Cardio T1-11 Flashcards
- How does the American Heart Association define hypertension?
Hypertension is defined as persistent blood pressure of ≥130/80 mmHg. If only one is high, it is considered isolated systolic or diastolic hypertension.
How does the JNC 81 define hypertension?
The JNC 81 defines hypertension as persistent blood pressure of ≥140/90 mmHg.
What is the most common risk factor for hypertension?
The most common risk factor for hypertension is cardiovascular disease.
How is hypertension classified?
Hypertension is divided into primary (essential) hypertension and secondary hypertension based on the underlying cause.
What percentage of adult hypertension cases are due to primary hypertension?
About 95% of hypertension cases in adults are due to primary hypertension.
What percentage of children’s hypertension cases are due to primary hypertension?
About 20% of hypertension cases in children are due to primary hypertension.
What are some non-modifiable risk factors for primary hypertension?
Non-modifiable risk factors include a positive family history, ethnicity, and advanced age.
What are some modifiable risk factors for primary hypertension?
Modifiable risk factors include obesity, diabetes, smoking, a diet high in sodium or low in potassium, physical inactivity, and psychological stress.
What is considered optimal (normal) blood pressure?
Optimal blood pressure lies between 90/60 mmHg and 120/80 mmHg.
What is considered hypotension and hypertension based on blood pressure?
Blood pressure below 90/60 mmHg is considered hypotension, and above 120/80 mmHg is considered hypertension.
How are the grades (or stages) of hypertension defined?
The stages of hypertension are determined based on blood pressure levels, but specific stages were not detailed in this text.
What are the clinical features of primary hypertension?
Primary hypertension is usually asymptomatic until end-organ damage or a hypertensive crisis occurs.
What symptoms may accompany secondary hypertension?
Symptoms of secondary hypertension align with the underlying cause.
What are some nonspecific symptoms that may be associated with hypertension?
Nonspecific symptoms can include headaches (especially in the morning), dizziness, tinnitus, blurred vision, nervousness, fatigue, sleep disturbances, and chest discomfort.
How is primary hypertension diagnosed?
Primary hypertension is diagnosed over three separate office visits, with at least three blood pressure measurements taken per visit.
Describe the process of measuring blood pressure manually using the auscultatory method.
The patient rests in a seated position for at least 5 minutes. A blood pressure cuff is applied to the arm above the brachial artery, the cuff is inflated 30 mmHg above expected systolic pressure, and the stethoscope is placed over the brachial artery.
The cuff is deflated, and systolic pressure is noted when the pulse is first heard, and diastolic pressure is noted when the pulse disappears.
What factors should be avoided before taking a blood pressure measurement?
Caffeine intake, drug use, and smoking should be avoided before a blood pressure measurement.
What is White Coat Syndrome and masked hypertension?
White Coat Syndrome refers to higher blood pressure readings in a clinical setting due to anxiety, while masked hypertension is when blood pressure is normal in the clinic but elevated in everyday life.
What is Home Blood Pressure Monitoring (HBPM) and how can it benefit patients?
HBPM allows patients to take their own BP readings at home, helping avoid White Coat Syndrome. Studies show home readings can be about 30 mmHg lower than office readings. It is also more cost-effective than ambulatory BP monitoring.
What is Ambulatory Blood Pressure Monitoring (ABPM) and how does it work?
ABPM involves wearing a device that measures blood pressure every 30 minutes during the day and hourly at night for 24 hours, providing a comprehensive picture of the patient’s overall blood pressure.
What is a hypertensive crisis, and how is it defined?
A hypertensive crisis is an acute increase in blood pressure (>180/120 mmHg) that can cause or worsen end-organ damage. It is further subdivided into hypertensive urgency and hypertensive emergency.
What is aortic stenosis (AS)?
Aortic stenosis is a valvular heart disease characterized by the narrowing of the aortic valve, reducing the normal orifice size from about 4 cm² to less than 1 cm² in severe cases, obstructing blood flow from the left ventricle into the aorta.
What are the consequences of aortic stenosis on the left ventricle?
Aortic stenosis leads to chronic and progressive excess load on the left ventricle, potentially resulting in left ventricular failure.
What are the common symptoms of aortic stenosis when it becomes symptomatic?
Common symptoms of symptomatic aortic stenosis include syncope, angina pectoris, and dyspnea upon exertion.
What is a key finding during auscultation in a patient with aortic stenosis?
Auscultation reveals a harsh, crescendo-decrescendo systolic murmur that radiates to the carotids, and there are delayed and diminished carotid upstrokes.
What is the gold standard for diagnosing aortic stenosis?
Echocardiography is the noninvasive gold standard for diagnosing aortic stenosis.
How is mild asymptomatic aortic stenosis managed?
Mild asymptomatic aortic stenosis is managed conservatively with monitoring and medical treatment of related conditions such as hypertension.
What is the definitive treatment for symptomatic or severe aortic stenosis?
The definitive treatment for symptomatic or severe aortic stenosis is aortic valve replacement (AVR), either through surgical AVR or transcatheter AVR (TAVR) for high-risk patients.
What acute complications are patients with severe aortic stenosis at risk for?
Patients with severe aortic stenosis are at high risk for acute complications such as heart failure and cardiogenic shock, requiring critical care and expedited surgery or TAVR.
What is the most common valvular heart disease in industrialized countries?
Aortic stenosis is the most common valvular heart disease in industrialized countries.
What are the most common causes of aortic stenosis?
The most common causes of aortic stenosis are:
Aortic valve sclerosis (calcification and fibrosis of the leaflets), which is prevalent in older patients.
Bicuspid aortic valve, which predisposes the valve to calcification.
Rheumatic fever (less common, often affects the mitral valve).
Endocarditis (least common cause).
What condition related to aging is the most common cause of aortic stenosis?
Aortic valve sclerosis, the calcification and fibrosis of the leaflets, is the most common cause of aortic stenosis and increases in prevalence with age (35% of patients over 80).
How does a bicuspid aortic valve contribute to aortic stenosis?
A bicuspid aortic valve, caused by the fusion of two leaflets in utero, predisposes the valve to dystrophic calcification, leading to aortic stenosis.
What is the pathophysiology of aortic stenosis?
A narrowed aortic valve opening during systole obstructs blood flow from the left ventricle, increasing LV pressure, leading to left ventricular concentric hypertrophy, which results in increased LV oxygen demand and impaired ventricular filling during diastole, causing left heart failure.
What are the three major symptoms (SAD) associated with severe aortic stenosis?
The three major symptoms (SAD) of severe aortic stenosis are syncope, angina pectoris, and dyspnea.
What are some physical exam findings in aortic stenosis?
Physical exam findings include small BP amplitude, decreased pulse pressure, and a weak and delayed distal pulse known as “pulsus parvus et tardus.”
What is a key auscultation finding in aortic stenosis?
A harsh crescendo-decrescendo systolic murmur best heard in the 2nd right intercostal space, which may also radiate to the carotids, is a key auscultation finding in aortic stenosis.
What characterizes severe aortic stenosis during auscultation?
Severe aortic stenosis is characterized by a soft S2 sound and may also have an early systolic ejection click.
What is the preferred method for diagnosing aortic stenosis?
Echocardiography is the preferred method for diagnosing aortic stenosis, assessing LV function, wall thickness, valve area, and transvalvular systolic gradient.
What are the two types of echocardiography used to diagnose aortic stenosis?
Transthoracic echocardiography (TTE) is the primary noninvasive test, while transesophageal echocardiography (TEE) is used for confirmation of TTE findings.
Is there any medical therapy that improves outcomes in aortic stenosis?
No medical therapy can improve the outcome of aortic stenosis, though coexisting hypertension should be treated and sinus rhythm should be maintained.
What are the indications for intervention in aortic stenosis?
Intervention is indicated in symptomatic patients with severe, high-gradient aortic stenosis (mean gradient ≥40 mmHg) and asymptomatic patients with severe AS and reduced LVEF (<50%).
When is surgical aortic valve replacement (AVR) recommended?
Surgical aortic valve replacement is recommended for patients with low surgical risk.
When is transcatheter aortic valve replacement (TAVR) recommended?
TAVR is recommended for patients unsuitable for surgery or those with high surgical risk.
What is transcatheter aortic valve replacement (TAVR), and when is it performed?
TAVR is a procedure for high-risk surgical patients with severe aortic stenosis and a predicted survival of over 12 months. It can be performed via transfemoral, transaortic, or transapical routes.
What is percutaneous balloon valvuloplasty, and who is it used for?
Percutaneous balloon valvuloplasty is used in younger patients without aortic valve calcification to relieve aortic stenosis.
- What is ischemic heart disease (IHD) and its most common cause?
Ischemic heart disease (also known as coronary artery disease) is most commonly caused by atherosclerosis, which leads to a reduced blood supply to the myocardium, causing a mismatch between oxygen supply and demand.
What is the cardinal symptom of ischemic heart disease?
The cardinal symptom of ischemic heart disease is acute retrosternal chest pain, also known as angina.
What are other common symptoms of ischemic heart disease besides angina?
Other common symptoms include dyspnea, dizziness, anxiety, and nausea.
What can severe myocardial ischemia lead to?
Severe myocardial ischemia can lead to myocardial infarction (MI).
How is ischemic heart disease diagnosed?
Ischemic heart disease is diagnosed using a cardiac stress test and/or coronary catheterization.
What are the main components of ischemic heart disease management?
Management includes primary and secondary prevention of atherosclerosis, antianginal treatment, and, in severe cases, revascularization.
How is ischemic heart disease subdivided?
Ischemic heart disease is subdivided into Chronic (Stable) Coronary Syndrome and Acute Coronary Syndrome.
What are INOCA and MINOCA in the context of ischemic heart disease?
INOCA refers to ischemia with no obstructive coronary artery disease, while MINOCA refers to myocardial infarction with nonobstructive coronary arteries.
What are the main risk factors for ischemic heart disease?
The main risk factors include diabetes mellitus, family history, smoking, hyperlipidemia, obesity, hypertension, and age.
What is the leading cause of death worldwide, and what is its most common underlying cause?
Coronary artery disease (CAD) is the leading cause of death worldwide, with atherosclerosis being the most common underlying cause.
What are the possible clinical manifestations of ischemic heart disease?
The clinical manifestations include asymptomatic cases (less than 70% stenosis), angina (stable or unstable), myocardial infarction (MI), and sudden cardiac death.
What is the first step in diagnosing ischemic heart disease?
The first step is taking the patient’s history and conducting a physical examination.
What is the best initial test for all types of chest pain?
A resting ECG is the best initial test for all types of chest pain.
What ECG findings may indicate a previous MI or unstable angina?
ST-segment depression or T-wave inversion/flattening may indicate a previous MI or unstable angina.
What is the test of choice for diagnosing stable ischemic heart disease?
A cardiac exercise stress test is the test of choice for diagnosing stable ischemic heart disease.
When is a cardiac pharmacological stress test performed?
It is performed when a patient cannot exercise or has contraindications for exercising, using agents like dobutamine.
What is the gold standard for diagnosing coronary artery disease (CAD)?
Cardiac catheterization is the gold standard for diagnosing CAD.
What is Holter monitoring used for in ischemic heart disease?
Holter monitoring is used to detect silent ischemia.
What do elevated heart enzymes such as troponin, creatine kinase, and myoglobin indicate?
Elevated heart enzymes in the blood indicate heart damage, such as from a myocardial infarction (MI).
What does coronary angiography involve, and what does it diagnose?
Coronary angiography involves injecting dye into the heart’s blood vessels and taking X-ray images to diagnose blockages in coronary arteries.
How are cardiac CT and MRI used in diagnosing coronary artery disease?
Cardiac CT and MRI provide detailed images of the heart and blood vessels, showing artery narrowing or heart enlargement.
What are the general treatment approaches for coronary artery disease?
All patients should reduce risk factors and start on antiplatelet drugs. Mild CAD is treated with pharmacologic therapy, moderate CAD may require coronary angiography and PCI, and severe CAD may need revascularization or coronary artery bypass grafting (CABG).
What is the first-line antianginal treatment for ischemic heart disease?
First-line antianginal treatment includes β-blockers and nitrates.
What are second-line antianginal medications?
Second-line antianginal medications include calcium channel blockers (CCBs) and ranolazine.
What are the two types of revascularization procedures for treating CAD?
The two types of revascularization procedures are percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
What is cardiac rehabilitation, and what is its main goal?
Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification program aimed at helping patients restore and maintain optimal health while reducing the risk of future heart problems.
Who can benefit from cardiac rehabilitation programs?
People recovering from heart attacks, heart surgery, or percutaneous coronary intervention (PCI) procedures, such as stenting and angioplasty, can benefit from cardiac rehabilitation programs.
What are the main components of a cardiac rehabilitation program?
Components include medical evaluation, physical activity program, counseling and education, lifestyle modification, and support for returning to normal activities and work.
What is the purpose of the medical evaluation in cardiac rehabilitation?
The medical evaluation helps assess the patient’s needs and limitations, allowing the medical staff to tailor a rehabilitation program and set appropriate goals.
How is physical activity managed in cardiac rehabilitation programs?
Physical activity is tailored to the patient’s needs, and heart rate and blood pressure are monitored during exercise to ensure safety.
What types of lifestyle education are typically included in cardiac rehabilitation?
Lifestyle education includes counseling on understanding and managing the heart condition, dietary planning with a dietitian, smoking cessation, and stress management.
How long do most cardiac rehabilitation programs last?
Most cardiac rehabilitation programs last about three months, though some patients may follow the program longer or participate in an intensive program lasting one to two weeks.
Who are the members of the cardiac rehabilitation team?
The cardiac rehabilitation team includes cardiologists, nurses, dietitians, physical therapists, and mental health specialists.
In what settings can cardiac rehabilitation be performed?
Cardiac rehabilitation can be done as an inpatient program or an outpatient program, depending on the reason for therapy initiation.
What therapies are included in cardiac rehabilitation?
Therapies include nutritional therapy, weight loss programs, management of lipid abnormalities, blood pressure control, diabetes management, stress management, and smoking cessation.
What are the benefits of exercise-based programs in cardiac rehabilitation?
Exercise-based programs improve cardiac fitness, microvascular circulation, quality of life, and reduce readmission rates.
- What is heart failure (CHF) and its main causes?
Heart failure, or congestive heart failure (CHF), is a condition where the heart can’t pump enough blood to meet the body’s needs due to pathological changes in the myocardium. The three main causes are coronary artery disease (CAD), hypertension, and diabetes mellitus.
What are the two types of ventricular dysfunction in heart failure?
The two types are systolic dysfunction (HFrEF) and diastolic dysfunction (HFpEF). Systolic dysfunction is characterized by the heart’s inability to pump effectively, while diastolic dysfunction is related to impaired filling of the heart.
What are the common causes of systolic and diastolic dysfunction in heart failure?
Systolic dysfunction (HFrEF): CAD, MI, hypertension, valvular heart disease, diabetic cardiomyopathy, dilated cardiomyopathy, arrhythmias, myocarditis.
Diastolic dysfunction (HFpEF): Restrictive cardiomyopathy, hypertrophic cardiomyopathy, pericardial tamponade, constrictive pericarditis.
What are the clinical features of left-sided heart failure (LHF) and right-sided heart failure (RHF)?
LHF: Leads to pulmonary edema causing dyspnea (shortness of breath).
RHF: Leads to systemic venous congestion, causing pitting edema, jugular venous distention, and hepatomegaly.
What is biventricular (global) CHF, and how does it manifest?
Biventricular CHF involves both left and right heart failure, presenting with symptoms of both types, such as pulmonary edema, systemic venous congestion, fatigue, tachycardia, and nocturia.
What is the difference between systolic and diastolic dysfunction in terms of ejection fraction?
Systolic dysfunction (HFrEF): Increased EDV, reduced stroke volume, and ejection fraction (EF).
Diastolic dysfunction (HFpEF): Reduced stroke volume and EDV but preserved ejection fraction (EF). Normal EF is between 50%-70%.
How is congestive heart failure (CHF) diagnosed?
CHF is diagnosed based on clinical presentation and tests like brain natriuretic peptide (BNP) levels, chest X-ray, and ECG to assess severity and determine the underlying causes.
What is the main treatment approach for congestive heart failure (CHF)?
Treatment involves lifestyle modifications, managing underlying conditions (e.g., hypertension), comorbidities (e.g., anemia), and using pharmacologic agents to reduce the heart’s workload.
What are the hallmark symptoms of right-sided heart failure (RHF)?
Symptoms of RHF include pitting edema, jugular venous distension, and hepatomegaly, and it may lead to Cor pulmonale if caused by a respiratory system disorder.
What is high-output CHF, and what causes it?
High-output CHF is a rare form of heart failure caused by conditions that increase cardiac output, overwhelming the heart’s capacity to pump efficiently.
What is hypertrophic cardiomyopathy, and how does it affect the heart?
Hypertrophic cardiomyopathy occurs when the cardiac muscle wall enlarges, crowding the ventricular space, which reduces the room for ventricular filling.
What is restrictive cardiomyopathy, and how does it impact heart function?
Restrictive cardiomyopathy is when the cardiac muscle wall becomes stiff and less compliant, preventing the heart from filling properly during diastole.
What are some risk factors for congestive heart failure (CHF)?
Risk factors for CHF include obesity, smoking, COPD, and drug/alcohol abuse.
What is the Frank-Starling mechanism, and how is it affected in heart failure?
The Frank-Starling mechanism normally regulates contractility by increasing preload, but in CHF, this compensatory mechanism fails, leading to impaired cardiac output.
What are the consequences of systolic and diastolic dysfunction in heart failure?
Systolic dysfunction: Reduced cardiac output leading to poor organ perfusion, potentially causing organ dysfunction (e.g., renal failure, hypotension).
Diastolic dysfunction: Increased LV volume and pressure, leading to pulmonary congestion, edema, and organ congestion.
What is “nutmeg liver,” and what causes it?
“Nutmeg liver” is the macroscopic appearance of the liver, resembling a nutmeg seed, caused by ischemia and fatty degeneration due to hepatic venous congestion in heart failure.
What are the main clinical symptoms of left-sided heart failure?
Symptoms of left-sided heart failure include dyspnea (shortness of breath), orthopnea, paroxysmal nocturnal dyspnea, and pulmonary congestion (e.g., crackles/rales at lung bases).
What are the key signs of right-sided heart failure?
Signs of right-sided heart failure include peripheral pitting edema, jugular vein distention, nocturia, hepatomegaly, ascites, and Kussmaul sign (jugular vein distention during inspiration).
What are the NYHA (New York Heart Association) stages of heart failure?
Class I: Symptoms only occur with vigorous activity, nearly asymptomatic.
Class II: Symptoms with moderate exertion, slight limitation of activity, comfortable at rest.
Class III: Symptoms with daily activities, marked limitation, comfortable only at rest.
Class IV: Symptoms at rest, incapacitating.
What diagnostic tools are used to assess heart failure?
Transthoracic echocardiogram: Gold standard to assess systolic and diastolic function.
Chest X-ray: Shows cardiomegaly (boot-shaped heart) and pulmonary congestion.
Lab tests: Elevated BNP, NT-pro BNP, and ANP levels.
What is secondary hypertension (HTN), and how common is it in adults and children?
Secondary HTN is hypertension caused by an identifiable underlying condition. It accounts for 5-15% of cases in adults and 70-85% of cases in children under 12 years old.
What are the age groups typically associated with the onset of secondary hypertension?
Secondary hypertension typically occurs in people younger than 25 years old or older than 55 years old.
What does the pneumonic “RECENT” stand for in causes of secondary hypertension?
R: Renal (e.g., renal artery stenosis, SLE, tumors)
E: Endocrine (e.g., Cushing syndrome, Conn syndrome, hyperthyroidism)
C: Coarctation of the aorta
E: Estrogen (oral contraceptives)
N: Neurologic (e.g., increased intracranial pressure)
T: Treatment (e.g., NSAIDs, corticosteroids)
What are some renal causes of secondary hypertension?
Renal causes of secondary hypertension include renal artery stenosis, systemic lupus erythematosus (SLE), tumors, autosomal dominant polycystic kidney disease (ADPKD), and renal failure.
Name a few endocrine causes of secondary hypertension.
Endocrine causes include Cushing syndrome, Conn syndrome (primary hyperaldosteronism), and hyperthyroidism.
What medications can lead to secondary hypertension?
Medications that can cause secondary hypertension include NSAIDs, sympathomimetic drugs, and corticosteroids.
What general indicators suggest secondary hypertension?
General indicators of secondary hypertension include young age, abrupt onset, disproportionate end-organ damage, recurrent hypertensive crises, and resistant hypertension.
What diagnostic tests are used to determine the underlying cause of secondary hypertension?
Diagnostic tests may include urinalysis, complete blood count (CBC), blood chemistry profile, and imaging modalities like ultrasound of the kidney and its vessels.
What is the primary approach to treating secondary hypertension?
The primary treatment for secondary hypertension is managing the underlying cause, such as using medications or surgery (e.g., removing a tumor). Once the condition is controlled, hypertension often normalizes.
What should be done if hypertension persists after treating the underlying cause of secondary hypertension?
If hypertension remains elevated after addressing the underlying condition, both pharmacological (medications) and nonpharmacological measures (lifestyle changes) should be implemented.
- What is angina, and what causes it?
Angina is severe chest pain caused by inadequate blood supply to the heart, commonly due to atheromatous plaque buildup leading to coronary artery narrowing. Other causes include anemia, aortic stenosis, tachyarrhythmias, hypertrophic cardiomyopathy, and small vessel disease.
What distinguishes stable angina from other types of angina?
Stable angina occurs when there is over 70% stenosis of a coronary artery, leading to symptoms during physical or emotional stress, whereas it remains asymptomatic at rest.
What is Prinzmetal (vasospastic) angina, and how does it differ from stable angina?
Prinzmetal angina is caused by vasospasm of coronary vessels, typically affecting young women at rest rather than during exertion. It is associated with ST-segment elevation on ECG due to transmural ischemia, unlike stable angina.
What is the classic triad of symptoms for stable angina?
The classic triad includes substernal pain or pressure exacerbated by stress/exertion, relieved by rest or nitrates, with pain lasting usually 1-5 minutes.
What are the key clinical features associated with stable angina?
Key features include gradual onset of pain, potential radiation to the neck or arm, and associated symptoms like shortness of breath, nausea, dizziness, and lightheadedness.
What lifestyle changes can help manage stable angina?
Management includes reducing risk factors associated with ischemic heart disease (IHD), such as smoking cessation, healthy diet, and regular exercise.
What is the first-line diagnostic test for stable angina?
An ECG is the first-line test for chest pain; however, it is usually normal in stable angina but may show signs of past myocardial infarction (MI) or ST-segment depression.
What are the steps in diagnosing stable angina?
Diagnosis includes:
ECG: Normal in stable angina.
Cardiac enzyme tests: Should be normal.
Stress testing: Exercise or pharmacologic stress test.
Coronary angiography: Definitive test for coronary artery disease (CAD).
How is Prinzmetal angina diagnosed?
Coronary angiography is definitive and can show vasospasm when provoked with IV ergonovine or acetylcholine.
What are the main treatment strategies for stable and vasospastic angina?
Treatment strategies aim to reduce heart oxygen demand (using nitrates, CCBs, beta-blockers) and increase oxygen delivery (using nitrates and CCBs to relieve vasospasm).
What specific treatments are recommended for stable angina?
Risk factor management: Lifestyle changes and medication adherence.
Aspirin and β-blockers: Shown to decrease mortality.
Nitroglycerin: Causes vasodilation, reduces preload and cardiac work, thereby reducing oxygen demand.
What is the role of nitroglycerin in treating stable angina?
Nitroglycerin acts as a vasodilator, reducing preload and cardiac work, leading to decreased oxygen demand in the heart.
What is pulmonary hypertension (PH) and its definition?
Pulmonary hypertension (PH) is defined as elevated pressure in the pulmonary arteries, measured at ≥ 25 mm Hg at rest. It can be idiopathic or secondary to chronic pulmonary or cardiac diseases.
What are the potential consequences of untreated pulmonary hypertension?
Over time, PH can lead to structural changes (dilation or hypertrophy) and impaired function of the right ventricle, potentially resulting in cor pulmonale.
What is cor pulmonale?
Cor pulmonale is the alteration in structure and function of the right ventricle caused by a primary disorder of the respiratory system, most commonly due to pulmonary hypertension.
