Cardiovascular and Endocrine

Question 1

CHF & BNP

Answer 1

B-type natriuretic peptide–secreted in ventricles and is sensitive to changes in left ventricular function. [BNP] correlate with end-diastolic pressure, which correlates with dyspnea and CHF; useful when trying to determine if dyspnea is cardiac, pulmonary, or deconditioning etiologies. initial mgmt. - loop. Beta-natriuretic peptide (BNP) is a 32-amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal presence in storage granules, its release is directly proportional to ventricular dysfunction.

Question 2

preeclampsia & edema

-is it helpful diagnostically?

Answer 2

Lower-extremity edema in last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia.

Question 3

how do ace-I damage kidney

Answer 3

Blood flow to the kidney is autoregulated so as to sustain pressure within the glomerulus. This is influenced by angiotensin II–related vasoconstriction. ACE inhibitors can impair the kidney’s autoregulatory function, resulting in a decreased glomerular filtration rate and possibly acute renal injury. usually reversible if it is recognized and the offending agent stopped. NSAIDs can exert a similar effect, but they can also cause glomerulonephritis and interstitial nephritis.

Question 4

exercise and the elderly

Answer 4

Initial exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level exercise is planned. A target heart rate of 60%–75% of the predicted maximum should be set as a ceiling. Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the risk of damage to their feet.

Question 5

before beginning medication for hyperlipidemia, should screen for

Answer 5

any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications

Question 6

mgmt. afib

Answer 6

most efficacious drugs for rate control are calcium channel blockers and beta-blockers. Digoxin is less effective for rate control and should be reserved as an add-on option for those not controlled with a beta-blocker or calcium channel blocker, or for patients with significant left ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin.

Question 7

cilostazol

drug class, contraindications and indications

Answer 7

Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication. Cilostazol should be avoided in patients with congestive heart failure.

Question 8

causes sudden death in long QT

Answer 8

long QT syndrome that have sudden arrhythmia death syndrome usually have either torsades de pointes or ventricular fibrillation.

Question 9

initial management of HTN in elderly

Answer 9

Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy.

Question 10

INITIAL treatment of choice in the management of severe hypertension during pregnancy is:

Answer 10

primary treatment objective=prevent cerebral complications, ie encephalopathy and hemorrhage. IV hydralazine, IV labetalol, or oral nifedipine may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy.

Question 11

Which have been shown to decrease mortality late after a myocardial infarction

Answer 11

Beta-blockers and ACE inhibitors have been found to decrease mortality late after myocardial infarction.

Question 12

preferred drugs for congestive heart failure due to left ventricular systolic dysfunction

Answer 12

ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously.

Question 13

Clinical predictors of increased perioperative cardiovascular risk for elderly patients

Answer 13

major risk: unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated CHF, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), severe valvular disease.

Intermediate predictors: mild angina, previous MI, compensated CHF, DM, renal insufficiency.

Minor predictors: advanced age, abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, hx of stroke, uncontrolled HTN

Question 14

diagnostic impression of peripheral vascular disease

Answer 14

Peripheral vascular disease (PVD) is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure. ankle-brachial index is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle-brachial indices in the range of 0.91–1.30 are thought to be normal.

Question 15

severe vs mild preeclampsia

Answer 15

criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count

Question 16

what is most appropriate for prophylaxis against deep vein thrombosis

Answer 16

Prophylaxis is indicated with total knee or hip replacements. 2 regimens: low–molecular-weight heparin and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression.

Question 17

NSAIDS & CHF

Answer 17

NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs, including high-dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE inhibition. They have been shown to have a negative impact on the long-term morbidity and mortality benefits that ACE inhibitors provide.

Question 18

Subclinical hypothyroid & cholesterol

Subclinical hyperthyroid associations with arrhythmia, bone density, cardiac dysfunction

Answer 18

With subclinical thyroid dysfunction, TSH is either below or above the normal range, free T3 or T4 levels are normal, and the patient has no symptoms of thyroid disease. Subclinical hypothyroidism (TSH >10 µU/mL) is likely to progress to overt hypothyroidism, and is associated with increased LDL cholesterol. Subclinical hyperthyroidism (TSH

Question 19

what drug is assoc with hypothyroidism

Answer 19

only lithium is associated with the development of hypothyroidism. In patients taking lithium, it is recommended that in addition to regular serum lithium levels, thyroid function tests including total free T4, and TSH be obtained yearly.

Question 20

Li & Ca

Answer 20

Lithium therapy can elevate calcium levels by elevating parathyroid hormone secretion from the parathyroid gland.

Question 21

diabetes meds that cause or exacerbate gastroparesis

Answer 21

Delayed gastric emptying may be caused or exacerbated by medications for diabetes, including amylin analogues (e.g., pramlintide) and glucagon-like peptide 1 (e.g., exenatide). Delayed gastric emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of postprandial hyperglycemia

Question 22

what meds can cause hyperparathyroidism

Answer 22

An elevated PTH may occur with lithium or thiazide use, tertiary hyperparathyroidism associated with end-stage renal failure, or familial hypocalciuric hypercalcemia,

Question 23

Metformin

Answer 23

Metformin ( biguanide ) increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic patients on metformin. first line treatment in T2DM.
main advantages over other oral agents is that it does not cause hypoglycemia. Lactic acidosis can occur in patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining or weight loss effect. Gastrointestinal distress is a common side-effect of metformin, particularly early in therapy.

Question 24

red flags indicating possible thyroid cancer

Answer 24

When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include male gender; age 65 years; rapid growth of the nodule; symptoms of local invasion such as dysphagia, neck pain, and hoarseness; a history of head or neck radiation; a family history of thyroid cancer; a hard, fixed nodule >4 cm; and cervical lymphadenopathy

Question 25

Thiazides and calcium

Answer 25

While thiazide diuretics do not cause hypercalcemia by themselves, they can exacerbate the hypercalcemia associated with primary hyperparathyroidism. Thiazides decrease the renal clearance of calcium by increasing distal tubular calcium reabsorption.

Question 26

if administration of radiocontrast material is required or urgent surgery is needed what diabetes medication should be held

Answer 26

general anesthesia–> hypotension–> renal hypoperfusion and peripheral tissue hypoxia–> lactate accumulation. Therefore, if administration of radiocontrast material is required or urgent surgery is needed, metformin should be withheld and hydration maintained until preserved kidney function is documented at 24 and 48 hours after the intervention.

Question 27

growth delays kids

Answer 27

Hypothyroidism –>bone age relative to height age and chronologic age.

In CF, bone age and height age are equivalent, but both lag behind chronologic age.

chromosomal anomalies such as trisomy 21 (Down syndrome) or XO or maternal substance abuse have a height age which is delayed relative to bone age.

Question 28

Chronic excess thyroid hormone replacement over a number of years in postmenopausal women can lead to

Answer 28

mild chronic excess thyroid hormone replacement over many years can cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The elevated calcium decreases parathyroid hormone

Question 29

Indications for parathyroid surgery

Answer 29

Indications for parathyroid surgery include kidney stones, age less than 50, a serum calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone density

Question 30

absolute contraindication to use of an ACE inhibitor

Answer 30

Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. Elevated creatinine levels are not an absolute contraindication to ACE inhibitor therapy.