Cardiovascular

Question 1

Danger Signals

(5)

Answer 1

Acute Coronary Syndrome

Stable and Unstable Angina

Heart Failure

Infective Endocarditis

Abdominal Aortic Aneurysm

Question 2

ACS

(3)

Classic Presentation

Answer 2

STEMI, NSTEMI, Unstable Angina

Middle-Older aged man + steady chest, substernal discomfort described as squeezing, tightness, crushing, knot in center of chest, heavy pressure (“elephant sitting on my chest”), band like

Radiation to arms, shoulder, neck, jaw

Question 3

ACS

• Provoked by (3)
• Atypical symptoms experienced by women, elderly, diabetics include
  
  • ep______ discomfort
  • in______
  • n_____/v_____
  • new onset f_____, d_______

Answer 3

• Provoked by physical exertion, emotional upset, eating heavy meal
• Atypical symptoms experienced by women, elderly, diabetics
  
  • epigastric discomfort
  • indigestion
  • nausea/vomiting
  • new onset fatigue, dizziness

Question 4

ACS

Best diagnostic test =

Treatment =

Answer 4

12 lead EKG

Give ASA 162-325mg to chew and swallow, call 911

Question 5

Stable Angina

=

Answer 5

Brief 2-5 min, precipitated by exercise, emotional upset, heavy meals, or lifting heavy objects, relieved with rest or nitroglycerin

Question 6

Unstable Angina

=

Answer 6

Occurs after minimal activity/occurs at rest, does becomes more severe, frequent, prolonged and does not respond to rest or nitroglycerin

If myocardial ischemia present, unstable angina is considered a type of ACS

Question 7

Heart Failure S/S

• Age =
• ____ of breath and ___headedness with minimal exertion
• Progresses to dyspnea at _____
• (1) shortness of breath when lying down
• (1) sudden awakening from sleep dt SOB and relieved with upright sitting position
• Peripheral _____ caused by fluid retention
• _____ appetite
• ___ quadrant abdominal pain

Answer 7

• Age = usually elderly
• Short of breath and lightheadedness with minimal exertion
• Progresses to dyspnea at rest
• Orthopnea: shortness of breath when lying down
• Paroxysmal Nocturnal Dyspnea: sudden awakening from sleep dt SOB and relieved with upright sitting position
• Peripheral edema caused by fluid retention
• Poor appetite
• RUQ abdominal pain

Question 8

Heart Failure Causes

(2) types

• C_____ a_____ disease
• Ar_____
• Cardio_____
• Hypo______
• Uncontrolled ____

Answer 8

HFrEF (reduced ejection fraction) < 40%

HFpEF (preserved ejection fraction) > 50%

• Coronary artery disease (CAD)
• Arrhythmias
• Cardiomyopathy
• Hypothyroidism
• Uncontrolled HTN

Question 9

Heart Failure Physical Exam Findings

• lung sounds (2)
• Heart sounds (2)
• RR =
• HR =
• Jugular vein _____
• Decompensation can be caused by increased _____ intake, and ______ with medications

Answer 9

• lung sounds = crackles, wheezing
• Heart sounds = S3 gallop, paradoxical splitting of S2
• RR = tachypnea
• HR = tachycardia
• Jugular vein distension
• Decompensation can be caused by increased sodium intake, and noncompliance with medications

Question 10

Infective Endocarditis (Bacterial Endocarditis) Risk Factors

• IV d____ use
• Val_____ abnormalities
• Arr______
• Hemod______

Answer 10

• IV drug use
• Valvular abnormalities
• Arrhythmias
• Hemodialysis

Question 11

Infective Endocarditis

Most common causes (2)

Answer 11

MSSA (Methicillin-sensitive staphylococcus aureus)

MRSA (Methicillin-resistance staphylococcus aureus)

Question 12

Infective Endocarditis S/S

• F____, Ch_____
• New-onset m____ (85%)
• An_____, weight _____
• Skin findings*
  
  • Nail bed =
  • Palate =
  • Fingers and toes =
  • Palms and soles =
• Fundoscopic exam* =

Answer 12

• Fever, Chills
• New-onset murmur (85%)
• Anorexia, weight loss
• Skin findings*
  
  • Nail bed = subungual hemorrages (spinter hemorrhages)
  • Palate = petechiae
  • Fingers and toes = Osler nodes* (painful violet-colored nodes)
  • Palms and soles = Janeway lesions* (nontender red spots)
• Fundoscopic exam = Roth spots* (retinal hemorrhages)

Question 13

Infective Endocarditis Diagnostic Test

(1)

Answer 13

Transthoracic Echocardiogram

Question 14

AAA S/S

If not ruptured =

If ruptured =

Answer 14

Majority asymptomatic

Severe, Sharp, Excruciating Abdominal, Back, or Flank pain + pulsatile abdominal mass

Question 15

AAA Risk Factors

• Age > ___yo
• Gender =
• Race =
• Social activity =
• Diagnosed with =

Answer 15

• Age > 70 yo
• Gender = Male
• Race = White
• Social activity = Smoker
• Diagnosed with = HTN

Question 16

AAA Diagnosis

Initial Imaging =

If incidental finding on Xray, what will you see?

Answer 16

Ultrasound

Chest X-ray findings = widened mediastinum, tracheal deviation, and obliteration of aortic knob (thoracic aortic dissection)

Question 17

Normal Position of the Heart

Estimated heart size?

Which chamber of the heart lies closest to the sternum?

Where is the apical impulse generated? and where can you feel it?

Apex beat is caused by which ventricle?

Answer 17

Size o large adult fist

right ventricle

lower border of left ventricle, fifth intercostal space by the midclavicular line on the left side of the chest

left ventricle

Question 18

What situations is there a displacement of the point of maximal impulse?

(3)

Answer 18

Severe LVH

Cardiomyopathy

Third Trimester Pregnancy

Question 19

Why is there displacement of the point of maximal impulse in

1. Severe LVH and cardiomyopathy?
2. Third trimester pregnancy?

Answer 19

1. displaced laterally bc size of heart gets bigger (larger >3cm) in size and more prominent
2. Uterus grows and pushes against diaphragm causing shift to left of chest anteriorly → displaced PMI now slightly upward, may also hear S3 heart sound during pregnancy

Question 20

Order of how deoxygenated blood flows through the heart?

Answer 20

Superior vena cava and inferior vena cava → right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → lungs and alveoli where RBCs pick up oxygen and release CO2

Question 21

Order of how Oxygenated blood circulates through the heart?

Answer 21

Oxygenated blood from lungs enters pulmonary vein → left atrium → mitral valve → left ventricle → aortic valve → aorta → general circulation

Question 22

Systole and Diastole

Pneumonic =

Which valves make the S1 heart sound?

Which valves make the S2 hear sound?

Answer 22

“Motivated Apples”

S1 = Mitral, Tricuspid, AV valves

S2 = Aortic valve, Pulmonic valve, Semilunar valves

Semilunar valves = valves that prevent backflow into ventricles (between right ventricle and pulmonary artery, between left ventricle and aorta)

Question 23

S1 (Systole)

• “Motivated” =
• The “___” sounds (of “lub-dub”)
• Closure of which valves?

Answer 23

• “Motivated” = Mitral and Tricuspid (AV vlaves)
• The “lub” sounds of (“lub-dub”)
• Closure of the mitral and tricuspid valves

Question 24

S2 (Diastole)

• “Apples” =
• The “___” sound (of “lub-dub”)
• Closure of which valves?

Answer 24

• “Apples” = Aortic and Pulmonic (semilunar valves)
• The “dub” sound (of “lub-dub”)
• Aortic and pulmonic valves (semilunar valves)

Question 25

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 25

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)

Question 26

S4 Heart Sound

Usually indicates (1)

Occurs during ___ diastole (also called (2))

Sounds like (1)

Best heard where? Using what part of the stethoscope?

Answer 26

Increased resistance dt stiff left ventricle → LVH

Occurs during late diastole (“atrial gallop”, “atrial kick”)

“Tennessee”

Apex (apical area/mitral area), Bell of stethoscope

Question 27

When to use the Bell of the Stethoscope

What kind of tones? aka (2)

What murmur (1)

Answer 27

Low tones (S3 or S4)

Mitral Stenosis

Question 28

When to use the Diaphragm of the Stethoscope

What kind of sounds? such as ____ sounds

(2) murmurs

Answer 28

Mid-high pitched tones such as lung sounds

Mitral regurgitation, Aortic Stenosis

Question 29

Heart Sounds that are Benign Variants

(2)

Answer 29

Physiological S2 Split

S4 in the Elderly

Question 30

Physiological S2 Split

Cause =

Best heard where?

Only normal if it appears during _____ and disappears at ______

Answer 30

Splitting of aortic and pulmonic components

Pulmonic area (second ICS upper left of sternum)

+ inspiration, - expiration

Question 31

S4 in the Elderly

Also known as (1)

When is it considered normal?

When is it pathological?

Answer 31

“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)

Question 32

Tips for Murmur Questions

T_____ of murmur (1) or (1)

L______ of murmur (1) or (1) or (1)

Answer 32

Timing of murmur (systole or diastole)

Location of murmur (Aortic, Erb’s point, or Mitral area)

Question 33

Systolic Murmurs Acronym

(2)

Systolic murmurs also described as occurring during

• S__
• h___systolic, p__systolic, e___ systolic, l___ systolic, m__systolic
• Soft or louder compared to diastolic murmurs?
• Can radiate to (2)

Answer 33

MR. ASS

Mitral Regurgitation, Aortic Stenosis

• S1
• holosystolic, pansystolic, early systolic, late systolic, midsystolic
• Louder
• Can radiate to Neck or Axillae

Question 34

Diastolic Murmurs Acronym

(2)

• S__
• E___ diastole, l___ diastole, or m__ diastole
• Unlike systolic murmurs, diastolic murmurs are always indicative of?

Answer 34

MS. ARD

Mitral Stenosis, Aortic regurgitation

• S2
• Early diastole, Late diastole, Mid diastole
• Always indicative of heard disease

Question 35

Murmurs heard over the Mitral Area

Mitral area is known as the _____ of the heart

Which intercostal, distance from midsternal line, relative to location of midclavicular line?

Answer 35

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

Question 36

Murmurs heard over the Aortic Area

Where is the aortic area?

Answer 36

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

Question 37

Murmurs Heard over Erb’s Point

Where is erbs point?

Answer 37

Left 3rd-4th intercostal left sternal border

Question 38

Mitral Regurgitation

A ___systolic (___systolic) murmur

Best heard at what location of the heart?

May radiate to _____

L____ blowing and ___-pitched murmur (use the ____ of the stethoscope)

Answer 38

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)

Question 39

Aortic Stenosis

A __systolic e_____ murmur

Best heard where?

May radiate to the ____

A h____ and noisy murmur (use _____ of the stethoscope)

Patients with this should avoid over_____ bc increased risk of ____ → refer to (1) to be monitored by (1)

Tx (1) may be needed if worsens

Answer 39

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

Question 40

Mitral Stenosis

Also called an (1), use ___ of stehoscope

Best heard where?

Answer 40

Also called an opening snap, use bell of stehoscope

Best heard at the apex (apical area)

Question 41

Aortic Regurgitation

A ___ pitched diastolic murmur (use _____ of stethoscope)

• If AR due to (1) = heard at Erb’s point
• If AR due to (1) = heard at Aortic area

Answer 41

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

Question 42

Grading of Murmurs

Match each description to Grade of Murmur

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

Answer 42

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

Question 43

Pathological Murmurs

All ____ murmurs are abnormal

All benign murmurs occur during _____

Benign murmurs do not have a ____, only very ___ murmurs will produce a thrill

Answer 43

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.

Question 44

Exam Tips

1. There are usually ____ questions regarding heart murmurs on the exam.
2. Learn to use the mnemonics (2)
3. All murmurs with “_____” 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 (1). If an apical/apex murmur occurs during S2, it is (1)
5. On the exam, only the ______ murmurs radiate (to the ____ in mitral regurgitation and to the ____ with aortic stenosis).

Answer 44

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).

Question 45

Exam Tips

1. S3 is a sign of (1); S4 is a sign of (1)
2. A physiological split S2 is best heard at the ______ area (upper left sternum).
3. Memorize the mnemonic (1) 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 (1).
5. Rule out (1) 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 ______ and ___.
6. Learn the signs/symptoms of (1) (bacterial endocarditis).

Answer 45

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).

Question 46

EKG Exam Tips

1. Only ___ or none EKG strips will appear per exam
2. Occasionally, an arrhythmia will be _____ 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 (1) or other complex arrhythmias
4. Important rhythms
   
   1. (1) = irregularly irregular rhythm w no P waves
   2. (1) = ST segment elevation in leads V2-V4
   3. (1) = jagged irregular QRS

Answer 46

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

Question 47

What is this rhythm?

Answer 47

Atrial Fibrillation

Question 48

What does this EKG show?

(most common of MI)

(2) PQRST changes

What is the term for the abnormal QRS waves?

Answer 48

Anterior Wall MI

ST segment elevation + wide QRS

Wide QRS in V2-V4 called “TOMBSTONING”

Question 49

What does this EKG strip show?

Common in who?

Answer 49

Sinus Arrhythmia

More common in healthy children and young adults

P waves are uniform but the PP interval varies during inspiration and exhalation

Question 50

What Arrhythmia does this describe?

• Most common arrhythmia in the US
• Major cause of stroke
• Classified as supraventricular tachyarrhythmia

Answer 50

Atrial Fibrillation

Question 51

What Arrhythmia does this describe?

Atria beat regularly but faster than usual ie) 4 atrial beats per ventricular beat

Answer 51

Atrial Flutter

Question 52

Afib and Aflutter Risk Factors

1. H_ _
2. C _ _
3. A _ _
4. L _ _
5. (1) like caffeine, cocaine, nicotine, amphetamine
6. ____thyroidism
7. Al_____ (“holiday heart”)
8. Pulmonary e_______
9. C _ _ _
10. Sleep ____

Answer 52

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

Question 53

Version of Afib that is intermittent, self terminating: episodes terminate within 7 days or less (usually <24 hours), Usually Asymptomatic

However if pt hemodynamically unstable (chest pain/angina, hypotension, HF, cold clammy skin, AKF), or new onset AF with severe symptoms, what should you do?

Answer 53

Paroxysmal AF

(Persistent AF = >12m)

Call 911 if new onset AF w severe sx

Question 54

What heart rhythm do you think this patient has?

Patient reports a sudden onset of heart palpitations described as feeling like “a fish is flopping in my chest” or “drums are pounding in my chest” that is accompanied by feelings of weakness, dizziness, and tachycardia. There is a reduction of exercise capacity. May complain of dyspnea, chest pain, and feeling like passing out (presyncope to syncope). Rapid and irregular pulse may be more than 110 beats/min with hypotension.

Answer 54

Atrial Fibrillation

Question 55

Once Afib is diagnosed, the next step is determining if anticoagulation therapy is needed, what tool can you use to do that?

Answer 55

CHAD2 Score

Question 56

CHA2DS2-VASc

1. C =
2. H =
3. A =
4. D =
5. S2 =
6. V =
7. A =
8. S =

Answer 56

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

Question 57

CHA2DS2-VASc Scoring System

Low risk score =

Score for anticoagulation =

Answer 57

Low risk score = 0

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

Question 58

New Onset Afib Workup

Find underlying cause

1. Diagnostic (2)
2. Labs (5)
3. Consider (1) monitor if paroxysmal
4. (1) level if on Digoxin
5. Lifestyle advice in the meantime is to avoid (1)

Answer 58

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

Question 59

Afib Medications

(usually referred to cardiologist for med management)

1. For rate control (3)
2. Antiarrhythmics (1)
3. Anticoagulant for valvular AF (1)
4. Anticoagulant for nonvalvular AF (1)

Answer 59

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

Question 60

Amiodarone (Cordarone)

Black Box Warnings

• P_____ toxicity
• H_____ injury
• Hyper or hypo______
• V_____ impairment
• Peripheral _______
• Worsened arr______

Answer 60

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

Question 61

Warfarin (Coumadin)

Vitamin K antagonist

For anticoagulation in patients with abnormal or damaged (1) and (1) disease

Baseline labs (5)

If you suspect bleeding episode, check (3)

Answer 61

Abnormal/Damaged heart valves and CKD

INR, aPTT, CBC (to check platelets), Creatinine, LFTs

INR, PT, PTT

Question 62

Warfarin Dosing

Initial daily dosing for average adult =

Initial daily dosing for elderly/>70, frail, sensitive =

Full effect takes ___ days

Check INR every __-__ days until therapeutic for __ consecutive checks, then recheck every ____ until INR is stable at __-__

Once stable check every __ weeks

Answer 62

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

Question 63

Warfarin Drug Interactions

1. (1) = Methyprednisolone, prednisone
2. (1) and (1) = fluoxetine, sertraline, duloxetine, fluvoxamine, venlafaxine
3. (1) = ciprofloxacine, levofloxacin, moxifloxacin, norfloxacin
4. (1) = azithromycin, clarithromycin, erythromycin
5. (1) = amoxicillin, amoxicillin-clavulanate
6. (1) = fluconazole, miconazole
7. (1) = fluvastatin, lovastatin, rosuvastatin, simvastatin
8. Other meds = tr_____, feno_____, trim_____ s_______

Answer 63

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

Question 64

DOACS

• _______ (Pradaxa)
• _______ (Xarelto)
• _______ (Savaysa)
• _______ (Eliquis)

Advise pts to take meds on schedule and do not skip doses bc effect is lost after ___ hours

Does it require monitoring? Any diet restrictions? Any drug interactions?

Answer 64

• 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

Question 65

Complications from Afib and Afib Treatment

• Death by a (1) event (ie stroke, PE), C_ , an_____
• Warfarin associated intracerebral ______ has very high mortality and causes 90% of warfarin deaths (medical emergency, call 911)

1. Rx (1) associated life threatening bleeding episode
2. Rx (1) associated life threatening bleeding episode

Answer 65

• 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

Question 66

Warfarin Associated Life Threatening Bleeding Episode Treatment

1. _____ Warfarin and all anticoagulants such as ASA, NSAIDs
2. Give vitamin __ , 4-factor pro____ complex concentrate (PCC< inactivated), or fresh (1)
3. Check labs (3)

Answer 66

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

Question 67

DOAC associated life threatening bleeding episode treatment

(1) Rx for bleeding caused by rivaroxaban (xarelto), apixaban (eliquis)

(1) Rx for bleeding caused by dabigatran (pradaxa)

Answer 67

Andaxanet alfa (Andexxa)

Idarucizumab (Praxbind)

Question 68

Anticoagulation Guidelines

Goal INR for

1) Afib

2) Synthetic/Prosthetic Values

Answer 68

Afib = INR 2-3

Synthetic/Prosthetic Values = INR 2.5-3.5

Question 69

Management of Elevated INR

INR <4.5 and no presence of bleeding =

INR 4.5-10 and none or not clinically significant bleeding =

Answer 69

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

Question 70

DOACS Patient Education

1. Advise patients to be consistent with their day-to-day consumption of (1) foods.
2. Give patient a _____ of foods with high levels of vitamin K such as? (7)
3. Only _____ serving per day is recommended for very high vitamin K foods.

Answer 70

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.

Question 71

Rhythm that is part of the narrow QRS complex tachycardias with regular ventricular response. Defined as intermittent episodes of regular but rapid heartbeat, which starts and stops abruptly, EKG shows tachycardia with peaked QRS complex with P waves present

(2) Examples

Answer 71

Paroxysmal Supraventricular Tachycardia

Wolff Parkinson-White (WPW) syndrome

Atrial Tachycardia

Can be misdiagnosed as a panic attack

Question 72

What heart rhythm does this describe?

Patient complains of an abrupt onset of palpitations (“feels like fluttering in my chest”), rapid pulse, lightheadedness, shortness of breath, and anxiety. May feel weak and fatigue or faint. Rapid heart rate can range from 150 to 250 beats/min. Reports previous episodes that resolved spontaneously. Can start in childhood or older; it may resolve spontaneously or reccur at a later time.

Can be precipitated by digitals toxicity, alcohol, hyperthyroidism, caffeine intake, and illegal drug use

Answer 72

Paroxysmal Supraventricular Tachycardia

Question 73

Paroxysmal Supraventricular Tachycardia Treatment

What should you do if the EKG shows WPW (Wolff-Parkinson White) Syndrome or pt is symptomatic?

Answer 73

Refer to Cardiologist or Call 911 if hemodynamically unstable, may need cardioversion

WPW increases risk of death → refer to cardiologist for catheter ablation

Question 74

Paroxysmal Supraventricular Tachycardia Treatment

American College of Cardiology 2015 guidelines

(2) maneuvers you can try first for acute treatment? describe each maneuver? are there any contraindications?

Answer 74

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

Question 75

Defined as a fall in systolic BP (SBP) of more than 10 mmHg during the inspiratory phase

Sign of (1)*

Pumonary causes (2)

Cardiac causes (3)

Answer 75

Pulses Paradoxus (paradoxical pulse)

important sign of cardiac tamponade*

Asthma, Emphysema (increased + pressure)

Cardiac tamponade, Pericarditis, Cardiac effusion (decreased movement of left ventricle)

Question 76

Exam Tips

1. PR interval signifies what? Duration in seconds and boxes?
2. How many EKG strips on exam?
3. Memorize appearance of (3) specific rhythms*!
4. Goal INR for Afib? If INR between 4.01-4.99, what should you do?
5. Definition of pulsus paradoxus

Answer 76

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

Question 77

Clinical Pearls

1. Can major bleeding occur with a normal INR? What labs to order if you suspect bleeding?
2. How long does it take to see a change in INR when changing the warfarin dose?
3. Warfarin (Coumadin) is a FDA category __ drug. Meaning it is _______

Answer 77

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.

Question 78

Definition of HTN

BP >____/____

Majority of pts have what type of HTN?

Only 5-10% people have what type of HTN?

Generally, what type of treatment is first line for newly diagnosed HTN?

What if someone has newly diagnosed HTN but also has risk factors like CAD?

Answer 78

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

Question 79

Diagnosis of HTN

=

• Important to compare (1) BP to (1) BP, difference of < ___mmHg is not significant
• Instruct about accurate s____ of cuff, if cuff is too small it will falsely _____ BP
• Advise patient to take it at ____ times of the day and during work
• What should you rule out if home BP is lower?

Answer 79

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

Question 80

Blood Pressure Measurement

• Avoid consuming _____ or s_____ 30min before measurement
• Legs should not be ______
• Begin measurement after __min of rest
• _____ sphygmomanometer preferred over _____ machines
• 2 or more readings separated by ___ min should be averaged per visit
• What if one number is stage 2 and the other number is stage 1?

Answer 80

• 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

Question 81

HTN Stages

Normal =

Elevated =

Stage 1 =

Stage 2 =

Answer 81

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

Question 82

HTN Screening

Starts screening at what age? how frequent? What if they have risk factors?

Answer 82

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

Question 83

BP = CO x PVR

Any change in PVR or CO results in a change in BP, examples include

(1)

• water retention increases vascular volume, resulting in increased (1) part of the equation (BP increases)
• Renin levels are higher in what age? what race?

(1)

• This hormone increases vasoconstriction and will increase PVR (BP increases)

(1)

• This system causes increases in epinephrine and cortisol secretion which increases PVR (BP increases)

Answer 83

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)

Question 84

BP = CO x PVR

Any change in PVR or CO results in a change in BP, examples include

(3)

• Drugs decrease peripheral vascular resistance from vasodilation (BP decreases).

(1)

• Systemic vascular resistance is ____ because of hormones (SBP and diastolic blood pressure [DBP] decrease during the first and second trimesters).
• The ___ heart sound is common in the _____ trimester of pregnancy.
• Drugs used to control BP in pregnancy are methyl___, lab______, _____-blockers, and di_______.

Answer 84

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.

Question 85

HTN Screening Labs and Diagnostic Tests

1. Kidneys: (3)
2. Endocrine: (2)
3. Electrolyte: (3)
4. Heart: (1) panel
5. Anemia: (1)
6. Baseline (2) (to rule out cardiomegaly)

Answer 85

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)

Question 86

Microvascular Target Organ Damage from HTN

• Eyes
  
  • (2) wire arterioles
  • Arteriovenous junction _____ (caused when an arteriole crosses on top of a vein)
  • F______-shaped hemorrhages, pap______
• Kidneys
  
  • (2) urias
  • Elevated (2)
  • Peripheral or generalized e_____

Answer 86

• 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

Question 87

Macrovascular Target Organ Damage from HTN

• Heart
  
  • S__ (CHF)
  • S__ (LVH)
  • Carotid _____ (narrowing due to plaque, increased risk of CAD)
  • C_ _ and acute __
  • Decreased or absent peripheral p_____ (peripheral arterial disease [PAD])
• Brain
  
  • T____
  • ______ St_____

Answer 87

• 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

Question 88

Secondary Hypertension

In about __-__% 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 _____, poly___kidneys, C_ _)
2. Endocrine (hyperth_____, hyperal_____, pheo_______)
3. Other causes (obstructive (1), c_____ of the aorta)

• Out of these cause, what is most associated with younger vs. middle aged vs. older adults?

Answer 88

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

Question 89

When should you suspect Secondary HTN?

1. Age < ___ yo
2. S____ HTN or ac____ rise in BP (previously stable patient)
3. R_____ HTN despite treatment with at least _____ antihypertensive agents
4. M______ HTN (severe HTN with (1) damage such as retinal hemorrhages, papilledema, acute renal failure, and severe headache)

Answer 89

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)

Question 90

Coarctation of the Aorta

Secondary Cause of HTN

1. Normal difference between BP in the legs vs. arms?
2. What is difference between BP in the legs and arms found in coarctation of the aorta?
3. Look for what in femoral pulses? How to check?

Answer 90

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).

Question 91

Sleep Apnea

Secondary Cause of HTN

Sleep partner will report severe _____ with a_____ episodes during sleep.

Marked hy____ episodes during sleep increase BP.

Answer 91

Sleep partner will report severe snoring with apneic episodes during sleep.

Marked hypoxic episodes during sleep increase BP.

Question 92

Secondary HTN Clinical Findings

Kidneys

• (1) = Bruit in epigastric, abdomen, or flank area: avoid (2) Rx
• (1) = Enlarged kidneys with cystic renal masses
• (1) = Increased creatinine and decreased eGFR

Answer 92

• 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

Question 93

Primary Hyperaldosteronism (Conn’s Syndrome)

Endocrine Cause of Secondary HTN

Role of Aldosterone =

Most common cause is an aldosterone-producing ______ (usually benign) and less commonly adrenal ______

Treatment =

HTN + what K and Na levels indicate this condition?

Answer 93

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

Question 94

Hyperthyroidism

Secondary Cause of HTN S/S

• Weight ___, ____cardia, fine tr_____, _____ skin, an______
• New onset of (1) (check EKG)
• Check T___

Answer 94

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

Question 95

Pheochromocytoma

Endocrine Secondary Cause of HTN

=

• Labile increase in BP accompanied by pal_____
• Sudden onset of an____, sw____, severe h_____
• Order (1) for (high-risk patient) or (1) (low risk patient)

Answer 95

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)

Question 96

Defined as an SBP >180 mmHg and/or DBP >120 mmHg without target organ damage

Most common cause (1)

Tx =

Answer 96

Hypertensive Urgency

Noncompliance with antihtn therapy

Restart or intensify antihtn therapy with close follow up

Question 97

Defined as a SBP >180 mmHg and/or DBP >120 mmHg with clinical findings of target organ damage, such as nausea and vomiting, increased intracranial pressure (ICP), cerebrovascular accident (CVA)/TIA, MI, acute PE, acute renal failure, retinopathy (flame-shaped hemorrhages), papilledema, or acute severe low-back pain (dissecting aorta)

Tx =

Answer 97

Hypertensive Emergency

Call 911

Question 98

Defined as office SBP 120 to 129 mmHg with normal DBP <80 mmHg after 3-month lifestyle modification trial, while daytime home measurement BP is 130/80 mmHg or higher.

Answer 98

Masked Hypertension

Question 99

Isolated Systolic Hypertension in the Elderly

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

Answer 99

• 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.

Question 100

Elderly are at higher risk for this type of HTN due to a less active autonomic nervous system and slower metabolism of drugs by the liver (prolongs half-life of drugs).

Answer 100

Orthostatic Hypotension

Question 101

Orthostatic Hypotension

• Check BP in both _____ and _____ positions, especially in the elderly, before and after ______ for HTN
• Check for poly______, carefully review the medication history, and search for meds that lower BP
• Ask patient if d_____ or ___headed with changes in position

Answer 101

• 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

Question 102

Management of HTN

1. First, assess 10-year risk for (1) using the new (1) risk calculator
2. Reassess in __ month/s for effectiveness of BP-lowering medication therapy.
3. If goal is met at 1 month, reassess in __-__ months.
4. If goal is not met after 1 month, consider di_____ medication or ti_____
5. Continue m______ follow-up until BP control is achieved.

Answer 102

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.
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.

Question 103

Management of Normal Blood Pressure

SBP

Treatment and frequency of monitoring?

Answer 103

SBP <120 and DBP <80

Encourage heart-healthy lifestyle, evaluate yearly

Question 104

Elevated Blood Pressure

SBP? and DBP?

Recommend _____-healthy lifestyle and weight ____ if overweight/obese. Reassess in __ to __ months.

Answer 104

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.”

Question 105

Hypertension Stage 1

SBP = (1) or DBP = (1)

• Goal BP =*
• Risk less than 10%:* Start with ______ lifestyle recommendations and reassess in __ to __ months.
• Risk greater than 10% or known clinical cardiovascular disease (or diabetes, CKD):* L______ recommendations and (1)

Answer 105

SBP 130-139 or DBP 80-89

• 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.

Question 106

Hypertension Stage 2 Management

SBP = (1) or DBP (1)

Goal BP:

_________ changes and #____ BP-lowering medications of _____ classes. Reassess BP in?

If goal is met after 1 month, reassess in ___ to __ months.

If goal not met after 1 month, consider d_____ medications or ti______

Continue m_____ follow-up until BP control is achieved.

Answer 106

SBP 140 or higher OR DBP 90 or higher

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.

Question 107

Lifestyle Modifications in HTN

This is the first-line therapy for HTN, hyperlipidemia, and type 2 diabetes mellitus (DM):

Weight

1. Lose weight if overweight (body mass index [BMI] __–__) or obese (BMI __ or higher).
2. Normal weight is a BMI of ___ to ___

Smoking

1. ____ smoking. Reduce st____ level.

Sodium and Potassium

1. Reduce dietary sodium:
2. Maintain adequate dietary intake of potassium (>_____ mg/day) in patients with normal kidney function.

Limit Alcohol Intake

1. For men: 1 ounce (30 mL); up to ____ drinks or less per day
2. For women: 0.5 ounce; up to ____ drink or less per day
3. Eat fatty cold-water ____ (salmon, anchovy) ____ times a week.

Answer 107

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.

Question 108

DASH Diet (Dietary Approaches to Stop Hypertension)

Recommended for prehypertension, HTN, and weight loss.

• Goal is to eat foods rich in (3) electrolytes.
• Reduce ____ meat and pr_____ foods.
• Eat more whole gr____ and le_____.
• Eat more f___ and p______.
• This diet is high in fr____ and v______, has moderate low-fat d____, and is low in animal pr_____.

Answer 108

• 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.

Question 109

DASH Diet

1. Grains: __-__ daily servings
2. Fruits and vegetables: ___-___ daily servings
3. Nuts, seeds, and dry beans: ____- ____ servings per week
4. Fats, oils, or fat-free dairy products: ____-____ daily servings
5. Meat, poultry, and fish: ___ or fewer daily servings
6. Sweets: Try to limit to fewer than ____ servings per week
7. Avoid high-sodium foods: Cold c___, ready-m___ foods, any p_____ foods (cucumbers, eggs, pork parts)

Answer 109

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

Question 110

Dietary Sources of Minerals

• ______ (low-fat dairy)
• _______ (most fruits and vegetables)
• ________ (dried beans, whole grains, nuts)
• _____ oils (anchovy, krill, salmon, flaxseed)

Answer 110

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

Question 111

Exercise

Advise that aerobic physical activity will reduce LDL cholesterol and BP.

• Frequency: ____ or ____ sessions per week
• Intensity: _____ to _____(50%–80% of exercise capacity)
• Duration: ___ minutes average
• Modalities: W_____, tr____, cy____, r______, st____ climbing; include res_____ exercises for 2 to 3 days (e.g., el____ bands, weight ma_____, dumb____)

Answer 111

• 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)

Question 112

Diuretics for HTN

• All diuretics will decrease blood v_____, venous pr______, and ___load (cardiac filling).
• Effect is antagonized by Rx (1). Monitor electrolytes, especially (2)

Answer 112

• 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+).

Question 113

Thiazide Diuretics

MOA

Favorable effect with those who also suffer from (1) bc it slows down demineralization by slowing calcium excretion by kidneys

Patient education to avoid (1), why?

Avoid if patient has (1) allergy

Answer 113

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.

Question 114

Thiazide Diuretics SE

Hyper (3)

Hypo (3)

Answer 114

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

Question 115

Thiazide Diuretics CI

• G____
• ____tension
• ____kalemia
• R_____ failure
• L______ treatment
• Sensitivity to s____ drugs and thiazides

Answer 115

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

Question 116

Thiazide Diuretics Rx

(1) 12.5 to 25 mg PO daily
(1) (Hygroton) 12.5 to 25 mg PO daily
(1) (Lozol) PO daily
(1) (Diuril) daily or divided dose

Answer 116

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

Question 117

Loop Diuretics for HTN

MOA

(1) (Lasix) PO BID
(1) (Bumex) PO BID

Answer 117

Inhibit the sodium–potassium–chloride pump of the kidney in the loop of Henle.

Furosemide (Lasix) PO BID

Bumetanide (Bumex) PO BID

Question 118

Loop Diuretics SE

• (1) (potentiates digoxin toxicity, increases risk of arrhythmias)
• (1) (hold diuretic, restrict water intake, replace K+ loss)
• _____magnesemia
• Possibly altered excretion of li____ and sal______

Answer 118

• 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

Question 119

Loop Diuretics CI

___uria (kidney failure)

Sen_____ to loop diuretics

Answer 119

Anuria (kidney failure)

Sensitivity to loop diuretics

Question 120

Sulfa Allergy and Diuretics

If people are allergic to sulfa, they may have cross-sensitivity to (2) diuretics. Other drugs with sulfa are sulfonylureas, sulfa antibiotics, sulfasalazine, and some pr_____ inhibitors (darunavir, fosamprenavir). May also be sensitive to topical sulfas (oph_____ drops) or topical silver sulfadiazine (Silvadene).

Answer 120

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).

Question 121

Aldosterone Receptor Antagonist Diuretics

• Action:* Rx (1) antagonizes the action of aldosterone. Increases elimination of _____ in the kidneys and conserves _____. Drug class also known as (1) - (2) Rx
• Indications:* R_______ HTN, heart _____, hirs_____, ac___, precocious puberty, primary ______ism

Very high risk of (1) if used with ACEIs, ARBs, potassium supplements, or NSAIDS. Monitor carefully for (1)

Answer 121

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

Question 122

Spironolactone SE

• G______, gal______
• Hyper______
• G_______(GI; vomiting, diarrhea, stomach cramps)
• postmenopausal ______
• _______ dysfunction

Answer 122

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

Question 123

Spironolactone CI

• Hyperkalemia (serum potassium >___ mEq/L)
• Renal insufficiency (serum creatinine >___ mg/dL in men or >___ mg/dL for women)
• Type 2 DM with micro________

Answer 123

• 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

Question 124

Beta Blockers for HTN

MOA

Avoid abrupt discontinuation after chronic use. Wean slowly. Why?

Two types of beta-receptors in the body: (1) (cardiac effects) and (1) (e.g., lungs, vascular smooth muscle).

Answer 124

Binds with beta-receptors on the heart and peripheral blood vessels. Decreases vasomotor activity, decreases CO, and inhibits renin (kidneys) and norepinephrine release.

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).

Question 125

Beta Blockers CI

(4) lung disorders
(2) heart blocks, which heart block is it not contraindicated for?

Sinus _____cardia

Answer 125

Asthma, COPD, chronic bronchitis, emphysema (chronic lung disease)

Second- and third-degree heart block (fine to use with first-degree block)

Sinus bradycardia

Question 126

Beta Blockers Other Uses besides HTN

1. Acute and Post ___: Reduces mortality during acute MI and post-MI
2. A______ pectoris: Treats symptoms
3. M______ headache: For prophylaxis only (not for acute attacks)
4. (1) : Reduces intraocular pressure (Betimol ophthalmic drops for open-angle)
5. Resting _____cardia (target heart rate <100 beats/min)
6. Hyper_____/storm, Pheo________: Controls symptoms until primary disease is treated
7. Essential (1): Treat symptoms with nonselective beta-blocker propranolol

Answer 126

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

Question 127

Cardioselective Beta Blockers (B1 receptors)

(3)

Answer 127

Atenolol (Tenormin)

Metoprolol (Lopressor)

Bisoprolol

Question 128

Nonselective beta-blockers (inhibits both B1 and B2 receptors)

(3)

Answer 128

Propranolol (Inderal)

Timolol

Pindolol

Question 129

Beta-blockers with alpha- and beta-blocking action

(2)

Answer 129

Labetalol (Normodyne)

Carvedilol

Question 130

Calcium Channel Blockers

MOA

Answer 130

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

Question 131

CCB

(1) type of CCBs have greater depressive effect on cardiac conduction and contractility (negative inotropic effect). - Rx (2)
(1) type of CCBs are potent vasodilators with little to no negative impact on contractility or conduction.

Answer 131

Nondihydropyridines type of CCBs have greater depressive effect on cardiac conduction and contractility (negative inotropic effect). - Verapamil, Diltiazem

Dihydropyridines type of CCBs are potent vasodilators with little to no negative impact on contractility or conduction.

Question 132

CCB Indications

(3)

CCB Contraindications

(3)

Answer 132

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

Question 133

CCB SE

• ______aches (due to vasodilation)
• Ankle ______ (caused by vasodilation and considered benign)
• Heart _____ or _____cardia (depresses cardiac muscle and AV node)
• Reflex ________ (seen with dihydropyridines such as nifedipine)

Answer 133

• 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)

Question 134

Calcium Channel Blockers

Dihydropyridines (3)

Nondihydropyridines (2)

Answer 134

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

Question 135

HTN: Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

ACEI MOA

ARB MOA

Combination antihypertensive drugs: ACEIs or ARBs are combined with other drug classes such as (2)

Answer 135

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

Question 136

ACEI and ARB Indications

Preferred drugs (monotherapy or combined with other drug classes) for

1. H___
2. D______
3. C___
4. Congestive _____ and after ___, especially those with heart failure or reduced ___tolic function

Answer 136

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

Question 137

ACEI and ARBs Side Effects

• (1) (up to 10% with ACEIs; less with ARBs)
• Hyper______
• (1) (rare but may be life-threatening)

Answer 137

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

Question 138

ACEI and ARB Contraindications

1. Moderate-to-severe _______ disease
2. (1) : 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. (1) (First Trimester) and (1) (Second and Third Trimesters) → Fetal kidney malformations, fetal hypotension, fetal death

Answer 138

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

Question 139

ACE Inhibitors Examples

All end in _____

• ______ (Altace) once a day in one or two divided doses
• ________ (Lotensin) once a day initially
• ________ (Vasotec) once a day in one or two divided doses
• _________ (Monopril) once a day
• ________ *Qbrelis, Prinivil, Zestril) once day

Answer 139

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

Question 140

ARB Examples

All end in _____

• ______(Cozaar) once a day in one or two divided doses
• ________ (Atacand) once a day in one or two divided doses
• _______ (Benicar) once a day in one or two divided doses
• ________ (Avapro) once a day

Answer 140

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

Question 141

HTN: Alpha-1 Blockers/Antagonists

• Also known as (1) blockers. Suffix of -_____.
• MOA =
• Side effects: ____ness and ____tension.
• Give at ____time at very ____ doses and ______ titrate up.

Answer 141

• 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.

Question 142

Alpha-1 Blockers SE

Not a first line choice for HTN except for what population? Why what does it do?

• 1st dose (1) is common - warn patient
• (2) common side effects, advise patient to (1)
• May cause severe ____tension and reflex _____

Answer 142

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

Question 143

Alpha-1 Blockers Examples

• ______ (Hytrin): Used for both HTN and BPH (starting dose 1 mg PO at bedtime)
• ______ (Cardura): Used for both HTN and BPH
• ______ (Flomax): Used for BPH only

Answer 143

• 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

Question 144

Direct Renin Inhibitors for HTN

MOA

Can you combine with ACEI or ARB? why?

• _______ (Tecturna) once a day
• Ali_____ and Hy_______ once a day

Answer 144

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

Question 145

Angiotensin Receptor-Neprilysin Inhibitors - HTN

(1)*

Indication

What is it?

Answer 145

Sacubitril/Valsartan (Entresto)

New drug class for treatment of HFrEF

Combo of neprilysin inhibitor (sacubitril) with ARB (valsartan)

Question 146

Antihypertensive SE

Match the Antihypertensive to its side effects

1. Dry cough, angioedema, hyperkalemia, Careful with CKD, renovascular disease, Do not use during pregnancy
2. Hyperkalemia, Do not use during pregnancy
3. Hypotension, hyperkalemia, cough, angioedema
4. Heart block, bradycardia, constipation
5. Headache, flushing, tachycardia, pedal edema, Short-acting nifedipine and nicardipine cause reflex tachycardia; not recommended for hypertension
6. Bradycardia, fatigue, insomnia, erectile dysfunction, bronchospasm (asthma, COPD)
7. Orthostatic hypotension

Answer 146

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)

Question 147

Antihypertensive SE

1. (1) diuretics: Hypokalemia, hyponatremia, hyperuricemia, hypercalcemia, dehydration
2. (1) diuretics: Hypokalemia, hyponatremia, hyperuricemia, dehydration
3. (1) diuretics: Hyperkalemia, hyponatremia, dehydration

Answer 147

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

Question 148

HTN Sample Case Scenarios

• (1):* Diuretics, ARNI, ACE inhibitor or single-agent ARB, beta-blocker (BB).
• DM:* (1) or (1) 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:* (1) or (1) as first-line; can add CCBs or thiazides or another drug class.
  (1) Race (including people with DM): Thiazides or CCBs may be more effective.

Answer 148

• 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.

Question 149

Recommended Drug Class based on Condition

Diabetes Mellitus (5)

Chronic kidney disease (GFR <60) (2)

HFrEF (5)

After acute MI (3)

Answer 149

Question 150

Exam Tips

1. Eye findings: Learn to distinguish the findings in hypertensive (2) vs. diabetic retinopathy (3)
2. Preferred medications for isolated systolic HTN in elderly? (2)
3. How to assess orthostatic hypotension?
4. Memorize all the side effects of thiazide diuretics (5)
5. Side effect of spironolactone is (1)

Answer 150

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

Question 151

Exam Tips

1. ACEI or ARBs indications other than HTN (3), may cause a (1) 10%
2. Careful when combining ACEI and (1) diuretics (ie triamterene, spironolactone) bc of increased risk of hyperkalemia
3. (1)* = ACEI or ARB when given with this condition can precipitate acute renal failure
4. (1) are not first line drugs for HTN, except if pt has preexisting BPH
5. Women with HTN and osteopenia/osteoporosis should receive (1) bc can help bone loss by (2)

Answer 151

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

Question 152

Clinical Pearls

For BP control, most patients will require at least ____ medications.

From 5% to 20% of patients on ACEIs will develop a (1)

ACEI cough is more common in what gender?

Answer 152

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.

Question 153

Heart Failure

Systolic Heart Failure (HF_EF) =

Diastolic failure (HF_EF) =

Causes

• Acute ___
• C_ _ (most common)
• H_ _
• fluid r_______
• Val_____ abnormalities
• Arr______

Answer 153

Systolic Heart Failure (HFrEF) <40%

Diastolic failure (HFpEF) > 40%

Causes

• Acute MI
• CAD (most common)
• HTN
• fluid retention
• Valvular abnormalities
• Arrhythmias

Question 154

Symptoms of what side ventricular failure?

Crackles, bibasilar rales (rales on lower lobes of the lungs), cough, dyspnea, decreased breath sounds, dullness to percussion

Answer 154

Left Ventricular Failure

Question 155

Symptoms of what side ventricular failure?

Paroxysmal nocturnal dyspnea, orthopnea, nocturnal nonproductive cough, wheezing (cardiac asthma), HTN, and fatigue

Answer 155

Left and Right heart failure

Question 156

Symptoms of what side ventricular failure?

JVD: Normal JVD is 4 cm or less

Enlarged spleen and enlarged liver causes anorexia, nausea, and abdominal pain

Lower extremity edema with cool skin

Answer 156

Right Ventricular Failure

Question 157

Sign of what cardiac condition?

Presence of S3 gallop, which can be accompanied by anasarca (severe generalized edema due to effusion of fluid into the extracellular space)

Answer 157

Heart Failure

Question 158

Chest X-Ray Findings in HF

• Heart size =
• Interstitial and alveolar =
• (1) lines
• Other signs of pulmonary _____

Answer 158

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

Question 159

Labs and Diagnostics to collect in HF

• Labs
  
  • Tr_____C_ _, B _ _
  • Kidney function (2)
  • C_ _ , l_____ function tests
• Chest (1)
• (1) with doppler flow study
• W____ checked daily to detect fluid accumulation

Answer 159

• 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

Question 160

Treatment Plan for HF

• Acute decompensated heart failure = refer to ___ for (IV fur____, vaso_____)
• Rx (1) used to relieve symptoms of volume overload (dyspnea, peripheral edema) in primary care.
• Stabilized HFrEF: Combination treatment with Rx (1) + (1) + (1)
• Limit ______ intake

Answer 160

• 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

Question 161

Treatment Plan for HF

• Patients with HF are best managed by (1) or at a ____ clinic.
• Use Rx (1) if HFrEF (_____lol, _____lol, extended-release _____ succinate); start with very ___ dose; careful with initial dosing, can worsen; consult or refer to experienced heart clinic. Started after the patient has been initiated on (1)/(1)/or(1).
• Use (1) system to classify patient’s degree of cardiac disability (Table 1).
• Refer to (1); if in distress, refer to (1)

Answer 161

• 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).
• Refer to cardiologist; if in distress, refer to ED.

Question 162

NYHA Classes of Functional Capacity

Class I

Class II

Class III

Class IV

Answer 162

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

Question 163

Lifestyle Modifications in HF

• Restrict or abstain from al_____. Smoking ______ if smoker; weight ____.
• Restrict sodium to __ to __ g/d.
• ______ restriction (1.5–2 L/d) may help some patients.

Answer 163

• 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.

Question 164

HF Notes

Here is an easy way to remember whether a sign or symptom is from the left or right side of the heart:

Both left and lung start with the letter L. Symptoms are ____ related, such as dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.

Right-sided heart failure symptoms are ___ related (anorexia, nausea, and right upper quadrant abdominal pain)

Answer 164

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)

Question 165

Thrombi develop inside the deep venous system of the legs or pelvis secondary to stasis,trauma to vesselwalls, inflammation, or increased coagulation. Pulmonary embolus is considered another manifestation of this thromboembolic disorder.

Answer 165

Deep Vein Thrombosis

Question 166

Deep Vein Thrombosis Etiologies

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

Answer 166

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

Question 167

Classic Case of DVT

A patient with risk factors for DVT complains of gradual onset of sw_____ on a lower extremity after a history of tr_____ (more than 3 hours) or prolonged sitting or prolonged inactivity. The patient complains of a ____ful and swollen lower extremity that is r__ and w___. If patient has (1), it is accompanied by abrupt onset of chest pain, dyspnea, dizziness, or syncope. Mayn patients are __symptomatic

Answer 167

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.

Question 168

Types of DVTs

(1) DVT: No identifiable environmental cause

(1) DVT: Caused by known event (e.g., surgery, major surgery >30 minutes, hospitalization)

Answer 168

Unprovoked DVT: No identifiable environmental cause

Provoked DVT: Caused by known event (e.g., surgery, major surgery >30 minutes, hospitalization)

Question 169

Homan’s Sign

=

Sensitivity?

Answer 169

Lower leg pain on dorsiflexion of the foot

(low sensitivity)

Question 170

DVT Workup

Labs

Imaging

Answer 170

CBC (platelets), Clotting time (PT/PTT, INR), D-Dimer

EKG, Chest X-ray, US of whole or proximal leg

Question 171

DVT Treatment

Can it be treated outpatient?

What medications are you going to give? Rx(1) → Rx(1)

If this is its initial episode duration of treatment with (1) Rx for at least __ months

For recurrent DVT or elderly, antithrombotic treatment may last a ______.

Answer 171

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.

Question 172

DVT Complications

(3)

Answer 172

Pulmonary Embolism

Stroke

Death

Question 173

Exam Tips

• Memorize presentation of a patient with NYHA class __ heart disease.
• First-line medication for stable HF is an (1) or (1).
• The S__ heart sound is a sign of HF, although it can also be heard in pregnant women and children/young adults.
• Learn DVT risk factors =

Answer 173

• 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

Question 174

Inflammation of a superficial vein due to local trauma. Higher risk if indwelling catheters, IV drugs (e.g., potassium), secondary bacterial infection (S. aureus). Some patients may have coexistent DVT.

Answer 174

Superficial Thrombophlebitis

Question 175

Classic Case of Thrombophlebitis

Adult patient complains of an acute onset of an indurated v___ (localized r____, sw____, and t______). Usually located on the extremities. The patient is afebrile with normal vital signs.

Answer 175

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.

Question 176

Objective Findings of Superficial Thrombophlebitis

• In______ cord-like vein that is warm and t_____ to the touch with a surrounding area of er_____.
• There should be no swelling or edema of the ____ limb (think of ___).

Answer 176

• 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).

Question 177

Superficial Thrombophlebitis Treatment Plan

Administer Rx (1), such as ibuprofen or naproxen sodium (Anaprox DS), BID.

_____ compresses. ______ limb.

If septic cause?

Answer 177

Administer NSAIDs, such as ibuprofen or naproxen sodium (Anaprox DS), BID.

Warm compresses. elevate limb.

If septic cause, inpatient hospitalization

Question 178

Gradual (decades) narrowing and/or occlusion of medium-to-large arteries in the lower extremities. Blood flow to the extremities gradually decreases over time, resulting in permanent ischemic damage (gangrene of the toes/foot).

Answer 178

Peripheral Arterial Disease

(Previously known as peripheral vascular disease)

Question 179

Peripheral Arterial Disease Risk Factors

H__

Sm_____

D_____

Hyper______

Answer 179

HTN
Smoking

Diabetes

Hyperlipidemia

Question 180

PAD Classic Case

Older patient who has a history of sm____ and hyper_____ complains of worsening p____ on ambulation (intermittent cl______) that is instantly relieved by ____. Over time, symptoms worsen until the patient’s walking distance is greatly limited. Atrophic ____ changes. Some have _______ on one or more toes.

Answer 180

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.

Question 181

PAD S/S

Skin: A______ changes (sh___ and hyperp_____ ankles that are h____less and _____ to the touch); ______ of the toe(s)

Cardiovascular: ____ to _____ dorsal pedal pulse (may include popliteal and posterior tibial pulse), ______ capillary refill time (<2 seconds), and br_____ over partially blocked arteries

Answer 181

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

Question 182

What test is done to evaluate the severity of PAD?

(1)

Normal =

Diagnostic for PAD =

Severe PAD =

Answer 182

Ankle Brachial Index

Normal = 0.91-1.3

Diagnostic for PAD < 0.9

Severe PAD < 0.5

Question 183

How do you measure an Ankle Brachial Index?

Answer 183

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

Question 184

Peripheral Arterial Disease Treatment

(2) Rx

Which one is better and can it be taken with aspirin or clopidogrel? What can increase serum concentrations of this med (3) ?

• Encourage ______ cessation and daily ______ exercises
• For severe cases?

Answer 184

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.

Question 185

Peripheral Arterial Disease Complications

• G______ of foot and/or lower limb with am______
• Increased risk of C _ _
• Increased risk of car____ plaquing (check for carotid _____)

Answer 185

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

Question 186

Reversible vasospasm of the peripheral arterioles on the fingers and toes due to an exaggerated response to cold temperature or emotional stress. Cause is unknown

Answer 186

Raynaud’s Phenomenon

Question 187

Raynaud’s Phenomenon Risks

Primary Raynaud’s Phenomenon =

Secondary Raynaud’s Phenomenon =

Increased risk with (1) disorders (ie th____ disorder, pernicious _____, _____ arthritis)

Most common in what gender?

Answer 187

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.

Question 188

Raynaud’s Phenomenon Evaluation

Sp_______ remission of Raynaud’s phenomenon may occur. To evaluate, check d_____ pulses, is_____ signs (ischemic ul____ at the fingers/toes).

Answer 188

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

Question 189

Raynaud’s Phenomenon Classic Case

A middle-aged woman complains of chronic and recurrent episodes of c_____ changes on her finger____ in a _____ pattern (both hands and both feet). The colors range from ____ (pallor) and ____ (cyanosis) to ____ (reperfusion). Complains of ____ness and ti______. Attacks last for several hours. Hands and feet become numb with very cold temperatures. Some have _____ 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 ul____ (that eventually heal) on some of the fingertips.

Answer 189

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.

Question 190

Raynaud’s Phenomenon Treatment Plan

• Avoid touching ____ objects and being in cold w____; avoid st_____ (e.g., caffeine). Maintain whole body w_____. Use th____ underwear, lay______ clothing, h__, gloves/m_____, and hand war___.
• _______ cessation is important; ____dipine (Adalat) or ____dipine (Norvasc).
• Do not use any vaso_______ drugs (e.g., Imitrex, ergots, pseudoephedrine/decongestants, amphetamines) or d___ pills; avoid nonselective ____-blockers.

Answer 190

• 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.

Question 191

Exam Tips

Raynaud’s phenomenon: Think of the colors of the (1) as a reminder for this disorder.

Medications include (1) (nifedipine, amlodipine).

Answer 191

Raynaud’s phenomenon: Think of the colors of the American flag as a reminder for this disorder.

Medications include CCBs (nifedipine, amlodipine).

Question 192

Bacterial Endocarditis

(Infective endocarditis)

Common pathogens gram _____ (2)

Presentations range from (1) to (1)

Route (1) antibiotics for native valve endocarditis can range from __-__ weeks

Answer 192

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

Question 193

Classic Case of Bacterial Endocarditis

An adult male presents with fever, chills, and malaise that are associated with (1) on nails and tender violet-colored (1) on the fingers and/or on toes (_____ nodes). Palms and soles may have tender red spots on the skin (_____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 v____, history of valvular or congenital heart disease, cardiac device, IV d____ use, IV lines, recent d____ or surgical procedure. Maintain high index suspicion due to ____ mortality.

Answer 193

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.

Question 194

Treatment Plan Bacterial Endocarditis

• Refer to ____logist or ___ for hospitalization and IV (1)
• Blood _____ × three (first 24 hours)
• CBC (elevated ___s) and ______ rate >20 mm per hour (elevated)

Answer 194

• 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)

Question 195

Bacterial Endocarditis Complications

• Valvular des_____
• Myocardial ab____
• Em____
• D_____

Answer 195

• Valvular destruction
• Myocardial abscess
• Emboli
• Death

Question 196

Endocarditis Prophylaxis

Not approved anymore for

(3)

Answer 196

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)

Question 197

Endocarditis Prophylaxis

Used for what high risk conditions

(4)

Answer 197

History of bacterial endocarditis

Prosthetic heart valves including homografts, valvular repair

Unrepaired (or repaired) cyanotic congenital heart disease

Cardiac transplant with valvulopathy

Question 198

Endocarditis Prophylaxis

For those with high risk conditions, which procedures require prophylaxis?

(2)

Answer 198

• 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

Question 199

Endocarditis Prophylaxis

Standard Regimen

Give (1) Rx when?

If penicillin allergy

(3) Rx

Answer 199

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

Question 200

Mitral Valve Prolapse

Murmur =

Common cause for mitral ____, risk for (1) heart rhythm

Higher risk for thrombo_____, T_ _, _____ chordae tendinae

Best Diagnostic Test* (1)

Answer 200

Midsystolic click

Mitral regurgitation, A-Fib

Higher risk for thromboemboli, TIA, ruptured chordae tendinae

Transthoracic 3D Echo (TTE)

Question 201

Classic Case of MVP

T___ and th__ adult _____ patient complains of fatigue, palpitations, and lightheadedness (_____ 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. (1)* is the most common symptom. May be asymptomatic. Rule out (1) syndrome if patient with pectus excavatum, hypermobility of the joints, and arm span greater than height.

Answer 201

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.

Question 202

Mitral Valve Prolapse Treatment

Asymptomatic MVP =

MVP with palpitations = Rx (1) + Avoid?

(1) Diagnostic test recommended for patients with clinical exam suggestive of MVP or those with family history of MVP

Answer 202

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.

Question 203

Hyperlipidemia

What tool do we use to determine if someone needs a statin?

May underestimate risk in what populations?

Answer 203

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).

Question 204

Screening for Hyperlipidemia

The U.S. Preventive Services Task Force (USPSTF) recommends lipid screening in both men and women who are at increased ____ for _____ heart disease (CHD)

Men aged __ years or older

Women aged __ years and older

Adults aged 76 years and older with no history of CVD?

Answer 204

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)

Question 205

Total Cholesterol

Normal =

Borderline High =

High =

Answer 205

Normal: <200 mg/dL

Borderline high: 201 to 239 mg/dL

High: >240 mg/dL

Question 206

High-Density Lipoprotein Cholesterol

Normal Range

Men: >__ mg/dL

Women: >__ mg/dL

• HDL >__ mg/dL associated with lower risk of heart disease
• HDL
• What is the most common reason for low high-density lipoprotein cholesterol (HDL-C).

Answer 206

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

Question 207

HDL Cholesterol

Can you just treat HDL-C alone?

Medications that increase HDL Rx (3), however (1) has failed to reduce vascular events (stroke, ASCVD) and has fallen out of favor)

Answer 207

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.

Question 208

HDL - Cholesterol Lifestyle Modifications

• Engage in regular moderate (1) most days of the week
• Lose w____
• Eat healthy fats (s_____, t____, n___)
• Eliminate _____ fats
• Stop (1)*

Answer 208

• 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

Question 209

LDL Goals

• Optimal:*
• LDL:*
• Heart disease or diabetes:*

Answer 209

• 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

Question 210

Triglyceride Goal

Normal:

Hypertriglyceridemia = >_____ mg/dL

High risk of acute pancreatitis: ≥______ mg/dL

Answer 210

Normal: <150 mg/dL

Hypertriglyceridemia = >150 mg/dL

High risk of acute pancreatitis: ≥1,000 mg/dL

Question 211

Hypertriglyceridemia Possible Causes

• M______ syndrome
• D _
• F_______ hypertriglyceridemia
• Al______ abuse
• ______thyroidism
• k_____ disease
• medications
  
  • anabolic st____
  • Acc_____ (isotretinoin)
  • Oral est______, tamox____
  • di______
  • second-generation antips____
  • antiretro____
  • nonselective _____-blockers (e.g., propranolol).

Answer 211

• 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).

Question 212

Lifestyle modifications for Hypertriglyceridemia

• Decrease su____ and simple c____hydrates (junk food)
• avoid _____ drinks
• follow low-f___ diet
• eat ____ with omega-3 (salmon, sardines) twice a week
• lose w_____
• and increase a____-type physical activity.

Answer 212

• 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.

Question 213

If Triglycerides >500 mg/dL

Avoid drinking (1) because can precipitate acute _______*

First line medications Rx (3)*

Rx (1) 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 (1) or “prickly heat” sensation (from vasodilation), take it with aspirin

Rx (1) high dose ie Rx (2) 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 213

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)

Question 214

Clinical Pearl

Diets that improve serum lipids

(5)

Answer 214

DASH Diet

Mediterranean Diet

Vegetarian Diet

Low-Carbohydrate Diet

Low-Trans-Fatty Acid Diet

Question 215

Risk Factors: Heart Disease

• H _ _
• _______ history of premature heart disease (women with MI before age 65 years or men with MI before age 55 years)
• D _ (considered a CHD risk equivalent even if patient has no history of preexisting heart disease)
• Dysl______
• Low ____-C (<40 mg/dL)
• A__ (men older than 45 or women older than 55)
• Cig______
• Ob____ (BMI ≥30 kg/m²)
• Microal________
• Car_____ artery disease
• P______ vascular disease (PVD)

Answer 215

• 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)

Question 216

Heart Disease (Hyperlipidemia) Treatment Plan

1. First line treatment
2. Reduce dietary ____ intake and learn about the (1) diet
3. Encourage use of soluble _____ in diet (inulin, guar gum, fruit, vegetables) to enhance lowering of LDL (lowers LDL by blocking absorption in GI tract up to 10%)
4. Target is to lower what lipid level first? (except if high (1) > 500) because patients are high risk for acute pancreatitis
5. Low ____ alone (even if normal LDL and cholesterol) is a risk factor for heart disease

Answer 216

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

Question 217

American College of Cardiology and American Heart Association Updated Guidelines

Very High Risk for Future Atherosclerotic Cardiovascular Disease Events

• Recent ______ syndrome (within the past 12 months)
• History of M_
• History of ischemic st_____
• Symptomatic (1) disease (history of claudication with ABI <0.85 or previous revascularization or lower extremity amputation)

Answer 217

• 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)

Question 218

High-Risk Conditions for ASCVD

• Age: ≥__ years
• Cardiovascular (CV): History of prior coronary artery (2) surgeries, C _ _ , H_ _
• D _
• Current sm_____
• Kidney: C_ _ (eGFR 15–59 mL/minute)
• Persistently elevated ____ of ≥100 mg/dL despite statin therapy and ezetimibe

Answer 218

• 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

Question 219

Secondary Prevention (Presence of ASCVD)

1. Patients with any form of clinical ASCVD (history of MI, CAD, angina, stroke/TIA, PAD, coronary revascularization):

• High-intensity (1) (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 (1)
• LDL goal is __ mg/dL
• If already on high-intensity dose of statin and not at goal (LDL 70 mg/dL), add a nonstatin such as (1)/Zetia.
• If on statin and ezetimibe (LDL remains >70 mg/dL), adding a proprotein convertase subtilisin/kexin type 9 (1) inhibitor is reasonable (although long-term safety >3 years is unknown).

Answer 219

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).

Question 220

Secondary Prevention (Presence of ASCVD)

3. Diabetic patients with LDL of ≥70 mg/dL:

• Age 40 to 75 years: ________-intensity statin therapy (without calculating 10-year ASCVD risk)
• Age 50 to 75 years: Can use ____-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: ____-intensity statin (without calculating 10-year ASCVD risk)
• If on high-intensity statin and LDL ≥100 mg/dL, add _____ (Zetia).
• If multiple risk factors for ASCVD, consider adding a _____ inhibitor to statin.

5. Assess adherence and percentage response to LDL-lowering medications and lifestyle changes:

• Repeat lipid measurement in __ to __ weeks after statin initiation or dose adjustment.
• Repeat every 3 to 12 months as needed.

Answer 220

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.

Question 221

Primary Prevention (No ASCVD)

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). If decision to start statins uncertain, check the (1) score. If the score is 1 to 99, favor starting statin therapy.

Answer 221

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). 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.

Question 222

Primary Prevention (No ASCVD)

If 10-year ASCVD risk of 20% or higher (high risk):

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

Answer 222

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%.

Question 223

ACC/AHA Updated Guideline on the Treatment of Blood Cholesterol (2018)

Answer 223

Question 224

High Intensity Statins

Lower’s LDL by how much %?

Atorvastatin (Lipitor) ___-___ mg

Rosuvastatin (Crestor) ___-___ mg

Answer 224

Lower’s LDL by > 50%

Atorvastatin (Lipitor) 40-80 mg

Rosuvastatin (Crestor) 20-40 mg

Question 225

Moderate Intensity Statins

Lowers LDL by how much %?

Atorvastatin __-__ mg

Rosuvastatin (Crestor) ___- ___ mg

Simvastatin (Zocor) ___ - ___ mg

Pravastatin (Pravachol) ___- ___ mg

Lovastatin (Mevacor) ___mg

Answer 225

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

Question 226

Low-Intensity Statins

Lower LDL

Simvastatin __ mg/d

Pravastatin __–__ mg/d

Lovastatin __ mg/d

Fluvastatin __–__ mg/d

Answer 226

Lower LDL <30%

Simvastatin 10 mg/d

Pravastatin 10–20 mg/d

Lovastatin 20 mg/d

Fluvastatin 20–40 mg/d

Question 227

Risk-Enhancing Factors for Atherosclerotic Cardiovascular Disease

• F_____ history of ___mature ASCVD
• Persistently elevated ____-C levels of ≥160 mg/dL
• M_______ syndrome
• Chronic ______ disease (CKD)
• History of pre_____ or premature meno____ (age <40 years)
• High-risk ethnic groups such as South ______ (from India, Pakistan, Sri Lanka, Nepal, Bangladesh)
• Chronic inf_______ disorders (e.g., psoriasis, RA, or chronic HIV)
• Persistent tri______ elevations
• Elevated C-reactive protein of ≥__.0 mg/L
• Ankle-brachial index (ABI) ≤0.__
• ASCVD, atherosclerotic cardiovascular disease; RA, rheumatoid arthritis.

Answer 227

• 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.

Question 228

Hyperlipidemia When to Refer

Rule out (1) hypercholesterolemia (FH) if presence of (1) (Achilles, subpatellar, or hand extensor tendons).

Answer 228

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

Question 229

Lipid Lowering Medications

(1) is the enzyme in the liver that is responsible for cholesterol synthesis. (1) inhibits 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 _____ doses.

Answer 229

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.

Question 230

Lipid Lowering Medications

If patient is a high-intensity statin candidate, start at _____ doses and titrate up _____ to the recommended dose to minimize ______ effects. Check baseline _____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 230

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.

Question 231

Lipid Lowering Medications

If patient is at very high risk for ASCVD or has severe primary hypercholesteremia (LDL >___ mg/dL) and is not at LDL goal (but already on high-dose statin), the next step is to add (1)* to the statin. If still not at goal (LDL of __ mg/dL), can add a (1)* to statin and ezetimibe.

Answer 231

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.

Question 232

HMG-CoA Reductase Inhibitors (Statins)

Pravastatin (Pravachol), lovastatin (Mevacor), simvastatin (Zocor), atorvastatin (Lipitor), rosuvastatin.

• (2) drug interactions (high risk of rhabdomyolysis):
  
  • Avoid ______ juice
  • Fi____
  • Anti_____ (itraconazole, ketoconazole)
  • ______ (erythromycin, clarithromycin, telithromycin)
  • ______ (Cordarone), some ____ (diltiazem, amlodipine, verapamil)
• Combination regimens of a statin with ezetimibe (Zetia) is acceptable for some _____-risk patients

Answer 232

• 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

Question 233

Nicotinic Acid

Niacin (OTC) daily or TID, Niaspan (slow-release niacin) daily. _____ combining niacin with statin (higher risk of _____ damage).

Adding statins to niacin, does it produce further benefit? is there increased risk of anything?

Answer 233

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.

Question 234

Fibrates

Gemfibrozil (Lopid), fenofibrate (Tricor), benzafibrate (Bezalip). Do not use with severe _______ disease.

Action =

Very good agents for lowering ______ and elevating____ level. _____ effective at lowering LDLs compared with the statins.

Side effects: Dys_____ and ____stones; my_____

Answer 234

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

Question 235

Bile Acid Sequestrants

________ (Questran Light), colestipol (Colestid), colesevelam (Welchol)

Action:

_______ drug for patients who cannot tolerate statins, fibrates, and niacin

If used alone, how is it compared to LDL?; no ______.

Side effects: Bloating, flatulence, abdominal pain; start at low doses and titrate up slowly. Side effects mainly from the ___ tract; advise patient to take ______ tablets daily.

Answer 235

Cholestyramine (Questran Light), colestipol (Colestid), colesevelam (Welchol)

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.

Question 236

Cholesterol-Absorption Inhibitors

(1)*

MOA =

Can we combine them with statins? If so, for who?

Contraindication (1)

Can be taken alone or combined with a _____ or _____ (e.g., simvastatin [Vytorin])

Side effects: Di_____, ____pains, t____ness

Answer 236

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

Question 237

Proprotein Convertase Subtillisin/Kexin Type 9 Inhibitors

PCSK9 Inhibitors Rx (2)

What are they?

Can decrease LDL by __% to __%.

Route, Frequency

Reduces risk of (3)

Can be used alone or with other lipid-lowering therapies (statins, ezetimibe).

Current guidelines recommend adding PCSK9 to statins for patients that are?

Answer 237

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

Question 238

(1)

Acute breakdown and necrosis of skeletal muscle (myoglobins) will cause acute renal failure. Triad of muscle pain (myalgia), weakness, and red-to-brown urine. More than half of patients do not report muscular symptoms

Answer 238

Rhabdomyolysis

Question 239

Rhabdomyolysis

• If symptoms present, most commonly in which muscles? (4)
• Higher doses of (1) or combined therapy have higher risk
• What should you do with the statin if you suspect this?

Answer 239

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

Question 240

Rhabdomyolysis Labs

CK levels =

Urine =

What other labs should you order?

Answer 240

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

Question 241

ACUTE DRUG-INDUCED HEPATITIS

Symptoms = An_____, n____, ___-colored urine, j_____, f______, f___-like symptoms

• Labs will show elevated (2)
• Discontinue (1) Rx, Stop (1) intake
• Avoid prescribing statins to (1)
• Advise patient to report symptoms of hepatitis or rhabdomyolysis. If present, tell patient to stop the drug and call or go to ____

Answer 241

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

Question 242

Exam Tips

1. First line treatment for HTN =
2. First line treatment for HLD =
   
   1. but presences of (1) 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 what intensity statin? Rx (2)
   2. An adult with LDL > ___ (without ASCVD or DM) is a candidate for ____-intensity statin dosing

Answer 242

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

Question 243

Exam Tips

1. If patient has markedly high triglycerides (___ mg/dL or higher), lower triglycerides _____ (Rx (1) or (1)) before treating the high cholesterol and LDL levels. Very high triglycerides increase risk of acute ______.
   
   1. Educate to avoid (2) use.
   2. Obese patients: Encourage weight loss and reduce simple c_____, s_____, and j____ foods.
   3. Advise patient to reduce intake of simple carbohydrates, junk foods, and fr____ foods

Answer 243

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

Question 244

Exam Tips

1. (2) Rx are best agents for lowering triglycerides.
2. Become familiar with dietary sources of _____sium, ____sium, and ____ium.
3. Bacterial (1) prophylaxis drug and dose, _____ hemorrhages on nails, _____ lesions (red macules on palms/soles not painful), _____ nodes (painful violaceous nodes found mostly on pads of the fingers and toes, thenar eminence).

Answer 244

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).

Question 245

Clinical Pearls

What reversible cognitive effects can statins cause?

Patients on simvastatin and lovastatin should avoid what type of food? what drug class?

Where does muscle pain from rhabdomyolysis usually happen? What does the urine look like?

Answer 245

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

Question 246

Obesity Prevalence

All obese and overweight patients should have their BMI and abdominal obesity calculated.

In the United States, more than one-third (39.6%) of adults are obese. As of 2015 and 2016 (latest data), the prevalence of obesity in men is 37.9% and 41.1% in women.

The prevalence of obesity in Canada is rising. By 2013, more than 22% of men and 20% of women were obese. Nauru (Oceania) has the highest obesity rate in the world at 61% (2016).

• (1) Ethnicity with highest rates of obesity (48.1%), followed by (1) (42.5%), and (1) (34.5%) - about 40.2% are ___-aged adults (40-59yo)
• Evaluate for _____ syndrome and (1) disease
• Obesity increases risk of mortality and other health risks, including type 2 DM, H___, dysli_____, C_D, ___ apnea, and decreased mob_____.

Answer 246

• 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.

Question 247

BMI Classifications

Underweight =

Normal weight =

Overweight =

Obese =

Grossly obese =

Answer 247

Underweight <18.5

Normal weight 18.5-24.9

Overweight 25-29.9

Obese 30-39.9

Grossly obese >40

Question 248

Body Type of Obesity

(1) body type is considered more dangerous for health compared to (1) body type

Answer 248

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

Question 249

Abdominal Obesity

Waist Circumference

• Males: >__ inches (102 cm); South Asians, >__ inches (90 cm)
• Females: >__ inches (88 cm); South Asians, >__ inches (80 cm)

Waist to Hip Ratio

• Males: ___ or higher
• Females: ___ or higher

Answer 249

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

Question 250

Obesity Treatment

• Weight loss with d___tary therapy and ____style and be______ modifications
• There are many “dietary” methods (e.g., W____ Watchers, k___, N____system, Atkins) and apps (e.g., Noom, Weight Watchers) that help promote weight loss. It depends on patient preferences.
• Meal _____ 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 250

• 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).

Question 251

Obesity Treatment

• Exercise: __ minutes of moderate to vigorous physical activity at least __ or __ times per week. Walking ____ 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 ____ group sites, blogs, and articles about weight loss on the Internet.
• Therapies not recommended by experts are l___suction (it does not improve insulin sensitivity or risk factors for heart disease), ____ dietary supplements, and very-low-_____diets (<1,000 kcal/day).

Answer 251

• 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).

Question 252

(1)

A metabolic disorder with a cluster of symptoms. These patients are at higher risk for type 2 DM, cardiovascular disease, and stroke. Also known as insulin resistance syndrome or syndrome X.

Answer 252

Metabolic syndrome

Question 253

Criteria for Metabolic Syndrome (Adult Treatment Panel III)

Diagnosis requires ___/5

1. _________ obesity (>__ inches [102 cm] in men and >__ inches [88 cm] in women)
2. BP >___/___ mmHg
3. Elevated fasting plasma glucose (>____ mg/dL)
4. Elevated triglycerides (>___ mg/dL) or on drug treatment for elevated triglycerides
5. Decreased ___ (<40 mg/dL in men and <50 mg/dL in women)

Answer 253

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)

Question 254

Metabolic Syndrome Labs

• Fasting (from 9 to 12 hours) ____ profile (especially triglycerides and HDL)
• Fasting blood _____
• _____ (BMI), ____ circumference, B_

Answer 254

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

Question 255

(1)

Triglyceride fat deposits (steatosis) in the hepatocytes of the liver

Answer 255

Nonalcoholic Fatty Liver Disease

Question 256

Nonalcoholic Fatty Liver Disease

• Do most have symptoms? Can present with or without in_______.
• It is more common in _____ industrialized countries.
• The most common reasons for fatty liver are chronic heavy _____ consumption and _____ (with type 2 diabetes and/or with metabolic syndrome).
• Risk factors include c_____ obesity, type 2 _____, _____syndrome.

Answer 256

• 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.

Question 257

Classic Case of Nonalcoholic Fatty Liver Disease

Usually __symptomatic. Some patients may have hepatom_____. Annual physical exam labs will show mild-to-moderate elevations of A__ and A__. If symptomatic, complaints of fat___ and malaise with vague right upper quadrant ___. Associated with obesity, metabolic syndrome, DM, and hyperlipidemia

Answer 257

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

Question 258

Labs for NAFLD

Gold Standard =

(1) 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 _____ levels, gl_____, A__.

Order ______ A, B, and C profile.

Initial imaging test is liver ____ and NAFLD _____ score.

Answer 258

Refer to GI specialist for management and a liver biopsy

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.

Question 259

NAFLD Treatment Plan

• Lose w______, exercise, and watch diet.
• Discontinue ____ intake permanently.
• Avoid hepato____ drugs (e.g., acetaminophen, isoniazid, statins).
• Recommend ______ for hepatitis A and B and annual ___ vaccine.
• Refer to __ specialist

Answer 259

• 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

Question 260

Patient Education for NAFLD

• All obese and overweight patients should be advised to lose ____ (especially diabetics).
• _____ changes are important (diet, nutrition, exercise, portion control).
• Daily _____ exercise (e.g., walking, swimming, biking) for __ to __minutes is recommended.
• Weight ______ : Some patients like the support and education (tertiary prevention).

Answer 260

• 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).

Question 261

Exam Tips

• Know metabolic syndrome criteria (5) caused by hyperinsulinemia and peripheral insulin resistance.
• NAFLD is associated with metabolic syndrome and/or obesity. Look for slight _____ of ALT and AST (not related to alcohol or medications) and ______ hepatitis A, B, and C.
• Abdominal obesity in males (>___inches [102 cm]) and females (>___inches [88 cm]).
• Do not confuse BMI formula with the PEF (peak expiratory flow). PEF is calculated using what mneumonic?
• A person with a BMI of ___ is overweight (initiate lifestyle education).

Answer 261

• 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).

Question 262

Exam Tips

• There are usually ___ questions regarding heart murmurs on the exam.
• Learn to use the mnemonics “MR. ASS” and “MS. ARD.” =
• All murmurs with “mitral” in their names are only described as located:
  
  • On the ___ (or _____ area) of the heart or
  • On the ____ ICS on the ____ side of the sternum medial to the _______ line
• If an apical/apex murmur occurs during S1, it is (1) (MR. ASS). If an apical/apex murmur occurs during S2, it is (1) (MS. ARD).
• On the exam, only the ______ murmurs radiate (to the ____ in mitral regurgitation and to the ____ with aortic stenosis).

Answer 262

• 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).

Question 263

Exam Tips

• S3 is a sign of ____
• S4 is a sign of ____
• A physiological split S2 is best heard at the ______ area (____-____ sternum).
• Memorize the mnemonic “motivated apples” to help you remember the names of the valves that are responsible for producing S1 and S2. =
• Grading murmurs: Be aware that the first time a thrill is palpated is at grade ___.
• Rule out ____ 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 __ and __.
• Learn the signs/symptoms of IE (bacterial endocarditis) (4)

Answer 263

• 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) = splinter hemorrhages, petechiae, Osler nodes, Janeway lesions

Question 264

Exam Tips

• The PR interval (atrial depolarization) duration is ____ to _____ seconds (3–5 small boxes).
• ____ 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 (____-like pattern).
• AF: Goal is INR of __ to __. If INR is between 4.01 and 4.99, what should you do? . Do not give (1)
• Learn the definition of pulsus paradoxus =

Answer 264

• 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.

Question 265

Clinical Pearls

Major bleeding episodes can occur even with a normal INR. Order an (1) with (1) if you suspect bleeding.

It may take up to __ days after changing the warfarin dose to see a change in the INR.

Warfarin (Coumadin) is an FDA category X drug. It is ______

Answer 265

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.