Cardiovascular Flashcards
Most common cause of secondary HTN in young women
Birth control pills
Meds causing secondary HTN
Endocrine causes
OCP, decongestants, estrogen, TCAs, NSAIDs
Hyperaldo Thyroid or pth dz Cushings Pheo Acromegaly
Goals in evaluating pt with HTN
Look for secondary causes
Assess damage to target organs heart, kidneys, eyes, CNS
Assess overall cardio risk
Therapy decisions based on above
What kind of cuff falsely elevated BP?
Cuff that is too small
BP categories
Normal: < 120/80
PreHTN: 120-139 or 80-89
–tx w lifestyle mod
Stage I HTN: 140-159 or 90-99
–tx w lifestyle mod or med
Stage II HTN: >=160 or >=100
–tx w lifestyle mod + 2 meds
Dx HTN
2 elevated readings at different times within 4 wks
HTN tx that decreases risk of new onset diabetes
ACEi
ARBs
Categories of anti HTN meds
Thiazides Beta blocker ACEi ARBs CCBs
Alpha blockers
Vasodilators (hydralazine, minoxidil)
Thiazides side effects
HYPO K, Mg
Hyper GLUC
- glucose
- lipid
- uric acid
- calcium
ACEi side effects
“CHATS”
Cough HYPER K Altered taste Teratogen Skin rash
Beta blocker side effects
Bradycardia Bronchospasm Insomnia Mask hypoglycemia in insulin diabetics Impotence
Initial mono therapy drugs for HTN
Thiazides
CCBACEi or ARB
Best to start with ace or CCB since trial showed ace and CCB was better than ace and diuretic at controlling HTN
Meds causing elevated lipids or LDL
Thiazides B blockers Estrogens Steroids HIV protease inhibitors
Best for dec TGs
What drug for hld increases TGs?
Fibrates (gemfibrozil) to dec TGs
Bile acid resins (cholestyramine) increases TGs
Secondary causes of hyperlipidemia
Chronic liver dz diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, some medications.
What HLD drugs work well together
Statins
Bile acid resins
HLD drug with lft issues
Statins
Fibrates
HLD not good for diabetics
Niacin
Tx peripheral vascular disease
EXERCISE
Antiplatelet to reduce risk of stroke (no effect on claudication)
- aspirin
Of the dietary factors recommended for the prevention and treatment of cardiovascular disease, which one has been shown to decrease the rate of sudden death
Omega 3 fatty acids
Tx aortic dissections
Acute dissection of the ascending aorta is a surgical emergency, dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura, rupture, or occlusion of major branch A.
- Initial management” reduce the systolic blood pressure to 100-120 mm Hg
- —β-blocker such as propranolol or labetalol is 1st line
—-If SBP > 100 still, IV nitroprusside
——–Without prior beta-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta.
Tx supraventricular tachy
Tx underlying cause
If trying to find…
1) adenosine –> 2) IV verapamil or beta blocker if adenosine doesn’t work3) IV propanefone or Flecanide if 2 doesn’t work
Monotherapy for hypertension in African-American patients is more likely to consist of
diuretics or calcium channel blockers NOT β-blockers or ACE inhibitors.
Peds pt Systolic heart murmur low, short tone no radiation decreases with inspiration asymptomatic
What is it?
Stills murmurcan be due to vibrations in chordae tendinae, semilunar valves or ventricular wall
Venous hum
continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, it worsens with inspiration or diastole
Enoxaparin elimination
Renal
Initial eval of palpitations
EKG
When do you give thrombolytics for acute MI?
new LBBBsuggests occlusion of LAD
MI dx
Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads.
Antihypertensives that can worsen depression
B-blockersClonidine
axillosubclavian vein thrombosis (ASVT)
more frequent with the increased use of indwelling subclavian vein catheters. Spontaneous ASVT (not catheter related) is seen most commonly in young, healthy individuals. - The most common associated etiologic factor is the presence of a compressive anomaly in the thoracic outlet.
Tx 1st episode of unprovoked DVT
Warfarin at least 3 mo
Give for acute MI
Mona
Morphine
Oxygen
Nitrates
ASA
Beta blocker
ACEi
Statins a few days later
New onset angina. What drug is contraindicated?
Nifedipine
Can increase mortality
Symptoms of congestive heart failure in infants are often related to
feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive.
Best med for HTN + diabetes
ACEi
When to tx aortic stenosis
mean aortic-valve gradient exceeds 50 mm Hg
aortic-valve area is not larger than 1 cm2
Symptomatic from AS
Valve replacement is tx. Not valvuloplasty
Contraindications to beta-blocker use include
hemodynamic instability, heart block, bradycardia, severe asthma.
How can you ppx for surgery-related cardiac complications in pts w/ CV risk factors?
Beta blockers
Exercise in elderly…considerations
Initial exercise routines for the elderly can be as short as 6 minutes in duration. A target heart rate of 60%–75% of the predicted maximum should be set as a ceiling.
What should any person with HLD undergo before starting lipid lowering therapy?
Investigate secondary causes of HLD
NOT ok for WPW
Intravenous and oral digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract
Contraindicated in CHF
NSAIDs
High dose ASA
—-They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation
Cilostazol
Best to control what for afib first?
Rate
Patients with long QT syndrome that have sudden arrhythmia death syndrome usually have
either torsades de pointes or ventricular fibrillation.
1st line for HTN, including in elderly!
thiazide diuretics and long-acting calcium channel blockers as first-line therapy.
Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least
160 mm Hg.
The INITIAL treatment of choice in the management of severe hypertension during pregnancy is
IV hydralazine, IV labetalol, or oral nifedipine
what have been found to decrease mortality late after myocardial infarction
Beta-blockers and ACE inhibitors
Preferred drugs for congestive heart failure due to left ventricular systolic dysfunction,
ACEi because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative
Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as
unstable coronary syndrome (acute or recent myocardial infarction, unstable angina),
decompensated congestive heart failure,
significant arrhythmia (high-grade AV block,
symptomatic ventricular arrhythmia,
supraventricular arrhythmias with uncontrolled ventricular rate),
severe valvular disease.
Intermediate predictors of increased perioperative cardiovascular risk for elderly patients include
mild angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus, renal insufficiency.
Minor predictors of increased perioperative cardiovascular risk for elderly patients include
advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, history of stroke, uncontrolled hypertension.
Tx WPW
Amiodarone
Procainamide
The primary treatment for symptomatic mitral valve prolapse is
β-blockers.
Natural tx for varicose veins
Horse chestnut seed extract has been shown to have some effect when used orally for symptomatic treatment of chronic venous insufficiency, such as varicose veins.
greatest risk factor for AAA
cigarette smoking
For patients with a history of previous stroke, JNC-7 recommends using what for HTN control?
combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination has been clinically shown to reduce the risk of recurrent stroke.
Tx UE DVT
heparin should be given for 5 days, and an oral vitamin-K antagonist for at least 3 months.
Tx acute pulmonary edema 2/2 CHF
FurosemideNItro if BP is increasedMorphine as adjunct
Tx CHF- what reduces mortality?- what reduces hospitalizations?
Reduce mortality:
- ACEi/ARB
- beta blockers (for NYHA 2&3
Reduce hospitalizations
- Digoxin
- Diuretics
FOr NYHA 3&4:
- aldosterone blockers
What tx is NOT ok for systolic heart failure
CCB
- will increase mortality
- only exception is amlodipine
CCB, diuretics, ARBs for diastolic failure
Tx for acute exacerbation of CHF
ACEi
Diuretics (furosemide)
NOT beta blockers
Tx NYHA class 3/4 CHF
Aldo blockers
Cardiac resynchroniation tx if maxed out drug therapy
- will decrease mortality adn hospitalization in symptomatic ppl
How does HCM murmur change with valsalva? supine position?
valsalva - increases
supine - decreases
Common triggers of CHF
Anemia (because increased CO needed –> heart failure sx)
Infection
CHF CXR
Cardiomegaly > 50% heart: thorax ratio
Cephalization of pulmonary vasculature
Pleural effusions
In patients with a drug-eluting stent, what meds should a person be on as well?
combined therapy with clopidrogel and aspirin is recommended for 12 months because of the increased risk of late stent thrombosis
A 60-year-old male is recovering from a non–Q-wave myocardial infarction. He has a 40-pack-year smoking history, currently smokes a pack of cigarettes per day, and has a strong family history of coronary artery disease. Studies ordered by the cardiologist showed no indication for any coronary artery procedures. His BMI is 27.5 kg/m 2 and his blood pressure is 130/70 mm Hg. Laboratory tests reveal a fasting blood glucose level of 85 mg/dL, a total cholesterol level of 195 mg/dL, and an LDL-cholesterol level of 95 mg/dL.Which one of the following secondary prevention measures would be LEAST likely to improve this patient’s cardiovascular outcome? (check one)
A. A weight reduction diet
B. A β-blocker
C. A statin
D. An antiplatelet agent
E. Smoking cessation
A
Although dietary management may be appropriate, a weight reduction diet is not likely to improve this patient’s cardiovascular outcome. In fact, even if this person were obese, there is insufficient evidence that weight reduction would decrease his cardiovascular mortality (SOR C). There is good evidence that the other options, even β-blockers in a patient with normal blood pressure, are indicated. All of these measures have evidence to support their usefulness for secondary prevention of coronary artery disease
Diet to reduce BP
High K
High Ca
Isolated systolic HTN in elderly responds best to
Diuretics
Most common cause of HTN in kids
Renal parynchymal dz
Get a UA, urine cx, and renal US for all kids with HTN
Postural orthostatic tachycardia syndrome (POTS)
is manifested by a rise in heart rate >30 beats/min or by a heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms usually include position-dependent headaches, abdominal pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lie down quickly enoughcondition is thought to have a genetic predisposition, is often incited after a prolonged viral illness, and has a component of deconditioning. The recommended initial management is encouraging adequate fluid and salt intake, followed by the initiation of regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers
The cardiac toxicity of methadone is primarily related to
QT prolongation and torsades de pointes.
CHADS 2 score
Congestive heart failure,
Hypertension,
Age >75,
Diabetes mellitus,
previous Stroke or transient ischemic attack.
> 4 = high risk
2-3 = moderate risk
1 or less = low risk
Tx:
- low risk = ASA 81-325mg
- mod-high risk = warfarin
What we the factors used to determine optimal LDL levels?
- Cigarette smoking
- Hypertension (blood pressure ≥140/90 mm Hg or on antihypertensive med-ication)
- Low HDL
- Age (
When should you send a kid here for sports eval to cardiologist?
Diastolic murmur 3/6 or louder
HOCM suggestive murmur
Marfans
What is a CHD risk equivalent?
peripheral arterial disease,
cerebrovascular disease, abdominal aortic aneurysm
type 2 diabetes
multiple risk factors that together raise the risk of CHD to greater than or equal to 20% in 10 years
Effective tx for venous ulcers
Pentoxifylline is effective when used with compression therapy for venous ulcers
Sick sinus syndrome
usually involves a dysfunction of the SA node that leads to bradycardia and can cause fatigue and syncope.
Patients, however, can also have a tachycardia-bradycardia variety of sick sinus syndrome in which they also experience supraventricular tachycardia with its associated symptoms of palpitations and angina pectoris.
Brugada syndrome
is an ion channel disorder that is most common in Asian males. On an ECG, it presents as ST-segment elevation in leads V1 to V3, and it too can cause dangerous arrhythmias that result in death.
multifocal atrial tachycardia (MAT) classically found in presence of
COPD
Long QT syndrome
is caused by mutations in multiple genes and can have an autosomal dominant pattern. It is seen more commonly in females. Prolonged QT interval is defined as QT 470 msec in men or greater than 480 msec in women
Meds prolonging QT
quinidine, procainamide, sotalol, amiodarone, and tricyclic antidepressants
Tx primary supraventricular tachy
Tx symptomatic SVT
β-blockers
calcium channel blockers
Digoxin
Symptomatic (SVT): self-treated by patients with recurrent episodes by several vagal stimulation techniques. Carotid sinus massage, Valsalva maneuver, and cold applications to the face (diver’s reflex) can trigger vagus nerve stimulation, which may break an episode of SVT. If unsuccessful, IV adenosine
- if works, then the arrhythmia is most likely a reentry SVT.
- If it does not, then the rate may be slowed down with β-blockers or calcium channel blockers. At that point, consultation with a cardiologist should be sought.
the most common cause of palpitations
Primary rhythm disturbances
Tx Ventricular fibrillation
Patients with ventricular tachycardia, who are unstable, need to be electrically cardioverted. Amiodarone should be given to a patient with stable ventricular tachycardia and in patients who were converted back into a sinus rhythm through cardioversion. Can give lidocaine if allergic to iodine
Causes of secondary HTN
Pheo hyper PTH thyroid dz renal artery stenosis Obesity
Tx PAD refractory to lifestyle changes + exercise
Cilostazol
all children suspected of ingesting a calcium channel blocker should be
admitted to a pediatric intensive-care unit for monitoring and management.
Specific criteria for the diagnosis of polycythemia vera
include an elevated red cell mass, a normal arterial oxygen saturation (>92%), the presence of splenomegaly. In addition, patients usually exhibit thrombocytosis (platelet count >400,000/mm3 ), leukocytosis (WBC>12,000/mm3 ), a low serum erythropoietin level, and an elevated leukocyte alkaline phosphatase score
Goal HTN in chronic renal failure
<130/80 mm Hg
What is the most effective imaging study for the diagnosis of pericardial effusion
Echocardiography
A well-known use of intravenous magnesium is for
correcting torsades de pointes.
When should you change statins because of side effects?
Research has proven that up to a threefold increase above the upper limit of normal in liver enzymes is acceptable for patients on statins.
For persistent ventricular fibrillation (VF), in addition to electrical defibrillation and CPR, patients should be given
a vasopressor, which can be either epinephrine or vasopressin. Amiodarone should be considered for treatment of VF unresponsive to shock delivery, CPR, and a vasopressor
Adenosine is used for…
narrow complex, regular tachycardias
Amiodarone to tx…
WPW
acute management of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability.
afib only in symptomatic patients with left ventricular dysfunction and heart failure
Secondary prevention of cardiac events in high risk pts or those who had MI already
aspirin, β-blockers after myocardial infarction, ACE inhibitors in patients at high risk after myocardial infarction, angiotensin II receptor blockers in those with coronary artery disease, amiodarone in patients who have had a myocardial infarction and have a high risk of death from cardiac arrhythmias
Tx STEMI
STEMI is defined as an ST-segment elevation of greater than 0.1 mV in at least two contiguous precordial or adjacent limb leads. The most important goal is to begin fibrinolysis less than 30 minutes after the first contact with the health system. The patient should be given oral clopidogrel, and should also chew 162–325 mg of aspirin.
S/E Anticholinesterase meds
significant increased risk of bradycardia, syncope, and pacemaker therapy with cholinesterase inhibitor therapy. (Eg donepezil)
Circumflex occlusion causes changes in
I, AVL, and possibly V5 and V6 as well.
Left anterior descending coronary artery occlusion causes changes in
V1 to V6.
Right coronary occlusion causes changes in
II, III, and AVF.
Tx pericarditis
NSAIDs, such as aspirin and ibuprofen.
Recent studies demonstrate that adding colchicine to aspirin may be beneficial in reducing the persistence and recurrence of symptoms
Intensive management of hyperglycemia also has a beneficial effect on cardiovascular disease in patients with DM 1 or 2 or both?
type 1 diabetes mellitus but, unfortunately, not in patients with type 2 diabetes mellitus.
A 58-year-old male complains of leg claudication. Subsequent tests reveal that he has significant bilateral peripheral arterial disease. His current medications include atenolol (Tenormin), 50 mg/day, and aspirin, 325 mg/day. His blood pressure is 128/68 mm Hg, and his pulse rate is 64 beats/min. His LDL-cholesterol level is 123 mg/dL.
The addition of which one of the following could reduce this patient’s symptoms?
(check one)
A. Epoetin alfa (Epogen)
B. Nifedipine (Procardia)
C. Simvastatin (Zocor)
D. Testosterone supplementation
E. Warfarin (Coumadin) titrated to an INR of 2.0–3.0
Peripheral arterial disease (PAD) is a common malady that has several proven treatments. The outcomes of these treatments can be separated into two primary categories: reducing PAD symptoms and preventing death due to systemic cardiovascular events (CVEs), especially myocardial infarction. Routine exercise up to near-maximal pain on a regular basis has been shown to be one of the most effective treatments for symptoms of PAD. Smoking cessation and aspirin are also standard recommendations, and can both prevent CVEs and slow the rate of progression of PAD symptoms.
Statin drugs (specifically simvastatin and atorvastatin) have been shown to be beneficial for treatment of PAD symptoms and prevention of CVEs through the reduction of cholesterol, but they also appear to have other properties that help reduce leg pain in patients with PAD. Although lowering abnormally high blood pressure is recommended in PAD patients, only ACE inhibitors have been shown to reduce symptoms of PAD directly. Furthermore, the combination of atenolol and nifedipine has actually been shown to worsen symptoms of PAD. The addition of warfarin to aspirin has no additional benefit in either reduction of PAD symptoms or prevention of CVEs, but it may have a role in preventing clots in patients who have undergone revascularization.
causes of fetal bradycardia
Epidural anesthesia, post-dates pregnancy, and umbilical cord prolapse
Causes of fetal tachycardia include
maternal fever, fetal hypoxia, hyperthyroidism, maternal or fetal anemia, medication effects of parasympatholytic or sympathomimetic drugs, chorioamnionitis, fetal tachyarrhythmia, and prematurity
First-line therapy for proteinuric kidney disease with HTN includes
an ACEI or an ARB.
Because these drugs can cause elevations in creatinine and potassium, these levels should be monitored.
A serum creatinine level as much as 35% above baseline is acceptable in patients taking these agents and is not a reason to withhold treatment unless hyperkalemia develops.
Tx s/p MI depression
Several studies have demonstrated that SSRIs are safe and effective in treating depression in patients with coronary disease
Kawasaki disease
usually self-limited, with fever and acute inflammation lasting 12 days on average without therapy.
if untreated, this illness can result in heart failure, coronary artery aneurysm, myocardial infarction, arrhythmias, or occlusion of peripheral arteries.
Dx:
- fever must be present for 5 days or more with no other explanation + 4/5 of following:
- 1) nonexudative conjunctivitis that spares the limbus;
- 2) changes in the oral membranes such as diffuse erythema, injected or fissured lips, or “strawberry tongue”;
- 3) erythema of palms and soles, and/or edema of the hands or feet followed by periungual desquamation;
- 4) cervical adenopathy in the anterior cervical triangle with at least one node larger than 1.5 cm in diameter; and,
- 5) an erythematous polymorphous rash, which may be targetoid or purpuric in 20% of cases.
Tx:
- IV Ig
- ASA
DO NOT USE PREDNISONE as can cause coronary
The presence of nonthrombocytopenic palpable purpura, colicky abdominal pain, and arthritis is most consistent with which one of the following? (check one) A. Kawasaki disease B. Takayasu arteritis C. Wegener granulomatosis D. Polyarteritis nodosa E. Henoch-Schonlein purpura
The most common pediatric vasculitis is Henoch-Schonlein purpura. It is an IgA-mediated small-vessel vasculitis that classically presents with the triad of nonthrombocytopenic palpable purpura, colicky abdominal pain, and arthritis. Kawasaki disease is manifested by conjunctival injection, mucosal erythema, rash, and lymphadenopathy. Takayasu arteritis has numerous manifestations, including night sweats, fatigue, weight loss, myalgia, and arthritis. Later findings may include hypertension, skin lesions, and cardiac disorders. Wegener granulomatosis causes constitutional symptoms also, including weight loss and fatigue, with later findings including respiratory problems, ophthalmologic lesions, neuropathies, glomerulonephritis, and skin lesions. Polyarteritis nodosa is another disease that causes constitutional symptoms such as fatigue, fever, and myalgias. It also causes skin lesions, gastrointestinal symptoms such as postprandial abdominal pain, and cardiac lesions.
Dx rheumatic criteria
JONES criteria
Two major criteria, or one major criterion and two minor criteria, plus evidence of a preceding streptococcal infection, indicate a high probability of the disease.
Major: Joints (migrathory polyarthritis) O = pancarditis N = SubQ nodules E = erythema marginatum S = syndeham chorea
Minor criteria: F = fever A = arthralgia C = high CRP level E = high ESR P = prolonged pulse rate interval on EKG.
