Cardiovascular Disorders Flashcards
ASCVD 10-yr risk scores ages 40-79 by category
Low risk <5%; Borderline risk 5 - 7.4%; Intermediate risk 7.5 - 19.9%; High risk > or = 20%
Characteristics of a “heart healthy” diet
Mediterranean, DASH, or plant-based diets. Specifically, high in vegetables, fruits, nuts, whole grains, lean animal protein (preferably fish), vegetable fiber
Diets associated with higher ASCVD risk (3)
high in carbohydrates, animal fat, and animal proteins
The most potent risk factor for ASCVD over age 50yo is:
diabetes
Define: T2 Diabetes Mellitus
T2DM is a metabolic disorder characterized by insulin resistance leading to hyperglycemia. The development and progression of this condition is highly affected by diet, physical activity, and body weight.
HgbA1c diagnostic of T2DM
> 6.5%
Physical activity recommendation
150 minutes of moderate to vigorous intensity exercise per week
First line therapy in T2DM to improve gylcemic control and improve ASCVD risk
metformin
T2DM medications with favorable ASCVD risk reduction profiles (3)
metformin, SGLT2 inhibitors, GLP1 receptor antagonists
Important patient education prior to lipids lab work
Fast for 6-8 hours before blood draw. You can still take your morning medications, you can only have water or black coffee.
Before starting someone on lipids medications, draw these baseline labs (2)
CMP (for BL liver function), fasting lipid panel (also consider a BL creatinine kinase in case of rhabdo)
FUP schedule for patients on lipid therapy
Recheck in 4-12 weeks after initiation of therapy, repeat after 4-12 weeks anytime changing a medication or dose. Once on a stable dose with lipid control, can fup annually.
Your patient on lipid therapy develops myalgias and ascites. What labs do you need to draw?
CMP (liver function, CK (rhabdomyelosis risk)
Lipid and ASCVD screening recommendations for adults
Lipid panel Q5 years >20yo. Estimate 10-yr ASCVD Risk Q4-6 years
If triglyceride lab comes back super high, first question to ask the patient…
did you have anything to eat? (triglyceride results very affected by fasting status)
Total cholesterol lab results
Optimal <200 mg/dL; High >240 mg/dL
LDL lab results
Optimal <100 mg/dL; Very high >190 mg/dL
Triglyceride lab results
Optimal <150 mg/dL; Very high >500 mg/dL
HDL lab results
Optimal >60; Very low <40 mg/dL
DIAGNOSE: Fasting serum triglycerides >400 mg/dL
hypertriglyceridemia
First line therapy for hypertrigylceridemia
Fibrates - decrease triglyceride levels by 35-50% and raise HDL by 5-20%
Priority lab monitoring when prescribing fibrates
LFTs
Top 3 most common causes of pancreatitis
alcohol, gall stones, hypertriglyceridemia
Your pt’s recent lab results demonstrate fasting serum triglycerides at 900 mg/dL. Worry about…..
acute pancreatitis
If ASCVD risk decision making is uncertain as far as whether or not to start a statin, consider ordering…..
Coronary artery calcium scoring (CAC)
CAC scores and subsequent statin recommendation
0: low risk, repeat testing in 5-10 years. only consider statin if diabetes, family hx of coronary heart disease, or tobacco use
1 - 99: favors statin (particularly >55yo)
> or = 100: initiate statin
(2) examples of high intensity statin regimens and expected benefit
Atorvastatin 40-80mg QD; Rosuvastatin 20-40mg QD. Daily dose of high intensity statin is expected to lower LDL by >50%
What therapy would you consider for your 15yo new pt who relays hx of familial hypercholesterolemia
start statin, refer to specialist
Therapy recommendation for any pt ages 20-75 with an LDL >190 mg/dL
initiate high intensity statin
Therapy recommendation for pt age 40-75 with normal lipid panel and T2DM
initiate moderate intensity statin
Coronary Artery Calcium (CAC) testing: Overview
CAC is a CT scan of the coronary arteries to show existing calcium deposits. These calcifications are an early sign of CAD. Not recommended for pts younger than 40yo or those with high ASCVD 10-yr risk. May benefit clinical decision-making for pts who are reluctant to start statin therapy or ASCVD 10-yr borderline risk (5-7.5%). A CAC of 0 indicates very low risk and no role for statin therapy (unless diabetic, fam hx of premature heart disease,or tobacco use), with repeat testing in 5-10 years. CAC scores 1-99 favor moderate intensity statin therapy, particularly for folks >50-55yo. CAC scores 100 or greater definitively indicate a role for statin therapy to reduce risk with the addition of 81mg ASA (excepting those at high risk for bleeding)
Guidelines regarding primary prevention of ASCVD with aspirin therapy
May consider low dose ASA use (70-100mg) for primary prevention in adults ages 40-70 who are at high risk for ASCVD with no increased bleeding risk. ASA is NOT recommended as routine primary prevention in adults over 70 (still appropriate in secondary prevention, i.e., h/o heart attack)
BMI Criteria
Underweight <18.5; Healthy 18.5 - 24.9; Overweight 25 - 29.9; Obese > or = 30
METs: Overview
METs, or metabolic equivalent, is a score used to represent the intensity of an exercise. Generally speaking, MET 1 - 1.5 is sedentary, 1.6 - 2.9 is Light exercise, 3.0 - 5.9 is Moderate exercise, and 6 or greater is vigorous exercise. Light activity includes activities such as walking, light house work, and cooking. Moderate exercise includes brisk walking, biking, dancing, yoga, and recreational swimming. Vigorous exercise includes jogging, running, biking >10mph, swimming laps, or tennis
BP and HTN diagnostic categories (ACC/AHA)
Healthy <120/<80; Elevated 120-129/<80; Stage 1 HTN 130-139/80-89; Stage 2 HTN > or = 140/ > or = 90
BP and HTN diagnostic categories (JNC 8)
Healthy < or = 120/80; Pre-hypertension 120-139/80-89; Hypertension > or = 140/ > or = 90
What constitutes hypertensive urgency or emergency
> 180/>120 OR >160/>100 with s/s of end organ damage
Your pt without any pertinent PMH has a BP today of >130/80 but less than 160/100. What is your next step in determining if they have HTN?
Recommend at home monitoring for the next 7 days. Take BP 2x per day, and toss the first day, then average those 12 readings.
Initial work-up of a new diagnosis of HTN would include what labs/diagnostic tests and why?
CMP: BUN/Cre, and potassium tells you about kidney function. Glucose tells you about underlying diabetes. Calcium helps you r/o underlying thyroid or parathyroid condition.
TSH: R/o underlying thyroid condition.
CBC: Particularly, the hematocrit tells you about kidney function and potential end-organ damage.
Lipid panel: Tells you about contributing hyperlipidemia, metabolic syndrome, and overall CVD risk.
Urinalysis: Proteinuria can tell us about kidney function, glucosuria about diabetes.
Uric acid: Elevated levels can lead to HTN and indicate kidney disease.
ECG: Important to establish BL and to look for any underlying cardiac events
Renal artery ultrasound: r/o renal artery stenosis cause
Essential (Primary) HTN: Overview
Condition of increased peripheral vascular resistance with no underlying identifiable cause. Primary hypertension represents the vast majority of hypertension diagnoses at 95%.
DIAGNOSE: Abrupt, severe onset of elevated BP in your pt who is <35 yo with no pertinent fam hx and failure to respond to therapy despite compliance
Secondary hypertension
Causes of secondary hypertension
1 most common cause is renovascular disease (such as renal artery stenosis), renal parenchymal disease (polycystic kidney disease), alcohol, illicit drugs, medications, primary hyperaldosteronism (suspected in pts with unprovoked hypokalemia), or obstructive sleep apnea
A new patient presents to you with elevated BP, and a CMP demonstrates hypokalemia. What might you suspect?
primary hyperaldosteronism
Frequently used medications that may cause secondary hypertension (7)
amphetamines antidepressants, atypical antipsychotics, decongestants, oral contraceptives, NSAIDs, steroids
Goal for sodium intake in HTN
<1500mg (or reduce current by 1000mg)
ABCDEs of HTN pharmacologic management
ACEs/ARBs Beta blockers Calcium channel blockers Diuretics Everything else
First line pharmacotherapy for HTN (4)
ACEs, ARBs, CCBs, Thiazide diuretics
How often should someone receive FUP based on their BP?
Healthy: Q1 year
Elevated: Q3-6 months
Stage 1 and ASCVD risk <10%: Q3-6 months
Stage 1 and ASCVD risk >10%: Q1 month until reach target then Q3-6 months
Stage 2: Q1 month until reach target then Q3-6 months
When to refer for HTN patient (3)
- uncontrolled on 3 full dose or maximally-tolerated therapies
- Secondary cause requires specialist
- Orthostatic hypotension with hypertension while supine (challenging case r/t autonomic failure)
Evidence of end-organ damage in hypertensive emergencies may include….
advanced grade retinopathy, altered mental status, dizziness, blurred vision, loss of vision, focal neuro deficits, GI symptoms, chest pain, DOE with ECG changes
DIAGNOSE: Prodromal symptoms of chest pressure followed by tingling, tenderness, and pain along one side of the chest. On physical exam, you note grouped vesicles along an erythematous base along one side of the chest.
Herpes zoster (shingles)
DIAGNOSE: Anterior chest pain, sharply localized. Pain is reproducible by pressure near the midsternal line
Costochondritis
DIAGNOSE: Chest pain that worsens with inspiration. Fever, chills, productive cough, and dyspnea. On physical exam, crackles over RLL. Increased fremitus and egophony with dullness to percussion
Pneumonia
DIAGNOSE: Sudden onset, severe, unilateral chest pain that is generally pleuritic in nature (worse with breathing). Dyspnea. On physical exam, found to have diminished breath sounds on the affected side.
Pneumothorax
DIAGNOSE: Sudden onset, substernal chest pressure with throat tightness and dyspnea. On physical exam, decreased breath sounds on one side with tracheal deviation to the affected side.
Tension pneumothorax
DIAGNOSE: Sudden onset dyspnea and pleuritic chest pain. On physical exam, decreased breath sounds to affected area. Hypotensive with hemoptysis, tachycardia, and hypoxia
Pulmonary embolus
DIAGNOSE: Sudden onset of severe tearing, stabbing pain over chest with diaphoresis, nausea, vomiting, and near-syncope. On physical exam, pulses diminished, +neuro symptoms
Aortic dissection
How do you diagnose CAD?
Positive stress test with follow-up left heart catheterization to determine obstructive vs. non-obstructive disease. May have h/o CABG or coronary stents
Post-cath management for drug-alluding vs bare metal stents
Drug alluding stents require antiplatelet therapy for at least 1 year. Bare metal stents require antiplatelet therapy for 3 months.
All patients who have had an MI, ACS, or L ventricular dysfunction with or without HF symptoms should be on this medication class for secondary prevention of CAD
beta blockers
Normal left ventricular ejection fraction (LVEF)
> 55% (percentage of blood volume ejected with each contraction)
Family history concerning for heart failure
1st degree relatives with HF, sudden cardiac death in family <55yo male or <65yo female
INTERPRET: Heart failure symptoms with LVEF >40-45%
HFpEF
INTERPRET: Heart failure symptoms and LVEF <40%
HFrEF
HFpEF is also known as ______ failure
diastolic
HFrEF is also known as _________ failure
systolic
Primary risk factor for HFpEF
Hypertension
Alcohol is a negative _______
inotrope
Most patients (70%) have this type of HF
HFrEF
Primary risk factor for HFrEF
CAD (cause of HF in 2/3 of these pts)
ACC/AHA HF Stage determines ______, while NYHA Functional class determines ________
ACC/AHA = risk NYHA = level of control
NYHA Functional Classes of HF
Class 1: asymptomatic
Class 2: Symptomatic with moderate exertion
Class 3: Symptomatic with minimal exertion
Class 4: Symptomatic at rest
ACC/AHA HF Stages
Stage A: High risk with no structural disease
Stage B: Structural disease but no HF symptoms
Stage C: Structural disease with prior or current symptoms
Stage D: Refractory, end-stage
Common symptoms of HF (7)
DOE, dyspnea at rest, orthopnea, paroxysmal noctural dyspnea, edema, ascites, scrotal edema
Less common symptoms of HF (7)
wheezing, cough, confusion, depression, weakness, fatigue, GI symptoms (satiety, n/v, discomfort)
DIAGNOSE: Elevated JVP, positive hepatojugular reflux, LE edema bilaterally, S3 S4 gallop, laterally displaced PMI, systolic murmur, unable to lie flat r/t dyspnea
Heart failure
Most informative diagnostic lab for HF
BNP
Most informative diagnostic test for HF
Echocardiogram (TTE)
Single most useful diagnostic test in the evaluation of heart failure
echocardiogram
Pharmacotherapy options for HF - mortality benefit
ACEs, ARBs, ARNIs, beta blockers, aldosterone antagonists (spironolactone),, hydralazine (vasodilator/nitrate),
Pharmacotherapy options for HF - symptomatic treatment
loop diuretics (for FVO), potassium supplements (PRN for loop diuretics), digoxin, thiazide diuretics
I-NEED-HELP Acronym
I = IV Inotropes N = NYHA Stage III-IV or persistently elevated BNP E = end organ dysfunction E = ejection fraction <35% D = ? H = Hospitalized >1x E = Edema despite diuretics L = Low BP, high HR P = Progressive intolerance
Atrial Fibrillation increases risk of (3)
stroke, embolism, HF
In treatment for A Fib, Warfarin should be titrated to maintain the INR between….
2-3
How often to measure INR in warfarin therapy for a fib
Weekly until stable, then monthly
Drugs of choice for rate control in A Fib (2)
beta blockers, nondihydropyridine calcium channel blockers (verapamil, diltiazem)
In A Fib lasting >48 hours, how long should your pt be on anticoagulation therapy before and after cardioversion
4 weeks before and at least 4 weeks after
This procedure is used before cardioversion to exclude presence of left atrial thrombus
TEE
Preferred class of anticoagulation therapy in A Fib
NOACs (novel anticogulants)
When to refer for A Fib
New onset should be hospitalized for initial workup, chronic a fib or flutter in symptomatic patient, worried well patient with repeated visits for palpitations, abnormal ECG, or SVT not responding to CCBs or vagal maneuvers
Type of limb pain: increased with standing, decreased with elevation, better with walking, localized
venous
Type of limb pain: increased with walking, relieved with rest, increased with elevation, regional
arterial
Labs ordered in the workup of peripheral vascular disease
serum glucose, lipid profile, C-reactive protein, homocysteine
Intermittent claudication is what type of pain
arterial
Edema is more common in [arterial vs. venous] insufficiency
venous
Thin, shiny, atrophic skin with loss of hair is more common with [arterial vs. venous] insufficiency
arterial
Brown pigmentation of the skin is more common with [arterial vs venous] insufficiency
venous
Compression stockings are okay as long as the ABI is…
> 0.8
When to refer regarding PVD and ABI result
ABI <0.39
True or false: You should order arteriography or CT before referring your pt with PVD to a specialist
False. In general, neither arteriography nor CT should be ordered without consultation with a vascular specialist
The closer you are to ____, the better with ABI
1
Interpretation of ABI results
Noncompressible >1.30; Normal 0.91 - 1.30; Mild to moderate PAD 0.41-0.90; Severe PAD 0.0-0.4
Risk factors in PMH for cardiac valve disease (2)
rheumatic fever, IV drug abuse
Management of a new murmur
Send to cardiologist for an echo
When to refer for valve disease
new onset murmur, symptomatic, or concerning changes in symptoms
Concerning symptoms in valve disease that may warrant referral (4)
increased DOE, presyncope, syncope, chest pain
