Cardiovascular Part 2

Question 1

What circumstance should raise the most suspicion for a secondary cause for HTN? What are some common secondary causes?

Answer 1

Circumstance: Patient refractory to anti-hypertensives
Causes: renovascular is the most common secondary cause. Others: hyperaldosteronism, AUD, sleep apnea, pheochromocytoma, coarctation of the aorta, OCPs, sudafed, COX-2 inhibitors.

Question 2

What is the most common cause of end-stage renal disease in the US?

Answer 2

DM –> HTN 2nd most common cause.

Question 3

What is required for a diagnosis of HTN?

Answer 3

2 elevated readings on 2 separate occasions.

Question 4

Which BP, systolic or diastolic, is more associated with risk of CAD?

Answer 4

Systolic > 140 indicates higher risk of CAD in patients older than 50.

Question 5

Describe the AHA’s stages of HTN.

Answer 5

Normal: SBP < 120 / DBP < 80
Elevated: 120-129 / < 80
Stage 1: 130-139 / 80-89
Stage 2: > 140 / > 90
Stage 3: > 180 / > 120

Question 6

What is the management goal in the average patient diagnosed with HTN? In patients with chronic kidney disease? In patients over age 65?

Answer 6

General: SBP < 130 / DBP < 80
CKD: < 140 / < 90
Over 65: < 150 / < 90

Question 7

What four durg classes can be used as first-line therapy in an uncomplicated, non-African Americn patient with a new diagnosis of HTN?

Answer 7

Thiazide diuretics, ACEIs, ARBs, CCB

Question 8

What is the most commonly used first-line medication in the treatment of chronic HTN?

Answer 8

HCTZ

Question 9

What two first line therapy options for treatment of HTN have a synergistic effect when given together?

Answer 9

ACEIs and thiazides –> decrease preload and afterload

Question 10

Which patients with HTN benefit most from ACEIs (or ARBs) and why?

Answer 10

DM, nephropathy, CHF, prior MI –> ACEIs and both renal and cardio protective.

Question 11

What medications are best for use in African American patients with HTN?

Answer 11

CCBs and thiazides –> ACEIs and ARBs are n ot indicated in African-Americans.

Question 12

Which HTN medications are contraindicated in pregnancy?

Answer 12

ACEIs and ARBs

Question 13

What patients would most commonly receive consideration for an ARB to treat HTN?

Answer 13

Patients unable to tolerate ACEIs or BBs

Question 14

Which CCBs are the most potent vasodilators, and thus, best for use in HTN?

Answer 14

Dihydropyridines - nifedipine and amlodipine.

Question 15

What are the contraindications to use of CCBs?

Answer 15

2nd/3rd degree heart block, patients taking BBs

Question 16

What is the MOA of HCTZ?

Answer 16

Dec Na and H2O retention by limiting their reabsorption at the distal tubule.

Question 17

What are the AEs associated with HCTZ?

Answer 17

HypoNA, HypoK, hyperuricemia, hyperglycemia.

Question 18

What is the MOA of loop diuretics?

Answer 18

Inc excretion of Na, Cl, and K to inhibit water reabsorption at the loop of Henle.

Question 19

What are the AEs associated with loop diuretics?

Answer 19

HypoK, hyperuricemia, HypoCl, metabolic alkalosis, hyperglycemia

Question 20

What diuretics are contraindicated in patients that have a sulfa allergy?

Answer 20

HCTZ and loop diuretics.

Question 21

Which diuretics do not decrease serum potassium?

Answer 21

Spironolactone, amiloride, eplernone

Question 22

What is the MOA of potassium sparing diuretics?

Answer 22

Inhibit aldosterone mediated Na and H2O reabsorption at the distal tubule.

Question 23

List the AEs associated with potassium sparing diuretics.

Answer 23

Hyperkalemia, gynecomastia specific to spironolactone.

Question 24

When would BB medications be considered for use in management of HTN?

Answer 24

No longer first line –> more common in patients with CAD HX, especially prior MI or tachycardia.

Question 25

Identify BBs that are nonselective, B1 selective, and both alpha and beta.

Answer 25

Non-sel: propranolol most common B1 sel: atenolol, metoprolol, esmolol A & B: labetalol, carvedilol

Question 26

Identify three alpha-1 antagonists and state what they are used for?

Answer 26

Prazosin, terazosin, doxazosin --> 1at line in patients with HTN and BPH

Question 27

Differentiate the pathophysiology of STEMI from NSTEMI.

Answer 27

STEMI: Necrosis of full thickness of myocardial wall from complete CA occlusion. NSTEMI: Myocardial necrosis not associated with complete occlusion and likely not full thickness.

Question 28

State the lead location of ST elevation found in anterior, inferior, lateral, and posterior STEMI.

Answer 28

Ant: I, aVL, V2 - V6 Inf: II, III, aVF Lat: I, aVL, V5, V6 Post: No STE --> depression in V1 - V4

Question 29

What is the mainstay of treatment for STEMI?

Answer 29

PCI within 90 minutes of first medical contact --> thrombolytics if PCI not immediately available.

Question 30

What medications may be considered as adjunctive therapy in the management of STEMI?

Answer 30

BB, NTG, ASA, plavix, heparin, statins, analgesia

Question 31

Describe the serum labs used to assess NSTEMI.

Answer 31

Troponin: appears at 2-4 hours, peaks at 12-24 hours and lasts 7-10 days CK/CK-MB: appears at 4-6 hours, peaks at 12-24 hours and lasts 2-3 days Myoglobin: appears at 1-4 hours, peaks at 12 hours and lasts 1 day

Question 32

What is the treatment for NSTEMI?

Answer 32

Same medications but PCI is less time sensitive.

Question 33

What is the gold standard diagnostic test for myocarditis?

Answer 33

endomyocardial biopsy

Question 34

What will be seen on echocardiography in a patient with myocarditis?

Answer 34

decreased ventricular EF with hypokinesis

Question 35

What S/S are associated with myocarditis and which is most indicative?

Answer 35

Most indicative: tachycardia disproportionate to fever or discomfort. Other: fatigue, ,fever, chest discomfort, dyspnea, palpitations.

Question 36

What is the treatment for myocarditis?

Answer 36

Mostly supportive. Antiarrhythmics PRN and heart failure meds PRN.

Question 37

Describe the pathophysiology of pericarditis.

Answer 37

Inflammation of the pericardial sac --> often with pericardial effusion.

Question 38

What clinical presentation is most associated with pericarditis?

Answer 38

Pleuritic chest pain worse when supine and during inspiration but better when leaning forward, pericardial friction rub on auscultation.

Question 39

What diagnostic test findings are indicative of pericarditis?

Answer 39

ECG: Diffuse ST elevation and PR depression Echo: may show pericardial effusion

Question 40

What is the treatment for pericarditis?

Answer 40

Treat underlying cause (abx, etc.), NSAIDs, keep head at 45 degrees, steroids, pericardiocentesis PRN

Question 41

Define Dressler's syndrome.

Answer 41

Pericarditis 2-5 days after acute MI

Question 42

What is the most common presentation of peripheral artery disease and what are other S/S?

Answer 42

MC = intermittent claudication. Other --> erectile dysfunction, pain brought on by exercise and relieved with rest.

Question 43

What is leriche syndrome and what does it indicate?

Answer 43

Claudication, erectile dysfunction, and diminished femoral pulses --> indicates peripheral artery disease at aortic bifurcation.

Question 44

What are the six P's associated with acute arterial embolism?

Answer 44

``` Pain Pulselessness Pallor Parestehsias Poiklothermia Paralysis ```

Question 45

What is the gold standard diagnostic test for peripheral artery disease and what other tests are used?

Answer 45

Gold: arteriography (only if revascularization planned) Other: doppler ultrasound, ankle-brachial index < 0.9

Question 46

What is the first-line treatment for peripheral artery disease? What is the mainstay pharmacological treatment and what other meds may be used.

Answer 46

1st line: risk factor modification (DM, HTN, etc.) Mainstay pharm: cilostazol Other pharm: ASA, clopidogrel, BBs, ACEIs, statins

Question 47

What S/S are associated with varicose veins and which vein is most commonly involved?

Answer 47

MC: saphenous | S/S: dilated, tortuous veins, reticular veins, telangiectasia (aka spider veins)

Question 48

What is the treatment for varicose veins?

Answer 48

Compression stockings, control risk factors

Question 49

What S/S are most commonly associated with phlebitis?

Answer 49

dull pain, erythema, swelling, heat, redness, induration

Question 50

What is Homan's sign and what does it indicate?

Answer 50

Calf pain with dorsiflexion --> indicates phlebitis

Question 51

What S/S are most indicative of chronic venouos insufficiency?

Answer 51

progressive edema; itching; dull pain; ulcerations; shiny, thin, atrophic skin

Question 52

What diagnostic test is most commonly used to evaluate for disease of peripheral veins?

Answer 52

Duplex ultrasound

Question 53

Describe rheumatic fever.

Answer 53

Inflammatory response to infection (usually group A strep) with formation of antistreptolysin antibodies which react with proteins on synovium, heart muscle, heart valves.

Question 54

How long after initial infection does rheumatic fever usually manifest?

Answer 54

2 - 4 weeks

Question 55

What is the treatment for rheumatic fever?

Answer 55

ASA, NSAIDs, steroids, abx

Question 56

What prophylaxis against rheumatic fever is given for recurrent strep infections?

Answer 56

penicillin G benzathine 1.2 million units IM q3-4 weeks for 5-10+ years

Question 57

Differentiate clinical S/S of aortic aneurysm from aortic dissection.

Answer 57

Aneurysm: flank pain, hypotension, pulsatile abdominal mass Dissection: tearing C/P, diminished pulses, wide mediastinum, unequal BPs on each arm

Question 58

When is surgical repair indicated for abdominal aortic aneurysm?

Answer 58

5.5+ cm or increase by > 0.5cm per year

Question 59

What is the treatment for aortic dissection?

Answer 59

Surgical emergency if involving ascending aorta, BBs otherwise.

Question 60

Define Giant Cell Arteritis

Answer 60

Inflammation of large and medium vessels (AKA temporal arteritis)

Question 61

What S/S are most commonly associated with giant cell arteritis?

Answer 61

Jaw claudication, unilateral HA, scalp pain elicited by light touch, acute vision disturbances

Question 62

In addition to clinical presentation, what is used to diagnose giant cell arteritis?

Answer 62

ESR > 100, temporal artery biopsy

Question 63

What is the treatment for giant cell arteritis?

Answer 63

Urgent, high dose prednisone