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Adult Primary Care > Cardiovascular Disorders > Flashcards

Cardiovascular Disorders Flashcards

1
Q

ASCVD 10-yr risk scores ages 40-79 by category

A

Low risk <5%; Borderline risk 5 - 7.4%; Intermediate risk 7.5 - 19.9%; High risk > or = 20%

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2
Q

Characteristics of a “heart healthy” diet

A

Mediterranean, DASH, or plant-based diets. Specifically, high in vegetables, fruits, nuts, whole grains, lean animal protein (preferably fish), vegetable fiber

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3
Q

Diets associated with higher ASCVD risk (3)

A

high in carbohydrates, animal fat, and animal proteins

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4
Q

The most potent risk factor for ASCVD over age 50yo is:

A

diabetes

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5
Q

Define: T2 Diabetes Mellitus

A

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.

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6
Q

HgbA1c diagnostic of T2DM

A

> 6.5%

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7
Q

Physical activity recommendation

A

150 minutes of moderate to vigorous intensity exercise per week

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8
Q

First line therapy in T2DM to improve gylcemic control and improve ASCVD risk

A

metformin

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9
Q

T2DM medications with favorable ASCVD risk reduction profiles (3)

A

metformin, SGLT2 inhibitors, GLP1 receptor antagonists

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10
Q

Important patient education prior to lipids lab work

A

Fast for 6-8 hours before blood draw. You can still take your morning medications, you can only have water or black coffee.

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11
Q

Before starting someone on lipids medications, draw these baseline labs (2)

A

CMP (for BL liver function), fasting lipid panel (also consider a BL creatinine kinase in case of rhabdo)

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12
Q

FUP schedule for patients on lipid therapy

A

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.

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13
Q

Your patient on lipid therapy develops myalgias and ascites. What labs do you need to draw?

A

CMP (liver function, CK (rhabdomyelosis risk)

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14
Q

Lipid and ASCVD screening recommendations for adults

A

Lipid panel Q5 years >20yo. Estimate 10-yr ASCVD Risk Q4-6 years

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15
Q

If triglyceride lab comes back super high, first question to ask the patient…

A

did you have anything to eat? (triglyceride results very affected by fasting status)

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16
Q

Total cholesterol lab results

A

Optimal <200 mg/dL; High >240 mg/dL

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17
Q

LDL lab results

A

Optimal <100 mg/dL; Very high >190 mg/dL

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18
Q

Triglyceride lab results

A

Optimal <150 mg/dL; Very high >500 mg/dL

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19
Q

HDL lab results

A

Optimal >60; Very low <40 mg/dL

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20
Q

DIAGNOSE: Fasting serum triglycerides >400 mg/dL

A

hypertriglyceridemia

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21
Q

First line therapy for hypertrigylceridemia

A

Fibrates - decrease triglyceride levels by 35-50% and raise HDL by 5-20%

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22
Q

Priority lab monitoring when prescribing fibrates

A

LFTs

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23
Q

Top 3 most common causes of pancreatitis

A

alcohol, gall stones, hypertriglyceridemia

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24
Q

Your pt’s recent lab results demonstrate fasting serum triglycerides at 900 mg/dL. Worry about…..

A

acute pancreatitis

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25
Q

If ASCVD risk decision making is uncertain as far as whether or not to start a statin, consider ordering…..

A

Coronary artery calcium scoring (CAC)

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26
Q

CAC scores and subsequent statin recommendation

A

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

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27
Q

(2) examples of high intensity statin regimens and expected benefit

A

Atorvastatin 40-80mg QD; Rosuvastatin 20-40mg QD. Daily dose of high intensity statin is expected to lower LDL by >50%

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28
Q

What therapy would you consider for your 15yo new pt who relays hx of familial hypercholesterolemia

A

start statin, refer to specialist

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29
Q

Therapy recommendation for any pt ages 20-75 with an LDL >190 mg/dL

A

initiate high intensity statin

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30
Q

Therapy recommendation for pt age 40-75 with normal lipid panel and T2DM

A

initiate moderate intensity statin

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31
Q

Coronary Artery Calcium (CAC) testing: Overview

A

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)

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32
Q

Guidelines regarding primary prevention of ASCVD with aspirin therapy

A

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)

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33
Q

BMI Criteria

A

Underweight <18.5; Healthy 18.5 - 24.9; Overweight 25 - 29.9; Obese > or = 30

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34
Q

METs: Overview

A

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

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35
Q

BP and HTN diagnostic categories (ACC/AHA)

A

Healthy <120/<80; Elevated 120-129/<80; Stage 1 HTN 130-139/80-89; Stage 2 HTN > or = 140/ > or = 90

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36
Q

BP and HTN diagnostic categories (JNC 8)

A

Healthy < or = 120/80; Pre-hypertension 120-139/80-89; Hypertension > or = 140/ > or = 90

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37
Q

What constitutes hypertensive urgency or emergency

A

> 180/>120 OR >160/>100 with s/s of end organ damage

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38
Q

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?

A

Recommend at home monitoring for the next 7 days. Take BP 2x per day, and toss the first day, then average those 12 readings.

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39
Q

Initial work-up of a new diagnosis of HTN would include what labs/diagnostic tests and why?

A

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

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40
Q

Essential (Primary) HTN: Overview

A

Condition of increased peripheral vascular resistance with no underlying identifiable cause. Primary hypertension represents the vast majority of hypertension diagnoses at 95%.

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41
Q

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

A

Secondary hypertension

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42
Q

Causes of secondary hypertension

A

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

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43
Q

A new patient presents to you with elevated BP, and a CMP demonstrates hypokalemia. What might you suspect?

A

primary hyperaldosteronism

44
Q

Frequently used medications that may cause secondary hypertension (7)

A

amphetamines antidepressants, atypical antipsychotics, decongestants, oral contraceptives, NSAIDs, steroids

45
Q

Goal for sodium intake in HTN

A

<1500mg (or reduce current by 1000mg)

46
Q

ABCDEs of HTN pharmacologic management

A 
ACEs/ARBs
Beta blockers
Calcium channel blockers
Diuretics
Everything else
47
Q

First line pharmacotherapy for HTN (4)

A

ACEs, ARBs, CCBs, Thiazide diuretics

48
Q

How often should someone receive FUP based on their BP?

A

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

49
Q

When to refer for HTN patient (3)

A
  1. uncontrolled on 3 full dose or maximally-tolerated therapies
  2. Secondary cause requires specialist
  3. Orthostatic hypotension with hypertension while supine (challenging case r/t autonomic failure)
50
Q

Evidence of end-organ damage in hypertensive emergencies may include….

A

advanced grade retinopathy, altered mental status, dizziness, blurred vision, loss of vision, focal neuro deficits, GI symptoms, chest pain, DOE with ECG changes

51
Q

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.

A

Herpes zoster (shingles)

52
Q

DIAGNOSE: Anterior chest pain, sharply localized. Pain is reproducible by pressure near the midsternal line

A

Costochondritis

53
Q

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

A

Pneumonia

54
Q

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.

A

Pneumothorax

55
Q

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.

A

Tension pneumothorax

56
Q

DIAGNOSE: Sudden onset dyspnea and pleuritic chest pain. On physical exam, decreased breath sounds to affected area. Hypotensive with hemoptysis, tachycardia, and hypoxia

A

Pulmonary embolus

57
Q

DIAGNOSE: Sudden onset of severe tearing, stabbing pain over chest with diaphoresis, nausea, vomiting, and near-syncope. On physical exam, pulses diminished, +neuro symptoms

A

Aortic dissection

58
Q

How do you diagnose CAD?

A

Positive stress test with follow-up left heart catheterization to determine obstructive vs. non-obstructive disease. May have h/o CABG or coronary stents

59
Q

Post-cath management for drug-alluding vs bare metal stents

A

Drug alluding stents require antiplatelet therapy for at least 1 year. Bare metal stents require antiplatelet therapy for 3 months.

60
Q

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

A

beta blockers

61
Q

Normal left ventricular ejection fraction (LVEF)

A

> 55% (percentage of blood volume ejected with each contraction)

62
Q

Family history concerning for heart failure

A

1st degree relatives with HF, sudden cardiac death in family <55yo male or <65yo female

63
Q

INTERPRET: Heart failure symptoms with LVEF >40-45%

A

HFpEF

64
Q

INTERPRET: Heart failure symptoms and LVEF <40%

A

HFrEF

65
Q

HFpEF is also known as ______ failure

A

diastolic

66
Q

HFrEF is also known as _________ failure

A

systolic

67
Q

Primary risk factor for HFpEF

A

Hypertension

68
Q

Alcohol is a negative _______

A

inotrope

69
Q

Most patients (70%) have this type of HF

A

HFrEF

70
Q

Primary risk factor for HFrEF

A

CAD (cause of HF in 2/3 of these pts)

71
Q

ACC/AHA HF Stage determines ______, while NYHA Functional class determines ________

A 
ACC/AHA = risk
NYHA = level of control
72
Q

NYHA Functional Classes of HF

A

Class 1: asymptomatic
Class 2: Symptomatic with moderate exertion
Class 3: Symptomatic with minimal exertion
Class 4: Symptomatic at rest

73
Q

ACC/AHA HF Stages

A

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

74
Q

Common symptoms of HF (7)

A

DOE, dyspnea at rest, orthopnea, paroxysmal noctural dyspnea, edema, ascites, scrotal edema

75
Q

Less common symptoms of HF (7)

A

wheezing, cough, confusion, depression, weakness, fatigue, GI symptoms (satiety, n/v, discomfort)

76
Q

DIAGNOSE: Elevated JVP, positive hepatojugular reflux, LE edema bilaterally, S3 S4 gallop, laterally displaced PMI, systolic murmur, unable to lie flat r/t dyspnea

A

Heart failure

77
Q

Most informative diagnostic lab for HF

A

BNP

78
Q

Most informative diagnostic test for HF

A

Echocardiogram (TTE)

79
Q

Single most useful diagnostic test in the evaluation of heart failure

A

echocardiogram

80
Q

Pharmacotherapy options for HF - mortality benefit

A

ACEs, ARBs, ARNIs, beta blockers, aldosterone antagonists (spironolactone),, hydralazine (vasodilator/nitrate),

81
Q

Pharmacotherapy options for HF - symptomatic treatment

A

loop diuretics (for FVO), potassium supplements (PRN for loop diuretics), digoxin, thiazide diuretics

82
Q

I-NEED-HELP Acronym

A 
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
83
Q

Atrial Fibrillation increases risk of (3)

A

stroke, embolism, HF

84
Q

In treatment for A Fib, Warfarin should be titrated to maintain the INR between….

A

2-3

85
Q

How often to measure INR in warfarin therapy for a fib

A

Weekly until stable, then monthly

86
Q

Drugs of choice for rate control in A Fib (2)

A

beta blockers, nondihydropyridine calcium channel blockers (verapamil, diltiazem)

87
Q

In A Fib lasting >48 hours, how long should your pt be on anticoagulation therapy before and after cardioversion

A

4 weeks before and at least 4 weeks after

88
Q

This procedure is used before cardioversion to exclude presence of left atrial thrombus

A

TEE

89
Q

Preferred class of anticoagulation therapy in A Fib

A

NOACs (novel anticogulants)

90
Q

When to refer for A Fib

A

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

91
Q

Type of limb pain: increased with standing, decreased with elevation, better with walking, localized

A

venous

92
Q

Type of limb pain: increased with walking, relieved with rest, increased with elevation, regional

A

arterial

93
Q

Labs ordered in the workup of peripheral vascular disease

A

serum glucose, lipid profile, C-reactive protein, homocysteine

94
Q

Intermittent claudication is what type of pain

A

arterial

95
Q

Edema is more common in [arterial vs. venous] insufficiency

A

venous

96
Q

Thin, shiny, atrophic skin with loss of hair is more common with [arterial vs. venous] insufficiency

A

arterial

97
Q

Brown pigmentation of the skin is more common with [arterial vs venous] insufficiency

A

venous

98
Q

Compression stockings are okay as long as the ABI is…

A

> 0.8

99
Q

When to refer regarding PVD and ABI result

A

ABI <0.39

100
Q

True or false: You should order arteriography or CT before referring your pt with PVD to a specialist

A

False. In general, neither arteriography nor CT should be ordered without consultation with a vascular specialist

101
Q

The closer you are to ____, the better with ABI

A

1

102
Q

Interpretation of ABI results

A

Noncompressible >1.30; Normal 0.91 - 1.30; Mild to moderate PAD 0.41-0.90; Severe PAD 0.0-0.4

103
Q

Risk factors in PMH for cardiac valve disease (2)

A

rheumatic fever, IV drug abuse

104
Q

Management of a new murmur

A

Send to cardiologist for an echo

105
Q

When to refer for valve disease

A

new onset murmur, symptomatic, or concerning changes in symptoms

106
Q

Concerning symptoms in valve disease that may warrant referral (4)

A

increased DOE, presyncope, syncope, chest pain

Adult Primary Care (6 decks)

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