Cardio Flashcards
1
Q
What is HTN a major contributing factor in?
A
Coronary artery dz Stroke CHF Chronic renal failure Atherosclerosis
2
Q
Nl BP
A
<120/<80
3
Q
Prehypertension
A
120-139/80-89
4
Q
Stage 1 HTN
A
140-159/90-99
5
Q
Stage 2 HTN
A
160-179/100-109
6
Q
Blood pressure formula
A
CO x SVR
7
Q
What are the primary factors determining blood pressure?
A
Sympathetic nervous system
Renin-angiotensin-aldosterone system
Plasma volume
8
Q
What is the cause of the majority of HTN?
A
Idiopathic (primary)
Numerous genetic and environmental factors
9
Q
When should one have clinical suspicion of secondary HTN?
A
Onset <30 or >50
Sudden onset of HTN
Sudden change in chronic HTN
Multi-drug resistant HTN
10
Q
Risk factors for primary HTN
A
Increasing age Obesity FHx Physical inactivity Ethnicity EtOH Smoking DM
11
Q
Secondary causes of HTN
A
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
12
Q
End organ damage in HTN
A
Claudication Bruits LVH Retinopathy Renal disease
13
Q
Labs for HTN
A
CBC CMP BUN/creatinine FBS/Hgb A1c Lipid panel TSH
14
Q
Additional testing for HTN
A
CXR ECG Ambulatory BP monitoring Echo Labs for secondary causes
15
Q
HTN eval
A
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
16
Q
MOA of ACE inhibitors
A
Prevent conversion of angiotensin I to angiotensin II
Prevention of breadkdown of bradykinin
17
Q
MOA of dihydropyridine calcium channel blockers
A
Work more in the peripheral vasculature, cause vasodilation
18
Q
Contraindications of ACE/ARB
A
Pregnancy
19
Q
MOA of nondihyrdopyridine CCBs
A
Work centrally on the heart
Have inotropic and chronotropic effects
Increase HR and contractility
20
Q
Contraindication of dihydropyridine calcium channel blockers
A
Heart failure
Be careful using nondihyrdopyridines with BBs, specifically cardioselective because of decrease in HR
21
Q
Examples of thiazide diuretics
A
Chlorthiadone
Indapamide
Hydrochlorothiazide
22
Q
Examples of loop diuretics
A
Bumetanide
Furosemide
Torsemide
23
Q
Examples of aldosterone antagonists
A
Spironolactone
Eplerenone
24
Q
Examples of potassium sparing diuretics
A
Amilioride
Triamterene
25
When to use aldosterone antagonists for HTN
Esp spironolactone
| Used in resistant HTN
26
Which diuretics are not affected by renal function?
Loops
27
Which beta blockers are considered cardioselective?
Metoprolol
Atenolol
Bisoprolol
28
Recommendations for HTN med dosing
Titrate to max dose, then add a second drug
29
What is treating resistant HTN predicted on?
Lifestyle factors
Appropriate tx of secondary outcomes
Effective multi-drug regimens
30
Med regimens for resistant HTN
Diuretic therapy
Combo therapy
Mineralcorticoid receptor antagonists
Beta blockers, central alpha 2 agonists, direct vasodilators
31
What med regimen should be in place before diagnosing resistant HTN?
Thiazide
CCB
ACE/ARB
32
What is the difference in ejection fraction between systolic and diastolic heart failure?
Systolic ~33%
Diastolic ~57%
Nl ~66%
33
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
```
34
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
```
35
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
```
36
What is stage B heart failure?
Pts with structural heart disease but are asymptomatic
37
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
```
38
What 3 BBs are utilized in heart failure?
Carvedilol
Bisoprolol
Metoprolol succinate
39
MOA of BBs
Inhibitor/block beta receptors
Net effect:
-Decreased sensitivity to circulating catecholamines
-Decreased HR/BP
40
When should BBs be initiated in heart failure?
Only initiate beta blocker when heart failure is stable and pt is euvolemic
41
What is the net effect of ACE inhibitors?
Arterial and venous vasodilation
| Reduction of preload and afterload (reduced workload on heart)
42
Absolute contraindications of ACE inhibitors
Hx of angioedema secondary to ACE inhibitor
Pregnancy (category X)
Bilateral renal artery stenosis
43
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)
44
Stage C tx for diastolic heart failure
Diuresis to relieve sx of congestion
| Follow guideline driven indications for comorbidities
45
Stage C tx for systolic heart failure
```
All txs for stage A
ACEI or ARB
BB (select medications)
Diuretics
Devices
-Biventricular pacing
-Implantable defibrillators
```
46
MOA of diuretics
Block Na resorption at the thick ascending loop of Henle
47
MOA of aldosterone antagonists
Inhibits aldosterone
-Increased levels of aldosterone in HF to increase Na/H2O retention and improve CO
Weak diuretic effect
48
Stage D heart failure tx
```
All txs for stage A-C
Heart transplant
Chronic inotropic meds
Mechanical support
Palliative care/hospice
```
49
MOA of sacubitril/valsartin
Valsartan: ARB
Sacubitril: inhibits neprilysin
-Net effect: Increase natriuretic peptides that decrease blood volume and preload
50
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
```
51
S/sx of hypoperfusion in HF exacerbation
Cool extremities
Sleepy
Declining Na levels
52
S/sx of congestion in HF exacerbation
```
Orthopnea
DOE
High JVP
Pulmonary edema
Peripheral edema
Elevated BNP
Wt gain
```
53
How to address congestion in HF exacerbation
Loop diuretics
| +/- vasodilators
54
How to address hypoperfusion in HF exacerbation
Positive inotropes
| +/- fluid replacement
55
How to address congestion and hypoperfusion in HF exacerbation
Mixture of diuretics, vasodilators, inotropes
56
Vasodilators for HR exacerbation
Nitroprusside- not seen often
Nitroglycerin
Nesiritide
57
Inotropes utilized for HR exacerbation
Dopamine
Dobutamine
Milrinone
58
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
```
59
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
60
Indications for thiazide diuretics
Volume control with heart failure or chronic kidney dz
61
Indication for CCB
Rate control with atrial fib or control of angina
62
Indications for BB
Acute MI
Rate control for A fib
Angina
63
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
64
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
```
