Cardiovascular Flashcards
What is the sound of S2?
The sound of the semilunar valves (aortic/pulmonic) closing
S3 heart sound
“Ken-tuck-y”
Increased fluid states: pregnancy, CHF
S4 heart sound
“Ten-nes-see”
Stiff ventricular wall
(HTN, MI, young athletes)
Grading of murmurs
1- barely audible 2- faint but audible 3- easily heard 4- associated with a thrill 5- heard with one corner of stethoscope off the chest 6- loudest
Name that murmur: diastolic, 5th intercostal space
mitral stenosis
Name that murmur: systolic, 5th intercostal space
mitral regurgitation (also known as mitral valve prolapse)
Name that murmur: 2nd intercostal space radiating to neck, systolic
aortic stenosis
Name that murmur: diastolic, 2nd ICS
aortic regurgitation
What side heart failure is acute heart failure?
Left sided heart failure
What side heart failure is chronic heart failure?
Right sided heart failure
Symptoms of left sided heart failure
Acute
dyspnea
crackles
frothy cough
Symptoms of right sided heart failure
Chronic
Jugular vein distention
Edema
fatigue on exertion
What is the most common cause of right sided heart failure?
- Left side heart failure
- Cor pulmonale (result of pulmonary hypertension)
Management of heart failure
- Lifestyle- low sodium, rest/activity balance, weight loss
2. Medications- ACE inhibitors, diuretics
New York Heart Association Functional Classifications of Heart Failure
I- no activity limitations
II- slight activity limitations, comfortable at rest
III- marked activity limitations, comfortable at rest
IV- severe activity limitations, symptoms while at rest
What kind of headache may hypertension cause?
Suboccipital pulsating headache, occurring early in the morning and resolving throughout the day
What are some s/sx of hypertension, if any occur?
headache
dizziness/lightheadedness
epistaxis (worse in afternoon)
S4 heart sound
What tests could you do for new hypertension to rule out secondary cause?
Renal studies
Chest x-ray (if cardiomegaly is suspected)
Plasma aldosterone level (to rule out aldosteronism)
AM/PM cortisol levels (to rule out Cushing’s)
EKG
Labs: UA, CBC, BMP, Lipid panel
What is normal BP according to JNC 7?
What is prehypertension according to JNC 7?
120-139/80-89
What is stage 1 hypertension according to JNC 7?
140-159/90-99
What is stage 2 hypertension according to JNC 7?
≥ 160/≥100
When do you start treating hypertension according to JNC 8?
What antihypertensives are recommended for non-African-American patients?
Thiazide diuretics
Calcium Channel blockers
ACE/ARB
What antihypertensives are recommended for African Americans?
Thiazide diuretics
Calcium channel blockers
What antihypertensives are recommended for adults with chronic kidney disease?
ACE/ARB regardless of race or other medical conditions
How long do you wait to reassess hypertension after new intervention?
One month, and continue to assess monthly until goal is reached
What two types of antihypertensive drug can you not use together?
ACE and ARB
At what point do you refer for hypertension?
If it requires 3 or more drugs to manage
MOA of thiazide diuretics? Special considerations?
increase excretion of sodium and water
screen for sulfa allergy before administering
can decrease potassium
MOA of ACE inhibitors? Special considerations?
cause vasodilation, block sodium and water retention
do not use with renal artery stenosis
contraindicated in pregnancy
may cause dry cough, angioedema
MOA of ARBs? Special considerations?
cause vasodilation and block sodium and water retention
reserved for patients intolerant to ACE inhibitors
contraindicated in pregnancy
What is the sound of S1?
Sound of the AV valves closing (mitral, tricuspid)
MOA of beta blockers? Special considerations?
directly relax the heart
monitor heart rate
may cause fatigue
MOA of peripheral alpha-1 antagonists? Examples of meds? Special considerations?
cause vasodilation
examples: prazosin, terazosin, doxazosin
take at bedtime, may cause orthostasis
MOA of central alpha-2 antagonists? Examples? Special considerations?
prevent vasoconstriction, cause vasodilation, slow the heart rate
Examples: clonidine, methyldopa
do not discontinue abruptly
MOA of arterial vasodilators? Examples? Special considerations?
directly relax the vascular smooth muscle resulting in arterial dilation
Examples: hydralazine
reduce frequency in renal dysfunction
may cause reflex tachycardia
MOA of renin inhibitors? Examples? Special considerations?
inhibits renin, which inhibits conversion of angiotensin I to II
Examples: aliskiren (Tekturna)
expensive
teratogenic
Hypertensive urgency
≥180/110
may or may not be symptomatic
treat with oral clonidine
Hypertensive emergency
≥180/120
require decrease in BP within 1 hour
examples: malignant hypertension, hypertensive encephalopathy, intracranial hemorrhage, unstable angina, acute MI, dissecting aortic aneurysm, eclampsia
Tx: refer to ER/ICU
What does dissecting aortic aneurysm present with?
Back pain
BP different on right and left sides
Stable angina
Exertional, subsides with rest
Prinzmetal’s angina (variant angina)
caused by coronary vasospasm
causes ST elevation, typically find out diagnosis in cath lab
Unstable angina
MI/ACS, pre-infarction
not relieved with rest
Microvascular angina
related to Metabolic Syndrome
Levine’s sign
“clenched fist sign”
90 percent diagnostic for angina
“Feel like something is squeezing my chest”
Dx for angina
EKG
Exercise EKG/stress test
Check lipid panel
Normal lipid panel values
Cholesterol:
What is a lipid panel value that is a NEGATIVE cardiac risk factor?
HDL ≥ 62
Management of hyperlipidemia/angina/cardiac risk
Low fat diet
Baby ASA daily
Statin if indicated by ASCVD (esp. diabetics, smokers)
What are the “strongest” and “weakest” statins?
Strongest: atorvastatin, rosuvastatin
Weakest: pravastatin, fluvastatin
How much does LDL decrease on average with high-intensity statin therapy?
greater than 50 percent
How much does LDL decrease on average with moderate intensity statins?
30-50 percent
How much does LDL decrease on average with low-intensity statin therapy?
Less than 30 percent
What to do if high-dose statin therapy is not enough to get patient within goal?
- Add Niacin
2. Add fenofibrate (like gemfibrozil)
Examples of bile acid sequestrants? What do they lower?
Mostly LDL; may increase triglycerides
Examples: cholestyramine, colesevelam (Welchol), colestipol
Examples of fibrates? What do they lower?
Decrease triglycerides, slightly lower LDL, possibly increase HDL
Examples: gemfibrozil, fenofibrate
Examples of cholesterol absorption inhibitor? What do they lower?
Used in conjunction with statin to lower LDL
Example: ezetimibe
What does niacin lower?
LDL and triglycerides, and increases HDL
What causes MI/ACS?
“clot on plaque”
Diagnosis of MI/ACS?
EKG- up to 30 percent without any initial EKG changes
Peaked T waves, ST elevation, Q wave development
Cardiac enzyme- elevations within 4 to 6 hours and remain high for 3 days to 3 weeks
Which EKG leads indicate lateral MI?
I, aVL
What EKG leads indicate inferior MI?
II, III, aVF
What EKG leads indicate anterior MI?
V leads (precordial) or V3 and V4
Treatment of acute MI?
Activate EMS, then…
- Aspirin 325mg
- Nitroglycerin
- Oxygen
Which cardiac markers are true to cardiac problem only?
TNI and CKMB
INR normal
0.8 to 1.2
APTT normal
28 to 38 seconds
PT normal
11-16 seconds
PTT
60 to 90
Indications for TPA for MI
Unrelieved chest pain >30 minutes and
Risk factors for DVT
immobility female post operative period use of oral contraceptives (especially with smokers) clotting disorder
Signs and symptoms DVT
Pain especially while walking
Dull ache or “tight” feeling
Edema, skin may be cool to touch
Diagnosis and management of DVT
Ultrasound, D Dimer, Venography
Tx: Bed rest 7-14 days, Lovenox 1mg/kg every 12 hours, Coumadin therapy for 12 weeks, referral
Peripheral vascular disease: symptoms
arterial disease
Sx: claudication, cold/numb extremities, shiny/hairless skin, dependent rubor and pallor with elevation, ulcerations, reduced pulses
PVD: Diagnosis, management
Dx: Doppler US, ABI, arteriography
Tx: Stop smoking, exercise (to grown collateral circulation), weight loss, angioplasty, bypass surgery, amputation
Meds: pentoxifylline or cilostazol (Trental/pletal)
Chronic venous insufficiency: symptoms
venous disease
Sx: women > men, history of leg trauma, varicose veins, aching of BLE alleviated by elevation of legs, edema with prolonged standing, night cramps of BLE, brownish discoloration, ulcers, edema, dermatitis, cool to touch
Chronic venous insufficiency: Diagnosis and management
Dx: rule out other causes of edema
Tx: elevate legs, TEDS stockings, weight loss
Treatment of acute weeping dermatitis
Wet compresses
0.5% hydrocortisone cream after compresses
