Cardio

Question 1

Acute coronary syndrome

Answer 1

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

Question 2

Stable & Unstable Angina

Answer 2

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

Question 3

Abdominal Aortic Aneurysm

Answer 3

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

Question 4

What ventricle is closest to the sternum and generates the apical impulse?

Answer 4

Right ventricle

Question 5

What disorder causes a displacement of the point of maximal impulse?

Answer 5

Severe left ventricular hypertrophy and cardiomyopathy

Can also be caused by pregnancy in the third trimester

Question 6

Describe the path of Deoxygenated Blood

Enters the heart through the superior vena cava and inferior vena cava

Answer 6

Right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → the lungs → alveoli

Question 7

Describe the path of oxygenated Blood

Exits the lungs through the pulmonary veins and enters the heart

Answer 7

Left atrium → mitral valve → left ventricle → aortic valve → aorta → general circulation

Question 8

What can cause an S3 murmur?

Answer 8

HF or CHF
Always abnormal if occurs after age 40
Can be normal in children, pregnancy and athletes <35

Question 9

What can cause an S4 murmur?

Answer 9

Increase resistance of stiff left ventricle, LVH
Can be normal finding in elderly

Question 10

Is an S2 split normal?

Answer 10

Normal if present during inspiration and disappears during expiration

Question 11

What can cause a systolic murmur?

Answer 11

MR, ASS

Mitral regurgatation
Aortic stenosis

Question 12

What can cause a diastolic murmur?

Answer 12

MS. ARD

Mitral stenosis
Aortic regurgitation

Question 13

Which murmurs radiate?

Answer 13

Systolic

to the axilla in mitral regurgitation and to the neck with aortic stenosis

Question 14

Which murmurs cannot be benign?

Answer 14

Diastolic

Question 15

Where are mitral murmurs heard?

Answer 15

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

Question 16

S3 is a sign of ___; S4 is a sign of ___.

Answer 16

S3 is a sign of CHF; S4 is a sign of LVH.

Question 17

Grading murmurs: Be aware that the first time a thrill is palpated is at grade __

Answer 17

Grade IV

Question 18

Atrial Fibrillation and flutter

Answer 18

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)

Question 19

CHA2DS2-VASc

Answer 19

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

Question 20

DOAC-associated life-threatening bleeding episode reversal agents

Answer 20

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).

Question 21

Anticoagulation Guidelines
INR goals

Answer 21

Atrial Fibrillation: INR 2.0 to 3.0
Synthetic/Prosthetic Valves: INR 2.5 to 3.5

Question 22

Paroxysmal Supraventricular Tachycardia

Answer 22

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

Question 23

Pulsus Paradoxus

Answer 23

fall in systolic BP (SBP) of more than 10 mmHg during the inspiratory phase

Sign of cardiac tamponade
Other causes: asthma, emphysema, pericarditis

Question 24

What is a normal PR interval?

Answer 24

The PR interval (atrial depolarization) duration is 0.12 to 0.20 seconds (3–5 small boxes).

Question 25

Hypertension

Answer 25

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

Question 26

Blood pressure stages

Answer 26

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

Question 27

When do you screen for HTN?

Answer 27

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).

Question 28

Target organ damage of HTN

Answer 28

Eyes: hypertensive retinopathy Kidneys: microalbuminuria and proteinuria Heart: murmurs, MI Brain: TIA, stroke

Question 29

What are the three major causes of secondary hypertension?

Answer 29

1. Renal (renal artery stenosis, polycystic kidneys, CKD) 2. Endocrine (hyperthyroidism, hyperaldosteronism, pheochromocytoma) 3. Other causes (obstructive sleep apnea, coarctation of the aorta)

Question 30

What are the risk factors for secondary HTN?

Answer 30

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)

Question 31

What is the difference between hypertensive urgency and emergency

Answer 31

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

Question 32

Masked HTN

Answer 32

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.

Question 33

Isolated Systolic Hypertension in the Elderly

Answer 33

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)

Question 34

Orthostatic Hypotension Who is at risk? How do you check?

Answer 34

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)

Question 35

How do we use the ASCVD score in HTN management

Answer 35

1. assess 10 year risk 2. Reassess in 1 month after medication implimentation 3. If goal met, reassess in 3 and 6 months 4. If goal not met, consider different meds or titration, continue monthly until goals met

Question 36

What is the goal BP for Stage 1 and Stage 2 HTN

Answer 36

<130/80 mmHg

Question 37

When do you begin introducing HTN medication

Answer 37

At stage 1 if ASCVD risk >10% Any time at stage 2

Question 38

Lifestyle modifications for HTN

Answer 38

-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.

Question 39

What is the DASH diet?

Answer 39

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.

Question 40

Antihypertensive Medications: Diuretics

Answer 40

Decrease blood volume, venous pressure, and preload Types: Thiazides Loop diuretics Aldosterone receptor antagonist

Question 41

Thiazide diuretic

Answer 41

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

Question 42

Loop diuertics

Answer 42

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

Question 43

If people are allergic to sulfa, they may have cross-sensitivity to _____ diuretics.

Answer 43

thiazides and loop diuretics

Question 44

Aldosterone Receptor Antagonist Diuretics

Answer 44

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

Question 45

Beta-blockers

Answer 45

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

Question 46

Calcium Channel Blockers

Answer 46

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

Question 47

Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

Answer 47

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

Question 48

Alpha-1 Blockers/Antagonists

Answer 48

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

Question 49

Direct Renin Inhibitors

Answer 49

Inhibits RAS Do not combine aliskiren with ACEI or ARB (higher risk hyperkalemia). Aliskiren (Tecturna) once a day Aliskiren and hydrochlorothiazide once a day

Question 50

Angiotensin Receptor-Neprilysin Inhibitors

Answer 50

New drug class for the treatment of HFrEF Combination of neprilysin inhibitor (sacubitril) with ARB (valsartan) Sacubitril/valsartan (Entresto)

Question 51

Heart Failure

Answer 51

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)

Question 52

New York Heart Association Functional Capacity Ratings

Answer 52

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

Question 53

Deep Vein Thrombosis

Answer 53

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

Question 54

Superficial thrombophlebitis

Answer 54

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

Question 55

Peripheral Arterial Disease

Answer 55

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

Question 56

Ankle-bradial index (ABI)

Answer 56

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

Question 57

Raynaud’s Phenomenon

Answer 57

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

Question 58

Bacterial Endocarditis

Answer 58

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

Question 59

Mitral valve prolapse

Answer 59

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

Question 60

Lipid panel values: Total cholesterol HDL LDL Triglycerides

Answer 60

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

Question 61

Hyperlipidemia

Answer 61

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

Question 62

Secondary Prevention (Presence of ASCVD)

Answer 62

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)

Question 63

extensor tendon xanthomas

Answer 63

Lipid deposits in tendons Achilles, subpatellar, or hand extensor tendons Refer to cardio(?) to rule out familial hypercholesterolemia (FH)

Question 64

Statins

Answer 64

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.

Question 65

Fibrates:

Answer 65

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.

Question 66

Bile Acid Sequestrants

Answer 66

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

Question 67

Cholesterol-Absorption Inhibitors

Answer 67

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

Question 68

Rhabdomyolysis

Answer 68

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

Question 69

Memorize these statin case scenarios

Answer 69

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.

Question 70

What should you do with pt triglycerides >500? What are they at risk for?

Answer 70

Start niacin or fibrates At risk for pancreatitis

Question 71

dietary sources of magnesium, potassium, and calcium.

Answer 71

Magnesium: Potassium: potatoes, bananas Calcium: dairy

Question 72

BMI

Answer 72

Underweight <18.5 Normal weight 18.5–24.9 Overweight 25–29.9 Obese 30–39.9 Grossly obese >40

Question 73

Waist circumference & Waist to hip ratio

Answer 73

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

Question 74

Metabolic syndrome

Answer 74

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)

Question 75

Nonalcoholic Fatty Liver Disease

Answer 75

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