolic syndrome:
-Abdominal obesity (>40 inches [102 cm] in men and >35 inches [88 cm] in women)
-BP>130/85 mmHg
-Elevated fasting plasma glucose (>100 mg/dL)
-Elevated triglycerides (>150 mg/dL) or on drug treatment for elevated triglycerides
-Decreased HDL (<40 mg/dL in men and <50 mg/dL in women)
Nonalcoholic Fatty Liver Disease
Caused by triglyceride deposits (steatosis) in liver
Most are asymptomatic
If symptomatic: fatigue and malaise with RUQ pain
Dx: AST/ALT likely elevated
Hep A, B, and C
Liver ultrasound
Gold standard: liver biopsy
Tx:
Diet & exercise
DC alcohol permanently
DC hepatotoxic drugs (statin, tylenol)
Hep A, B vaccine, flu vaccine
Refer to GI
