Cardiovascular Flashcards

Question

S3 Heart Sound **Usually indicative of? (1)** Occurs during early _____ (also called (2)) Sounds like what word? Always considered abnormal if it occurs after ___ yo This can be a normal finding in (3)

Answer 1

**Heart Failure/CHF** Occurs during early diastole (aka “ventricular gallop”, “S3 gallop") “Kentucky” Always considered abnormal if it occurs after 40yo Can be normal in children, pregnant women, some athletes (\>35yo)

Answer 2

Increased resistance dt stiff left ventricle → LVH Occurs during late diastole ("atrial gallop", “atrial kick”) “Tennessee" Apex (apical area/mitral area), Bell of stethoscope

Answer 3

Low tones (S3 or S4) Mitral Stenosis

Answer 4

Mid-high pitched tones such as lung sounds Mitral regurgitation, Aortic Stenosis

Answer 5

Physiological S2 Split S4 in the Elderly

Answer 6

Splitting of aortic and pulmonic components Pulmonic area (second ICS upper left of sternum) + inspiration, - expiration

Answer 7

“Atrial kick” (atria have to squeeze harder to overcome resistance of stiff left ventricle) No S/S of heart/valvular disease Pathological if associated with LVH (resistance from left ventricle)

Answer 8

Timing of murmur (systole or diastole) Location of murmur (Aortic, Erb's point, or Mitral area)

Answer 9

**MR. ASS** **Mitral Regurgitation, Aortic Stenosis** * S1 * holosystolic, pansystolic, early systolic, late systolic, midsystolic * Louder * Can radiate to Neck or Axillae

Answer 10

MS. ARD **Mitral Stenosis, Aortic regurgitation** * S2 * Early diastole, Late diastole, Mid diastole * Always indicative of heard disease

Answer 11

Mitral area is known as the *apex (apical area (PMI) of the heart)* 5th left intercostal 8-9cm from midsternal line, slightly medial to midclavicular line

Answer 12

Right second ICS by the right side of the sternum at the base of the heart

Answer 13

Left 3rd-4th intercostal left sternal border

Answer 14

A pansystolic (holosystolic) murmur Best heard at the apex (apical area) of the heart May radiate to axilla Loud blowing and high-pitched murmur (use the diaphragm of the stethoscope)

Answer 15

A midsystolic ejection murmur Best heard right side 2nd ICS May radiate to the neck A harsh and noisy murmur (use diaphragm of the stethoscope) Patients with this should avoid overexertion bc increased risk of death → refer to cardiologist to be monitored by doppler flow studies Surgical valve replacement may be needed if worsens

Answer 16

Also called an *opening snap,* use bell of stehoscope Best heard at the apex (apical area)

Answer 17

A high pitched diastolic murmur (use diaphragm of stethoscope) * If AR due to **diseased aortic valve** = heard at Erb's point * If AR due to **abnormal aortic root** = heard at Aortic area

Answer 18

1. A very soft murmur heard only under optimal conditions 2. Mild to moderately loud murmur 3. Loud murmur that is easily heard once the stethoscope is placed on the chest 4. A louder murmur. First time that a thrill (palpable murmur) is present. 5. Very loud murmur heard with edge of stethoscope off the chest. Thrill is more obvious. 6. Murmur is so loud that it can be heard even without stethoscope. Thrill is easily palpated

Answer 19

All diastolic murmurs are abnormal. All benign murmurs occur during systole. Benign murmurs do not have a thrill; only very loud murmurs will produce a thrill.

Answer 20

1. There are usually **two** questions regarding heart murmurs on the exam. 2. Learn to use the mnemonics **“MR. ASS” and “MS. ARD.”** 3. All murmurs with “**mitral**” in their names are only described as located: 1. On the apex (or apical area) of the heart or 2. On the fifth ICS on the left side of the sternum medial to the midclavicular line 4. If an apical/apex murmur occurs during S1, it is **mitral regurgitation (MR. ASS)**. If an apical/apex murmur occurs during S2, it is **mitral stenosis (MS. ARD)**. 5. On the exam, **only the systolic murmurs radiate** (to the **axilla in mitral regurgitation** and to the **neck with aortic stenosis).**

Answer 21

1. S3 is a sign of **CHF**; S4 is a sign of **LVH**. 2. A physiological split S2 is best heard at the **pulmonic** area (upper left sternum). 3. Memorize the mnemonic “**motivated apples**” to help you remember the names of the valves that are responsible for producing S1 and S2. 4. Grading murmurs: Be aware that the first time a **thrill** is palpated is at **grade IV**. 5. Rule out **AAA** in an older male who has a **pulsatile abdominal mass** that is more than 3 cm in width. The next step is to order an abdominal **ultrasound** and **CT**. 6. Learn the signs/symptoms of **IE** (bacterial endocarditis).

Answer 22

1. Only 1 or none EKG strips will appear per exam 2. Occasionally, an arrhythmia will be described without a strip such as “irregularly irregular rhythm with no visible P waves (AF)” 3. Most common arrhythmias included bc FNP and AGNP function in primary care, not expected to interpret EKG strip with AV block or other complex arrhythmias 4. Important rhythms 1. **AF** = irregularly irregular rhythm w no P waves 2. **Anterior wall MI**= ST segment elevation in leads V2-V4 3. **Ventricular tachycardia** = jagged irregular QRS

Answer 23

Atrial Fibrillation

Answer 24

Anterior Wall MI ST segment elevation + wide QRS Wide QRS in V2-V4 called “TOMBSTONING”

Answer 25

Sinus Arrhythmia More common in healthy children and young adults P waves are uniform but the PP interval varies during inspiration and exhalation

Answer 26

Atrial Fibrillation

Answer 27

Atrial Flutter

Answer 28

1. HTN 2. CAD 3. ACS 4. LVH 5. Stimulants like caffeine, cocaine, nicotine, amphetamine 6. Hyperthyroidism 7. Alcohol ("holiday heart") 8. Pulmonary embolism 9. COPD 10. Sleep apnea

Answer 29

Paroxysmal AF (Persistent AF = \>12m) Call 911 if new onset AF w severe sx

Answer 30

Atrial Fibrillation

Answer 31

CHAD2 Score

Answer 32

1. C = CHF 2. H = HTN 3. A = Age \>75 4. D = Diabetes 5. S2 = Stroke or TIA 6. V = Vascular disease 7. A = Age 65-74 8. S = Sex female gender higher risk

Answer 33

Low risk score = 0 Score of 2 = anticoagulation (however some physicians will treat score of 1)

Answer 34

1. EKG, Echo (RO valvular pathology) 2. TSH, Electrolytes (Ca, K, Mg, Na), Renal function, BNP (RO HF), Troponin (RO MI) 3. 24 hours Holter monitor 4. Dig level if on digoxin 5. Avoid stimulants in the meantime (caffeine, cocaine, nicotine, decongestants) and alcohol

Answer 35

1. Beta Blockers, Calcium Channel Blockers, Digoxin 2. Amiodarone 3. Warfarin (Coumadin) for valvular AF 4. DOACS first line for nonvalvular AF

Answer 36

* Pulmonary toxicity * Hepatic injury * Hyper or hypothyroidism * Visual impairment * Peripheral neuropathy * Worsened arrythmia

Answer 37

Abnormal/Damaged heart valves and CKD INR, aPTT, CBC (to check platelets), Creatinine, LFTs INR, PT, PTT

Answer 38

5mg daily 2.5mg daily 3 days for full effect Check INR Q2-3 days until therapeutic for 2 consecutive checks, then recheck weekly until INR 2-3 Q4 weeks when stable

Answer 39

1. Glucocorticoids 2. SSRIs and SNRIs 3. Fluoroquinolones 4. Macrolides 5. Penicillins 6. Azole antifungals 7. Statins 8. Tramadol, fenofibrate, trimethoprim-sulfamethoxazole

Answer 40

* Dabigatran (Pradaxa) * Rivaroxaban (Xarelto) * Edoxaban (Savaysa) * Apixaban (Eliquis) Advise pts to take meds on schedule and do not skip doses bc effect is lost after 12 hours Does not require INR monitoring, no major dietary restrictions, has fewer drug interactions

Answer 41

* Death by a thromboembolic event (ie stroke, PE), CHF*,* angina * Warfarin associated intracerebral hemorrhage has very high mortality and causes 90% of warfarin deaths (medical emergency, call 911) 1. **Warfarin associated life threatening bleeding episode** 2. **DOAC associated life threatening bleeding episode**

Answer 42

1. Stop Warfarin and all anticoagulants such as ASA, NSAIDs 2. Give vitamin K **,** 4-factor prothrombin complex concentrate (PCC, inactivated), or fresh frozen plasma 3. Check labs INR, PT, and PTT

Answer 43

**Andaxanet alfa (Andexxa)** **Idarucizumab (Praxbind)**

Answer 44

**Afib = INR 2-3** **Synthetic/Prosthetic Values = INR 2.5-3.5**

Answer 45

Skip next dose or slightly reduce maintenance dose, check INR 1-2x per week when adjusting dose. Do NOT give vitamin K. (if INR only minimally elevated, maintenance dose does not need to be reduced) Hold one or two doses, with or without giving Vitamin K (1-2.5mg), Monitor INR every 2-3 days until stable. Decrease warfarin maintenance dose

Answer 46

1. Advise patients to be consistent with their day-to-day consumption of vitamin K foods. 2. Give patient a list of foods with high levels of vitamin K (“greens” such as kale, collard, mustard, spinach, iceberg or romaine lettuce, brussels sprouts, potatoes). 3. Only one serving per day is recommended for very high vitamin K foods.

Answer 47

Paroxysmal Supraventricular Tachycardia Wolff Parkinson-White (WPW) syndrome Atrial Tachycardia *Can be misdiagnosed as a panic attack*

Answer 48

Paroxysmal Supraventricular Tachycardia

Answer 49

Refer to Cardiologist or Call 911 if hemodynamically unstable, may need cardioversion *WPW increases risk of death → refer to cardiologist for catheter ablation*

Answer 50

1. Vagal Maneuver **Carotid Sinus Massage**: pt supine, monitor VS/continuous 12-lead EKG if in clinical setting, change in HR/rhythm and/or BP is a + response 1. CI = hx TIA or stroke within last 3m, presence of carotid bruits, etc 2. Valsalva Maneuver = holding breath and straining hard for 10-15 seconds, then release and breath normally

Answer 51

Pulses Paradoxus (paradoxical pulse) important sign of cardiac tamponade\* Asthma, Emphysema (increased + pressure) Cardiac tamponade, Pericarditis, Cardiac effusion (decreased movement of left ventricle)

Answer 52

1. PR interval = atrial depolarization, 0.12-0.20 seconds (3-5 small boxes) 2. 1 EKG strip, or none 3. Sinus arrhythmia, Afib, and anterior wall MI (tombstone like pattern)! 4. INR 2-3 for afib. If INR 4.01-4.99, hold one dose, do not give vitamin K 5. Drop in SBP \>10 during inspiratory phase

Answer 53

1. Major bleeding episodes can occur even with a normal INR. Order an INR with the PT and PTT if you suspect bleeding. 2. It may take up to 3 days after changing the warfarin dose to see a change in the INR. 3. Warfarin (Coumadin) is an FDA category X drug. It is teratogenic.

Answer 54

BP \>130/80 Primary (Essential) HTN most common Secondary HTN 5-10% Lifestyle nonpharm treatment for majority of newly diagnosed HTN Lifestyle + Pharm tx for newly diagnosed with risk factors

Answer 55

**2 serial BP measurements 1-4 weeks apart** * Important to compare home BP to office BP, difference of _\<_ 5mmHg is not significant * Instruct about accurate size of cuff, if cuff is too small it will falsely elevate BP * Advise patient to take it at different times of the day and during work * RO white coat HTN if home BP lower than office BP several times

Answer 56

* Avoid consuming caffeine or smoking 30min before measurement * Legs should not be crossed * Begin measurement after 5 min of rest * Mercury sphygmomanometer preferred over digital machines * 2 or more readings separated by 2 min should be averaged per visit * Higher number determines BP stage

Answer 57

**Normal** \<120 and \<80 **Elevated** 120-129 and \<80 **Stage 1** 130-139 or 80-89 **Stage 2** 140 or higher or 90 or higher

Answer 58

Start at 18yo, annually if normal, semiannually (twice/year) if risk factors present

Answer 59

**NA + (sodium)** * water retention increases vascular volume, resulting in increased CO part of the equation (BP increases) * Renin levels are higher in younger and white patients **Angiotensin I and Angiotensin II** * This hormone increases vasoconstriction and will increase PVR (BP increases) **Sympathetic System Stimulation** * Stimulation of this system causes increases in epinephrine and cortisol secretion which increases PVR (BP increases)

Answer 60

**Alpha-Blockers, Beta-Blockers, Calcium-Channel Blockers** * Drugs decrease peripheral vascular resistance from vasodilation (BP decreases). **Pregnancy** * Systemic vascular resistance is lowered because of hormones (SBP and diastolic blood pressure [DBP] decrease during the first and second trimesters). * The S3 heart sound is common in the third trimester of pregnancy. * Drugs used to control BP in pregnancy are methyldopa, labetalol, beta-blockers, and diuretics.

Answer 61

1. *Kidneys:* Creatinine, estimated glomerular filtration rate (eGFR), urinalysis 2. *Endocrine:* TSH, fasting blood glucose 3. *Electrolyte:* Potassium (K⁺), sodium (Na⁺), calcium (Ca²⁺) 4. *Heart:* Cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (complete lipid panel) 5. *Anemia:* CBC 6. Baseline EKG and chest x-ray (to rule out cardiomegaly)

Answer 62

* **Eyes** * Silver and/or Copper wire arterioles * Arteriovenous junction nicking (caused when an arteriole crosses on top of a vein) * Flame-shaped hemorrhages, papilledema * **Kidneys** * Microalbuminuria and Proteinuria * Elevated serum Cr, eGFR (ro kidney disease) * Peripheral or generalized edema

Answer 63

* Heart * S3 (CHF) * S4 (LVH) * Carotid bruits (narrowing due to plaque, increased risk of CAD) * CAD and acute MI * Decreased or absent peripheral pulses (peripheral arterial disease [PAD]) * Brain * TIAs * Hemorrhagic Strokes

Answer 64

In about 5-10% of patients with HTN, there is a secondary cause. If the condition is correctable and/or treatable, then the HTN will resolve. The causes of secondary HTN can be classified into three major groups: 1. ***Renal** (renal artery stenosis, polycystic kidneys, CKD)* 2. ***Endocrine** (hyperthyroidism, hyperaldosteronism, pheochromocytoma)* 3. ***Other causes** (obstructive sleep apnea, coarctation of the aorta)* * Renal artery stenosis more common in younger, Endocrine related disorders more common in middle aged, CKD more common in elderly

Answer 65

1. Age **\< 30 years** 2. **Severe HTN or acute rise in BP** (previously stable patient) 3. **Resistant HTN** despite treatment with at least **three antihypertensive agents** 4. **Malignant HTN** (severe HTN with **end-organ damage** such as retinal hemorrhages, papilledema, acute renal failure, and severe headache)

Answer 66

1. Usually, SBP is higher on the legs (normal finding) because it takes more force to circulate the blood back to the heart. 2. But with coarctation, the opposite is found. If there is a narrowed aorta in the abdomen (abdominal aorta), the part of the body above the narrowed aorta (the arms) will have higher BP and bounding pulses. The part of the body below the narrowed aorta (the legs) will have lesser blood flow, so the SBP on the legs will be lower, and the pulses will be weaker. 3. Look for delayed or diminished femoral pulses (check both radial and femoral pulse at the same time and compare).

Answer 67

Sleep partner will report severe snoring with apneic episodes during sleep. Marked hypoxic episodes during sleep increase BP.

Answer 68

* **Renal artery stenosis**: Bruit epigastric, abdomen, or flank area (renal artery stenosis): avoid angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) * **Polycystic kidney** = Enlarged kidneys with cystic renal masses (polycystic kidney) * **Renal insufficiency to Acute Kidney Failure** = Increased creatinine and decreased eGFR

Answer 69

Aldosterone helps control BP by sodium retention and potassium excretion Most common cause is an aldosterone-producing adenoma (usually benign) and less commonly adrenal cancer Surgical removal of tumor HTN + hypokalemia + normal to elevated sodium levels

Answer 70

* Weight loss, tachycardia, fine tremor, moist skin, anxiety * New onset of AF (check EKG) * Check TSH

Answer 71

**Excessive secretion of catecholamines (severe HTN, arrhythmias)** * Labile increase in BP accompanied by palpitations * Sudden onset of anxiety, sweating, severe headache * Order plasma-free metanephrine (high-risk patient) or urine metanephrines fractionated (low risk)

Answer 72

**Hypertensive Urgency** Noncompliance with antihtn therapy Restart or intensify antihtn therapy with close follow up

Answer 73

**Hypertensive Emergency** Call 911

Answer 74

**Masked Hypertension**

Answer 75

* Caused by loss of recoil in the arteries (atherosclerosis), which increases PVR. * Pulse pressure (SBP – DBP) increases in this disorder. * Emphasize nonpharmacologic treatment, especially dietary salt restriction and weight loss in the obese. Treat BP in older or frailer patients carefully; start at lower doses and titrate up slowly so that it takes about 3 to 6 months. * Initial monotherapy with a low-dose thiazide diuretic, a CCB (long-acting dihydropyridine), or an ACEI or ARB.

Answer 76

**Orthostatic Hypotension**

Answer 77

* Check BP in both supine and standing positions, especially in the elderly, before and after treatment for HTN * Check for polypharmacy, carefully review the medication history, and search for meds that lower BP * Ask patient if dizzy or lightheaded with changes in position

Answer 78

1. First, assess 10-year risk for heart disease using the new ASCVD (atherosclerotic cardiovascular disease) Risk Estimator Plus calculator at [http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate](http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate). 2. Reassess in 1 month for effectiveness of BP-lowering medication therapy. 3. If goal is met at 1 month, reassess in 3 to 6 months. 4. If goal is not met after 1 month, consider different medication or titration. 5. Continue monthly follow-up until BP control is achieved.

Answer 79

SBP \<120 and DBP \<80 Encourage heart-healthy lifestyle, evaluate yearly

Answer 80

SBP 120 to 129 mmHg and DBP \<80 mmHg Recommend heart-healthy lifestyle and weight loss if overweight/obese. Reassess in 3 to 6 months. No more “prehypertension” stage; instead, it is known as “elevated BP.”

Answer 81

SBP 130-139 or DBP 80-89 ## Footnote * Goal BP:* \<130/80 mmHg. * Risk less than 10%:* Start with healthy lifestyle recommendations and reassess in 3 to 6 months. * Risk greater than 10% or known clinical cardiovascular disease (or diabetes, CKD):* Lifestyle recommendations and BP-lowering medication.

Answer 82

SBP 140 or higher OR DBP 90 or higher ## Footnote *Goal BP:* \<130/80 mmHg Lifestyle changes and BP-lowering medications (two meds of different classes). Reassess BP in 1 month. If goal is met after 1 month, reassess in 3 to 6 months. If goal not met after 1 month, consider different medications or titration. Continue monthly follow-up until BP control is achieved.

Answer 83

**Weight** 1. Lose weight if overweight (body mass index [BMI] 25–29.9) or obese (BMI 30 or higher). 2. Normal weight is a BMI of 18.5 to 24.9. **Smoking** 1. Stop smoking. Reduce stress level. **Sodium and Potassium** 1. *Reduce dietary sodium:* \<1.5 g per day (1,500 mg/d) 2. Maintain adequate dietary intake of potassium (\>3,500 mg/day) in patients with normal kidney function. **Limit Alcohol Intake** 1. For men: 1 ounce (30 mL); up to two drinks or less per day 2. For women: 0.5 ounce; up to one drink or less per day 3. Eat fatty cold-water fish (salmon, anchovy) three times a week.

Answer 84

* Goal is to eat foods rich in potassium, magnesium, and calcium. * Reduce red meat and processed foods. * Eat more whole grains and legumes. * Eat more fish and poultry. * This diet is high in fruits and vegetables, has moderate low-fat dairy, and is low in animal protein.

Answer 85

1. *Grains:* Seven to eight daily servings 2. *Fruits and vegetables:* Four to five daily servings 3. *Nuts, seeds, and dry beans:* Four to five servings per week 4. *Fats, oils, or fat-free dairy products:* Two to three daily servings 5. *Meat, poultry, and fish:* Two or fewer daily servings 6. *Sweets:* Try to limit to fewer than five servings per week 7. *Avoid high-sodium foods:* Cold cuts, ready-made foods, any pickled foods (cucumbers, eggs, pork parts

Answer 86

* Calcium (low-fat dairy) * Potassium (most fruits and vegetables) * Magnesium (dried beans, whole grains, nuts) * Omega-3 oils (anchovy, krill, salmon, flaxseed)

Answer 87

* *Frequency:* Three or four sessions per week * *Intensity:* Moderate to vigorous (50%–80% of exercise capacity) * *Duration:* 40 minutes average * *Modalities:* Walking, treadmill, cycling, rowing, stair climbing; include resistance exercises for 2 to 3 days (e.g., elastic bands, weight machines, dumbbells)

Answer 88

* All diuretics will decrease blood volume, venous pressure, and preload (cardiac filling). * Effect is antagonized by NSAIDs. Monitor electrolytes, especially sodium (Na+) and potassium (K+).

Answer 89

Controls BP by **inhibiting reabsorption of sodium and chloride ions in the distal tubules of the kidneys.** Have a favorable effect with **osteopenia/osteoporosis** (slows down demineralization) by slowing down calcium excretion by the kidneys. Can cause **photosensitivity** reaction **(avoid tanning).** All thiazides contain sulfa compounds. Avoid if patient has a **sulfa allergy.**

Answer 90

1. **Hyperglycemia** (be careful with diabetics) 2. **Hyperuricemia** (can precipitate a gout attack; contraindicated in gout) 3. **Hypertriglyceridemia** and **hypercholesteremia** (check lipid profile) 1. **Hypokalemia** (potentiates digoxin toxicity, increases risk of arrhythmias) 2. **Hyponatremia** (hold diuretic, restrict water intake, replace K+ loss) 3. **Hypomagnesemia**

Answer 91

* Gout * Hypotension * Hypokalemia * Renal failure * Lithium treatment * Sensitivity to sulfa drugs and thiazides

Answer 92

Hydrochlorothiazide 12.5 to 25 mg PO daily Chlorthalidone (Hygroton) 12.5 to 25 mg PO daily Indapamide (Lozol) PO daily Chlorothiazide (Diuril) daily or divided dose

Answer 93

Inhibit the sodium–potassium–chloride pump of the kidney in the loop of Henle. Furosemide (Lasix) PO BID Bumetanide (Bumex) PO BID

Answer 94

* Hypokalemia (potentiates digoxin toxicity, increases risk of arrhythmias) * Hyponatremia (hold diuretic, restrict water intake, replace K+ loss) * Hypomagnesemia * Possibly altered excretion of lithium and salicylate

Answer 95

Anuria (kidney failure) Sensitivity to loop diuretics

Answer 96

If people are allergic to sulfa, they may have cross-sensitivity to thiazides and loop diuretics. Other drugs with sulfa are sulfonylureas, sulfa antibiotics, sulfasalazine, and some protease inhibitors (darunavir, fosamprenavir). May also be sensitive to topical sulfas (ophthalmic drops) or topical silver sulfadiazine (Silvadene).

Answer 97

*Action:* Spironolactone antagonizes the action of aldosterone. Increases elimination of water in the kidneys and conserves potassium. Drug class also known as *mineralocorticoid receptor antagonists* or *antimineralcorticoids.* * Spironolactone (Aldactone) daily * Eplerenone (Inspra) daily *Indications:* Resistant HTN, heart failure, hirsutism, acne, precocious puberty, primary aldosteronism Very high risk of hyperkalemia if used with ACEIs, ARBs, potassium supplements, or NSAIDS. Monitor carefully for hyperkalemia

Answer 98

* Gynecomastia, galactorrhea * Hyperkalemia * Gastrointestinal (GI; vomiting, diarrhea, stomach cramps) * postmenopausal bleeding * erectile dysfunction

Answer 99

* Hyperkalemia (serum potassium \>5.5 mEq/L) * Renal insufficiency (serum creatinine \>2.0 mg/dL in men or \>1.8 mg/dL for women) * Type 2 DM with microalbuminuria

Answer 100

**Binds with beta-receptors on the heart and peripheral blood vessels. Decreases vasomotor activity, decreases CO, and inhibits renin (kidneys) and norepinephrine release.** ## Footnote Avoid abrupt discontinuation after chronic use. Wean slowly. May precipitate angina and MI. Two types of beta-receptors in the body: B1 (cardiac effects) and B2 (e.g., lungs, vascular smooth muscle).

Answer 101

Asthma, COPD, chronic bronchitis, emphysema (chronic lung disease) Second- and third-degree heart block (fine to use with first-degree block) Sinus bradycardia

Answer 102

1. ***Acute MI:*** Reduces mortality during acute MI and post-MI 2. ***Migraine headache**:* For prophylaxis only (not for acute attacks) 3. ***Glaucoma**:* Reduces intraocular pressure (Betimol ophthalmic drops for open-angle glaucoma) 4. ***Resting tachycardia*** (target heart rate \<100 beats/min) 5. ***Angina pectoris**:* Treats symptoms 6. ***Hyperthyroidism/thyroid storm and pheochromocytoma**:* Controls symptoms until primary disease is treated 7. ***Essential tremor:*** Treat symptoms with nonselective beta-blocker propranolol

Answer 103

Atenolol (Tenormin) Metoprolol (Lopressor) Bisoprolol

Answer 104

Propranolol (Inderal) Timolol Pindolol

Answer 105

Labetalol (Normodyne) Carvedilol

Answer 106

Blocks voltage-gated calcium channels in cardiac smooth muscle and the blood vessels. Results in systemic vasodilation.

Answer 107

**Nondihydropyridines** type of CCBs have greater depressive effect on cardiac conduction and contractility (negative inotropic effect). - **Verapamil, Diltiazem** ## Footnote **Dihydropyridines** type of CCBs are potent vasodilators with little to no negative impact on contractility or conduction.

Answer 108

1. HTN 2. Angina 3. Arrhythmias 1. Second- and third-degree heart block (fine to use with first-degree block) 2. Bradycardia 3. CHF

Answer 109

* Headaches (due to vasodilation) * Ankle edema (caused by vasodilation and considered benign) * Heart block or bradycardia (depresses cardiac muscle and AV node) * Reflex tachycardia (seen with dihydropyridines such as nifedipine)

Answer 110

**Dihydropyridine CCBs (-pine ending):** 1. Nifedipine (Procardia XL) daily 2. Amlodipine (Norvasc) daily 3. Felodipine (Plendil) daily **Nondihydropyridine CCBs:** 1. Verapamil (Calan SR) daily or BID 2. Diltiazem (Cardizem CD) daily

Answer 111

***ACEIs**:* Inhibit activity of angiotensin-converting enzyme, which decreases conversion of angiotensin I to II (more potent vasoconstrictor) ***ARBs**:* Block the effect of angiotensin II Combination antihypertensive drugs: ACEIs or ARBs are combined with other drug classes such as CCBs or thiazide diuretics

Answer 112

1. HTN 2. Diabetes 3. CKD 4. Congestive HFrEF and after MI, especially those with heart failure or reduced systolic function

Answer 113

* Dry hacking cough (up to 10% with ACEIs; less with ARBs) * Hyperkalemia * Angioedema (rare but may be life-threatening)

Answer 114

1. **Moderate-to-severe kidney disease** 2. **Renal artery stenosis:** Precipitates acute renal failure if given ACEI or ARB, Hyperkalemia (this is also a side effect of ACEIs and ARBs; will have additive effect) 3. ***Pregnancy Category C (First Trimester) and Category D (Second and Third Trimesters)** →* Fetal kidney malformations, fetal hypotension, fetal death

Answer 115

All end in pril * Ramipril (Altace) once a day in one or two divided doses * Benazepril (Lotensin) once a day initially * Enalapril (Vasotec) once a day in one or two divided doses * Fosinopril (Monopril) once a day * Lisinopril (Qbrelis, Prinivil, Zestril) once day

Answer 116

All end in sartan * Losartan (Cozaar) once a day in one or two divided doses * Candesartan (Atacand) once a day in one or two divided doses * Olmesartan (Benicar) once a day in one or two divided doses * Irbesartan (Avapro) once a day

Answer 117

* Also known as *alpha-adrenergic blockers*. Suffix of *-zosin*. * Potent vasodilators. * Side effects: Dizziness and hypotension. * Give at bedtime at very low doses and slowly titrate up.

Answer 118

Men with both HTN and benign prostatic hyperplasia (BPH). Alpha-blockers relax smooth muscle found on the bladder neck and prostate gland and relieve obstructive voiding symptoms such as weak urinary stream, urgency, and nocturia. * “First dose orthostatic hypotension” is common - warn patient * Dizziness and Postural hypotension common side effects, advise patient to get out of bed slowly * May cause severe hypotension and reflex tachycardia

Answer 119

* *Terazosin (Hytrin):* Used for both HTN and BPH (starting dose 1 mg PO at bedtime) * *Doxazosin (Cardura):* Used for both HTN and BPH * *Tamsulosin (Flomax):* Used for BPH only

Answer 120

Inhibits the renin-angiotensin system (RAS) by blocking renin. Reduces renin activity by about 75%. Do not combine aliskiren with ACEI or ARB (higher risk hyperkalemia). * Aliskiren (Tecturna) once a day * Aliskiren and hydrochlorothiazide once a day

Answer 121

**Sacubitril/Valsartan (Entresto)** New drug class for treatment of HFrEF Combo of neprilysin inhibitor (sacubitril) with ARB (valsartan)

Answer 122

1. ACE inhibitors 2. ARBs 3. Angiotensin receptor-neprilysin inhibitor (Entresto) 4. CCB (nondihydropyridines) 5. CCB (dihydropyridine) 6. Beta blockers (Beta adrenergic antagonist) 7. Alpha blockers (Alpha adrenergic antagonists)

Answer 123

1. Thiazide diuretics 2. Loops Diuretics 3. Potassium-sparing diuretics

Answer 124

* HFrEF:* Diuretics, ARNI, ACE inhibitor or single-agent ARB, beta-blocker (BB). * DM:* ACEI or ARB as first-line. African Americans are less sensitive to ACEIs and ARBs. If BP still elevated, combine it with a CCB or thiazide diuretic. * CKD:* ARB or ACEI as first-line; can add CCBs or thiazides or another drug class. * African Americans* *(including people with DM):* Thiazides or CCBs may be more effective.

Answer 125

1. *Eye findings:* Learn to distinguish the findings in hypertensive (copper and silver wire arterioles, arteriovenous nicking) vs. diabetic retinopathy (neovascularization, cotton wool spots, microaneurysms) 2. Preferred medications for isolated systolic HTN in elderly = low dose thiazide diuretic or CCB (long acting dihydropyridine) 3. How to assess orthostatic hypotension = supine in both arms first, then standing BP 4. Memorize all the side effects of thiazide diuretics = Hypokalemia, hyponatremia, hyperuricemia, hypercalcemia, dehydration 5. Side effect of spironolactone is = gynecomastia

Answer 126

1. ACEI or ARBs indications other than HTN: DM, CKD, and HT, may cause a dry cough 10% 2. Careful when combining ACEI and potassium sparing diuretics (ie triamterene, spironolactone) bc of increased risk of hyperkalemia 3. Bilateral renal artery stenosis\* = ACEI or ARB when given with this condition can precipitate acute renal failure 4. Alpha blockers are not first line drugs for HTN, except if pt has preexisting BPH 5. Women with HTN and osteopenia/osteoporosis should receive thiazide bc can help bone loss by slowing down calcium loss (from the bone) and stimulating osteoclasts

Answer 127

For BP control, most patients will require at least two medications. From 5% to 20% of patients on ACEIs will develop a dry cough. ACEI cough is more common in women.

Answer 128

**Systolic Heart Failure (HFrEF) \<40%** **Diastolic failure (HFpEF) _\>_ 40%** Causes * Acute MI * CAD *(most common*) * HTN * fluid retention * Valvular abnormalities * Arrhythmias

Answer 129

Left Ventricular Failure

Answer 130

Left and Right heart failure

Answer 131

Right Ventricular Failure

Answer 132

Heart Failure

Answer 133

* Heart size = increased * Interstitial and alveolar = edema * Kerley B lines * Other signs of pulmonary edema

Answer 134

* Labs * Troponin, CPK*,* BNP (can also be elevated with CKD) * Kidney function (2) * CBC *,* liver function tests * Chest X ray * Echo with doppler flow study * Weight checked daily to detect fluid accumulation

Answer 135

* Acute decompensated heart failure = refer to ED for (IV furosemide, vasodilators) * **Diuretic** used to relieve symptoms of volume overload (dyspnea, peripheral edema) in primary care. * ***Stabilized HFrEF**:* Combination treatment with **diuretic + ACEI/ARB/ARNI (sacubitril/valsartan aka entresto) + beta blocker** * Limit sodium intake

Answer 136

* Patients with HF are best managed by cardiologists or at a heart clinic. * Use BB if HFrEF (carvedilol, bisoprolol, extended-release metoprolol succinate); start with very low dose; careful with initial dosing, can worsen; consult or refer to experienced heart clinic. Started after the patient has been initiated on ACEI or ARB or ARNI. * Use New York Heart Association (NYHA) system to classify patient’s degree of cardiac disability ([**Table 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)). * Refer to cardiologist; if in distress, refer to ED.

Answer 137

Class I No limitations on physical activity Class II Ordinary physical activity results in fatigue, exertional dyspnea Class III Marked limitation in physical activity Class IV Symptoms present at rest, with or without physical activity

Answer 138

* Restrict or abstain from alcohol. Smoking cessation if smoker; weight loss. * Restrict sodium to 2 to 3 g/d. * Fluid restriction (1.5–2 L/d) may help some patients.

Answer 139

Both *left* and *lung* start with the letter *L*. Symptoms are lung related, such as dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Right-sided heart failure symptoms are GI related (anorexia, nausea, and right upper quadrant abdominal pain)

Answer 140

Deep Vein Thrombosis

Answer 141

1. ***Stasis******:*** Prolonged travel/inactivity (more than 3 hours), bed rest, CHF 2. ***Inherited coagulation disorders:*** Factor C deficiency, Leiden, and so forth 3. ***Increased coagulation due to external factors******:*** Oral contraceptive use, pregnancy, bone fractures especially of the long bones, trauma, recent surgery, malignancy

Answer 142

A patient with risk factors for DVT complains of gradual onset of swelling on a lower extremity after a history of travel (more than 3 hours) or prolonged sitting or prolonged inactivity. The patient complains of a painful and swollen lower extremity that is red and warm. If patient has PE, it is accompanied by abrupt onset of chest pain, dyspnea, dizziness, or syncope. Many patients are asymptomatic.

Answer 143

***Unprovoked DVT**:* No identifiable environmental cause ***Provoked DVT:*** Caused by known event (e.g., surgery, major surgery \>30 minutes, hospitalization)

Answer 144

Lower leg pain on dorsiflexion of the foot (low sensitivity)

Answer 145

CBC (platelets), Clotting time (PT/PTT, INR), D-Dimer EKG, Chest X-ray, US of whole or proximal leg

Answer 146

Hospital admission **Low molecular weight heparin (SQ or IV) then Warfarin PO (Coumadin)** If this is its initial episode duration of treatment with DOACS for at least 3 months For recurrent DVT or elderly, antithrombotic treatment may last a lifetime.

Answer 147

Pulmonary Embolism Stroke Death

Answer 148

* Memorize presentation of a patient with NYHA class II heart disease. * First-line medication for stable HF is an ACEI or ARB. * The S3 heart sound is a sign of HF, although it can also be heard in pregnant women and children/young adults. * Learn DVT risk factors * Stasis = prolonged travel/inactivity (more than 3 hrs), bed rest, CHF * Inherited coag disorders = factor c deficiency, leiden, etc * Increased coagulation due to = oral contraceptives, pregnancy, bone fractures (esp long bones), trauma, recent surgery, malignancy

Answer 149

Superficial Thrombophlebitis

Answer 150

Adult patient complains of an acute onset of an indurated vein (localized redness, swelling, and tenderness). Usually located on the extremities. The patient is afebrile with normal vital signs.

Answer 151

* Indurated cord-like vein that is warm and tender to the touch with a surrounding area of erythema. * There should be no swelling or edema of the entire limb (think of DVT).

Answer 152

Administer NSAIDs, such as ibuprofen or naproxen sodium (Anaprox DS), BID. Warm compresses. elevate limb. If septic cause, inpatient hospitalization

Answer 153

Peripheral Arterial Disease (Previously known as peripheral vascular disease)

Answer 154

HTN Smoking Diabetes Hyperlipidemia

Answer 155

Older patient who has a history of smoking and hyperlipidemia complains of worsening pain on ambulation (intermittent claudication) that is instantly relieved by rest. Over time, symptoms worsen until the patient’s walking distance is greatly limited. Atrophic skin changes. Some have gangrene on one or more toes.

Answer 156

***Skin**:* Atrophic changes (shiny and hyperpigmented ankles that are hairless and cool to the touch); gangrene of the toe(s) ***Cardiovascular**:* Decreased-to-absent dorsal pedal pulse (may include popliteal and posterior tibial pulse), increased capillary refill time (\<2 seconds), and bruits over partially blocked arteries

Answer 157

Ankle Brachial Index Normal = 0.91-1.3 Diagnostic for PAD _\<_ 0.9 Severe PAD _\<_ 0.5

Answer 158

**Measure SBP using BP cuff and ultrasound probe on both ankles and arms (brachial) after being supine for 10 minutes** **Divide highest ankle SBP by highest arm SBP - ABI score done for each side**

Answer 159

Pentoxifylline (Trental) if indicated, but effect is marginal (compared with cilostazol). Cilostazol (Pletal)\* is a phosphodiesterase inhibitor (direct vasodilator) Can be taken with aspirin or clopidogrel Grapefruit juice, Diltiazem, Omeprazole can increase serum concentration if taken together * Encourage **smoking cessation** (smoking causes vasoconstriction) and daily **ambulation exercises.** * **Percutaneous angioplasty** or surgery for severe cases.

Answer 160

* Gangrene of foot and/or lower limb with amputation * Increased risk of CAD * Increased risk of carotid plaquing (check for carotid bruits)

Answer 161

Raynaud's Phenomenon

Answer 162

**Primary Raynaud's Phenomenon** = Patients with no underlying disease have “primary” Raynaud’s phenomenon. **Secondary Raynaud’s phenomenon** = occurs in patients with concurrent autoimmune disease such as lupus erythematosus and scleroderma. Associated with an increased risk of _autoimmune disorders_ (e.g., thyroid disorder, pernicious anemia, rheumatoid arthritis) Most patients are _females_ (60%–90%), with a gender ratio of 8:1.

Answer 163

Spontaneous remission of Raynaud’s phenomenon may occur. To evaluate, check distal pulses, ischemic signs (ischemic ulcers at the fingers/toes). Ulcers in fingers and toes is a complication

Answer 164

A middle-aged woman complains of chronic and recurrent episodes of color changes on her fingertips in a symmetric pattern (both hands and both feet). The colors range from white (pallor) and blue (cyanosis) to red (reperfusion). Complains of numbness and tingling. Attacks last for several hours. Hands and feet become numb with very cold temperatures. Some have livedo reticularis, which is violaceous mottling or reticular pattern of the skin of the arms and legs. Ischemic changes may be present after a severe episode such as shallow ulcers (that eventually heal) on some of the fingertips.

Answer 165

* Avoid touching cold objects and being in cold weather; avoid stimulants (e.g., caffeine). Maintain whole body warmth. Use thermal underwear, layered clothing, hat, gloves/mittens, and hand warmers. * Smoking cessation is important; nifedipine (Adalat) or amlodipine (Norvasc). * Do not use any vasoconstricting drugs (e.g., Imitrex, ergots, pseudoephedrine/decongestants, amphetamines) or diet pills; avoid nonselective beta-blockers.

Answer 166

*Raynaud’s phenomenon:* Think of the colors of the **American flag** as a reminder for this disorder. Medications include **CCBs** (nifedipine, amlodipine).

Answer 167

Common pathogens gram positive (viridans streptococcus, *Staph aureus*) Presentations range from subacute to full blown Route parenteral antibiotics for native valve endocarditis can range from 4**-**6 weeks

Answer 168

An adult male presents with fever, chills, and malaise that are associated with subungual hemorrhages (splinter hemorrhages on nail bed) and tender violet-colored nodules on the fingers and/or on toes (Osler’s nodes). Palms and soles may have tender red spots on the skin (Janeway lesions). Some patients may have a heart murmur. May not present with all of the preceding symptoms. Another clue is to look for cardiac risk factors such as a prosthetic valve, history of valvular or congenital heart disease, cardiac device, IV drug use, IV lines, recent dental or surgical procedure. Maintain high index suspicion due to high mortality.

Answer 169

* Refer to cardiologist or ED for hospitalization and IV antibiotics. * Blood cultures × three (first 24 hours) * CBC (elevated WBCs) and sedimentation rate \>20 mm per hour (elevated)

Answer 170

* Valvular destruction * Myocardial abscess * Emboli * Death

Answer 171

Mitral valve prolapse (unless history of bacterial endocarditis) Genitourinary surgery GI incisions/invasive procedures (except if there is an existing infection present, such as a urinary tract infection [UTI] before a cystoscopy)

Answer 172

**History of bacterial endocarditis** **Prosthetic heart valves** including homografts, valvular repair Unrepaired (or repaired) **cyanotic congenital heart disease** **Cardiac transplant with valvulopathy**

Answer 173

* Dental procedures that traumatize oral mucosa, gingiva, or the periapical area of the teeth, such as routine dental cleaning, tooth extractions, dental abscess drainage * Invasive procedures on the respiratory tract (especially if tissue is infected), only if procedure involves incision or biopsy

Answer 174

Give Amoxicillin 2g PO x 1 dose 1 hour before procedure Clindamycin 600 mg or clarithromycin (Biaxin) 500 mg or cephalexin (Keflex) 2 g for Penicillin Allergy

Answer 175

Midsystolic click Mitral regurgitation, A-Fib Higher risk for thromboemboli, TIA, ruptured chordae tendinae Transthoracic 3D Echo (TTE)

Answer 176

Tall and thin adult female patient complains of fatigue, palpitations, and lightheadedness (orthostatic hypotension) that is aggravated by heavy exertion. The patient may have dyspnea, dizziness, exercise intolerance, panic, and anxiety disorders. May have atypical or nonanginal chest pain. **Dyspnea\*** is the most common symptom. May be asymptomatic. Rule out Marfan’s syndrome if patient with pectus excavatum, hypermobility of the joints, and arm span greater than height.

Answer 177

**Asymptomatic MVP does not need treatment. MVP is usually benign.** MVP with palpitations is treated with **beta**-**blockers**; **avoid caffeine and stimulants, alcohol, and cigarettes; and reduce stress.** **Echocardiography** recommended for patients with clinical exam suggestive of MVP or those with family history of MVP.

Answer 178

ACC/AHA's ASCVD Risk Estimator This tool may underestimate 10-year and lifetime risk for persons from some race/ethnic groups such as American Indians, some Asians (e.g., South Asian), and some Hispanics (e.g., Puerto Ricans).

Answer 179

The U.S. Preventive Services Task Force (USPSTF) recommends lipid screening in both men and women who are at increased risk for coronary heart disease (CHD) Men aged 35 years or older Women aged 45 years and older *Adults aged 76 years and older with no history of CVD:* Do not screen (insufficient evidence)

Answer 180

Normal: \<200 mg/dL Borderline high: 201 to 239 mg/dL High: \>240 mg/dL

Answer 181

***Men:*** **\>40 mg/dL** ***Women:*** **\>50 mg/dL** * HDL \>60 mg/dL associated with lower risk of heart disease * HDL \<40 mg/dL associated with increased risk of CAD even if normal LDL or cholesterol. * Genetic causes

Answer 182

Do not treat low HDL-C alone (aim for lowering the LDL), since clinical trials have not shown a correlation between raising HDL-C and decreased rates of heart disease or stroke. 1. **Fibrates (gemfibrozil)** 2. X Niacin X 1. Although niacin can increase HDL (and decrease triglycerides), it has fallen out of favor, because it has failed to reduce vascular events (stroke, ASCVD). Low doses of niacin (vitamin B3) in over-the-counter (OTC) multivitamins or B-complex vitamins have not been implicated. 3. Some high-dose statins.

Answer 183

* Engage in regular moderate cardiovascular/aerobic exercises most days of the week * Lose weight * Eat healthy fats (salmon, tuna, nuts) * Eliminate trans fats * Stop smoki

Answer 184

* Optimal:* \<100 mg/dL * LDL:* \<130 mg/dL for low-risk patients with fewer than two risk factors * Heart disease or diabetes:* \<70 mg/dL

Answer 185

*Normal:* \<150 mg/dL Hypertriglyceridemia = \>150 mg/dL *High risk of acute pancreatitis:* ≥1,000 mg/dL

Answer 186

* Metabolic syndrome * DM * familial hypertriglyceridemia * alcohol abuse * hyperthyroidism * kidney disease * medications * anabolic steroids * Accutane (isotretinoin) * Oral estrogens, tamoxifen * diuretics * second-generation antipsychotics * antiretrovirals * nonselective beta-blockers (e.g., propranolol).

Answer 187

* Decrease sugar and simple carbohydrates (junk food) * avoid alcoholic drinks * follow low-fat diet * eat fish with omega-3 (salmon, sardines) twice a week * lose weight * and increase aerobic-type physical activity.

Answer 188

Avoid drinking **alcohol** because can precipitate **acute pancreatitis\*** **First line medications FENOFIBRATE (Tricor)\*, GEMFIBROZIL (Lopid)\*, BENZAFIBRATE (Bezalip)\*** **NIACIN high dose** can decrease triglyceride levels by up to 40% and raise HDL by 40%. Start at low doses, take after a meal, and slowly increase dose. To treat a niacin flush or “prickly heat” sensation (from vasodilation), take it with aspirin **STATINS high dose ie ATORVASTATIN (Lipitor) and ROSUVASTATIN (Crestor)** can lower triglycerides (33%–50%). Marine omega-3 acid ethyl esters are also effective (Lovaza 4 g/day). * Identify _____ (medications/PMH) * Treat _____ if very high (before treating high LDL/cholesterol)

Answer 189

DASH Diet Mediterranean Diet Vegetarian Diet Low-Carbohydrate Diet Low-Trans-Fatty Acid Diet

Answer 190

* HTN * Family history of premature heart disease (women with MI before age 65 years or men with MI before age 55 years) * DM (considered a CHD risk equivalent even if patient has no history of preexisting heart disease) * Dyslipidemia * Low HDL-C (\<40 mg/dL) * Age (men older than 45 or women older than 55) * Cigarette smoking * Obesity (BMI ≥30 kg/m²) * Microalbuminuria * Carotid artery disease * Peripheral vascular disease (PVD)

Answer 191

1. First line treatment 2. Reduce dietary salt intake and learn about the DASH diet (low salt, low saturated fat \<30%). 3. Encourage use of soluble fiber in diet (e.g., inulin, guar gum, fruit, vegetables) to enhance lowering of LDL (lowers LDL by blocking absorption in GI tract up to 10%). 4. Target goal is to lower LDL first (except if very high triglyceride levels). If high triglycerides (≥500 mg/dL), treat hypertriglyceridemia first because patients are at high risk for acute pancreatitis. 5. Low HDL alone (even if normal LDL and cholesterol) is a risk factor for heart disease

Answer 192

* Recent coronary syndrome (within the past 12 months) * History of MI * History of ischemic stroke * Symptomatic PAD (history of claudication with ABI \<0.85 or previous revascularization or lower extremity amputation)

Answer 193

* *Age:* ≥65 years * *Cardiovascular (CV):* History of prior coronary artery bypass surgery or percutaneous coronary intervention (PCI), CHF, HTN * DM * Current smoking * *Kidney:* CKD (eGFR 15–59 mL/minute) * Persistently elevated LDL of ≥100 mg/dL despite statin therapy and ezetimibe

Answer 194

1. Patients with any form of clinical ASCVD (history of MI, CAD, angina, stroke/TIA, PAD, coronary revascularization): * **High-intensity statin** (or maximally tolerated statin therapy) * **Decrease LDL level by \_\_%** 2. Very high risk ASCVD (defined as a history of multiple major ASCVD events or one major ASCVD event with multiple high-risk conditions): * **High-intensity statin** * **LDL goal is 70 mg/dL** * If already on high-intensity dose of statin and not at goal (LDL 70 mg/dL), add a nonstatin such as **Ezetimibe/Zetia.** * If on statin and ezetimibe (LDL remains \>70 mg/dL), adding a proprotein convertase subtilisin/kexin type 9 **PCSK9 inhibitor** is reasonable (although long-term safety \>3 years is unknown).

Answer 195

3. Diabetic patients with LDL of ≥70 mg/dL: * Age 40 to 75 years: Moderate-intensity statin therapy (without calculating 10-year ASCVD risk) * Age 50 to 75 years: Can use high-intensity statin to reduce LDL by 50% or more. 4. Severe primary hypercholesterolemia (LDL of 190 mg/dL or higher): * Age 20 to 75 years: High-intensity statin (without calculating 10-year ASCVD risk) * If on high-intensity statin and LDL ≥100 mg/dL, add ezetimibe (Zetia). * If multiple risk factors for ASCVD, consider adding a PCSK9 inhibitor to statin. 5. Assess adherence and percentage response to LDL-lowering medications and lifestyle changes: * Repeat lipid measurement in 4 to 12 weeks after statin initiation or dose adjustment. * Repeat every 3 to 12 months as needed.

Answer 196

If 10-year ASCVD risk of 7.5% or 19.9% (intermediate risk): * *Age 40 to 75 years with LDL 70 mg/dL to 189 mg/dL (without DM):* Assess risk-enhancing factors for ASCVD ([**Box 7.2**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#read/section/)). If decision to start statins uncertain, check the **coronary artery calcium (CAC) score**. If the CAC score is 1 to 99, favor starting statin therapy.

Answer 197

*Age 20 to 39 years with LDL ≥160 mg/dL (without DM):* If positive family history or premature ASCVD, initiate statin therapy to reduce LDL by 50%.

Answer 198

Lower's LDL by _\>_ 50% Atorvastatin (Lipitor) 40-80 mg Rosuvastatin (Crestor) 20-40 mg

Answer 199

Lowers LDL by 30-50% Atorvastatin 10**-**20 mg Rosuvastatin (Crestor) 5-10 mg Simvastatin (Zocor) 20-40 mg Pravastatin (Pravachol) 40- 80 mg Lovastatin (Mevacor) 40 mg

Answer 200

Lower LDL \<30% Simvastatin 10 mg/d Pravastatin 10–20 mg/d Lovastatin 20 mg/d Fluvastatin 20–40 mg/d

Answer 201

* Family history of premature ASCVD * Persistently elevated LDL-C levels of ≥160 mg/dL * Metabolic syndrome * Chronic kidney disease (CKD) * History of preeclampsia or premature menopause (age \<40 years) * High-risk ethnic groups such as South Asians (from India, Pakistan, Sri Lanka, Nepal, Bangladesh) * Chronic inflammatory disorders (e.g., psoriasis, RA, or chronic HIV) * Persistent triglyceride elevations * Elevated C-reactive protein of ≥2.0 mg/L * Ankle-brachial index (ABI) ≤0.9 * ASCVD, atherosclerotic cardiovascular disease; RA, rheumatoid arthritis.

Answer 202

Rule out **familial hypercholesterolemia** (FH) if presence of **extensor tendon xanthomas** (Achilles, subpatellar, or hand extensor tendons).

Answer 203

HMG-CoA reductase is the enzyme in the liver that is responsible for cholesterol synthesis. Statins inhibit this enzyme, which results in decreased lipoprotein production. HMG-CoA reductase inhibitors (statins) are best at lowering LDL, and some can increase HDL and decrease triglycerides at higher doses.

Answer 204

If patient is a high-intensity statin candidate, start at lower doses and titrate up slowly to the recommended dose to minimize adverse effects. Check baseline liver function testing before starting patient on statins. Some patients may not tolerate high-intensity statins (e.g., muscle pains, weakness) but can tolerate moderate-intensity statins.

Answer 205

If patient is at very high risk for ASCVD or has severe primary hypercholesteremia (LDL **\>190 mg/dL**) and is not at LDL goal (but already on high-dose statin), the next step is to add **ezetimibe (Zetia)** to the statin. If still not at goal (LDL of **70 mg/dL**), can add a **PCSK9 inhibitor (Repatha, Proluent)** to statin and ezetimibe.

Answer 206

* Simvastatin and lovastatin drug interactions (high risk of rhabdomyolysis): * Avoid grapefruit juice * Fibrates * Antifungals (itraconazole, ketoconazole) * Macrolides (erythromycin, clarithromycin, telithromycin) * Amiodarone (Cordarone), some CCBs (diltiazem, amlodipine, verapamil) * Combination regimens of a statin with ezetimibe (Zetia) is acceptable for some high-risk patients

Answer 207

Niacin (OTC) daily or TID, Niaspan (slow-release niacin) daily. Avoid combining niacin with statins (higher risk of liver damage). Addition of niacin to statins has not been shown to produce further benefit but may increase risk of hepatotoxicity.

Answer 208

Gemfibrozil (Lopid), fenofibrate (Tricor), benzafibrate (Bezalip). Do not use with severe renal disease. *Action:* Reduces production of triglycerides by the liver and increases production of HDL. Very good agents for lowering triglycerides and elevating HDL level. Less effective at lowering LDLs compared with the statins. *Side effects:* Dyspepsia and gallstones; myopathy

Answer 209

Cholestyramine (Questran Light), colestipol (Colestid), colesevelam (Welchol) ## Footnote *Action:* Work locally in the small intestine; interfere with fat absorption, including fat-soluble vitamins (vitamins A, D, E, and K) Alternative drug for patients who cannot tolerate statins, fibrates, and niacin If used alone, it is not as effective as statins in lowering LDL; no hepatotoxicity. *Side effects:* Bloating, flatulence, abdominal pain; start at low doses and titrate up slowly. Side effects mainly from the GI tract; advise patient to take multivitamin tablets daily.

Answer 210

**Ezetimibe (Zetia)\*** Absorbs cholesterol from the small intestines; combination of a statin with ezetimibe recommended for some high-risk ASCVD patients Contraindications: Active liver disease, unexplained persistent elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) Can be taken alone or combined with a statin or fibrate (e.g., simvastatin [Vytorin]) *Side effects:* Diarrhea, joint pains, tiredness

Answer 211

**Evolocumab (Repatha), alirocumab (Praluent)** Human Monoclonal Antibodies Can decrease LDL by 50% to 60%. Subcutaneous injection every 2 to 4 weeks. Reduction of risk of MI, stroke, and unstable angina Current guidelines recommend adding PCSK9 to statins for patients at very high risk of ASCVD, recent ACS (within 12 months), multiple MIs, or strokes

Answer 212

Rhabdomyolysis

Answer 213

* thighs, calves, shoulders, lower back * higher doses of statins or combined therapy have higher risk * Discontinue statin immediately and order labs

Answer 214

1,500 to \>100,000 IU/L Markedly elevated (at least 5x upper limit of normal) Reddish brown color (myoglobinuria) and Proteinuria in up to 45% LFTs (will be elevated) UA, BUN, Creatinine, Potassium/electrolytes, EKG

Answer 215

Symptoms = Anorexia, nausea, dark-colored urine, jaundice, fatigue, flu-like symptoms * Labs: Elevated ALT and AST * Discontinue statin Rx, Stop alcohol intake * Avoid prescribing statins to alcoholics * Advise patient to report symptoms of hepatitis or rhabdomyolysis. If present, tell patient to stop the drug and call or go to ED

Answer 216

1. First line treatment for HTN = lifestyle and dietary changes 2. First line treatment for HLD = lifestyle 1. but presences of ASCVD or equivalents requires drug therapy as well 3. Must memorize\* 1. An adult (21–75 years) with any type of ASCVD (e.g., CAD, PAD, stroke, TIA) = give high intensity statin **Atorvastatin 40-80mg or Rosuvastatin 20-40mg** 2. An adult with LDL \> 190 mg/dL (without ASCVD or DM) is a candidate for high-intensity statin dosing

Answer 217

1. If patient has markedly high triglycerides (500 mg/dL or higher), lower triglycerides first (niacin or fibrate) before treating the high cholesterol and LDL levels. Very high triglycerides increase risk of acute pancreatitis. 1. Educate to avoid alcohol and acetaminophen (hepatotoxic) use. 2. *Obese patients:* Encourage weight loss and reduce simple carbohydrates, sugars, and junk foods. 3. Advise patient to reduce intake of simple carbohydrates, junk foods, and fried foods

Answer 218

1. Niacin and fibrates are best agents for lowering triglycerides. 2. Become familiar with dietary sources of magnesium, potassium, and calcium. 3. Bacterial endocarditis prophylaxis drug and dose, splinter hemorrhages on nails, Janeway lesions (red macules on palms/soles not painful), Osler nodes (painful violaceous nodes found mostly on pads of the fingers and toes, thenar eminence).

Answer 219

Memory loss and confusion may happen with statins, reversible upon discontinuation of statin therapy. Remember, the brain and nerves are mostly fat Patients on simvastatin and lovastatin should avoid grapefruit juice, macrolides Muscle pain from rhabdomyolysis usually located on calves, thighs, lower back, shoulders. Urine will be darker than normal (reddish brown color) → rule out rhabdomyolysis if patient on statin complaints of muscular pain with dark-colored urine

Answer 220

* Evaluate for metabolic syndrome and type 2 DM * Blacks with highest rates of obesity (48.1%), followed by Hispanics (42.5%), and Whites (34.5%) - about 40.2% are middle-aged adults (40-59yo) * Evaluate for metabolic syndrome and type 2 DM * Obesity increases risk of mortality and other health risks, including type 2 DM, HTN, dyslipidemia, CHD, sleep apnea, and decreased mobility.

Answer 221

Underweight \<18.5 Normal weight 18.5-24.9 Overweight 25-29.9 Obese 30-39.9 Grossly obese \>40

Answer 222

**“apple shaped”** body type is considered more dangerous for health compared to **“pear-shaped”** body type

Answer 223

Waist Circumference * *Males:* \>40 inches (102 cm); South Asians, \>35 inches (90 cm) * *Females:* \>35 inches (88 cm); South Asians, \>31 inches (80 cm) Waist to Hip Ratio * *Males:* 1.0 or higher * *Females:* 0.8 or higher

Answer 224

* Weight loss with dietary therapy and lifestyle and behavioral modifications * There are many “dietary” methods (e.g., Weight Watchers, keto, Nutrisystem, Atkins) and apps (e.g., Noom, Weight Watchers) that help promote weight loss. It depends on patient preferences. * Meal delivery services can deliver fresh meals to homes. It makes cooking easier because the ingredients are provided for you (e.g., Blue Apron, Hello Fresh, Green Chef).

Answer 225

* *Exercise:* 40 minutes of moderate to vigorous physical activity at least 3 or 4 times per week. Walking 10,000 steps per day is a popular method of exercise. Use of smart watches that track steps and exercise is helpful. * There are many online social support group sites, blogs, and articles about weight loss on the Internet. * Therapies _not recommended_ by experts are liposuction (it does not improve insulin sensitivity or risk factors for heart disease), herbal dietary supplements, and very-low-calorie diets (\<1,000 kcal/day).

Answer 226

Metabolic syndrome

Answer 227

Diagnosis requires 3/5 1. Abdominal obesity (\>40 inches [102 cm] in men and \>35 inches [88 cm] in women) 2. BP \>130/85 mmHg 3. Elevated fasting plasma glucose (\>100 mg/dL) 4. Elevated triglycerides (\>150 mg/dL) or on drug treatment for elevated triglycerides 5. Decreased HDL (\<40 mg/dL in men and \<50 mg/dL in women)

Answer 228

* Fasting (from 9 to 12 hours) lipid profile (especially triglycerides and HDL) * Fasting blood glucose * Weight (BMI), waist circumference, BP

Answer 229

Nonalcoholic Fatty Liver Disease

Answer 230

* Most are asymptomatic. Can present with or without inflammation. * It is more common in Western industrialized countries. * The most common reasons for fatty liver are chronic heavy alcohol consumption and obesity (with type 2 diabetes and/or with metabolic syndrome). * Risk factors include central obesity, type 2 diabetes, metabolic syndrome.

Answer 231

Usually asymptomatic. Some patients may have hepatomegaly. Annual physical exam labs will show mild-to-moderate elevations of ALT and AST. If symptomatic, complaints of fatigue and malaise with vague right upper quadrant pain. Associated with obesity, metabolic syndrome, DM, and hyperlipidemia

Answer 232

**Refer to GI specialist for management and a liver biopsy** ## Footnote *Liver function tests:* ALT and AST may be slightly elevated from two to five times the upper limit of normal; normal transaminase levels do not exclude NAFLD. Fasting lipid levels, glucose, A1C. Order hepatitis A, B, and C profile. Initial imaging test is liver ultrasound and NAFLD fibrosis score.

Answer 233

* Lose weight, exercise, and watch diet. * Discontinue alcohol intake permanently. * Avoid hepatotoxic drugs (e.g., acetaminophen, isoniazid, statins). * Recommend vaccination for hepatitis A and B and annual flu vaccine. * Refer to GI specialist

Answer 234

* All obese and overweight patients should be advised to lose weight (especially diabetics). * Lifestyle changes are important (diet, nutrition, exercise, portion control). * Daily aerobic exercise (e.g., walking, swimming, biking) for 30 to 45 minutes is recommended. * Weight Watchers: Some patients like the support and education (tertiary prevention).

Answer 235

* Know metabolic syndrome criteria (abdominal obesity, HTN, hyperlipidemia or elevated triglycerides, low HDL, elevated fasting glucose \>100 mg/dL) caused by hyperinsulinemia and peripheral insulin resistance. * NAFLD is associated with metabolic syndrome and/or obesity. Look for slight elevation of ALT and AST (not related to alcohol or medications) and negative hepatitis A, B, and C. * Abdominal obesity in males (\>40 inches [102 cm]) and females (\>35 inches [88 cm]). * Do not confuse BMI formula with the PEF (peak expiratory fl ow). PEF is calculated using the **height, age, and gender (mnemonic is “HAG”).** * A person with a BMI of 27 is overweight (initiate lifestyle education).

Answer 236

* There are usually two questions regarding heart murmurs on the exam. * Learn to use the mnemonics “MR. ASS” and “MS. ARD.” = * Mitral Regurg. Aortic Stenosis Systolic * Mitral Stenosis, Aortic Regurg Diastolic * All murmurs with “mitral” in their names are only described as located: * On the apex (or apical area) of the heart or * On the fifth ICS on the left side of the sternum medial to the midclavicular line * If an apical/apex murmur occurs during S1, it is mitral regurgitation (MR. ASS). If an apical/apex murmur occurs during S2, it is mitral stenosis (MS. ARD). * On the exam, only the systolic murmurs radiate (to the axilla in mitral regurgitation and to the neck with aortic stenosis).

Answer 237

* S3 is a sign of CHF * S4 is a sign of LVH. * A physiological split S2 is best heard at the pulmonic area (upper left sternum). * Memorize the mnemonic **“motivated apples”** to help you remember the names of the valves that are responsible for producing S1 and S2. * Motivated M (mitral valve) T (tricuspid valve) AV (atrioventricular valves) Apples A (aortic valve) P (pulmonic valve) S (semilunar valves) * Grading murmurs: Be aware that the first time a **thrill** is palpated is at **grade IV**. * Rule out AAA in an older male who has a pulsatile abdominal mass that is more than 3 cm in width. The next step is to order an abdominal ultrasound and CT. * Learn the signs/symptoms of IE (bacterial endocarditis) = s**plinter hemorrhages, petechiae, Osler nodes, Janeway lesions**

Answer 238

* The PR interval (atrial depolarization) duration is 0.12 to 0.20 seconds (3–5 small boxes). * One EKG strip may show up in the exam. Some exams do not show EKG strips. * Memorize appearance of EKG of **sinus arrythmia, atrial fibrillation, and anterior wall MI (tombstone-like pattern).** * *AF:* Goal is INR of 2 to 3. If INR is between 4.01 and 4.99, hold one dose. Do not give vitamin K. * Learn the definition of **pulsus paradoxus** =Defined as a fall in systolic BP (SBP) of more than 10 mmHg during the inspiratory phase. Also known as a *paradoxical pulse.* It is an important physical sign of cardiac tamponade.

Answer 239

Major bleeding episodes can occur even with a normal INR. Order an INR with the PT and PTT if you suspect bleeding. It may take up to 3 days after changing the warfarin dose to see a change in the INR. Warfarin (Coumadin) is an FDA category X drug. It is teratogenic.