cardio Flashcards
Atherosclerosis and Cardiovascular Disease (CVD)
-Atherosclerosis is responsible for almost all cases of coronary heart disease (CHD).
- Insidious disease that begins with fatty streaks in adolescence and culminates in thrombotic occlusion
risk factors:
- Hypertension
- Diabetes
- Cigarette smoking
- Premature family history of ASCVD
- Chronic kidney disease
- Obesity
Hyperlipidemia
USPSTF Recommendations: Adults aged 40-75 with one or more CVD risk factors and a 10-year CVD risk >10% should be screened for elevated lipids.
Statin Therapy: Beneficial in preventing CVD.
LDL Reassessment: 6 weeks after initiation of therapy to evaluate lifestyle modification adherence and medication effectiveness.
Major Forms of ASCVD
Coronary Heart Disease (CHD) - Myocardial infarction (MI), angina pectoris, coronary death.
Cerebrovascular Disease - Stroke, transient ischemic attack (TIA).
Peripheral Artery Disease (PAD) - Intermittent claudication.
Aortic Atherosclerosis - Thoracic or abdominal aortic aneurysm.
Stable Coronary Artery Disease: definition and management
Definition: Reversible supply/demand mismatch due to ischemia, history of MI, or presence of plaque seen on catheterization or CT angiography
- disease is stable as long as they are asymptomatic or their symptoms are controlled by medication or revascularization
Management:
- Risk factor management: HTN, Diabetes, Hyperlipidemia, Smoking cessation, increased physical activity, weight control, healthy diet.
- Antiplatelet therapy: ASA 81mg PO QD (no increased benefit with 325 mg PO QD).
Evidence-Based Medicine for CVD Prevention
USPSTF Recommendations: screening for:
* high blood pressure
* statin use
* counseling on smoking cessation
* counseling on healthful diet and physical activity
* and screening for peripheral artery disease and CVD risk assessment with the ABI
* Low-dose aspirin use in certain persons at increased risk for CVD
Hypertension prevalence and risk factors
Prevalence: Affects ~45% of U.S. adults. Most commonly diagnosed condition at outpatient office visits
Major Risk Factor For: Heart failure, MI, stroke, chronic kidney disease.
High-Risk Groups:
- Older adults
- African Americans
- Family history of HTN
- Obesity
- Unhealthy lifestyle habits (e.g., tobacco use, poor diet, high alcohol intake, stress, inactivity)
Na sensitivity… common in blacks, elderly, CKD, DM, metabolic syndrome
Potassium higher levels blunt the effect of sodium.
Screening Guidelines: HTN
USPSTF: Initial screening for patients ≥18 years without a history of HTN.
Method: Annually via office blood pressure measurement (OBPM) measured at the brachial artery (upper arm) with the patient most commonly in a seated position after 5 minutes of rest and medical personnel present during measurement
Home blood pressure monitoring (HBPM) with validated and accurate devices should be used outside of a clinical setting to confirm a diagnosis of hypertension before starting treatment.
Patient’s who present with controlled BP but are high at home….
Patient’s who present with controlled BP but are high at home, need an intervention especially if they have the following risk factors:
* Elevated atherosclerotic cardiovascular disease risk (eg, a calculated 10-year risk of having an atherosclerotic cardiovascular event >10 percent)
* Chronic kidney disease
* Diabetes mellitus
* Evidence of hypertensive end-organ damage (eg, prior atherosclerotic cardiovascular event, heart failure, left ventricular hypertrophy, hypertensive retinopathy)
Hypertension Treatment:
Start low with monotherapy unless SBP >160, then initiate dual therapy.
- Increased benefit with comorbidity consideration when escalating of treatment
High-risk patients: Lifestyle changes + first-line medication*
DM without albuminuria: Same medications as for any HTN patient.
Why don’t ACE inhibitors/ARBs work as effectively as first-line agents in African Americans?
- Lower LEVELS OF RENIN reduces effectiveness compared to other populations.
ACE inhibitors and ARBs both work by interfering with the hormonal circuit in the body that increases blood pressure —the renin-angiotensin-aldosterone system. They work best when the cause of high blood pressure is a high level of renin. But Black adults with high blood pressure often havelower levels of renin.
Angioedema is more common in AA than any other race.
Secondary Hypertension Causes
Drug-Induced:
- Oral contraceptives (estrogen increases renin production)
- NSAIDs (COX-2 inhibition reduces sodium excretion)
-Stimulants (cocaine, methylphenidate)
-Antidepressants (venlafaxine)
Renovascular Disease (Most common correctable cause of secondary HTN)
Pheochromocytoma (Triad: headache, palpitations, sweating)
Primary Aldosteronism (Hypokalemia with urinary potassium wasting)
Cushing’s Syndrome (History of glucocorticoid use, central obesity)
Obstructive Sleep Apnea (Common in resistant HTN, sodium retention)
Hypothyroidism (Elevated TSH)
Primary Hyperparathyroidism (Elevated serum calcium)
Primary Kidney Disease (Elevated creatinine, abnormal uri
Angina Pectoris (Chest Pain): main sx and others
Pressure, squeezing, burning, tightness behind the breastbone.
- Pain and discomfort are the main symptoms of angina.
Additional symptoms:
- Extreme fatigue
-Light-headedness/fainting
-Nausea
-Shortness of breath
- Sweating
- Weakness
common causes of chest pain in primary care and types of angina
Common Causes in Primary Care:
- Chest wall pain (20-50%)
- Reflux esophagitis (10-20%)
- Costochondritis (13%)
-Angina is caused by ischemia to muscle. Initial evaluation needs to determine whether immediate referral to emergency department for ACS is necessary
Types of Angina:
- Stable Angina: Induced by exertion, relieved with rest or medication.
- Unstable Angina: Unpredictable, lasts longer than 5 minutes, not relieved by rest.
- variant (Prinzmetal) Angina: Occurs at rest, often at night, or early am
UA/NSTEMI Management Goals:
●Relief of ischemic pain.
●Assessment of the patient’s hemodynamic status and correction of abnormalities. Hypertension and tachycardia, both of which will markedly increase myocardial oxygen consumption requirements, may be managed with beta blockers and intravenousNitroglycerin
●Choice of a management strategy, ie, an early invasive strategy (with angiography and intent for revascularization with percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery as defined by the anatomy) versus a conservative strategy with medical therapy
● Estimation of risk
Risk Stratification
ACS
Early risk stratification in patients with acute coronary syndrome (ACS) is essential to identify those patients at highest risk for further cardiac events who may benefit from a more aggressive therapeutic approach
ACS tx: acute and longterm
Acute Mgmt includes:
* Antithrombotic therapy (including antiplatelet and anticoagulant therapies) to prevent further thrombosis of or embolism from an ulcerated plaque.
* Beta blocker therapy to prevent recurrent ischemia and life-threatening ventricular arrhythmias
To improve long-term prognosis, therapies include:
* Long-term antiplatelet therapy to reduce the risk of recurrent coronary artery thrombosis or, with PCI, coronary artery stent thrombosis. (Aspirin)
* Statins- reduce LDL decreases risk of fatal cardiac events
* Long-term oral anticoagulation in the presence of left ventricular thrombus or chronic atrial fibrillation to prevent embolization.
* ACE-Inhibitor in patients at increased risk.
acs eval and mangement algorithm
Arrhythmia
Main goal of the Family Medicine practitioner is to evaluate presence of arrhythmia and if symptomatic. And risk for complications
Heart palpitations most common symptom. Usually Afib (MC) vs. SVT
AFib: risk factors, management,
Atrial Fibrillation (AFib): Most common arrhythmia.
Risk Factors: HTN, CAD, COPD, diabetes, left ventricular hypertrophy.
Management:
- Determine if patient is stable for cardioversion.
- Electrical cardioversion (80% success rate) or medications (Amiodarone, Procainamide).
Chronic AFib: Rate control (CCB, BB, Digoxin).
Stroke Risk Assessment: CHA2DS2-VASc Score:
- Score 0: No anticoagulation needed.
- Score 1: Consider anticoagulation.
- Score ≥2: Anticoagulation should be started.
afib stroke risk
Afib increases risk for cerebral vascular risk by 5 times. For this reason Risk Stratification is important to weigh risk vs. benefit for AC
This scoring system is used, in part, to develop a treatment plan for a Afib and includes the following risk factors
C for Congestive heart failure adds 1 point.
H for Hypertension oadds 1 point
A for Age greater > 75 years adds 2 points
D for DM adds 1 point
S for prior Stroke or TIA adds 2 points
V for Vascular disease adds 1 point
A for Age between 65 and 74 years adds 1 point
S for female Sex adds 1 point
Results:
Score 0- no need for AC
Score 1 – consider AC
Score >2- AC should be started
Heart Failure (HF): rEF vs pEF, RHF vs LHF
- Complex clinical syndrome showing dyspnea and fatigue due to cardiac dysfunction (Abnormal left or right ventricular filling and elevated pressures)
- HF caused by LV dysfunction is commonly categorized according to LV ejection fraction (LVEF):
- ●HF with LVEF ≤40 percent is known as HF with reduced ejection fraction (HFrEF).
- ●HF with LVEF ≥50 percent may be caused by HF with preserved ejection fraction (HFpEF) or a cardiomyopathy (restrictive, hypertrophic, or noncompaction).
- Left HF pathology LV, Mitral valve, Aortic valve dysfxn
- Right HF pathology Pulm HTN or RV, Pulmonic valve, Tricuspid valve dysfxn
- Left HF is the most common cause of Right HF
HFrEF (Reduced EF <40%) vs. HFpEF (Preserved EF >50%)
Right HF Causes: Pulmonary HTN, RV dysfunction, tricuspid/pulmonic valve disease.
Left HF Causes: LV dysfunction, mitral/aortic valve disease.
HF Management: pharm meds
Pharmaceutical Interventions: (reduce risk of rehospitalizaiton)
- Volume Overload- Diuretics
- Elevated BNP- SGLT2 (Jardiance (Empaglifozin)and MRA ( Spironolactone); Careful if DM and already on medications; With CKD ACE or ARB can be added to a MRA; MRA be careful with risk of hyperkalemia
Ineffective therapies due to diminished exercise tolerance (utilized to treat other comorbidities)
- Nitrates
- Phosphodiesterase-5 inhibitors
- Digoxin
Heart Failure-Sx and 4 key findings suggesting greater severity of cardiac dysfunction
- Excess fluid accumulation (dyspnea, orthopnea, edema, pain from hepatic congestion, and abdominal discomfort due to distention from ascites)
- Reduction cardiac output (fatigue, weakness) that is most pronounced with exertion.
- Fluid retention in HF is initiated by the fall in cardiac output, leading to alterations in renal function, due in part to activation of the sodium-retaining renin-angiotensin-aldosterone and sympathetic nervous systems.
Four key findings suggest greater severity of cardiac dysfunction:
- resting sinus tachycardia
- narrow pulse pressure
- Diaphoresis
- peripheral vasoconstriction.
Heart Failure
Diagnostics
goals of tx HFrEF vs HFpEf
HFpEf: Reduce risk of mortality
- Reduce HF symptoms
- Increase functional status
- Reduce the risk of hospital admission
HFrEF: Reduce risk of mortality
- reduce symptom severity
- decrease the risk of mortality and morbidity
- attenuate or possibly reverse the process of adverse remodeling of the LV
HFrEF- Symptomatic
implantable devices
- PAP monitoring using the CardioMEMS™ system, in which it was advised that the use of the CardioMEMS™ system may be considered in symptomatic patients with HF with previous HF hospitalization in order to reduce the risk of recurrent HF hospitalization
- Implantable Cardioverter Defibrillator (ICD)Patients due to increased risk of sudden cardiac death due to ventricular arrhythmias especially in those who already suffered from previous ventricular arrhythmic events. In this “secondary prevention” situation where no reversible cause such as an acute myocardial infarction can be identified, an ICD is recommended with a class IA indication
- Cardiac Resynchronisation Therapy (CRT) device is indicated in patients with stable, symptomatic systolic heart failure despite 3 months of optimal medical treatment, an LVEF ≤ 35% and a QRS duration of ≥ 130 ms
