Cardio Flashcards
What is HTN a major contributing factor in?
Coronary artery dz Stroke CHF Chronic renal failure Atherosclerosis
Nl BP
<120/<80
Prehypertension
120-139/80-89
Stage 1 HTN
140-159/90-99
Stage 2 HTN
160-179/100-109
Blood pressure formula
CO x SVR
What are the primary factors determining blood pressure?
Sympathetic nervous system
Renin-angiotensin-aldosterone system
Plasma volume
What is the cause of the majority of HTN?
Idiopathic (primary)
Numerous genetic and environmental factors
When should one have clinical suspicion of secondary HTN?
Onset <30 or >50
Sudden onset of HTN
Sudden change in chronic HTN
Multi-drug resistant HTN
Risk factors for primary HTN
Increasing age Obesity FHx Physical inactivity Ethnicity EtOH Smoking DM
Secondary causes of HTN
Renal -Acute and chronic kidney dz Adrenal -Cushing's syndrome Pheochromocytoma (intermittent sx) Hyperaldosteronism (hypokalemia, HTN, metabolic alkalosis) OCPs Decongestants NSAIDs MAOIs Cocaine Wt loss meds Stimulants Hyperthyroid Hyperparathyroid Pregnancy Coarctation of the aorta
End organ damage in HTN
Claudication Bruits LVH Retinopathy Renal disease
Labs for HTN
CBC CMP BUN/creatinine FBS/Hgb A1c Lipid panel TSH
Additional testing for HTN
CXR ECG Ambulatory BP monitoring Echo Labs for secondary causes
HTN eval
Pt seated for 5 minutes, feet flat on the floor, arm supported at heart level
Appropriate sized cuff
At least two readings…both arms
1/2 hr after eating, drinking, smoking
MOA of ACE inhibitors
Prevent conversion of angiotensin I to angiotensin II
Prevention of breadkdown of bradykinin
MOA of dihydropyridine calcium channel blockers
Work more in the peripheral vasculature, cause vasodilation
Contraindications of ACE/ARB
Pregnancy
MOA of nondihyrdopyridine CCBs
Work centrally on the heart
Have inotropic and chronotropic effects
Increase HR and contractility
Contraindication of dihydropyridine calcium channel blockers
Heart failure
Be careful using nondihyrdopyridines with BBs, specifically cardioselective because of decrease in HR
Examples of thiazide diuretics
Chlorthiadone
Indapamide
Hydrochlorothiazide
Examples of loop diuretics
Bumetanide
Furosemide
Torsemide
Examples of aldosterone antagonists
Spironolactone
Eplerenone
Examples of potassium sparing diuretics
Amilioride
Triamterene
When to use aldosterone antagonists for HTN
Esp spironolactone
Used in resistant HTN
Which diuretics are not affected by renal function?
Loops
Which beta blockers are considered cardioselective?
Metoprolol
Atenolol
Bisoprolol
Recommendations for HTN med dosing
Titrate to max dose, then add a second drug
What is treating resistant HTN predicted on?
Lifestyle factors
Appropriate tx of secondary outcomes
Effective multi-drug regimens
Med regimens for resistant HTN
Diuretic therapy
Combo therapy
Mineralcorticoid receptor antagonists
Beta blockers, central alpha 2 agonists, direct vasodilators
What med regimen should be in place before diagnosing resistant HTN?
Thiazide
CCB
ACE/ARB
What is the difference in ejection fraction between systolic and diastolic heart failure?
Systolic ~33%
Diastolic ~57%
Nl ~66%
Causes of systolic heart failure
Reduction in muscle mass (MI) Dilated cardiomyopathies Ventricular hypertrophy -Pressure overload --Pulmonary HTN --Aortic/pulmonic valve stenosis -Volume overload --Valvular regurgitation --Shunts --High-output states
Causes of diastolic heart failure
Increase ventricular stiffness Ventricular hypertrophy -HCM Infiltrative myocardial disease -Amyloidosis -Sarcoidosis -Endomyocardial fibrosis Myocardial ischemia and infarction Mitral/tricuspid stenosis Pericardial disease -Pericarditis -Pericardial tamponade
Tx of stage A heart failure
Stage A: not symptomatic and NO current evidence of structural heart dz, pts at high risk for heart failure Aggressive risk factor control: -Control HTN per current guideline recs -Smoking cessation -Control dyslipidemia per current guidelines -Increased physical activity -Encourage wieght loss if obeses -Control diabetes per current guidelines -Discourage EtOH and illicit drug use
What is stage B heart failure?
Pts with structural heart disease but are asymptomatic
Tx of stage B heart failure
All txs for stage A ACE inhibitor or ARB -Pts s/p ACS/MI or reduced EF BB select medications -Pts s/p ACS/MI or reduced EF
What 3 BBs are utilized in heart failure?
Carvedilol
Bisoprolol
Metoprolol succinate
MOA of BBs
Inhibitor/block beta receptors
Net effect:
-Decreased sensitivity to circulating catecholamines
-Decreased HR/BP
When should BBs be initiated in heart failure?
Only initiate beta blocker when heart failure is stable and pt is euvolemic
What is the net effect of ACE inhibitors?
Arterial and venous vasodilation
Reduction of preload and afterload (reduced workload on heart)
Absolute contraindications of ACE inhibitors
Hx of angioedema secondary to ACE inhibitor
Pregnancy (category X)
Bilateral renal artery stenosis
MOA of ARBs
Block the AT1 receptor to stop the actions of angiotensin II
-Decreased vasoconstriction, aldosterone release, cellular growth promotion
Net effect:
-Arterial and venous vasodilation
-Reduction of preload and afterload (reduced workload on heart)
Stage C tx for diastolic heart failure
Diuresis to relieve sx of congestion
Follow guideline driven indications for comorbidities
Stage C tx for systolic heart failure
All txs for stage A ACEI or ARB BB (select medications) Diuretics Devices -Biventricular pacing -Implantable defibrillators
MOA of diuretics
Block Na resorption at the thick ascending loop of Henle
MOA of aldosterone antagonists
Inhibits aldosterone
-Increased levels of aldosterone in HF to increase Na/H2O retention and improve CO
Weak diuretic effect
Stage D heart failure tx
All txs for stage A-C Heart transplant Chronic inotropic meds Mechanical support Palliative care/hospice
MOA of sacubitril/valsartin
Valsartan: ARB
Sacubitril: inhibits neprilysin
-Net effect: Increase natriuretic peptides that decrease blood volume and preload
Causes of HF exacerbation
Acute coronary syndromes Med nonadherence Na/fluid restriction nonadherence Uncontrolled BP A fib Addition of drugs that worsen HF Pulmonary embolus Infection Excessive alcohol use
S/sx of hypoperfusion in HF exacerbation
Cool extremities
Sleepy
Declining Na levels
S/sx of congestion in HF exacerbation
Orthopnea DOE High JVP Pulmonary edema Peripheral edema Elevated BNP Wt gain
How to address congestion in HF exacerbation
Loop diuretics
+/- vasodilators
How to address hypoperfusion in HF exacerbation
Positive inotropes
+/- fluid replacement
How to address congestion and hypoperfusion in HF exacerbation
Mixture of diuretics, vasodilators, inotropes
Vasodilators for HR exacerbation
Nitroprusside- not seen often
Nitroglycerin
Nesiritide
Inotropes utilized for HR exacerbation
Dopamine
Dobutamine
Milrinone
What are ACEs first line therapy for?
Heart failure Left ventricular dysfunction In all pts with STEMI NSTEMI with an anterior MI Diabetes Systolic dysfunction Proteinuric chronic kidney dz
Indications for ARBs
Similar to ACEs
Specific benefit with severe HTN with EKG evidence of left ventricular hypertrophy
ARB indicated in those who don’t tolerate ACEs
Indications for thiazide diuretics
Volume control with heart failure or chronic kidney dz
Indication for CCB
Rate control with atrial fib or control of angina
Indications for BB
Acute MI
Rate control for A fib
Angina
How is orthostatic hypotension evaluated?
Evaluated by measuring the individual’s BP and pulse rate while he or she is reclining and again after the individual swiftly moves to a standing position
Test is positive with systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing
Testing for orthostatic hypotension
Tilt test Chemistry panel- hypoglycemia, dehydration CBC- anemia Blood/urine cultures- sepsis 12 lead EKG Echo Holter/event monitor UA CXR/CT
