Cardiovascular Flashcards

Question

Afib/flutter Complications

Answer 1

- Death caused by thromboembolic even (e.g., stroke, PE), CHF, angina, and others - Warfarin-associated intracerebral hemorrhage has high mortality and causes 90% of warfarin deaths; medical emergency, call 911! - Warfarin-associated life-threatening bleeding episode: stop warfarin and ALL anticoagulants such as acetylsalicylic acid (ASA) and NSAIDs; treat w/ vit k, 4-factor prothrombin complex concentrate (PCC, inactivated), and/or fresh frozen plasma ► check INR, PT, and PTT - DOAC-associated life-threatening bleeding episode: life-threatening bleeding caused by rivaroxaban (Xarelto) and apixaban (Eliquis); can be tx w/ andaxanet alfa (Anexxa) - bleeding caused by dabigatran (Pradaxa) is tx w/ idarucizumab (Praxbind)

Answer 2

Warfarin only, does NOT apply to Direct-Acting Anticoagulants - Advise pts to be consistent w/ their day-to-day consumption of vit K foods - Give pt a list of foods w/ high levels of vit K ("greens" such as kale, collard, mustard, spinach, iceberg or romaine lettuce, brussels sprouts, potatoes) - Only one serving/day is recommended for very high vit K foods

Answer 3

1. Presence of bleeding: None ► Skip next dose and/or reduce slightly the maintenance dose; check INR once or twice a week when adjusting dose - do NOT give vit K - if INR elevation is minimal, often maintenance dose does not need to be ↓ 2. Presence of bleeding: None or not clinically significant bleeding ► Hold 1-2 doses; with or without administration of low-dose oral vit K (1-2.5 mg) - Monitor INR Q2-3 days until stable - ↓ warfarin maintenance dose

Answer 4

1. tachycardia w/ peaked QRS complex w/ P waves present - regular but rapid heartbeat, which starts and stops abruptly (intermittent episodes) - can be misdiagnosed as panic or anxiety attack - PSVT → part of the narrow QRS complex tachycardias w/ regular ventricular response (several types including Wolff-Parkinson-White [WPW] syndrome, atrial tachycardia) - can start in childhood or older - may resolve spontaneously or reoccur at a later time Episodes can be precipitated by digitalis toxicity, alcohol, hyperthyroidism, caffeine intake, and illegal drug use 2. - abrupt onset of palpitations ("feels like fluttering in my chest") - rapid pulse (150-250 bpm) - lightheadedness - SOB - anxiety - may feel weak and fatigue or faint - may report previous episode that resolved spontaneously 3. - EKG; if WPW or symptomatic → Refer to cardiologist 4. - if hemodynamically unstable → may require cardioversion → call 911! - Vagal maneuvers for acute treatment of SVT; several types

Answer 5

narrow QRS complex tachycardia → ↑ risk for death → Refer to cardiology for catheter ablation

Answer 6

Vagal maneuvers: - carotid massage → pt supine, monitor VS * If done in clinical setting, continuous 12-lead EKG during procedure - responses are changes in HR or rhythm and/or BP after sinus massage Sinus massage contraindications: - TIA or stroke within previous 3 months - presence of carotid bruits and so forth Valsalva's maneuver - Holding one's breath and straining hard - maintain strain for 10-15 seconds, release, then breath normally

Answer 7

1. fall in SBP of >10 mm Hg during inspiraotry phase - AKA paradoxical pulse - important physical sign of cardiac tamponade - certain pulmonary and cardiac conditions that impair diastolic filling can cause an exaggerated ↓ of intrathoracic pressure during inspiration 2. - asthma - emphysema (↑ positive pressure) 3. - cardiac tamponade - pericarditis - cardiac effusion (↓ movement of LV)

Answer 8

Know "irregularly irregular rhythm w/ no visible p-waves" → Afib Memorize: - Afib - anterior wall MI (ST segment elevations in lead V2-V4) - Ventricular tachycardia (jagged irregular QRS) - SR, sinus arrhythmia PR interval (atrial depolarization): 0.12-0.2 seconds (3-5 small boxes)

Answer 9

- AKA anterior STEMI - most common type of MI EKG changes include: - ST segment elevation and Q waves - Wide QRS complex in leads V2 to V4 - resembles a "tombstone" → "tombstoning"

Answer 10

Sinus Arrhythmia → common variation of NSR - more common in healthy children and young adults - P waves show uniform morphology - PP interval increases and decreases during inspiration and exhalation

Answer 11

1. HTN = BP >130/80 mmHg * majority: Primary/essential HTN * ~5-10% have secondary HTN 2. - Nonpharmacologic tx/lifestyle changes recommended for majority of adults who are newly classified - If presence of RF (e..g, diabetes, CAD, HTN), pharmacologic therapy is recommended w/ lifestyle ► ANCC uses 2017 ACC/AHA ► AANPCB uses both 2017 ACA/AHA HTN guidelines and JNC 8 guidelines

Answer 12

- Instruct pt to avoid smoking or caffeine intake 30 mins before measurement and not cross their legs (↑ SBP) - Begin BP measurement after at least 5 mins of rest (mercury sphygmomanometer preferred over digital machines) - ≥2 reading separated by 2 mins should be averaged per visit - High # determines BP stage (BP 140/100 is stage 2 instead of stage 1)

Answer 13

1. SBP <120 and DBP <80 2. SBP 120-129 and DBP <80 3. SBP 130-139 or DBP 80-89 4. SBP >140 or >90

Answer 14

- Start at 18 years - screen BP every year - If normal, recheck in 1 year - If presence of RF for HTN, screen at least semiannually (twice a year)

Answer 15

Any changes in peripheral vascular resistance (PVR) or cardiac output (CO) → change in BP (increase/decrease) EX: Na (sodium) - Water retention ↑ vascular volume → ↑ CO, BP ↑ - Younger pts and whites have ↑ renin levels compared w/ the elderly Angiotensin I to Angiotensin II: Angiotensin II ↑ vasoconstriction and will ↑ PVR → ↑ BP Sympathetic System Stimulation: Epinephrine and cortisol secretion → tachycardia and vasoconstriction → ↑ BP Alpha-blockers, Beta-blockers, CCB: Drugs ↓ PVR from vasodilation → ↓ BP Pregnancy - SVR is ↓ d/t hormones (SBP and DBP ↓ during 1st and 2nd trimesters) - S3 heart sounds is common in 3rd trimester of pregnancy - Drugs used to control BP in pregnancy are methyldopa, labetalol, beta-blockers, and diuretics

Answer 16

Kidneys - Creatinine - eGFR - urinalysis Endocrine - TSH - fasting BG Electrolytes: K, Na, Ca Heart - cholesterol - HDL - LDL - triglycerides - complete lipid panel Anemia: CBC Baseline EKG and CXR (to r/o cardiomegaly)

Answer 17

Eyes (hypertensive retinopathy) - Silver and/or copper wire arterioles - arteriovenous junction nicking (caused when arteriole crosses on top of a vein) - Flame-shaped hemorrhages - papilledema Kidneys - microalbuminuria and proteinuria - ↑ serum creatinine and abnormal eGFR (r/o kidney ds) - Peripheral and generalized edema

Answer 18

- Silver and/or copper wire arterioles - arteriovenous junction nicking (caused when arteriole crosses on top of a vein) - Flame-shaped hemorrhages - papilledema

Answer 19

- microalbuminuria and proteinuria - ↑ serum creatinine and abnormal eGFR (r/o kidney ds) - Peripheral and generalized edema

Answer 20

Heart - S3 (CHF) - S4 (LVH) - Carotid bruits (narrowing d/t plaque, ↑ risk of CAD) - CAD and acute MI - ↓ or absent peripheral pulses (PAD) Brain - TIAs - Hemorrhagic strokes

Answer 21

1. HTN caused by another condition; if condition is corrected and/or treatable, then HTN will resolve - 5-10% are secondary HTN ** R/o secondary cause and maintain a high index of suspicion if the following: - <30 years - Severe HTN or acute rise in BP (previously stable pt) - Resistant HTN despite tx w/ at least 3 antihypertensive agents - Malignant HTN 2. ► Renal - renal artery stenosis * more common in younger adults - polycystic kidneys - CKD * more common in elderly pts ► Endocrine * middle-age adults more likely to have endocrine-related ds - hyperthyroidism - hyperaldosteronism - pheochromocytoma ► Others - OSA * sleep partner will report severe snowing w/ apneic episodes during sleep - marked hypoxic episodes during sleep ↑ BP - coarctation of the aorta (see notecard)

Answer 22

severe HTN w/ end-organ damage such as retinal hemorrhages, papilledema, acute renal failure, and severe headache

Answer 23

Normal: SBP is higher in legs (normal finding) because it takes more force to circulate blood back tp the heart In coarctation, opposite is true. If there is a narrowed aorta in abdomen (abdominal aorta), the part of the bode above the narrowed aorta (arms) will have higher BP and bounding pulses. The part of the body below the narrowed aorta (legs) will have lesser blood flow, so SBP on legs will be lower, and pulses will be weaker. - Look for delayed or diminished femoral pulses * Check both radial and femoral pulse at the same time and compare

Answer 24

- Bruit epigastric, abdomen, or flank area → Renal artery stenosis Tx: avoid ACEi and ARBs - Enlarged kidneys w/ cystic renal masses (polycystic kidneys) -↑ creatinine and ↓ eGFR (renal insufficiency to AKI)

Answer 25

Primary hyperaldosteronism (Conn's syndrome): * Aldosterone helps control BP by Na retention and loss of K * most common cause is an aldosterone-producing adenoma (usually benign); less commonly, adrenal CA S/s - HTN w/ hypokalemia (low K) is usually the only sign of this condition - Normal to elevated Na levels (high/normal Na+) Tx: surgical removal of tumor

Answer 26

S/S + diagnostics - weight loss - tachycardia - fine tremor - moist skin - anxiety - new onset of AF (check EKG) - Check TSH

Answer 27

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

Answer 28

- Check BP (serial BP) * Confirm diagnosis at another subsequent visit 1-4 wks after initial visit - Check BP at home and keep diary - Does office BP correlate w/ home BP? - Advise pt to bring their BP monitor to office so it can be checked against the office's machine * Difference of ≤ 5 mmHg, not significant - if home NP are lower, rule out "white coat" HTN → to r/o, have pt check their BP outside of clinic several times and compare w/ office BP → if home readings do not meet criteria for HTN, it is white coat HTN

Answer 29

- useful adjunct to supplement office readings - Advise pt to buy an automatic BP machine - Advise obese pt to buy a model w/ the larger-sized BP cuff (pt should measure diameter of upper arm) - if cuff is too small → false elevate BP - Advise pt to check BP at different times of day and during work - Instruct pt to bring their BP diary during visits if titrating meds * BP kiosk readings are acceptable

Answer 30

SBP >180 and/or DBP >120 WITHOUT target organ damage Common reason: noncompliance w/ antihypertensive therapy - if no clinical (or lab) evidence of new or worsening target organ damage, restart or intensify antihypertensive drug therapy w/ close follow-up

Answer 31

SBP >180 and/or DBP >120 WITH clinical findings of target organ damage such as... - N/V - ↑ ICP - CVA/TIA - MI - acute PE - ARF - retinopathy (flame-shaped hemorrhages) - papilledema - acute severe low-back pain (dissecting aorta) CALL 911!

Answer 32

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

Answer 33

- caused by loss of recoil in arteries (atherosclerosis) → ↑ PVR - Pulse pressure ↑ - emphasize nonpharmacologic tx, esp dietary salt restriction and weight loss in obese - Treat BP in older or frailer pts carefully (high fall risk, orthostatic hypotension); start at lower doses and titrate up slowly; will take 3-6 months Initial monotherapy w/ a low-dose thiazide diuretic, a CCB (long-acting dehydropyridine) or an ACEi or ARB

Answer 34

Elderly at higher risk d/t less active autonomic NS and slower metabolism of drugs by liver (prolongs half-life of drugs) To evaluate for orthostatic hypotension: - check BP in both supine and standing positions, esp in elderly, before and after treatment for HTN - check for polypharmacy → carefully review med hx and search for meds that ↓ BP - Ask pt if dizzy or lightheaded w/ changes in position

Answer 35

1. First, assess 10-year risk for heart ds using ASCVD 2. Reassess in 1 month for effectiveness of BP-lowering med therapy 3. If goal is met in 1 month, reassess in 3-6 months 4. If goal is NOT met in 1 month, consider different med or titration 5. Continue monthly follow-up until BP control is achieved Normal: SBP <120, DBP <80 * Encourage heart-healthy lifestyle, evaluate yearly

Answer 36

SBP 120-129, DBP <80 Recommend heart-health lifestyle and weight loss if overweight/obese - Reassess in 306 months - No more "prehypertension" stage; instead, it is known as "elevated BP"

Answer 37

SBP 130-139 or DBP 80-89 Goal BP: <130/80 Risk <10% → Start w/ healthy lifestyle recommendations and reassess in 306 months Risk >10% or known clinical cardiovascular ds (or diabetes, CKD) → Lifestyle recommendations and BP-lowering med

Answer 38

SBP >140 or DBP >89 Goal: <130/80 Tx plan: - Lifestyle changes and BP-lowering meds (two meds of different classes) - reassess BP in 1 month - If goal is met after 1 month, reassess in 3-6 months - If goal not met after 1 month, consider different medications or titration - Continue monthly follow-up until BP control is achieved

Answer 39

FIRST-line therapy for HTN, HLD, DM2 - Lose weight if overweight * BMI 25-29.9 or obese BMI >30 * Normal BMI: 18.5 0 24.9 - Stop smoking - Reduce stress level - Reduce dietary sodium: <1.5 g/day (1,500 mg/d) - Maintain adequate dietary intake of potassium (>3,500 mg/day) in pts w/ normal kidney fx - Limit alcohol intake - Eat fatty cold-water fish (salmon, anchovy) 3x/week

Answer 40

Men: 1 ounce (30 mL) - up to 2 drinks or less daily Women: 0.5 ounce (15 mL) - up to one drink or less daily

Answer 41

Recommended for preHTN, HTN, and weight loss Goal: 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 - Diet is high in fruits and vegetables - has mod low-fat diary - low in animal protein * Grains: 7-8 daily servings * Fruits and vegetables: 4-5 daily servings * Nuts, seeds, and dry bears: 4-5 servings per week * Fats, oils, or fat-free dairy products: 2-3 daily servings * Meat, poultry, and fish: <2 daily servings * Sweets: try to limit to fewer than 5 servings/week - Avoid high-sodium foods: cold cuts, ready-made foods, any pickled foods (cucumbers, eggs, pork parks)

Answer 42

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

Answer 43

- All diuretics will ↓ blood volume, venous pressure, and preload (cardiac filling) - Effect is antagonized by NSAIDs - Monitor electrolytes, esp Na and K

Answer 44

1. Controls BP by inhibiting reabsorption of Na and Cl ions in distal tubules of kidneys 2. - have favorable effect w/ osteopenia/osteoporosis (slows down demineralization) by slowing down calcium excretion by kidneys - Can cause photosensitivity reaction (avoid tanning) - all thiazides contain sulfa compounds; avoid if pt has sulfa allergy 3. "Hyper" - Hyperglycemia (careful w/ diabetes) - Hyperuricemia (can precipitate a gout attack; contraindicated in gout) - Hypertriglyceridemia and hypercholesteremia (check lipid profile) "Hypo" - Hypokalemia (potentiates digoxin toxicity, ↑ risk of arrhythmias) - hyponatremia (hold diuretic, restrict water intake, replace K loss) - hypomagnesemia 4. - Gout - Hypotension - Hypokalemia - Renal failure - Lithium treatment - Sensitivity to sulfa drugs and thiazides 5. - Hydrochlorothiazide 12.5 25 mg PO daily - Chlorthalidone (Hygroton) 12.5 to 25 mg PO daily - Indapamide (Lozol) PO daily - Chlorothiazide (Diuril) daily or divided dose

Answer 45

1. Inhibit the Na-K-Cl pump of the kidney in the loop of Henle 2. 3. - Hypokalemia (potentiates digoxin toxicity; increases risk of arrhythmias) - hyponatremia (hold diuretic, restrict water intake, replace K loss) - hypomagnesemia - possibly altered excretion of lithium and salicylates 4. - Anuria (kidney failure) - Sensitivity to loop diuretics 5. - Furosemide (Lasix) PO BID - Bumetanide (Bumex) PO BID

Answer 46

If sulfa allergies, may have cross-sensitivity to thiazides and loop diuretics Other drugs w/ sulfa: - sulfonylureas - sulfa antibiotics - sulfasalazine - some protease inhibitors (darunavir, fosamprenavir) - may also be sensitive to topical sulfas (ophthalmic drops) or topical silver sulfadiazine (Silvadene)

Answer 47

1. Spironolactone antagonizes action of aldosterone → ↑ elimination of water in kidneys and conserves potassium * Drug class: mineralocorticoid receptor antagonists or antimineralocorticoids 2. - Resistant HTN - HF - Hirsutism - Acene - Precocious puberty - Primary aldosteronism 3. - Gynecomastia, galactorrhea - Hyperkalemia - GI: vomiting, diarrhea, stomach cramps - postmenopausal bleeding - erectile dysfunction 4. - Hyperkalemia (serum K >5.5 mEq/L) - Renal insufficiency (serum creatinine >2.0 mg/dL in men; >1.8 mg/dL in women) - DM2 w/ microalbuminuria 5. - Spironolactone (Aldactone) daily - Eplerenone (Inspra) daily

Answer 48

1. Binds w/ beta-receptors on the heart and peripheral blood vessels; ↓ vasomotor activity; ↓ CO; inhibits renin (kidneys) and norepinephrine release - 2 types of beta-receptors: B1 (cardiac effects) and B2 (e.g., lungs, vascular smooth muscle) ** Avoid abrupt discontinuation after chronic use; wean slowly; may precipitate angina and MI 2. See notecard 3. 4. * Asthma, COPD, chronic bronchitis, emphysema (chronic lung ds) * 2nd/3rd heart block (fine to use w/ 1º heart block) * Sinus bradycardia 5. - Beta-blockers: ends w/ -olol Cardioselective beta-blockers (B1 receptors): - Atenolol (Tenormin) - Metoprolol (Lopressor) - Bisoprolol Nonselective beta-blockers (inhibits both B1 and B2 receptors): - Propranolol (Inderal) - Timolol - Pindolol ** Some beta-blockers have both alpha- and beta-blocking action: Labetalol (Normodyne) and carvedilol

Answer 49

Labetalol (Normodyne) and carvedilol

Answer 50

2. - Acute MI: ↓ mortality during acute MI and post-MI - Migraine headache: for prophylaxis only (not for acute attacks) - Glaucoma: ↓ intraocular pressure (Betimol ophthalmic drops for open-angle glaucoma) - Resting tachycardia (target HR <100 bpms) - Post-MI: ↓ mortality - Hyperthyroidism/thyroid storm and pheochromocytoma: Controls sx until primary ds is treated - Essential tremor: treat sx w/ nonselective beta-blocker propranolol

Answer 51

1. Blocks voltage-gated calcium channels in cardiac smooth muscle and the blood vessels → systemic vasodilation - Nondihydropyridines → less potent vasodilators but have greater depressive effect on cardiac conduction and contractility (negative inotropic effect) - Dihydropyridines → more potent vasodilators w/ little to no negative impact on contractility or conduction 2. - HTN - Angina - Arrhythmias 3. - Headaches (d/t vasodilation) - ankle edema (from vasodilation; benign) - heart block or bradycardia (depresses cardiac muscle and AV node) - Reflex tachycardia (seen w/ dihydropyridines [ex: nifedipine]) 4. - 2nd/3rd degree heart block (fine to use w/ 1st degree) - Bradycardia - CHF 5. Dihydropyridine CCBs (-pine ending): - Nifedipine (Procardia XL) daily - Amlodipine (Norvasc) daily - Felodipine (Plendil) daily Nondihydropyridine CCBs - Verapamil (Calan SR) daily or BID - Diltiazem (Cardizem CD) daily

Answer 52

1. ACEi = inhibit activity of angiotensin-converting enzyme → ↓ conversion of angiotensin I to II (more potent vasocontrictor) ARB = block the effect of angiotensin II 2. Preferred drugs (monotherapy or combined w/ other drug classes) for diabetes, CKD, congestive HFrEF, and after MI, esp. those w/ HF or reduced systolic fx *** Pregnancy Category C (First Trimester) and Category D (Second and Third Trimesters) ► Fetal kidney malformations, fetal hypotension, fetal death 3. - Dry hacking cough (up to 10% w/ ACEis; less w/ ARBs) - Hyperkalemia, angioedema (rare, but may be life-threatening) 4. - Mod-severe kidney disease - Renal artery stenosis → * precipitates ARF * Hyperkalemia; also a SE, will have additive effect 5. ACEIs - Ramipril (Altace) daily in 1-2 divided doses - Benazepril (Lotensin) daily initially - Enalapril (Vasotext) daily in 1-2 divided doses - Fosinopril (Monopril) daily ARBs - Losartan (Cozaar) daily in 1-2 divided doses - Candesartan (Atacand) daily in 1-2 divided doses - Olmesartan (Benicar) daily in 1-2 diveded doses - Irbesartan (Avapro) daily Combination antihypertensive drugs: ACEIs OR ARBs (not both together) are combine dw/ other drug classes such as CCBs or thiazide duiretics

Answer 53

1. Potent vasodilators; relax smooth muscle found on bladder neck, prostate gland, and relieves obstructive voiding sx such as weak urinary stream, urgency, and nocturia AKA alpha-adrenergic blockers 2. - suffix of -zosin - give at HS, very low doses; slowly titrate up - Tell pt to get out of bed slowly to prevent postural hypotension ** Not a first-choice for HTN except for men w/ both HTN and BPH 3. - Dizziness and hypotension (postural) - "First-dose orthostatic hypotension" is common (warn pt) - may cause severe hypotension and reflex tachycardia 4. 5. - Terazosin (Hytrin): HTN and BPH (starting dose 1 mg PO HS) - Doxazosin (Cardura): HTN and BPH - Tamsulosin (Flomax): BPH only

Answer 54

1. Inhibits RAS by blocking renin - ↓ renin activity by ~75% 2. Do NOT combine aliskiren w/ ACEi or ARB → higher risk of hyperkalemia 3. 4. 5. - Aliskiren (Tecturna) daily - Aliskiren and hydrochlorothiazide daily

Answer 55

1. Combination of neprilysin inhibitor (sacubitril) w/ ARB (valsartan) *New drug class for treatment of HFrEF 5. Sacubitril/valsartan (Entresto)

Answer 56

1. - Benazepril - Enalapril - Lisinopril - Ramipril 2. - Dry cough (5-20%; more common in females) - Angioedema - Hyperkalemia * Careful w/ CKD, renovascular ds * Do NOT use during pregnancy * Careful when using w/ potassium-sparing diuretics (e.g., triamterene, spironolactone) d/t ↑ risk of hyperkalemia

Answer 57

1. - Candesartan - Losartan - Valsartan - Irbesartan 2. - Hyperkalemia * Do NOT use during pregnancy

Answer 58

1. - Sacubitril w/ valsartan (Entresto) 2. - Hypotension - Hyperkalemia - Cough - Angioedema

Answer 59

1. - Verapamil - Diltiazem 2. - Heart block - Bradycardia - Constipation

Answer 60

1. - Amlodipine - Felodipine - Nicardipine - Long-acting nifedipine - Nisoldipine 2. - Headache - Flushing - tachycardia - Pedal EDema * short-acting nifedipine and nicardipine causes reflex tachycardia; NOT recommended for HTN

Answer 61

1. Beta-selective: atenolol, metoprolol Non-beta selective: Propranolol, nadolol Alpha-beta blockade: Carvedilol, labetalol 2. - Bradycardia - Fatigue - Insomnia - Erectile Dysfunction - Bronchospasm (asthma, COPD)

Answer 62

1. - Hydrochlorothiazide - Chlorthalidone - Indapamide 2. - Hypokalemia - hyponatremia - hyperuricemia - hypercalcemia - dehydration * Women w/ osteopenia/osteoporosis should receive this; helps bone loss by slowing down Cas loss (from bone) and stimulating osteoclasts

Answer 63

1. - Furosemide - Bumetanide - Torsemide 2. - Hypokalemia - hyponatremia - hyperuricemia - dehydration

Answer 64

1. - Triamterene - Amiloride Aldosterone antagonists: - Spironolactone - eplerenone 2. - Hyperkalemia - hyponatremia - dehydration

Answer 65

1. - Doxazosin - Prazosin - Terazosin 2. - Orthostatic hypotension

Answer 66

1. At least 2 meds; can initiate w/ one or two antihypertensive meds (combined or two separate agents) 2. Diuretics, ARNI, ACEI or single-agent ARB, BB 3. ACEI or ARB as first line - African Americans are less sensitive to ACEIs and ARBs; if BP still elevated, combine w/ dihydropyridine CCB or thiazide diuretic 4. ARB or ACEi as first line - can add CCBs or thiazides or another drug class 5. Thiazides or CCBs may be more effective 6. BB, ACEi, aldosterone

Answer 67

1. EF <40% → HFrEF, aka systolic HF EF >40% → HFpEF, diastolic HF Causes: - acute MI - CAD - HTN - Fluid retention - valvular abnormalities - arrhythmias 2. - Crackles, bibasilar rales (rales on LL of lungs) - cough - dyspnea - ↓ breath sounds - dullness to percussion 3. - JVD: normal JVD is 4cm or less - Enlarged spleen and enlarged liver → anorexia, nausea, and abdominal pain - LW edema w/ cool skin S/S of both LV and RV failure - paroxysmal nocturnal dyspnea - orthopnea - nocturnal nonproductive cough - wheezing (cardiac asthma) - HTN - fatigue 4. - S3 gallop, can be accompanied by anasarca * S3 heart sound is a sign of HR; although it can be heard in pregnant women and children/young adults

Answer 68

severe generalized edema d/t effusion of fluid into extracellular space

Answer 69

5. - CXR → increased heart size (cardiomegaly), interstitial and alveolar edema, Kerley B lines, and other signs of pulmonary edema - EKG, creatine phosphokinase (CPK), cardiac troponins (Troponin I, Troponin T) - B-type natriuretic peptide (BNP), N-terminal pro-BNP (NT-proBNP); both ↑ w/ HF but renal failure/CKD can also elevate these 2 labs - BUN and creatinine, electrolytes, CBC, LFTs - ECHO w/ Doppler flow study - Weight should be checked daily to detect fluid accumulation

Answer 70

6. - Acute decompensated HF → Refer to ED (IV furosemide, oxygen, vasodilators_ - Diuretic (typically loop diuretic) → used to relieve sx of volume overload (dyspnea, peripheral edema) in primary care - Stabilize HFrEF → Combination tx w/ diuretic, ACEi or ARB, or ARNI, and BB - Limit Na intake - Pts w/ HF are best managed by cardiologist or at a heart clinic - Use BB if HFrEF (carvedilol, bisoprolol, extended-release metoprolol succinate) ► start with very low dose ► careful w/ initial dosing; can worsen ► consult or refer to experienced heart clinic ► started after the pt has been initiated on ACEI/ARB/or ARNI - Use New York Heart Association (NYHA) system to classify pt's degree of cardiac disability - Refer to cardiologist; if in distress → Refer to ED! * First line of treatment for stable HF: ACEi or ARB

Answer 71

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 are present at rest, with or without physical activity

Answer 72

- Restrict or abstain from alcohol - smoking cessation if smoker - weight loss - Restrict Na to 2-3 g/d - Fluid restriction (1.5-2L/d) may help some pts

Answer 73

- Both left and lung start with "L" → symptoms are lung related → dyspnea, orthopnea, and paroxysmal nocturnal dyspnea Right-sided HF sx are GI related → anorexia, nausea, and RUQ abdominal pain

Answer 74

1. Thrombi develop inside deep venous system of legs or pelvis 2º to stasis, trauma to vessel walls, inflammation, or ↑ coagulation; PE is considered another manifestation of this thromboembolic ds Etiology: 3 categories - Stasis: Prolonged travel/inactivity (>3 hrs), bed rest, CHF - Inherited coagulation ds: factor C deficiency, Leiden, etc - ↑ coagulation d/t external factors: OC use, pregnancy, bone fractures esp of long bones, trauma, recent surgery, malignancy 2. - gradual onset of swelling on a LE after hx of travel (>3 hrs), prolonged sitting/inactivity - painful and swollen LE → red and warm - If PE → accompanied by abrupt onset of chest pain, dyspnea, dizziness, or syncope *Many pts are asymptomatic Unprovoked DVT: No identifiable environmental cause Provoked DVT: Caused by known event (e.g., surgery, major surgery >30 mins, hospitalization)

Answer 75

3. - Homan's sign - CBC, platelets, clotting time (PT/PTT/INR), D-dimer level, CXR, EKG - US (whole legs or proximal leg) 4. Hospital admission - Low-molecular-weight heparin SubQ or IV, then warfarin (Coumadin) PO - or initial episode duration of tx w/ DOACs for at least 3 months - For recurrent DVT or elderly, antithrombotic tx may last a lifetime 5. - PE, death - Stroke, and other embolic episodes

Answer 76

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

Answer 77

1. Inflammation of superficial vein d/t local trauma - Higher risk if indwelling catheters, IV drugs (e.g., potassium), 2º bacterial infection (S. aureus) - Some pts may have coexistent DVT) 2. - acute onset of an indurated vein (localized redness, swelling, and tenderness) - usually located on extremities - pt is afebrile w/ normal VS PE - Indurated cord-like vein that is warm and tender to touch w/ surrounding area of erythema - No swelling/edema of the entire limb (think of DVT) 3. - NSAIDs (ibuprofen or naproxen Na) BID - Warm compresses - elevated limb - If septic cause → admit to hospital

Answer 78

1. Gradual (decades) narrowing and/or occlusion of medium-to-large arteries in LE. Blood flow to extremities gradually ↓ over time → permanent ischemic damage (gangrene of toes/foot) - Higher risk: HTN, smoking, diabetes, HLD - Previously known as peripheral vascular disease 2. - older pt w/ hx of smoking and HLD - worsening pain w/ ambulation (intermittent claudication) → instantly relieved by rest - over time, sx worsen until pt's walking distance is greatly impaired - atrophic skin changes - some have gangrene on ≥1 toe(s) 3. Skin: atrophic changes → shiny and hyperpigmented ankles, hairless, cool to touch; gangrene of toes Cardiovascular: ↓-to-absent dorsal pedal pulsese (may include popliteal and posterior tibial pulse); ↑ capillary refill time (<2 sec); bruits over partially blocked arteries

Answer 79

1. Ankle-brachial index (ABI) used to evaluate severity of PAD - ≤0.9 → diagnostic for PAD - ≤0.5 → severe arterial disease → Refer to vascular specialist ABI 0.91 - 1.3 is normal 2. - SBP of ankle and arm (brachial) is checked after being in supine for 10 min using BP cuff and US probe - ABI score is done for each ankle To measure ABI: Divide highest SBP (measure each arm and choose the higher BP) by the highest SBP of each ankle

Answer 80

4. - Smoking cessation (smoking causes vasoconstriction) - daily ambulation exercises - Pentoxifylline (Trental) if indicated, but effect is marginal (compared with cilostazol) - Cilostazol (Pletal) - Percutaneous angioplasty or surgery for severe cases 5. - Gangrene of foot and/or LE w/ amputation - ↑ risk of CAD - ↑ risk of carotid plaquing (check for carotid bruits)

Answer 81

a phosphodiesterase inhibitor ( direct vasodilator) - can be taken with aspirin or clopidogrel - Grapefruit juice, diltiazem, and omeprazole can ↑ serum concentration if taken together To treat PAD.

Answer 82

1. Reversible vasospasm of peripheral arterioles on fingers and toes to an exaggerated response to cold temperature or emotional stress - Unknown cause - Associated w/ ↑ risk of autoimmune disorders (e.g., thyroid disorder, pernicious anemia, RA) - Most are females (60-90%); gender ratio 8:1 - Pt w/ no underlying disease have "primary" Raynauds - Secondary Raynauds occur in pts w/ concurrent autoimmune ds (e.g., SLE, scleroderma) - Spontaneous remission may occur To evaluation: check distal pulses, ischemic signs (ischemic ulcers on fingers/toes) 2. - middle-aged woman c/o chronic and recurrent episodes of color changes on fingers in a symmetric pattern (both hands and feet) - colors range from white (pallor) to blue (cyanosis) to red (reperfusion) - numbness and tingling - attacks lasts for several hours - hands and feet become numb w/ very cold temperatures - some have livedo reticularis - Ischemic changes may be present after a severe episode such as shallow ulcers (eventually heal) on some of the fingertips 3. - Avoid touching cold objects and being in cold water - avoid stimulants (e.g., caffeine) - maintain whole body warmth - use thermal underwear, layered clothing, hat, gloves/mittens, and hand warmers - smoking cessation is important - TX: CCBs → nifedipine (Adalat) or amlodipine (Norvasc) - Do not use any vasoconstricting drugs (e.g., Imitrex, ergots, pseudoephedrine/decongestants, amphetamines) or diet pills - avoid nonselective beta-blocker 4. - Small ulcers on fingers and toes ** Think of the colors of the American flag as a reminder for this disorder

Answer 83

violaceous mottling or reticular pattern of skin of the arms and legs

Answer 84

1. - Presentation range from full-blown d9sease to subacute endocarditis - common pathogens: * Gram+ (e.g., viridans streptococcus, S. aureus) - AKA IE - Parenteral antibacterial tx for native valve endocarditis can range4 from 4-6 weeks 2. - adult male w/ fevers - chills - malaise - a/w subungual hemorrhages - Osler's nodes - Janeway lesions - may have heart murmur - may not present w/ all preceding sx * Look for cardiac risk factors - prosthetic valve - hx of valvular or congenital heart ds - cardiac device - IVD, IV lines - recent dental/surgical procedure ** Maintain high suspicion d/t high mortality 3. - Refer to cardiologist/ED for hospitalization/IV abx - BC x3 (first 24 hours) - CBC (↑ WBCs) - sedimentation rate >20 mm/hr (↑) 4. - Valvular destruction - myocardial abscess - emboli - death

Answer 85

1. - Mitral valve prolapse (unless hx of bacterial endocarditis) - GU/GI incisions/invasive procedures (except if existing infection present [e.g., UTI before cystoscopy]) 2. High-risk Conditions - previous hx of bacterial endocarditis - prosthetic heart valves including homograft, valvular repair - unpaired (or repaired) cyanotic congenital heart ds - cardiac transplant w/ valvopathy Invasive Procedures - Dental procedures that traumatize oral mucosa, gingiva, or the periapical area of teeth, such as routine dental cleaning, tooth extractions, dental abscess drainage - Invasive procedures on respiratory tract (esp. if tissue is infected); only if procedure involves incision or biopsy 3. Amoxicillin 2 g PO x 1 dose (adults) If PCN allergy: clindamycin 600 mg or clarithromycin (Biaxin) 500 mg or cephalexin (Keflex) 2 g

Answer 86

splinter hemorrhages on nails

Answer 87

1. - Classing finding: midsystolic click w/ late systolic murmur - Common cause for mitral regurgitation - At higher risk for AF, thromboemboli, TIA, AF, and ruptured chordae tendinae * Best diagnostic: 3D-TEE Mitral valve prolapse syndrome: Pt w/ sx and MVP 2. - Tall, thin adult female c/o fatigue - palpitations - lightheadedness (orthostatic hypotension) aggravated by heavy exertion - dyspnea - dizziness - exercise intolerance - panic - anxiety ds - may be asymptomatic * R/o Marfan's syndrome if pt w/ pectus excavatum, hypermobility of joints, and arm span > height 3. - Asymptomatic → Does NOT need treatment; MVP usually benign - MVP w/ palpitations → BB * Avoid caffeine and stimulants, alcohol, cigarettes; ↓ stress - Echocardiography recommended for pt w/ clinical exam suggestive of MVP or those w/ family hx of MVP

Answer 88

1. - Elevated lipids - Most are asymptomatic until ASCVD; score using ASCVD; may underestimate 10-year and lifetime risk for some race/ethic groups such as American Indians, some Asians (e.g., South Asians), and some Hispanics (e.g., Puerto Ricans) 2. - USPSTF: screening in both men and women at an increased risk for coronary heart disease - Men ≥35 yo - Females ≥45 yo - Adults ≥76 w/ no hx of CVD: do NOT screen (insufficient evidence) 3. Risk Factors: Heart disease - HTN - Fam hx of premature heart disease (women w/ MI before 65 years; men w/ MI before 55 years) - DM (considered a CHD risk equivalent even if pt has no hx of preexisting heart ds) - Dyslipidemia - Low HDL-C (<40 mg/dL) - Age (Men >45; women >55) - Cigarette smoking - Obesity (BMI ≥30 kg/m2) - Microalbuminuria - Carotid artery disease - Peripheral vascular disease (PVD)

Answer 89

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

Answer 90

M: >40 mg/dL F: >50 mg/dL HDL > 60 mg/dL → associated w/ lower risk of heart disease HDL <40 mg/dL → associated w/ ↑ risk of CAD even if normal LDL or cholesterol - Genetic causes is probably most common reason for low HDL-C - Do NOT treat low HDL-C alone (aim for lowering LDL); clinical trials have not shown a correlation b/w raising HDL-C and ↓ rates of heart disease or stroke Meds ↑ HDL - fibrates (gemfibrozil) - niacin - some high-dose statins ** Although niacin can ↑ HDL (and ↓ triglycerides), it has fallen out of favor d/t having failed to reduce vascular events (stroke, ASCVD); low-dose niacin (vit B3) OTC multivitamins or B-complex vitamins have not been implicated Lifestyle modifications: - regular, moderate cardiovascular/aerobic exercises most days of the week - lose weight - eat health fats (salmon, tuna, nuts) - eliminate transfats - stop smoking

Answer 91

Optimal: <100 mg/dL LDL: <130 mg/dL for low-risk pts w/ fewer than 2 RF Heart disease or diabetes: <70 mg/dL

Answer 92

1. Normal: <150 mg/dL Hypertriglyceridemia: >150 mg/dL * Niacin and fibrates are best agents for ↓ triglycerides 2. - Very high levels can be d/t genetic (primary) and acquired (secondary) ds; both often coexists - Metabolic syndrome - DM - familial hypertriglyceridemia - alcohol abuse - hyperthyroidism - kidney disease - medications (e.g., anabolic steroids, Accutane) Meds that can ↑ triglycerides - Oral estrogens - diuretics - Second-gen antipsychotics - glucocorticoids - antiretroviral - tamoxifen - Isotretinoin - nonselective BB (e.g., propranolol) 3. ≥1,000 mg/dL 4. - Avoid alcohol if very high triglycerides, can precipitate acute pancreatitis; avoid alcohol and acetaminophen (hepatoxic use) - Identify case, such as certain meds and past med hx - treat triglycerides first if very high (before tx high LDL/cholesterol) - First-line meds: fibrates (fenofibrate [Tricor], gemfibrozil [Lopid], benzafibrate [Bazalip]) - Niacin (Vit B3) high dose can ↓ triglyceride by 40% and raise HDL by 40%; start at low dose, take aftr meal, and slowly ↑ dose * To tx niacin flush or "prickly heat" sensation (from vasodilation), take w/ aspirin - High doses of strong statins such as atorvastatin (Lipitor) and rosuvastatin (Crestor) can ↓ triglycerides (33-50%) - Marine omega-3 acid ethyl esters are also effective (Lovaza 4 g/day) 5. - ↓ sugar and simple carb (junk food) - avoid alcoholic drinks - follow low-fat diet - eat fish w/ omega-3 (Salmon, sardines) twice a week - lose weight; reduce simple carbs, sugars, and junk foods, fried foods - ↑ aerobic-type physical activity ** If pt has markedly high triglycerides (≥500 mg/dL), lower triglycerides FIRST (niacin or fibrate) before treating high cholesterol and LDL; very HIGH triglycerides ↑ risk of acute pancreatitis

Answer 93

- Mediterranean diet - DASH diet - vegetarian diet - low-carbohydrate diet - low trans-fatty acid diet

Answer 94

First line: lifestyle changes - weight loss - exercise most days of the week - diet low in saturated fat - smoking cessation - in the presence of ASCVD and other factors → initiate statin therapy w/ lifestyle changes - Reduce dietary salt intake and + DASH diet (low salt, low saturated fat <30%) - Encourage use of soluble fiber in diet (e.g., inulin, guar gum, fruit, vegetables) to enhance lowering LDL (lowers LDL by blocking absorption in GI tract up to 10%) - Target goal is to lower LDL first (except if very high triglyceride levels) - If high triglycerides (≥500 mg/dL), treat hypertriglyceridemia first d/t high risk of acute pancreatitis - Low HDL alone (even if normal LDL and cholesterol) is a risk factor for heart disease

Answer 95

- recent coronary syndrome (within past 12m) - Hx of MI - hx of ischemic stroke - Symptomatic PAD (hx of claudication w/ ABI <0.85 or previous revascularization or lower extremity emputation)

Answer 96

High Intensity Statin - Clinical ASCVD - Very high risk ASCVD* - Severe primary hypercholesteremia w/ LDL >190 mg/dL - Diabetic age 50-75 yrs w/ LDL > 70 mg/dL Moderate Intensity Statin - Diabetic age 40-75 years w/ LDL >70 mg/dL - Age 40-75 yo w/ 10-year ASCVD risk >7.5% w/ risk-enhancing factors - Age 40-75 yo w/ 10-year ASCVD risk 7.5-19.9% w/ risk-enhancing factors * Defined as hx of multiple major ASCVD events or one major ASCVD event w/ multiple high-risk conditions

Answer 97

High-Intensity Statins: Lowers LDL ≥50% - Atorvastatin (Lipitor) 40-80 mg/d* - Rosuvastatin (Crestor) 20-40 mg/d * Initiation at 80 mg/d is not recommended by the FDA; increases risk for myopathy/rhabdomyolysis; start at lower dose and titrate up to 80 mg (if tolerated) Moderate-Intensity Statins: Lowers LDL 30-50% - Atorvastatin 10-20 mg/d - Rosuvastatin (Crestor) 5-10 mg/d - Simvastatin (Zocor) 20-40 mg/d - Pravastatin (Pravachol) 40-80 mg/d - Lovastatin (Mevacor) 40 mg/d Low-Intensity Statins: Lowers LDL <30% - Simvastatin 10 mg/d - Pravastatin 10-20 mg/d - Lovastatin 20 mg/d - Fluvastatin 20-40 mg/d

Answer 98

- Age ≥ 65 years Cardiovascular - Hx of prior CABG, PCI, CHF, HTN Endocrine - DM Resp - Current smoker Kidney - CKD (eGFR 15-59 mL/min) Lipids - Persistently elevated LDL of ≥100 mg/dL despite statin therapy and ezetimibe

Answer 99

Patients w/ any form of clinical ASCVD (hx of MI, CAD, angina, stroke/TIA, PAD, coronary revascularization) → High-intensity statin (or max tolerated statin therapy) → ↓ LDL by 50% High-intensity Statins: * Memorize - adult 21-75 years w/ any type of ASCVD (e.g., CAD, PAD, stroke, TIA) is given high-intensity statins such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg - adult w/ LDL >190 mg/dL (w/out ASCVD or DM) is a candidate for high-intensity statin dosing Very high risk of ASCVD (defined as hx of multiple major ASCVD events or one major ASCVD event w/ 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 >3yrs is unknown) Diabetic [t /w LDL of ≥70 mg/dL: → 40-75 yrs: Moderate-intensity statin therapy (w/out calculating 10-year ASCVD risk) → 50-75 yrs: Can use high-intensity statin to ↓ LDL by 50% or more Severe primary hypercholesterolemia (LDL of 190 mg/dL or higher): - 20-75 years: High-intensity statin (w/out 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 Assess adherence and percentage response to LDL-lowering meds and lifestyle changes: - Repeat lipid in 4-12 weeks after statin initiation or dose adjustment - Repeat Q3-12 months PRN

Answer 100

If 10-year ASCVD risk of 7.5-19.9% (intermediate risk): - 40-75 years w/ LDL 70 mg/dL to 189 mg/dL (without DM) → Assess risk-enhancing factors for ASCVD; if decision to start statins uncertain, check the coronary artery calcium (CAC) score; if CAC score is 1-99, favor starting statin therapy If 10-year ASCVD risk ≥20% (high risk): - 20-38 years w/ LDL ≥160 mg/dL (without DM) → If positive fam hx or premature ASCVD, initiate statin therapy to ↓ LDL by 50%

Answer 101

R/o familial hypercholesterolemia (FH), if presence of extensor tendon xanthomas 9achilles, subpatellar, or hand extensor tendons)

Answer 102

- Family hx of premature ASCVD - Persistently elevated LDL-C levels of ≥160 mg/dL - Metabolic syndrome - CKD - Hx 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) - Persistent triglyceride elevations - Elevated C-reactive protein of ≥2.0 mg/L - ABI ≤0.9

Answer 103

HMG-CoA reductase: enzyme in liver that is responsible for cholesterol synthesis. Statins inhibit this enzyme, which results in ↓ lipoprotein production - Best at lowering LDL, and some can ↑ HDL and ↓ triglycerides at higher doses If pt is a high-intensity statin candidate, start at lower doses and titrate up slowly to the recommended dose to minimize adverse effect - Check baseline LFT before initiation - Some pts may not tolerate high-intensity statins (e.g., muscle pains, weakness) but can tolerate moderate-intensity statins - If pt at very high risk for ASCVD or has severe primary hypercholesteremia (LDL >190 mg/dL) and is NOT ta LDL goal (but already on high-dose statin), next step is to add ezetimibe (Zetia) to statin - If still not at goal (LDL 70 mg/dL), can add a PCSK9 inhibitor (Repatha, Proluent) to statin and ezetimibe Examples: - Pravastatin (Pravachol) - Lovastatin (Mevacor) - Simvastatin (Zocor) - Atorvastatin (Lipitor) - Rosuvastatin ** 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) ** May cause cognitive effects (e.g., memory loss, confusion); reversible upon discontinuation of statin therapy (brain and nerves are mostly fat) Combination regimens of a statin w/ ezetimibe (Zetia) is acceptable for some high-risk patients

Answer 104

- Niacin (OTC) daily or TID - Niaspan (slow-release niacin) daily - Avoid combining niacin w/ statins (higher risk of liver damage) - Adding niacin to statins has NOT been shown to produce further benefit but may increase risk of hepatotoxicity

Answer 105

- Gemfibrozil (Lopid) - Fenofibrate (Tricor) - Benzafibrate (Bezalip) * Do not use w/ severe renal disease Action: Reduces production of triglycerides by liver and increases production of HDL - Very good agents for lowering triglycerides and elevating HDL levels - Less effective at lowering LDLs compared w/ statins SE: - dyspepsia - gallstones - myopathy

Answer 106

- Cholestyramine (Questran Light) - Colestipol (Colestid) - Colesevelam (Welchol) Action: Works locally in small intestine; interfere w/ fat absorption, including fat-soluble vitamins (vit a, D, E, and K) Alternative rug for pts who cannot tolerate statins, fibrates, and niacin - If used alone, not as effective as statins in lowering LDL; no hepatotoxicity SE: Mainly GI - Bloating - flatulence - abdominal pain Start at lose dose and titrate up slowly. * Advise pt to take multivitamin tablets daily

Answer 107

- Ezetimibe (Zetia) Action: Absorbs cholesterol from small intestines; combination of a statin w/ ezetimibe recommended for some high-risk ASCVD pts Contraindications: - active liver disease - unexplained persistent elevation of ALT and AST - can be taken alone or combined w/ a statin or fibrate (e.g., simvastatin [Vytorin]) SE: - diarrhea - joint pains - tiredness

Answer 108

- Human monoclonal antibodies, can ↓ LDL by 50-60% - Reduction of risk for MI, stroke, and unstable angina - Can be used aone or w/ other lipid-lowering therapies (statins, ezetimibe) - SubQ Q2-4 wks Current guidelines: - add PCSK9 to statins for pts at very high risk of ASCVD, recent ACS (within 12 m), multiple MIs, or strokes Ex: - Evolocumab (Repatha) - Alirocumab (Praluent)

Answer 109

1. Acute breakdown and necrosis of skeletal muscle (myoglobins) will cause acute renal failure - >50% of pts do not report muscular sx - muscles involved are usually the thighs, calves, shoulders, and lower back - Higher doses of statins or combination therapy have higher risk * R/o rhabdo if pt on statin and complains of muscular pain w/ dark-colored urine 2. Triad of: - muscle pain (myalgia) - weakness - red-to-brown urine 3. order labs immediately! - Creatine kinase (if markedly elevated; at least 5x the upper limit of normal from 1,500 to >100,000 IU/L) - Urine: Reddish-brown color (myoglobinuria) and proteinuria in up to 45% LFTs (will be elevated) - Other labs: UA, BUN, creatinine, potassium/electrolytes, EKG 4. Discontinue statin immediately

Answer 110

splinter hemorrhages on nails

Answer 111

red macules on palms/soles, not painful (may be tender)

Answer 112

painful/tender violaceous (violet-color) nodes found mostly on pads of fingers/toes, thenar eminence

Answer 113

1. - >1/3 (39.6%) adults are obese * M: 38.0%, F: 41.4% - Non-Hispanic Blacks have highest rates of obesity (48.1%), then Hispanics (42.5%), and non-Hispanic Whites (34.5%) - Among obese, 40.2% are middle-age adults (40-59 yrs) Obesity increases risk of mortality and comorbidities: - DM 2, HTN, dyslipidemia, CHD, sleep apnea, and ↓ mobility 2. The "apple-shaped" body type is considered more dangerous for health compared to the "pear-shaped" body type

Answer 114

<18.5 - Underweight 18.5-24.9 - Normal weight 25-29.9 - Overweight 30-39.9 - Obese >40 - Grossly obese ** BMI 27 is overweight → initiate lifestyle education

Answer 115

M: >40 inches (102 cm) South Asians, >35 inches (90 cm) F: >35 inches (88 cm) South Asians, >31 inches (80 cm)

Answer 116

M: 1.0 or higher F: 0.8 or higher

Answer 117

- Weight loss w/ dietary therapy and lifestyle and behavioral modifications - Many dietary methods (e.g., Weight Watchers, keto, Nutrisystem, Atkins) and apps (e.g., Noom, Weight Watchers) that help promote weight loss; depends on pt preferences - Meal delivery services can deliver fresh meals to homes; makes cooking easier d/t provided ingredients (e.g., Blue Apron, Hello Fresh, Green Chef) - Exercise: 40 mins of moderate to vigorous physical activity at least 3-5x/week - Walking 10,000 steps daily is popular; use of smart watches that track steps and exercise is helpful - Many online social support group sites, blogs, and articles about weight loss Therapies not recommended: - liposuction (does not improve insulin sensitivity or risk factors for heart ds) - herbal dietary supplements - very low-calorie diets (<1,000 kcal/day)

Answer 118

1. Metabolic ds w/ cluster of sx; pts at higher risk for DM2, CVD, and stroke; AKA insulin resistance syndrome or syndrome X 2. At least 3/5 must be present to diagnose: - Abdominal obesity (>40 inches in men; >35 inches in women) - BP >130/85 mmHg - ↑ fasting plasma glucose (>100 mg/dL( - ↑ triglycerides (>150 mg/dL) or on drug tx for ↑ triglycerides - ↓ HDL (<40 mg/dL in men; <50 mg/dL in women) ** Caused by hyperinsulinemia and peripheral insulin resistance 3. - Fasting (9-12 hrs) lipid profile (esp. triglycerides and HDL) - Fasting BG - Weight (BMI), waist circumference, BP

Answer 119

1. - caused by triglyceride fat deposits (steatosis) in liver hepatocytes - most asymptomatic - can present w/ or w/out inflammation - common in Western industrialized countries - most common reason: chronic heavy alcohol consumption and obesity (w/ DM2 and/or w/ metabolic syndrome) RF: - central obesity - DM2 - metabolic syndrome 2. - Usually asymptomatic - May have hepatomeglay - annual PE will show mild-to-mod elevations of ALT and AST - if sx → fatigue, malaise, w/ vague RUQ pain - associated dw/ obesity, metabolic syndrome, DM, and hyperlipidemia 3. - LFT: ALT and AST may be slightly ↑ from 2-5x 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 US and HAFLD fibrosis score - Refer to GI for management and a liver biopsy (GOLD STANDARD!) ** NAFLD is a/w metabolic syndrome and/or obesity; look for slightly elevated ALT and AST (not related to alcohol or meds) and negative Hep A, B, and C 4. - Lose weight, exercise, and watch diet - D/c alcohol intake permanently - Avoid hepatotoxic drugs (e.g., acetaminophen, isoniazid, statins) - Recommend vaccination for hepatitis A, B, and annual flu vaccine - Refer to GI specialist 5. - All obese and overweight pts should be advised to lose weight (esp. diabetics) - lifestyle changes are important! (diet, nutrition, exercise, portion control) - Daily aerobic exercise (e.g., walking, swimming, biking) for 30-40 mins - Weight Watchers: Some pts like the support and education (tertiary prevention)