Cardiovascular & Hematology Flashcards
Possible causes of microcytic anaemia + mnemonic
TAILS; Thalassemia, anaemia of chronic disease, iron deficiency anemia, sideroblastic anemia, sickle cell
Causes of macrocytic anaemia + mnemonic
PreFAB; Preleukemia, folate deficiency, alcohol, B12/pernicious
True/ False; Decreased reticulocytes is associated with bone marrow suppression
True- indicatvive of aplastic anemia, hematologic cancers, drugs or toxins
True/False
Ferritin is the test of choice for the diagnosis of iron deficiency.
True
First-line therapy for iron deficiency anemia
Oral iron. One preparation is not preferred over another; patient tolerance should be the guide.
Anemia with IDA should correct in ______ with oral supplementation
2-4 months
Oral iron should be continued for _____ after anemia corrects
4-6 months
Causes of IDA
increased requirements
decreased intake
increased loss
decreased absorption
Name that condition –>
microcytic anemia, hypochromia, and decreased ferritin
IDA
True/False
All adults age >65 are at increased risk of IDA
True
Target ferritin for restless legs with iron deficiency
> 75 ug/L
In adults, iron deficiency is unlikely if ferritin >___ ug/L (or >___ to ____ in a patient with chronic inflammatory disease, or >___ in the elderly)
In adults, iron deficiency is unlikely if ferritin >30 ug/L (or >70-100 in a patient with chronic inflammatory disease, or >50 in the elderly)
True/False
Ferritin is an acute phase reactant. Testing ferritin is recommended during acute infection or hospitalization.
False.
Ferritin may be unreliable in patients with chronic disease, active inflammation, or malignancy. Testing ferritin is not recommended during acute infection or hospitalization.
True/False
If patient has microcytic anemia with suspected IDA, you may start supplementation before additional diagnostic tests are performed.
False
Patients with microcytic anemia should not be given iron supplements until iron deficiency is confirmed by testing ferritin. Low MCV in the setting of normal ferritin may indicate hemoglobinopathies such as thalassemia especially in high risk ethnic groups. Long term iron therapy is harmful for these patients.
What additional tests should be ordered for diagnosis of iron deficiency in patients with chronic disease, inflammation or malignancy? (AOCD + IDA)
ordering a fasting serum iron and transferrin saturation may be helpful to diagnose iron deficiency that may be missed by solely relying on ferritin
Results: +
low serum iron
low or normal transferrin (i.e. total iron binding capacity), and
fasting transferrin saturation below 20%
What is the current recommended test and threshold to confirm iron deficiency in CKD?
TSAT <24%
When to consideration of IV iron therapy for heart failure patients?
ejection fraction ≤40%, serum ferritin < 100 mg/L or between 100-299 mg/L, and TSAT <20%
What is the only indication for ordering asymptomatic CRP?
to review a therapeutic approach in primary prevention of cardiovascular disease in patients assessed at intermediate risk. This is the only indication for CRP assessment in asymptomatic individuals. MUST order hsCRP (high sensitivity CRP)
What patient populations with IDA would you suspect underlying malignancy?
AKA what populations are IDA uncommon?
Iron deficiency/IDA in adult men and post-menopausal women and in pre-menopausal women without menorrhagia is more likely to have a serious underlying cause of blood loss including malignancy. Consider upper/lower endoscopy.
What is a target normal ferritin for IDA?
Target normal ferritin >100 µg/L.
SE of oral iron supplements
Oral iron preparations may cause nausea, vomiting, dyspepsia, constipation, diarrhea or dark stools.
Instructions to prevent SE with oral iron supplements
start at a lower dose and increase gradually after 4 to 5 days (to reach target dose in a few weeks)
give divided doses
give the lowest effective dose
take supplements with meals (note: iron absorption is enhanced when supplements are taken on an empty stomach; however, tolerance and adherence may be improved when iron is taken with meals)
try a different iron preparation
try alternative dosing schedules such as every other day dosing
How to improve iron absorption with PO iron?
taking them on an empty stomach (at least 1 hour before or 2 hours after eating)
taking with 600-1200 mg vitamin C.
Iron absorption can be decreased by various medications and supplements such as multivitamins, calcium, or antacid tablets. Space administration by at least 2 hours apart. Avoid taking iron supplements with tea, coffee or milk.
When to reassess patients with moderate to severe anemia? What test to perform?
CBC as early as 2-4 weeks. Hemoglobin should increase by 10-20 g/L by 4 weeks. It may take up to 6 months to replenish iron stores.
Dosing for IV iron sucrose
100 to 300 mg IV intermittent per session, given as a total cumulative dose of 1000 mg over 14 days
In the elderly, serum ferritin below ____ ug/L should be investigated for iron deficiency
Investigation of anemia in the elderly is recommended if the life expectancy is more than ____.
50 ug/L
one year
Recommended daily allowance of B12
The recommended daily allowance of cobalamin is 2.4 mcg
What are two main RF for B12 deficiency?
Risk Factors Elderly people (>75-years) and long-term vegans
Testing for B12 deficiency should be considered with age >75 years, ,medical history: inflammatory bowel disease (of small intestine), Surgical history: gastric or small intestine resection, Dietary history: prolonged vegan diet, i.e., no meat, poultry or dairy products and Medication history: long-term use of H2 receptor antagonists or proton pump inhibitors (for at least _____), or metformin (at least _____)
Medication history: long-term use of H2 receptor antagonists8 or proton pump inhibitors (at least 12 months), or metformin (at least 4 months)
True/False
Elderly patients may have normal cobalamin levels with clinically significant cobalamin deficiency
True
First line therapy for low B12
Oral crystalline cyanocobalamin (commonly available form) is the treatment of choice. Dosing for pernicious anemia or food-bound cobalamin malabsorption is 1000 mcg/day. In most other cases a dose of 250 mcg/day may be used
When is parenteral B12 warranted?
reserved for those with significant neurological symptoms. It includes 1-5 intramuscular or subcutaneous injections of 1000 mcg crystalline cyanocobalamin daily, followed by oral doses of 1000-2000 mcg/day. Retest serum cobalamin levels after 4-6 months to ensure they are in the normal range.
Frequency of testing for non-nutritional B12 deficiency
Annually
What does HATCH score stand for and what is its relevance?
A higher HATCH score correlates with higher occurrence of AF and a higher risk for stroke.
Hypertension
Age > 75 years
TIA previously or Stroke
COPD
Heart Failure
Ejection click, crescendo-decrescendo murmur that can be heard in neck/carotids
AS
pansystolic murmur that is flat shape and heard at auxilla
MR
Early diastolic murmur, descrescendo in pattern heard at sternal border
AR
Opening snap with mid-diastolic rumble
MS
Midsystolic click, late systolic murmur
Mitral valve prolapse
Ventricular gallop and meaning
S3, volume overload
Atrial gallop and meaning
S4, pressure overload
Prolonged QTC in males and females
Males >450 ms
Female >470 ms
List 5 risk factors for prolonged QT
Hypokalemia (/=65 years, increased risk with increasing age Arrhythmia Female sex HTN Hypocalcemia Smoking Liver failure Renal dx (eGFR
Scoring system for risk for increased QTC
RISQ-PATH
BW for atrial fibrillation
- Complete blood count
- Coagulation profile
- Renal function
- Thyroid and liver function
- Fasting lipid profile
- Fasting glucose
Persistent A fib definition
AF episode
duration ≥ 7 days
Paroxysmal a fib definition
Paroxysmal
AF episode
duration < 7 days
True/False
OSA is a risk factor for atrial fibrillation
True
Rate control drug choices for the following with a. fib:
1) Heart failure
2) CAD
3) No HF or CAD
1) BB +/- digoxin
2) BB, ∆ Non-dihydropyridine calcium channel blockers (diltiazem, verapamil), combination Rx
3) BB, ND-CCB, Digoxin can be considered for rate control in patients who are sedentary, Combination Rx
Common SE of BB
Bronchospasm, depression, hypotension, fatigue, bradycardia
Common SE Verapamil
Bradycardia, hypotension, constipation
Common SE Diltiazem
Bradycardia, hypotension, ankle swelling
SE digoxin
Bradycardia, nausea, vomiting, visual disturbance
All of the following are criteria for what?
1) patients with symptomatic AF
2) sustained AF episodes (e.g. ≥ 2 hours)
3) AF episodes that occur less frequently than monthly
4) absence of severe or disabling symptoms during an AF episode
(e. g. fainting, severe chest pain, or breathlessness)
5) ability to comply with instructions, and proper medication use
Appropriate candidates for PIP
PIP administration for a. fib
Immediate release oral AV nodal blocker (one of diltiazem 60 mg, verapamil
80 mg, or metoprolol tartrate 25 mg) 30 minutes prior to the administration of
a class Ic AAD (300 mg of flecainide or 600 mg of propafenone if ≥ 70 kg; 200
mg of flecainide or 450 mg of propafenone if < 70 kg)
All of the following are criteria for what?
1) significant structural heart disease (e.g. left ventricular systolic dysfunction
[LVEF < 50%], active ischemic heart disease, severe left ventricular hypertrophy)
2) abnormal conduction parameters at baseline (e.g. QRS duration > 120 msec, PR
interval > 200 msec; or evidence of pre-excitation)
3) clinical or electrocardiographic evidence of sinus node dysfunction/bradycardia or
advanced AV block
4) hypotension (systolic BP < 100mmHg)
Contraindication to PIP
Instructions for subsequent out-of-hospital use of PIP
1) Patients should take the AV nodal agent 30 minutes after the perceived arrhythmia
onset, followed by the Class Ic AAD 30 minutes following the AV nodal agent.
2) Following AAD administration patients should rest in a supine or seated
position for the next 4 hours, or until the episode resolves.
Patients should present to the emergency department after taking PIP for a fib in the event that:
a) the AF episode did not terminate within 6-8 hours
b) they felt unwell after taking the medication at home (e.g. a subjective worsening
of the arrhythmia following AAD ingestion, or if they developed new or severe
symptoms such as dyspnea, presyncope, or syncope)
c) more than one episode occurred in a 24-hour period (patients should not take a
second PIP-AAD dose within 24 hours)
d) if the AF episode was associated with severe symptoms at baseline (e.g.
significant dyspnea, chest pain, pre-syncope, or symptoms of stroke), even in
the absence of PIP-AAD use.
With which of the following SYMPTOMATIC conditions is ablation first-line (benefits outweigh risks) A) Paroxysmal a fib B) Persistent C) Longstanding D) None. It is not first line.
A)
What is the CHA₂DS₂-VASc Score used for and what does the acronym stand for?
determine the 1 year risk of a TE event in a non-anticoagulated patient with non-valvular AF. CHF HTN Age >/= 65 Age >/= 75 (even higher risk) Diabetes Stroke/TIA/thromboembolism hx Sex - higher risk with females Vascular disease history (prior MI, peripheral artery disease, or aortic plaque)
According to the CCS algorithm, all the following conditions are indications for what treatment for atrial fibrillation? Age > 65 years Prior Stroke or TIA or Hypertension or Heart failure or Diabetes Mellitus
OAC
According to the CCS algorithm, all the following conditions are indications for what treatment for atrial fibrillation?
Coronary artery disease or
Peripheral arterial disease
Anti-platelet therapy
Therapeutic options include single antiplatelet therapy
(ASA 81-100 mg daily) alone; or in combination with
either a second antiplatelet agent (e.g. clopidogrel 75
mg daily or ticagrelor 60 mg bid), or an antithrombotic
agent (rivaroxaban 2.5 mg bid).
CCB Guideline - True/False
For patients with AF aged ≥ 65 years or with a CHADS2 score ≥ 1 and coronary or arterial vascular disease (peripheral vascular disease or aortic plaque), we recommend long-term therapy with OAC ONLY
True
What do you suspect if HTN that was previously controlled has an acute rise or a person has severe refractory HTN?
Secondary causes
What is your next step if you identify abnormal nocturnal BP differences (BP dip <10% or >20%) or increase in nocturnal BP OR more than 15mm Hg difference between arms
Refer to specialist
If you start medication for HTN when is appropriate follow up?
1-2 months (BC guideline)
Consider pharmacological treatment in all of the following for HTN except:
A) Average BP >135/85 with target organ damage or CVD risk >15%
B) Average BP >135/85 with 1+ comorbidities
C) Average BP SBP> 160
D) Desirable BP not achieved by lifestyle
E) Average BP >135/85 with 2+ comorbidities
E
ACEI contraindication
Pregnancy, hx angioedema, bilateral renal artery stenosis
CI to BB
2nd or 3rd degree AV block, SSS or SA block, bradycardia, decompensated HF, severe peripheral arterial circulatory disorders
CI to thiazides
Anuria
BW following initiation of BP medication and when to complete
2 weeks eGFR
Monthly until BP desired range for 2 consecutive visits
then Q3-6 months
CI to NOAC
Valvular a fib Mechanical heart valve Severe renal impairment Severe liver dysfunction Pregnant Interaction
After procedure or surgery NOACs should not be started within _______
24-48 hours
True/False
Missing 1-2 doses of NOACS does not increase risk for stroke
False due to relatively short half-life
True/False
Patients on warfarin are advised to avoid vitamin K containing foods
False, consistent diet is reccomended
True/False
Because warfarin is almost fully bound to albumin in blood, hypoalbuminemic patients need higher doses
False, they require lower doses
Full anticoagulant effect of warfarin may be ____
5-7 days
Relative CI to warfarin
Uncontrolled HTN (>160/110)
Severe liver dx
Recent surgery of spine, eye, NS
Which of the following are risk factors for bleeding on warfarin: (may have multiple options) A) > 60 years B) > 70 years C) within 3 months of starting warfarin treatment D) Uncontrolled HTN/HF E) Underlying malignancy F) smoking G) EtOH use H) use of NSAIDS
B, C, D, E, G, H
Starting dose of warfarin
5mg/day, may be < 5mg if >70 years
Instructions of how to take warfarin
Once daily in evening, BW in AM
Therapeutic range for warfarin
2-3 with increased range for valvular disorders
Monitoring schedule for warfarin
Every 2-4 days until therapeutic level for 2 consecutive then weekly. If 4 consecutive normal values can extend by 2 additional weeks and gradually increased to Q4 weeks, if >/= 3 months stable can extend to Q12 weeks
True/False
If INR normal range or 1.5< INR < 2 then no change in dose
True, if two consecutive INRs low then increase weekly dose by 10-20%
What to do if INR >9
D/C warfarin, consider admin vit k 2-5mg orally then recheck INR
What to do if INR <1.5
Give one time top up of 20% weekly dose and increase weekly dose by 10-20%
INR> therapeutic but <5.0
lower weekly dose 10-20% or consider omitting one dose
INR 5.0-9.0
Omit 1-2 dose and resume therapy at 10-20% lower weekly dose when INR therapeutic
Beers criteria
Dabigatran/rivaroxaban - use with caution for treatment of VTE or a fib in adults ____ years old
> /= 75 years old, due to increased risk for GI bleeding compared with warfarin
Drug-Drug interactions for warfarin (Beers)
(increased risk of bleeding) Cipro Macrolides (clarithromycin, excluding azithromycin) Septra (trimethoprim-sulfamethoxazole) NSAIDs Amiodarone
What NOAC can be given in non-valvular a.fib with reduced dose if CrCl 15-50 mls?
Rivaroxaban
What NOAC should be avoided with CrCL < 30
Dabigatran, apixaban should be avoided with CrCL <25
What rhythm control medication should be avoided as first line therapy for atrial fibrillation unless patient has HF or substantial LVH?
Amiodarone
Avoid this rate control agent as first-line therapy for atrial fibrillation or HF. If used for either, avoid dosages >0.125 mg/d
Digoxin
What test is used to determine pre-test probability for DVT?
Wells score
Diagnostic criteria for PE (Wells)
Score < 4 is low risk
The components of the modified Wells criteria for PE can be remembered with the mnemonic: “ EAT CHIPS”.
“E” is for edema in the leg or any other symptoms of DVT, and this is given 3 points.
“A” is for alternative diagnosis being less likely, and this also gets 3 points.
“T” is for tachycardia, which is given 1.5 points.
“C” and “H” are for cancer and hemoptysis, and each is given 1 point.
“I” is for immobilization, “P” is for previous history of DVT or PE, and “S” is for major surgery in the past month, and these are all are given 1.5 points.
Diagnostic criteria for PE (PERC)
HAD CLOTS
Hormones - Is the patient taking exogenous estrogen?
Age - Is the patient >/= 50 years old?
DVT/PE - Does the patient have prior history of DVT/PE?
Coughing blood - Does the patient have hemoptysis?
Lower extremity - Does the patient have unilateral lower extremity edema?
O2 sat - Does the patient have SpO2 < 95% on room air?
Tachycardia - Does the patient have heart rate >/= 100 bpm?
Surgery/trauma - Does the patient have history of surgery or trauma requiring hospitalization in the past 4 weeks?
Scoring system for bleeding risk with A. fib when considering anticoagulants and description of measurement.
HAS-BLED - The HAS-BLED score estimates the 1-year risk of major bleeding for patients on anticoagulation for atrial fibrillation.
HTN (SBP>160)
Age >65
Stroke
Bleeding history or predisposition.
Liver and Kidney dysfunction. 1pt each, a total of 2pts.
Elevated or unstable INRs, time in the therapeutic range <60%
Drugs and Alcohol. Drugs – Antiplatelets (Aspirin, Clopidogrel, NSAIDs). Alcohol – more than 8 drinks per week –1pt each, a total of 2pts.
Risk factors for VTE/Virchow’s triad
Risk factors for VTE revolve around Virchow’s triad, and can be remembered with the mnemonic “ THROMBOSIS”: “T” is for trauma or history of travel.
“H” is for hospitalization and hormones, meaning any form of exogenous estrogen such as hormone replacement therapy, tamoxifen or combined oral contraceptives, which promote the formation of clots in the venous circulation.
“R” is for relatives, that is family history of inherited hypercoagulable disorders, like Factor V Leiden.
“O” is for old age.
“M” is for having any malignancy.
“B” is for long bone fractures.
“O” is for obesity and obstetrics; that is pregnancy and the early post-partum period.
“S” is for any form of major surgery, especially orthopedic surgery as well as smoking.
“I” is for immobilization, such as a paralyzed limb.
And the final “S” is for other sickness, like antiphospholipid syndrome, nephrotic syndrome, and paroxysmal nocturnal hemoglobinuria.
If pretest probability of PE is moderate or high, what is the next step?
Treat with anticoagulants immediately and confirm diagnosis later (differs from DVT treatment)
Iron deficiency anemia causes
T- thalassemia A- anema lf CHronic disease I- iron def L- lead poison S- sideroblastic
Macrocytic anemoa causes- most common
B12, folate, atrophic gastroperesis, thyroid
True or false _ men between the age of 65-80 should have l time screening for aaa?
True
Select all that are RF for AAA Female sex male sex CVD dm Hyperlipidemia Smoking
Male sex, CVD, hyperlipidemia, smoking
Female sex and dm decrease risk
What diagnostic tests should be used with a wells score of 2+ ?
Compression US
What diagnostic tests for wells score of less than 2
D-dimer
True or false. In pts with a mod to high likelihood of DVTs treatment can start before results of tests are available
True
Warfarin indicated conditions when treating dvts
Antiphospholipid syndromes
wt extremes
Severe renal impairment
(Must bridge with LMWH)
Duration of anticoagulant treatment with duts
3 months minimum
CRAB neumonic for Multiple Myeloma
C- calcium high
R- renal failure
A- anemia
B- bone disease/ pain
Who qualifies for AAA screening as per Canadian task force
Men 65 to 80 – screen once with abdominal ultrasound
What are the two AV valves
Tricuspid & Bicuspid/ Mitral vale
Mighty mitral delivers blood to the rest of the body! Thank you mighty mitral!
What are the two semi lunar valves
Pulmonic and aortic valves
What are the three most common symptoms associated with atrial stenosis
SAD
Syncope- Angina- Dyspnea
Describe what is happening during the S1 heart sound x3
Takes place at the start of systole
When ventricular pressure > atrial pressure
Closing of AV valves
Describe what is happening during the S2 heart sound
Split S2
Start of diastole
closing of semilunar valves- aortic and pulmonic
Split S2= aortic closing before pulmonic
Crescendo decrescendo murmur that radiates to the carotid arteries, is best heard at the 2nd R ICS and includes a weak pulse
Aortic stenosis
When is a systolic murmur and diastolic murmur heard in the cardiac cycle?
Syst- between S1 & S2
Diast- between S2 & S1
A harsh murmur made worse with valsalva maneuvers (ie. leg raise)
Aortic stenosis
In aortic stenosis the murmur radiates to the carotid arteries. Which artery would you expect to hear the murmur more loudly
Left > right
Explain the pathology of aortic stenosis
Stiffening of the three leaflets of the aortic valve = obstruct blood OUT FLOW
increased stress on LV
Explain the pathophysiology of mitral valve regurgitation
The mitral valve allows blood to flow from the LA to the LV and closes during systole to prevent backflow.
Mitral regurg refers to the valves in ability to close, causing blood to flow from the LV to the LA during systole.
What does the presence of S3 indicate?
Dilated left ventricle
Holosystolic/ pansystolic murmur, soft S1, worse with increased peripheral resistance ie. hand squeeze/squad
Mitral valve regurgitation
Where is mitral regurgitation best heard and where does it radiate
Best heard- apex- L 5/6 ICS mid clavicular line
Radiates to left axilla
Common symptoms of mitral valve regurgitation
Palpitations and dyspnoea
Valvular disease in Atrial fibrillation is an indicator for what medication?
Warfarin
No DOACs
What is the potential complication of mitral regurgitation? (Think structurally/ other structures)
Increased in left atrial pressure can cause pulmonary hypertension.
Eventually leads to atrial dilation- increases pace maker cells irritability——> cause A-fib
Between Mitral Regurg and Atrial Stenosis- which one is; Systolic? Diastolic? Increases LA pressure? Increases LV pressure?
Syst- AS
Systolic- MR
LA- MR
LV- AS
Systolic vs diastolic
Stenotic valve dx=
Regurgitation valve dx=
Stenosis- systolic
Regurgitation- diastolic
Target INR in patients on Warfarin-
+ mitral valve replacement-
Target 2.5 (2-3)
MV- 3 (2.5-3.5)
T/F- Increased alcohol intake increase INR
True
Acute illness such as diarrhoea or fever does what to INR
Increases
Both increased edema and increaed physicalmactivity do what to INR?
Decrease
What is the antidote to warfarin?
Which of the NOACs has an antidote?
Vit K
Dabigatran- idarucizimab
ASA, Clopidogre; and Ticagrelor are examples of what type of medication
Anti-platelet
For patients with non-valvular atrial fibrillation or Atrial flutter+ aged <65, + NO CHADS-65 R/F
- is anticoagulation indicated?
- is anti-platelet therapy indicated?
No anti-coag
Yes anti platelet- ie. 81 mg ASA daily +/- clopidogreal or tecagralor if presence of CAD or PVD
Management approach to A-Fib focuses on what 2 aspects-
- Identify risk of thrombosis/stroke
2. Management of arrhythmia
A-fib rate control drug choice in patients with heart failure?
Beta blockers +/- Digoxin
A-fib rate control drug choise in pts with CAD
Beta blockers
calcium channel blockers
or combination
A-fib rate control drugs for pts with NO HF or CAD?
Beta blockers
Calcium channel blockers
Digoxin
Combo therapy
Bilateral aorta-iliac disease causes what symptom in male sex?
Erectile Dysfunction
Intermittent claudication + absent/diminished femoral pulses + erectile disfunction = what syndrome?
Leriche Syndrome
Pain in PAD Is indicative of what artery is involved. Aorta- Iliac- Commin femoral- Superficial femoral- Popliteal art- Tibial-
Aorta / Iliac- hip & buttock Common femoral- thigh Superficial femoral- upper 2/3 of calf Popliteal art- lower 2/3 of calf Tibial- foot
Peripheral pain worse with exercise, relieved with rest and dangling of legs, Deep ulcer wounds, on toes, Shiny hairless skin
Peripheral arterial disease
Peripheral pain that’s worse withstanding, shallow ulcers, haemosiderin staining, edema, relieved with elevation =
Peripheral Vascular Disease
Describe a cardiac stress test and it’s utility
Cardiac stress test compares CA Perfusion at rest and exertional via either treadmill or chemical i.e. with dobutamine.
Used to identify chest pain secondary to coronary artery ischaemia or narrowing.
Also used to evaluate progression of coronary artery disease and identify need for coronary angiography reperfusion therapy.
Early risk stratification to determine whether patients with coronary artery disease require early invasive interventions can be determined using what 2 scoring tools?
Timmi risk score (
Grace score
(>109/363 - Coronary angio in 24 or 72h)
< 109 = stress test to determine need for reperfusion
Stable versus unstable angina
Stable = no pain at rest Unstable = pain at rest
5 M’s of geriatric care
Matters Most Mind Mobility Medications Multi-complexity
What measurement is used for heparin monitoring?
Heparin antidote?
PTT
Protamine sulfate
Mnemonic for early Digoxin toxicity
Lab value = toxic
Brady/toely
Anorexia
Diarrhea
Visual disturbance
Abdo cramps
Nausea/vomit
> 2ng/ml
All of the following are risk factors for what condition:
- OSA
- diastolic dysfunction
- parenchymal lung disease
- long-term endurance exercise
- hyperthyroidism
- PE
- obesity
A. fib
RF for rupture of AA
Female, low FEV1, smoking, HTN
What laboratory test for CAD should be ordered with calculated ASCVD risk >7.5%?
Coronary artery calcium level
True/False
Stress imaging studies should NOT be ordered on asymptomatic pts
True
CT angiography is useful in patients with CAD if…
an uninterpretable ECG and in those who cannot exercise
Initial management of pts with angina should be completed by _____
Cardiology
Diagnostics for CAD
ASCVD (not validated for > 80 years old)
Framingham
S3 gallop can be commonly be heart with HFpEF. T/F?
False
PE for suspected HF
VS Wt Volume status CVS RES ABD PVS
Initial investigations for ? HF
CBC Electrolytes eGFR UA Glucose Thyroid
When ordering a BNP/proBNP for suspected HF. What results would lead you to order an ECHO?
proBNP >125
BNP >50
NYHA Classes
I - asymptomatic with normal activity
II - symptoms with ordinary activity, slight limitations with physical activity
III - symptoms with less than ordinary activity, noticeable limitations on physical activity
IV - symptoms at rest
Triple therapy example and target doses for HFrEF
Ramipril 5mg PO BID + Bisoprolol 10mg OD + Spironolactone 50mg OD
Walking 30 min 3 x per week can ____ or _____ walking distance with PAD
Double or triple
All patients with PAD should be on what medications?
Statin
ASA (antiplatelet)
How long do patients need to rest to relieve symptoms with intermittent claudication?
10 min
AAA definition
Increase in vessel diameter by 50% or > 3 cm
Red flag development with AAA
0.05-0.07 cm in 6 months or 1 cm in 12 months –> surgical repair
Monitoring for AAA
- 5-3.5 = 3-5 years
- 5-4.5 = yearly
- 5-5.5 = 6 months
CTF recommends screening for AAA in what population?
Male, 65-80 years, once
amaurosis fugax definition and what does it indicate?
transient unilateral vision loss, carotid stenosis
Which symptoms are NOT associated with carotid disease?
vertigo, ataxia (uncoordinated mvmts), diplopia, N/V, decreased LOC, generalized weakness
Subjective symptoms of carotid stenosis
unilateral weakness, numbness, paresthesia, aphasia, dysarthria
What treatment is indicated for carotid stenosis with > 60% and asymptomatic OR symptomatic with >50% stenosis
Carotid stenting
What treatment is indicated for carotid stenosis with longer segment occlusion or >70% stenosed?
Endarterectomy (CEA)
What diagnostic test is initially indicated for carotid stenosis?
Duplex US
What is the gold standard diagnostic test for carotid stenosis?
Digital angio
What class of CCB is amlodipine?
DHP CCB
What class of CCB is verapamil?
N-DHP CCB
What class of CCB is diltiazem?
N-DHP CCB
T/F?
Dihydropyridine (DHP) CCBs tend to be more potent vasodilators than non-dihydropyridine (non-DHP) agents, whereas the latter have more marked negative inotropic effects.
True
The usual 1st line medication prescribed for endocarditis prophylaxis in an adult patient, without any allergies, is which of the following?
Clindamycin 300mg PO
Cephalexin 2 mg PO
Amoxicillin 2 g PO
Doxycycline 200mg PO
Amoxicillin 2 g PO
What are 5 exam components to complete for PAD?
Checking for femoral bruits - indicates turbulent blood flow through major arteries of the lower extremity most often as a result of atherosclerotic changes
Grading pedal pulses - DP & PT. A number of studies have concluded that in healthy individuals the dorsalis pedis (DP), posterior tibial (PT) & femoral pulses are not palpable 8.1%, 2.9%, & 0% of the time, respectively (CCS, 2005). However, DP & PT arteries are both absent at the same time in only 0.7% of normal feet since hypoplasia of one of these vessels is usually compensated by prominence of the other. The absence of apparent palpable pulses may be often contradicted by the presence of audible arterial flow on further Doppler examination, such that true congenital absence of the DP and PT arteries is seen in only 2% and 0.1% of cases respectively.
Looking for trophic changes in hair, nails, or skin
Inspecting skin temperature and looking for pallor/rubor/venous dependent filling time or capillary refill
Palpation to exclude aneurysms (e.g. AAA)
Which of the following leukemias are more common in adults over age 60?
Acute Myelogenous Leukemia
Chronic Myeloid Leukemia
Acute Lymphocytic Leukemia
Chronic Lymphocytic Leukemia
Chronic Lymphocytic Leukemia
