Cardiovascular Flashcards
What is acute myocardial infarction
known as ST elevation myocardial infarction (STEMI) and acute coronary syndrome (ACS)
A classic case for MI
A middle-aged or older man c/o gradual onset of intense and steady chest discomfort or pain that is described as squeezing, tightness, crushing, heavy pressure (an elephant sitting on my chest), or band-like
What is MI characteristics
pain or discomfort may radiate to the left side of the neck, jaw, and left arm.
diaphoretic with cool, clammy skin
Women & elderly present with SOB, dyspnea, weakness, nausea and vomiting, fatigue, and syncope.
could also have back pain
CHF sxs
older patients complains of acute onset of dyspnea, fatigue, dry cough, and swollen feet and ankles
CHF characteristics
Lung exam reveal crackles on both the lung bases along with an S3 heart sound.
CHF risk factors
HX of CAD, angina, prior MI, previous episode of CHF
What is infective endocarditis
Known as bacterial endocarditis
Patient presentation with endocarditis
patient presents with fever, chills, and malaise that is associated with onset of a new murmur
Endocarditis skin findings
Found mainly on the fingers/hands and toes/feet
Known as sublingual hemorrhages (splinter hemorrhages on the nail bed)
Petechiae on the palate
painful violet- colored nodes on the fingers or feet (Osler nodes)
Nontender red spots on the palms/soles (Janaway lesions)
fundoycopic exam- rote spots or retinal hemorrhages
Abdominal Aortic Aneurysm (AAA)
Presentation
sudden onset of severe, sharp excruciating pain located in the abdomen, flank, or back.
accompanied by a distended abdomen and abnormal vital signs (hypotension)
AAA risk factors
older male patients who are smokers with hypertension are at higher risk
Chest x-ray- widened mediastinum, tracheal deviation, and obliteration of aortic knob
where is apical impulse located
5th intercostal space by the midclavicular line on the left side of the chest
what can cause displacement of the point of maximal impulse
Severe left ventricular hypertrophy and cardiomyopathy (PMI displaced laterally on the chest, larger in size (3 cm
Pregnancy 3rd trimester-PMI located slightly upward on the left side of the chest, may hear S3 heart sound during pregnancy
Where does deoxygenated blood enter the body
enters the heart through superior vena cava and inferior vena cava
then flows through right atrium>tricuspid valve>right ventricle>pulmonic valve>pulmonary artery>the lungs>alveoli
where does oxygenated blood exit the body
exits the lungs through the pulmonary veins and enters the heart
Systolic murmurs
MR.ASS (mitral regurgitation/aortic stenosis-systolic)
Diastolic murmurs
MS.ARD (mitral stenosis/aortic regurgitation =diastolic
Mitral area
AKA apex or the apical area of the heart
5th left ICS (8-9cm from the midsternal line and slightly medial to the midclavicular line
PMI/apical pulse is located here
Aortic area
2nd ICS to the right side of the upper border of the sternum
location also described as 2nd ICS by the right side of the sternum at the base of the heart. Also described as a murmur that is located on the right side of the upper sternum
Erb’s point
located at 3rd & 4th ICS on the left sternal border
MR.ASS (systolic murmurs mnemonics)
Described as occurring during S1, or as holosystolic, pansystolic, early systolic, late systolic, or midsytolic murmurs
louder and can radiate to the neck or axillae
MS.ARD (diastolic murmurs mnemonics)
Diastole AKA as the s2 heart sound, early diastole, late diastole, or middiastole
indicative of heart disease
indicated abnormal
Grade I heart murmur
very soft murmur heard only under optimal conditions
Grade II heart murmur
Mild to moderate loud murmur
Grade III heart murmur
loud murmur that is easily heard once the stethoscope is placed on the chest
Grade IV heart murmur
louder murmur, 1st time that a thrill is present, thrill is a palpable murmur
Grade V heart murmur
very loud heart murmur heard with edge of stethoscope off chest. Thrill is more obvious
Grade VI heart murmur
murmur is so loud that it can be heard even with the stethoscope off the chest. thrill is easily palpated
R/O AAA in an older male who has a pulsatile abdominal mass that is more than 3cm in width, what test is ordered
Abdominal ultrasound and CT
Mnemoic (MOTIVATED APPLES)
Motivated M-mitral valve T-tricuspid valve AV-atrioventricular valves (lub sound of Lub-dub), closure of the mitral and tricuspid valves
Apples A-aortic valve P-pulmonic valve S-semilunar valve (dub sound of Lub-dub), closure of the aortic and pulmonic valves
S3 sound indicates what heart disease
CHF
S4 sound indicates what heart disease
LVH
What is the most common cardiac arrhythmia in the United States
Atrial fibrillation
Risk factors for atrial fibrillation
HTN, CAD, ACS, caffeine, nicotine, hyperthyroidism, alcohol intake (holiday heart), heart failure, LVH, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), sleep apnea, paroxysmal AF
AF classic case
patient reports the sudden onset of heart palpitations accompanied by feelings of weakness, dizziness, dyspnea/dyspnea on exertion, and reduction in exercise capacity. May complain of chest pain and feelings of passing out (presyncope to syncope). Rapid and irregular pulse may be more than 110 beats/min with hypotension.
AF Treatment plan
1st determine underlying cause.
Tx depends on patient type and risk factors for stroke
Tool used is CHA2DS2VASc score
Diagnostic test=12 lead EKG (does not show P waves, irregularly rhythm)
New onset- EKG, TSH, electrolytes (calcium, potassium, magnesium, sodium), renal function, B-type natriuretic peptide
24 hour holter monitor
lifestyle: avoid stimulants (caffeine, nicotine, decongestants) and alcohol
AF treatment for new onset stable patients
cardio version within for 48 hours or rate control
AF rate control medications are?
beta-blockers, calcium channel blockers, & digoxin
What is the target goal INR for AF
2.0-3.0
What is the proper procedure to check for pulses paradoxus
measured by using the BP cuff and stethoscope.
What do you do if the INR <5.0
skip next dose and reduce the maintenance dose. Check INR once/twice a week when adjusting dose. Do not give vitamin K
What do you do if the INR 5.0-9.0
hold one or two doses; with or without administration of low-dosed vitamin K. Monitor INR every 2-3 days until it is stable. Decrease the Coumadin maintenance dose.
JNC 8 HTN TX goal
60 years or younger
<140/90, Same BP goal for all (including DM/CKD)
JNC 8 HTN
60 years or older
<150/90
systolic BP goal increased by 10mm Hg except if DM and/or CKD
JNC 8 HTN goal
Black
<140/90, thiazide diuretics and CCBS (alone or combined with another drug class)
if DM/CKD choose ACEI or ARB
JNC HTN goal
Non-black
<140/90, thiazide diuretics ACEI, ARB, or CCB (alone or combined with another drug class)
JNC HTN goal
CKD age 18 or older
<140/90, initiate ACEI or ARB
Applies to everyone regardless of race
JNC HTN goal
DM age 18 or older
<140/90, include ACEI or ARB
1st line therapy for HTN, hyperlipidemia, and type 2 DM
Lose weight, normal weight (18.5-24.9
stop smoking
reduce stress level
reduce dietary sodium (less than 2.4 g/2400 mg)
maintain adequate intake of potassium, calcium, and magnesium
limit alcohol intake (1oz or less per day for men, 0.5 oz or less per day for women)
eat fatty-cold water fish (salmon, anchovy) three times a week
HTN diet
DASH diet recommended for prehypertension, HTN, weight loss. Goal is to eat foods rich in potassium, magnesium, and calcium. Reduce red meat and processed foods. Eat more whole grains, legumes. Eat more fish and poultry.
Thiazide diuretics
Action: change the way that the kidney handles sodium, which increases output.
Have a favorable effect with osteopenia/osteoporosis (slows down demineralization).
Contains sulfa, should be avoided in patients with sulfa allergy.
SE: “Hyper”
Hyperglycemia ( caution with diabetics),
hyperuricemia (can cause a gout attcack)
Hypertriglyceridemia and hypercholestermia (check lipid profile)
Hypo
Hypokalemia (potentiates digoxin toxicity, increases risk of arrhythmias)
Hyponatremia ( hold diuretic, restrict water intake, replace K+ loss)
Hypomagnesimia
Contraindications: sensitivity to sulfa drugs and thiazides
Examples: hydrochlorothiazide 12.5 to 25 mg to PO daily
chlorthalidone (hygroton) 12.5 to 25 mg PO daily
indapamide (lozol) PO daily
Loop diuretics
Action: inhibit the sodium-potassium-chloride pump of the kidney in the loop of Henle.
SE: hypokalemia (potentiates digoxin toxicity, increase risk of arrhythmias)
Hyponatremia (hold diuretic, restrict water intake, replace K+ loss)
Hypomagnesemia
Possibly altered excretion of lithium and salicylates
Contraindications: sensitivity to loop diuretics
Examples: furosemide (lasix) PO BID, bumetanide (bumex) PO BID
Hypertensive retinopathy
copper and silver wire arterioles, arteriovenous nicking
AV nicking occurs when a retinal vein is compressed by an arteriole that causes the venue to collapse
Diabetic retinopathy
neovascularization, cotton wall spots, micro aneurysms
What are the preferred medication treatment in elderly patients with isolated systolic HTN
low-dose thiazide diuretic or CCB (long-acting dihydropyridine)
What is the side effect of spironolactone
gynecomastia
What is a main complaint from patients on ACEIs or ARBS
dry cough
What should the NP be cautious when prescribing ACEIs with potassium-sparing diuretics (triamterene & spironolactone)
Increase risk of hyperkalemia
What effect does ACEIs or ARBs have on patient with bilateral renal artery stenosis?
predicate acute renal failure
Alpha-blockers are not 1st line drugs for HTN except if patient has_____
preexisting BPH
Why should women with HTN and osteopenia/osteoporosis receive thiazides?
Thiazides help bone loss by slowing down calcium loss (from the bone) and stimulating osteoclasts
Left side heart failure
Remember lung. SXs are lung related such as dyspnea, orthopnea, and paroxysmal nocturnal dyspnea
right side heart failure
remember heart failure sxs are GI related( anorexia, nausea, and right upper quadrant abdominal pain)
NYHA class II heart disease
ordinary physical activity results in fatigue, exertion dyspnea
1st line treatment for stable HF
start on ACEI or ARB, then add a beta-blocker, aldosterone-receptor antagonist
Risk factors for DVT
Stasis: prolonged travel, inactivity (more than 3 hours), bed rest, CHF
Inherited coagulation disorders: Factor C deficiency, Leiden,
Increased coagulation due to external factors: oral contraceptive use, pregnancy, bone fractures especially of the long bones, trauma, recent surgery, malignancy
Classic case of DVT
A patient with risk factors for DVT c/o gradual onset of swelling on a lower extremity after a history of travel (more than 3 hours) or prolonged sitting. The patient c/o a painful and swollen lower extremity that is red and warm. If patient has PE, it may be accompanied by abrupt onset of chest pain, dyspnea, dizziness, or syncope. Many patients are asymptomatic.
Tx plan for DVT
Homan’s sign: lower leg pain on dorsiflexion of the foot
CBC, platelets, clotting time (PT/PTT, INR), D-dimer level, chest x-ray, EKG
ultrasonography
Heparin IV then warfarin PO for 3-6 months
Raynaud phenomenon
reversible vasospasm of the peripheral arterioles on the fingers and toes. Associated with an increased risk of autoimmune disorders (thyroid disorder, pernicious anemia, rheumatoid arthritis).
Raynaud classic sxs
Think of the colors of the American flag.
Classic case: 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 ranges from white (pallor) and blue (cyanosis) to red (repurfusion). C/o numbness and tingling. Attacks last for several hours. Hands and feet become numb with very cold temps. Ischemic changes may be present after a severe episode such as shallow ulcers on some of the fingertips.
Raynaud tx plan
Avoid touching cold objects, cold weather; avoid stimulants (caffeine)
smoking cessation is important; nifedipine or amlodipine
check distal pulses, ischemic signs
do not use any vasoconstriction drugs; avoid nonselective beta-blockers
1st line tx for hyperlipidemia
Lifestyle modifications, if presence of ASCVD or equivalents, need drug therapy
Statin treatment for adult 21-75 years
Any type of ASCVD (CAD, PAD, stroke, TIA, etc). is given high intensity statins such as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg.
what type of statin treatment is needed for an adult with LDL greater than 190?
high-intensity statins such as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg
what type of statin treatment is recommended for an adult (up to 75 years age) with 10 year estimated ASCVD risk is 7.5% or higher
high intensity statin dosing
if ASCVD risk is between 5%-7.5% what type of statin treatment is recommended?
lifestyle changes 1st
patient with markedly high triglycerides >500 what treatment is recommended
lower triglyceride first with niacin or vibrate before treating high cholesterol and LDL levels.
High triglycerides increase risk for what disease?
acute pancreatitis
what education should be provided in patients with high triglycerides?
avoid alcohol, acetaminophen (hepatotoxic)
obese patients: encourage weight loss and reduce simple carbohydrates, sugars, junk foods. Tx 1st before treating high LDL
advise patient to reduce intake of simple carbohydrates, junk foods, fried foods
What are the best agents to lowering triglycerides
niacin & vibrates
ex’s of bacterial endocarditis
splinter hemorrhages on nails
Janeway lesions (red macules palms/soles not painful)
Osler’s nodes (painful violaceous nodes found mostly on pads of the fingers and toes, thenar eminence
What can statins cause
memory loss, confusion, cognitive effects, which are reversible upon discontinuation of statin therapy
what food and drugs should be avoided if patient is on simvastatin and lovastatin
grapefruit juice and macrocodes
what are the sxs of rhabdomyolysis
muscle pain located on the calves, thighs, lower back, and shoulders, urine will be darker than normal (reddish-brown color). usually happen if patients are on statins
Criteria for metabolic syndrome
abdominal obesity (>40 in men, >35 in women)
HTN
hyperlipidemia
fasting plasma glucose>100
elevated triglycerides >150
decreased HDL <40
What labs are considered for diagnose of metabolic syndrome
fasting blood glucose from 9-12 hours
lipid profile (focusing on triglycerides and HDL)
What are the risk factors for nonalcoholic fatty liver disease
obesity, diabetes, metabolic syndrome, HTN, certain drugs
What are symptoms of nonalcoholic fatty liver disease
asymptomatic
hepatomegaly
mild-mod elevations of ALT & AST
fatigue & malaise with RUQ pain
