Cardiovascular

Question 1

Isolated Systolic Hypertension

Answer 1

Eti: Tends to occur in eldery due to loss of elasticity of arterial system
S/sx: Generally asymptomatic, wide pulse presure (SBP-DBP). Difficult to treat
Tx: Use ACE or ARBs, diuretics and CCBs, not beta blockers

Question 2

Essential hypertension

Answer 2

S/sx: Generally asymptomatic, left untreated can develop end organ damage.
Dx: must establish multiple episodes of hypertension, unless upon inital pressentation profoundly hypertensive greater than 200/125
Work up: EKG, UA, Blood glucose, lipids, GFR, K, HCT

Question 3

Primary aldosteronism

Answer 3

Eti: elevated serum aldosterone leads to Na retention and then water retention. Generally caused by adrenal adenoma or bilateral adrenal hyperplasia
S/sx: HTN that is refractory to multiple drugs
Dx: workup, plasma aldosterone/renin ration (discontinue ACE/ARB?Clonidine and beta blockers and spironolactone before testing

Question 4

Renal parenchymal disease

Chronic kidney disease

Answer 4

Eti: increased intravascular volume (lower GFR) and increase activity of renin-angiotnesion-aldosterone system RAAS
Cause by chronic kidney disease

Question 5

Renal artery stenosis

Answer 5

Eti: in young caused by fibromuscular dysplasia, others it is caused by atherosclerotic arteries. Lower kidney perfussion causes increase in renin which boost BP, decreased renal perfussion also caused less salt loss.
Dx: consider if HTN before 20 or after 50, multi drug resistant, if renal or epigastric bruits
Tests: renal arteriography is test of choice, can use MRI or CT or US if lower suspicion
Tx: if due to arteriosclerosis give ACE/ARB and statin

Question 6

Coarctation of the Aorta

Answer 6

Eti: congenital malformation of the aorta that results in narrowing past the arch.
S/sx: systemic HTN most common symptom, asymmetry of pulses, delay of pulses between upper and lower extremities
Dx: tranthoracic echo or MRI, ECG and CXR
Tx: surgical

Question 7

Pheochromocytoma

Answer 7

Hypertension caused by catecholamine excess (epi and norepi)
S/sx: HTN generally comes in episodes along with s/sx (HA, diaphoresis, palpitations, anxiety, nausea, angina, pulmonary edema)
Dx: 24 hour urine for fractionated metanephrines
Tx: surgery

Question 8

Drug induced HTN, which drugs?

Answer 8

Cyclosporines, tacrolimus, angiogenesis inhibitors, erythrocyte-stimulating agents, cocaine, ETOH, pseudoepherine, phynylephrine

Question 9

Thyroid/parathyroid disease

Answer 9

Increase in HR and vasular tone due to sympathetic activation leading to increased BP
-Hyperthyroidism
S/sx: lid lag, moist skin, palpitations, elevated HR, brittle hair, anxiety, exophthalmos, wt. loss, heat intolerance
Dx: check TSH, T3 and T4, check for graves diesase

Question 10

Beta-adrenergic blocking agents

Drugs and MOA

Answer 10

Cardioselective (atenolol, metoprolol, esmolol)
Non selective B1 and B2 (propranolol), Alpha and B1/2 (labetalol, carvedilol)
MOAcatecholamine inhibitor (blocks adrenergic renin release), decreases heart rate allow vessels to dialate

Question 11

Beta blocker indications

Answer 11

Indic: HTN, tachycardias, angina, acute MI, HF, pheochromocytomas, migraines
CI: 2nd/3rd heart block, decompenasted HF
AE: fatigue, depression, impotence, dizziness, lightheadedness, nausea, hypotension

Question 12

Alpha blockers

Answer 12

Drugs: prazosin, terazosin, doxazosin
MOA: inhibits postsynaptic alpha adrenergic receptors, causing arterial and venous dilation which decreases BP
Indication: HTN (also increases HDL and decreases LDL, improves insulin sensitivity

Question 13

Peripheral agents

Answer 13

Drug: reserpine
MOA: antiadrenergic agents
… need more here

Question 14

Central alpha-agonists

Answer 14

Drugs: clonidine, methyldopa
Clonidine: Used primary for HTN that has not responded well to two or more drugs. It does not decrease renal blood flow or GFR so good for HTN complicated by renal disease
Methyldopa: Used primarily to manage HTN in pregnancy, where it has a record of saftey

Question 15

Clonidine AE

Answer 15

Black box warning: for obstetrics postpartum or perioperative because of risk of hemodynamic instability
hypertensive crisis is d/c abruptly

Question 16

direct vasodilators

Answer 16

drugs: hydralazine, minoxidil
MOA: directly relaxes vascular smooth muscle.
Hydralazine: pregnancy induced HTN
AE: MI, HR, angina, arrhythmia, sweating
Minoxidil: used mainly for male pattern baldness (rogaine)
AE: hypertrichosis

Question 17

ACE inhibitors

Answer 17

Drugs: captopril, lisinopril, benazepril
MOA: cardio protective and renoprotective, synergistic effect when used with thiazides
Decreases angiotensin 2, decreases secretion of aldosterone, decreases Na and H2o retention
CI: prego cat X, angioedema
Adverse: cough, hyperkalemia, skin rash, hyperurecemia

Question 18

ARBs

Answer 18

Drugs: losartan, valsartan
MOA: directly blocks angiotensin 2, no cough
CI: pregnancy, angioedema

Question 19

Calcium channel blockers

Answer 19

Dihydropyridines (amlodipine, nifedipine)
- potent vasodilators (little effect on cardiac contraction or conduction)
Indic: most commonly used in HTN
Non-dihydropyridines (diltiazem, verapamil)
- affects cardiac contract and conduction
Indic: used with HTN with afib
CI: beta blockers, CHF, 2nd/3rd heart blocks
AE: vasodilation(HA, dizziness, flushing, peripheral edema, constipation esp with verapamil)

Question 20

carbonic anhydrase inhibitors

Answer 20

Drug: acetazolamide (Diamox)
MOA: inhibits CA which inhibits H ion excretion in PCT, increaseing Na, HCO2 and water excretion producing alkaline diuresis
Indic: HTN, glaucoma, CHF, seizures, altitude sickness
CI: hypokalemia, hyponatremia, …
AE: hypotension, dizziness

Question 21

Thiazide diuretics

Answer 21

HCTZ, chlorthalidone
MOA: inhibits reabsorption of Na in DCT, decreasing blood volume, decreasing BP
Indic: 1st line for HTN, cardioprotective
AE: hypoNa, hypoK, hyperuricemia, hyperglycemia

Question 22

Potassium sparring diuretic

Answer 22

Spironolactone, amiloride, eplerenone
MOA: inhibits aldosterone mediated Na/H2O absorption, weak diuretic
Indic: primary hyperaldosteronism, edematous conditions, CHF, hypokalemia
AE: gynecomastia, hyperkalemia

Question 23

Loop diuretic

Answer 23

Furosemide, toresmide, bumetanide
MOA: Inhibit cotransport Na+/K+/2Cl- in the asending loop of henly, greatest diuretic effect
Indic: HTN, CHF, hypercalcemia, severe edema
CI: Black box: can produce profound diuresis and electrolyte dysfucntion, sulfa allergy
AE: volume depletion, electrolye imbalance

Question 24

Osmotic diuretics

Answer 24

Mannitol
MOA: These substances are filtered out and experience very little reabsorption, increasing the osmolarity of the tubular fluid
Indic: used more for cerebral edema, increased intracranial pressure or acute renal failure due to shock, drug toxicities, and trauma.
CI: ??

Question 25

LDL level classification

Answer 25

Below 100: Optimal
100-129: Near optimal/above optimal
130-159: Borderline high
160-189: High
Greater than 190: very high

Question 26

When to screen adults for lipid disorder

Answer 26

Men 35 and older
Men and women 20-35 if at increased risk of CHD
Women 45 and older

Question 27

What is the suggested interval for screening for lipid disorders?

Answer 27

Every 5 years or more often who have elevated levels

Question 28

Bile-acid sequestering agents

Answer 28

MOA: Bind bile acids in the small intestines
Indications: Used in combintation with niacin for type IIA and IIB hyperlipidemias
CI: Pt. with significant hypertriglyceridemia, or hx of bowel obstruction
Drug INter: digoxin, warfarin, thyroid hormone
AE: Gi distrubances, impairment of fat-soluble vitamins

Question 29

Nicotinic Acid

Answer 29

MOA: Inhibitis lipolysis in adipose tissue, reduces production of free fatty acids
Reduces production of VLDL, LDL, increases HDL
Indic: Use in familial hyperlipidemias (often in combo with other drugs)
CI: Hepatic disease
Drug inter: EToH, antidiabetic agents, bile acid sequestrants, HMG-CoA reductase inhibitors
AE: flushing, pruritis, nauses, ab pain

Question 30

HMG Co-A reductase inhibitors

statins

Answer 30

MOA: help prevent the synthesis of cholesterol which decreases LDL
Indic: First line for ASCVD
CI: pregnancy and breastfeeding
Drug inter: may increase effect of warfarin
AE: elevated liver enzymes, myopathy and rhadbomyolysis..More??

Question 31

Fibric Acid Derivatives

Answer 31

MOA: bind to PPAEs (peroxisome proliferator-activated receptors). This causes decrease in triglyceride concentrations
Indic: increase HDL and lower triGs, Particular use in type III hyperlipidemia
CI: caution in patients w/ renal insufficiency…
Drug inter: Myopathy and rhabdo have been reported in people taking gemfibrozil and statins
AE: GI disturb, predispose to form gallstones, myositis, muscle weakness,and tenderness

Question 32

Frederickson classification of lipid disorders

Answer 32

Type 1:  Chylomicrons: Triglycerides up
Type 2a: LDL
Type 2b: LDL and VLDL
Type 3: VLDL and chylomicrons
Type 4: VLDL:

Question 33

What is the normal cholesterol level

Answer 33

Less than 200

Question 34

Levels for triglycerides

Answer 34

Normal: 150 or less
Boarderline: 150-199
High: 200-499
Very high: 500 and up

Question 35

Main side effects of statins?

Answer 35

Muscle aches 10%
GI upset
10% increased risk of diabetes

Question 36

What should be monitored when prescribing statins?

Answer 36

Liver enzymes when initiating therapy