Cardio. NBME 10 and 11, mehl. Cardio bullets (HTN, lipid) Flashcards
NBME 10. 22Q. 2DM + HTN. Cause of HTN?
Renal parenchymal disease (diabetic nephropathy).
Diabetic renal disease is the most likely mechanism for the patient’s increased blood pressure related to associated increased extracellular volume along with increased RAAS activation.
NBME 10. 22Q. effect of DM on kidney?
Nonenzymatic glycosylation of the glomerular basement membrane and efferent arterioles.
This results in thickening of the basement membrane along with compromise of the filtration barrier, which leads to an increased permeability to solutes and proteins.
NBME 10. 22Q. Diabetic nephropathy characteristically presents with ?? patho
eosinophilic nodular glomerulosclerosis, also known as Kimmelstiel-Wilson nodules.
Mesangial expansion of the efferent arteriole also occurs, which can initially increase the glomerular filtration rate (GFR).
NBME 10. 22Q. DM2 + nephro.
Basement membrane permeability and initially increased GFR progresses over time in patients with diabetes mellitus, beginning as microalbuminuria, progressing to macroalbuminuria (as seen in this case), and eventually to end-stage renal disease.
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NBME 10. 22Q. kiti ats. Hyperaldosteronism - source?
aldosterone-secreting adrenal tumor (Excess aldosterone production from an adrenal adenoma or bilateral adrenal hyperplasia)
NBME 10. 22Q. kiti ats. Hyperaldosteronism. electrolyte disturbances?
hypertension from salt and water retention but would also present with hypokalemia and metabolic alkalosis.
NBME 10. 22Q. kiti ats. Atherosclerosis of the renal arteries. how to establish Dx?
Diagnosis is established with renal artery Doppler ultrasound or magnetic resonance angiography.
Abdominal bruit is heard.
NBME 10. 22Q. kiti ats. pheochromocytoma. where located?
in the adrenal gland or within the para-aortic chain;
NBME 10. 22Q. kiti ats. pheochromocytoma. Produce what?
Produce an excess of metanephrines, such as epinephrine
NBME 10. 22Q. kiti ats. pheochromocytoma. CP?
episodes of increased blood pressure, headache, and palpitations.
NBME 10. 22Q. kiti ats. Renin-secreting adrenal tumor. disturbances?
hypertension along with hypokalemia.
NBME 10. 23Q.
25y/o woman + healthy + on active duty in the US Air Force, and her primary duty is flying drones. No symptoms, healthy, no medications. She does not smoke cigarettes or drink alcoholic beverages. Her paternal grandmother had a MI at 62 years. Vitals normal.
Results of fasting serum lipid studies obtained 1 year ago are shown
Cholesterol: Total 205; HDL-cholesterol 45; LDL-cholesterol 150; Triglycerides 50. Which of the following is the most appropriate screening laboratory study at this time?
No further testing is indicated (vs repeat measurement of fasting serum lipid studies)
While this patient’s LDL-cholesterol concentration is high, she is likely too young to receive much benefit from starting a statin medication, and this is not currently recommended by accepted guidelines.
Patients below these ages (men 35; female 40-45) rarely have an indication for screening unless there is a compelling reason, such as a family history of hypercholesterolemia or early cardiovascular disease in a first-degree relative.
NBME 10. 23Q.
Women under what age typically do not require screening for hyperlipidemia unless there is a compelling reason, such as a family history of familial hyperlipidemia or a myocardial infarction (MI) or stroke at a very young age. ???
Women under the age of 40 to 45 years
NBME 10. 23Q. The American College of Physicians recommends that cholesterol concentrations should be assessed in what age MEN?
should be assessed in asymptomatic men over the age of 35 years
NBME 10. 23Q.
The American College of Physicians recommends that cholesterol concentrations should be assessed in what age WOMEN?
asymptomatic women over the age of 40 to 45 years.
NBME 10. 23Q.
For patients between the ages of 40 and 75 years with no history of cardiovascular disease, the atherosclerotic cardiovascular disease (ASCVD) risk calculator can be helpful in determining the benefit of adding a statin medication to lower cholesterol concentrations.
The ASCVD calculator provides an estimate as to the probability that the patient will experience a stroke or a myocardial infarction in the next 10 years based on age, smoking status, race, blood pressure, and cholesterol concentration.
NBME 10. 23Q.
The ASCVD calculator A risk of LESS than 5%. intervention?
does not require intervention
NBME 10. 23Q
The ASCVD calculator A risk of less than 7,5%. intervention?
risk over 7.5% meets the criteria for the use of statin medication.
NBME 10. 23Q. A risk between 5% and 7.5%. Intervention?
requires a discussion between the patient and provider about the risks and benefits of statin therapy.
UW sako kad reikia lifestyle modifications. Kai jau didesne rizika - tai lifestyle ir statinai.
Zodziu lifestyle visada.
NBME 10. 23Q. kiti ats. LDL-receptor activity assay = when?
is indicated when testing for familial hypercholesterolemia.
NBME 10. 23Q. kiti ats.
Measurement of serum C-reactive protein (CRP) concentration (Choice C), particularly high sensitivity CRP, is sometimes used to risk stratify patients with an intermediate risk for cardiovascular disease. Higher concentrations are associated with an increased risk for heart disease.
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NBME 10. 23Q. kiti ats.
Repeat measurement of fasting serum lipid studies (Choice D) is indicated for routine screening when this patient reaches the age of 40 to 45 years. Since measuring lipids again will not change management, it should not be done.
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NBME 10. 23Q. kiti ats.
Measurement of serum apolipoprotein(a) concentration (Choice B) is not routinely indicated for patients. Low concentrations of apolipoprotein(a) lead to low HDL-cholesterol, which is associated with an increased risk for cardiovascular disease.
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NBME 11. 4Q. A 3-year-old boy is brought to the physician for a well-child examination. He is at the 50th percentile for height, weight, and head circumference. His appetite is good. His pulse is 85/min. His blood pressure is 140/75 mm Hg and 140/78 mm Hg in the right and left upper extremities, respectively. His blood pressure is 144/76 mm Hg and 145/79 mm Hg in the right and left lower extremities, respectively. Funduscopic, cardiopulmonary, and abdominal examinations show no other abnormalities. Results of a complete blood count; serum electrolyte, urea nitrogen, and creatinine concentrations; and urinalysis are within the reference ranges. Which of the following is the most appropriate next step in diagnosis?
D. Renal Doppler ultrasonography
In peds - pediatric patients with hypertension should always be evaluated for underlying causes.
NBME 11. 4Q. Ped HTN. zymejau Polysomnography, but OSA frequently presents with daytime somnolence and morning headaches and is not common in pediatric patients outside of tonsillar hypertrophy or congenital oropharyngeal structural anomalies.
This patient had normal weight, no somnolence.
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NBME 11. 4Q. PED HTN. Renal Doppler ultrasonography is the next most appropriate step in evaluation of this pediatric patient with hypertension
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NBME 11. 4Q. PED HTN.
While primary hypertension is more common in school-age children who are overweight or obese, it is less common is very young patients. Typical tests used for the initial evaluation of secondary hypertension include measurement of serum renin and aldosterone, serum and urine metanephrines, and renal ultrasonography with doppler to assess the patency of the renal arteries and evaluate the renal parenchyma. Renal artery stenosis can be diagnosed based on assessment of the velocity of blood flow through the renal arteries. Treatment may include renal artery stenting.
Secondary hypertension refers to increased blood pressure that is a result of another underlying medical condition. Some underlying causes include renal artery stenosis (also known as renovascular hypertension), renal parenchymal diseases such as glomerulonephritis, Cushing disease or syndrome, pheochromocytoma, and primary or familial hyperaldosteronism, among others.
NBME 11. 19Q. lipids.
37 y/o + observed BP of 175/97 following a dental extraction. The patient’s blood pressure was normal prior to the procedure. The patient reports pain at the site of extraction but does not have headache, change in vision, chest pain, or shortness of breath. Medical history is unremarkable, and he takes no medications. His father has hypertension and sustained a MI at age 45 years. The patient has smoked one pack of cigarettes daily for 15 years. He drinks alcoholic beverages socially but does not use illicit drugs. He is 185 cm (6 ft 1 in) tall and weighs 79 kg (175 lb); BMI is 23 kg/m . Blood pressure now is 133/74 mm Hg; remaining vital signs are normal. Physical examination discloses no abnormalities. Which of the following is the most appropriate next step in evaluation?
D. Serum lipid studies
vs no evaluation.
No further evaluation is indicated (Choice E) is incorrect. There exist additional modifiable risk factors for which screening should occur at this time.
NBME 11. 19Q. lipids.
The presence of HTN and a family history of coronary vascular disease at an early age are concerning for increased cardiovascular risk in this patient, and the most appropriate next step in evaluation is to investigate for the presence of additional risk factors with serum lipid studies. The United States Preventative Services Task Force (USPSTF) recommends screening for hyperlipidemia in men aged greater than 35 years and in women aged greater than 45 years who are at an increased risk for coronary vascular disease.
NBME 11. 19Q. lipids. first line for dislipidemia?
Statins
NBME 11. 19Q. lipids. kiti ats. Exercise stress testing (Choice B) is not indicated at this time for this young, asymptomatic patient.
Stress testing is recommended for patients with angina, prior acute coronary syndrome with new or changing symptoms, or for valvular disease, cardiomyopathy, or congestive heart failure in certain settings.
NBME 11. 109Q. HF presentation + HFeEF (30 proc.). What drug to give in addition to furosemide?
Lisinopril
Given that this is a new diagnosis for the patient and the underlying cause of the patient’s heart failure is not known, initial pharmacotherapy should prioritize volume and blood pressure management.
NBME 11. 109Q. HF presentation + HFeEF (30 proc.). in HF can be both S3 and S4
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NBME 11. 109Q. HF presentation + HFeEF (30 proc.). REDUCED IF LESS THAN 50 proc.
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NBME 11. 109Q. HF presentation + HFeEF (30 proc.). Tx?
The goals of pharmacotherapy are to improve symptoms, preserve myocardial function, and reduce mortality.
Initial guideline-recommended therapy is a combination of a BAB, a RAAS inhibitor, and a diuretic.
Given that this is a new diagnosis for the patient and the underlying cause of the patient’s heart failure is not known, initial pharmacotherapy should prioritize volume and blood pressure management.
NBME 11. 109Q. HF presentation + HFeEF (30 proc.).
In addition to furosemide, the initiation of lisinopril is most appropriate at this time. Once the patient’s volume status has been optimized, a repeat echocardiography may be performed to assess for the potential recovery of EF and inform further management decisions.
Metoprolol (Choice C) is a common β-adrenergic antagonist employed in the treatment of HFrEF. Given the patient’s significant volume overloaded status, new diagnosis, and unclear underlying cause, it is reasonable to first attempt volume reduction and blood pressure control with a diuretic and lisinopril. If a repeat echocardiography shows persistent HFrEF despite volume control, a β-adrenergic antagonist should be added to the patient’s regimen. Similarly, mineralocorticoid receptor antagonists such as spironolactone (Choice E) are recommended if additional blood pressure and volume control is needed, or if significant hypokalemia results from loop diuretic use.
NBME 11. 109Q. HF presentation + HFeEF (30 proc.). kiti ats - nifedipine.
Used in the treatment of high-altitude pulmonary edema and hypertensive emergency. Adverse effects include profound hypotension and reflex tachycardia.
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NBME 10. 66Q.
23 y/o + examination prior to employment. He is in his first year of law school and sleeps 4 to 5 hours nightly; he reports feeling stressed frequently because of the demanding course load. He has smoked one pack of cigarettes daily for 2 years and drinks one beer daily. He exercises by running for 30 minutes three times weekly. He is 178 cm (5 ft 10 in) tall and weighs 91 kg (200 lb); BMI is 29 kg/m . His pulse is 80/min, and blood pressure is 132/96 mm Hg. Serum electrolyte concentrations are within the reference ranges. Urinalysis shows no abnormalities. In addition to advising smoking cessation, which of the following is the most appropriate recommendation to manage this patient’s increased blood pressure?
Weight loss
NBME 10. 66Q. HTn and weight.
1 mmHg - how many weight to lose?
Loss of one pound of body weight correlates with a drop in blood pressure by around 1 mm Hg
NBME 10. 66Q. HTn and weight. in the patient was 132/92.
132 is already within hypertension range
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NBME 10. 66Q. HTn and weight. when consider evalatution for secondary HTN?
Particularly in young patients or those with ongoing hypertension despite the use of three medications including a diuretic, screening for causes of secondary hypertension should be considered.
NBME 10. 66Q. HTn and weight. kiti ats.
Alcohol?
Decreased alcohol consumption (Choice A) is unlikely to have a meaningful effect on blood pressure, although male patients with hypertension who drink three or more drinks per day should be advised to decrease their intake to two or fewer drinks per day.
NBME 10. 66Q. HTn and weight. kiti ats.
NBME 10. 66Q. HTn and weight. kiti ats.
Biofeedback (Choice D) is a mind-body technique that utilizes visual and/or auditory feedback in an attempt to gain control over involuntarily bodily functions. It is not a proven means of decreasing blood pressure.
NBME 10. 66Q. HTn and weight. kiti ats. Increased amount of sleep (Choice B) may be beneficial for managing this patient’s stress but is unlikely to have any effect on his blood pressure.
NBME 10. 66Q. HTn and weight. kiti ats.
Hydrochlorothiazide therapy (Choice E) is an appropriate first-line medication for patients with a diagnosis of essential hypertension, which requires two separate blood pressure readings taken at different times. This patient has a single blood pressure reading in the hypertensive range and does not meet criteria for the diagnosis yet. Additionally, lifestyle interventions such as weight loss are usually attempted first.
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NBME 10. 194Q. A 3-month-old girl has had increased blood pressure measurements since admission to the hospital for pneumonia and bronchiolitis 2 days ago. She was born at 26 weeks’ gestation because of premature labor and weighed 750 g (1 lb 10 oz) at birth. During the first 2 days of life, an umbilical artery catheter was used to monitor her blood pressure. She had several episodes of hypotension that resolved after administration of fluid boluses. She remained in the neonatal intensive care unit for management of respiratory distress and poor weight gain until the age of 10 weeks, when her vital signs had stabilized and condition had improved. At that time, she was discharged home on 0.5 L/min of oxygen. Her current medications are a multivitamin with iron and budesonide. She appears well developed and well nourished but is in respiratory distress. She weighs 3005 g (6 lb 10 oz). Her temperature is 37°C (98.6°F), pulse is 160/min, respirations are 70/min, and blood pressure is 128/86 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. On pulmonary examination, crackles over the left lung base and scattered bilateral expiratory wheezes are heard. On cardiac examination, a grade 1/6, systolic ejection murmur is heard best at the upper left sternal border. The abdomen is soft and nontender. Femoral pulses are 2+ bilaterally. Serum studies are most likely to show which of the following sets of findings?
Increased renin
Increased aldosterone
NBME 10. 194Q. Renal artery thrombosis is a rare complication of umbilical artery catheterization that can present up to several weeks after the catheter has been removed. Occlusion of the renal artery by the thrombus results in decreased afferent blood flow to the affected kidney and increased renin production from the juxtaglomerular apparatus. Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme (ACE) in the pulmonary vasculature. Angiotensin II is a potent vasoconstrictor that directly mediates systemic hypertension and stimulates aldosterone release by the adrenal cortex.
The overstimulation of the renin-angiotensin-aldosterone system results in secondary hypertension. Treatment of renal artery thrombosis includes systemic anticoagulation and volume resuscitation. Unilateral nephrectomy may be required in the setting of refractory hypertension.
NBME 11. 119Q. 65-y.o woman is prepared for discharge 15 days after undergoing uncomplicated surgical repair of the ventricular septum following an anterior ST-evelation MI. Her postoperative course has been uncomplicated. She has hypertension and hyperlipidemia. Her medications are clopidogrel, lisinopril, metoprolol, atorvastatin, and aspirin. Vital signs are within normal limits. Examination shows a clean, dry surgical incision. Echocardiography - EF 50%. In addition to continuation of the medication regimen, which of the following interventions is most likely to decrease this patient’s risk for a repeat myocardial infarction?
Following a Mediterranean diet
The Mediterranean diet consists primarily of a diet high in vegetables, whole grains, legumes, and olive oil, with moderate consumption of fish, poultry, and low-fat dairy products in addition to wine. This diet has been shown to reduce cardiovascular mortality, including MI and stroke, in patients without known coronary heart disease as well as in patients with established coronary disease, such as this patient. It has a favorable effect on lipids, blood pressure, and insulin sensitivity.
NBME 11. 119Q. Antioxidant supplementation (Choice A) has not been proven to reduce cardiovascular mortality in patients with established coronary artery disease.
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NBME 11. 189Q. Has pefiphral edema + HTN. What drug would most likely exacerbate this patient’s swelling?
Nifedipine (nu tipo CCB)
Dihydropyridine CCB agents, such as nifedipine or amlodipine, are potent arteriolar vasodilators that reduce blood pressure by decreasing vascular peripheral resistance.
The dihydropyridine CCBs have minimal cardiomyocyte activity and primarily act on vascular smooth muscle cells. CCBs may exacerbate peripheral edema, which is one of the most common causes for discontinuation of CCB treatment. CCBs may also cause headache, lightheadedness, facial flushing, and gingival hyperplasia.
