Cardiovascular Part 2 Flashcards
What circumstance should raise the most suspicion for a secondary cause for HTN? What are some common secondary causes?
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.
What is the most common cause of end-stage renal disease in the US?
DM –> HTN 2nd most common cause.
What is required for a diagnosis of HTN?
2 elevated readings on 2 separate occasions.
Which BP, systolic or diastolic, is more associated with risk of CAD?
Systolic > 140 indicates higher risk of CAD in patients older than 50.
Describe the AHA’s stages of HTN.
Normal: SBP < 120 / DBP < 80 Elevated: 120-129 / < 80 Stage 1: 130-139 / 80-89 Stage 2: > 140 / > 90 Stage 3: > 180 / > 120
What is the management goal in the average patient diagnosed with HTN? In patients with chronic kidney disease? In patients over age 65?
General: SBP < 130 / DBP < 80
CKD: < 140 / < 90
Over 65: < 150 / < 90
What four durg classes can be used as first-line therapy in an uncomplicated, non-African Americn patient with a new diagnosis of HTN?
Thiazide diuretics, ACEIs, ARBs, CCB
What is the most commonly used first-line medication in the treatment of chronic HTN?
HCTZ
What two first line therapy options for treatment of HTN have a synergistic effect when given together?
ACEIs and thiazides –> decrease preload and afterload
Which patients with HTN benefit most from ACEIs (or ARBs) and why?
DM, nephropathy, CHF, prior MI –> ACEIs and both renal and cardio protective.
What medications are best for use in African American patients with HTN?
CCBs and thiazides –> ACEIs and ARBs are n ot indicated in African-Americans.
Which HTN medications are contraindicated in pregnancy?
ACEIs and ARBs
What patients would most commonly receive consideration for an ARB to treat HTN?
Patients unable to tolerate ACEIs or BBs
Which CCBs are the most potent vasodilators, and thus, best for use in HTN?
Dihydropyridines - nifedipine and amlodipine.
What are the contraindications to use of CCBs?
2nd/3rd degree heart block, patients taking BBs
What is the MOA of HCTZ?
Dec Na and H2O retention by limiting their reabsorption at the distal tubule.
What are the AEs associated with HCTZ?
HypoNA, HypoK, hyperuricemia, hyperglycemia.
What is the MOA of loop diuretics?
Inc excretion of Na, Cl, and K to inhibit water reabsorption at the loop of Henle.
What are the AEs associated with loop diuretics?
HypoK, hyperuricemia, HypoCl, metabolic alkalosis, hyperglycemia
What diuretics are contraindicated in patients that have a sulfa allergy?
HCTZ and loop diuretics.
Which diuretics do not decrease serum potassium?
Spironolactone, amiloride, eplernone
What is the MOA of potassium sparing diuretics?
Inhibit aldosterone mediated Na and H2O reabsorption at the distal tubule.
List the AEs associated with potassium sparing diuretics.
Hyperkalemia, gynecomastia specific to spironolactone.
When would BB medications be considered for use in management of HTN?
No longer first line –> more common in patients with CAD HX, especially prior MI or tachycardia.
Identify BBs that are nonselective, B1 selective, and both alpha and beta.
Non-sel: propranolol most common
B1 sel: atenolol, metoprolol, esmolol
A & B: labetalol, carvedilol
Identify three alpha-1 antagonists and state what they are used for?
Prazosin, terazosin, doxazosin –> 1at line in patients with HTN and BPH
Differentiate the pathophysiology of STEMI from NSTEMI.
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.
State the lead location of ST elevation found in anterior, inferior, lateral, and posterior STEMI.
Ant: I, aVL, V2 - V6
Inf: II, III, aVF
Lat: I, aVL, V5, V6
Post: No STE –> depression in V1 - V4
What is the mainstay of treatment for STEMI?
PCI within 90 minutes of first medical contact –> thrombolytics if PCI not immediately available.
What medications may be considered as adjunctive therapy in the management of STEMI?
BB, NTG, ASA, plavix, heparin, statins, analgesia
Describe the serum labs used to assess NSTEMI.
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
What is the treatment for NSTEMI?
Same medications but PCI is less time sensitive.
What is the gold standard diagnostic test for myocarditis?
endomyocardial biopsy
What will be seen on echocardiography in a patient with myocarditis?
decreased ventricular EF with hypokinesis
What S/S are associated with myocarditis and which is most indicative?
Most indicative: tachycardia disproportionate to fever or discomfort.
Other: fatigue, ,fever, chest discomfort, dyspnea, palpitations.
What is the treatment for myocarditis?
Mostly supportive. Antiarrhythmics PRN and heart failure meds PRN.
Describe the pathophysiology of pericarditis.
Inflammation of the pericardial sac –> often with pericardial effusion.
What clinical presentation is most associated with pericarditis?
Pleuritic chest pain worse when supine and during inspiration but better when leaning forward, pericardial friction rub on auscultation.
What diagnostic test findings are indicative of pericarditis?
ECG: Diffuse ST elevation and PR depression
Echo: may show pericardial effusion
What is the treatment for pericarditis?
Treat underlying cause (abx, etc.), NSAIDs, keep head at 45 degrees, steroids, pericardiocentesis PRN
Define Dressler’s syndrome.
Pericarditis 2-5 days after acute MI
What is the most common presentation of peripheral artery disease and what are other S/S?
MC = intermittent claudication. Other –> erectile dysfunction, pain brought on by exercise and relieved with rest.
What is leriche syndrome and what does it indicate?
Claudication, erectile dysfunction, and diminished femoral pulses –> indicates peripheral artery disease at aortic bifurcation.
What are the six P’s associated with acute arterial embolism?
Pain Pulselessness Pallor Parestehsias Poiklothermia Paralysis
What is the gold standard diagnostic test for peripheral artery disease and what other tests are used?
Gold: arteriography (only if revascularization planned)
Other: doppler ultrasound, ankle-brachial index < 0.9
What is the first-line treatment for peripheral artery disease? What is the mainstay pharmacological treatment and what other meds may be used.
1st line: risk factor modification (DM, HTN, etc.)
Mainstay pharm: cilostazol
Other pharm: ASA, clopidogrel, BBs, ACEIs, statins
What S/S are associated with varicose veins and which vein is most commonly involved?
MC: saphenous
S/S: dilated, tortuous veins, reticular veins, telangiectasia (aka spider veins)
What is the treatment for varicose veins?
Compression stockings, control risk factors
What S/S are most commonly associated with phlebitis?
dull pain, erythema, swelling, heat, redness, induration
What is Homan’s sign and what does it indicate?
Calf pain with dorsiflexion –> indicates phlebitis
What S/S are most indicative of chronic venouos insufficiency?
progressive edema; itching; dull pain; ulcerations; shiny, thin, atrophic skin
What diagnostic test is most commonly used to evaluate for disease of peripheral veins?
Duplex ultrasound
Describe rheumatic fever.
Inflammatory response to infection (usually group A strep) with formation of antistreptolysin antibodies which react with proteins on synovium, heart muscle, heart valves.
How long after initial infection does rheumatic fever usually manifest?
2 - 4 weeks
What is the treatment for rheumatic fever?
ASA, NSAIDs, steroids, abx
What prophylaxis against rheumatic fever is given for recurrent strep infections?
penicillin G benzathine 1.2 million units IM q3-4 weeks for 5-10+ years
Differentiate clinical S/S of aortic aneurysm from aortic dissection.
Aneurysm: flank pain, hypotension, pulsatile abdominal mass
Dissection: tearing C/P, diminished pulses, wide mediastinum, unequal BPs on each arm
When is surgical repair indicated for abdominal aortic aneurysm?
5.5+ cm or increase by > 0.5cm per year
What is the treatment for aortic dissection?
Surgical emergency if involving ascending aorta, BBs otherwise.
Define Giant Cell Arteritis
Inflammation of large and medium vessels (AKA temporal arteritis)
What S/S are most commonly associated with giant cell arteritis?
Jaw claudication, unilateral HA, scalp pain elicited by light touch, acute vision disturbances
In addition to clinical presentation, what is used to diagnose giant cell arteritis?
ESR > 100, temporal artery biopsy
What is the treatment for giant cell arteritis?
Urgent, high dose prednisone
