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1
Q

S1 is associated with which heart valves?

A

S1 - Mitral and Tricuspid (AV) CLOSE

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2
Q

S2 is associated with which heart valves?

A

S2 - Aortic and Pulmonic (SL) CLOSE

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3
Q

Define systole.

A

The period between S1 and S2

1: MV) —–squeeze—– (2: AP

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4
Q

Define diastole.

A

Period between S2 and S1

2: AP) —– rest —– (1: MV

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5
Q

Which heart sound is associated with CHF?

A

S3 - atrial gallop - kentucky (bourbon sloshy)

passive blood flow hits dilated, non-compliant walls
- think: hypervolemia - CHF, pregnancy, etc

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6
Q

Which heart sound is associated with LVH?

A

S4 - ventricular gallop - tennessee (tenneseeze-squeeze - kick/thick)

atrial KICK kicks blood + it bounces off extra THICK wall like a soccer ball

  • think: stiff ventricular wall - LVH, htn, MI
  • LA squeezes harder to overcome thick LV
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7
Q

Describe a grade IV/VI heart murmur.

A

loud + thrill

IV has what III does not (III is just loud)

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8
Q

Patient presents with history of multiple syncopal episodes. Physical exam remarkable for loud diamond shaped systolic murmur at 2nd R ICS that radiates to neck. What do you suspect and what are your actions?

A

Aortic Stenosis - syncope r/t decreased cardiac output
Consult cardiology

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9
Q

Which murmur is associated with S3 systolic murmur at 5th ICS MCL that radiates to L axilla?

A

Mitral Regurgitation

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10
Q

what is heart failure?

A

syndrome where CO is insufficient to meet body’s metabolic needs

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11
Q

what is diastolic heart failure?

A

HFpEF: inability to relax and FILL = ↓ CO

WWJD: “the heart doesn’t FILL well!”

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12
Q

what is systolic heart failure?

A

HFrEF: inability to contract = ↓ CO

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13
Q

what is acute heart failure?

A

LEFT-sided failure r/t acute MI, valve rupture

also LVH, htn

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14
Q

what is chronic heart failure?

A

RIGHT-sided failure d/t inadequate compensatory mechanisms to improve ↓ CO

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15
Q

acute heart failure: s/s x5

A

LEFT heart failure; L = LUNGS

  • dyspnea @ rest
  • crackles/rales: all lung fields
  • wheezy, frothy cough
  • S3 gallop (hypervolemia!)
  • mitral regurg: systolic @ apex
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16
Q

What heart murmur is associated with acute heart failure? What heart sound?

A

murmur: mitral regurg (systolic @ apex)
sound: S3 gallop (hypervolemia!)

acute heart failure is LEFT-sided heart failure!

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17
Q

chronic heart failure: s/s x9

A

RIGHT heart failure. chRonic = RIGHT

  • JVD, dependent edema, abd fullness
  • hepatomegaly, splenomegaly
  • fatigue on exertion
  • paroxysmal nocturnal dyspnea (PND)
  • displaced PMI
  • S3 and/or S4
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18
Q

Which NYHA stage of heart failure could be described as “ordinary activity causes symptoms but comfortable at rest”?

A

Class III

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19
Q

What signifies a NYHA Class IV Heart Failure score?

A

inability to carry out ANY physical activity without discomfort
- s/s @ REST

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20
Q

heart failure: diagnostics x7

A

ABG: hypoxemia, hypocapnia
BMP: normal unless chronic failure
UA
CXR: pulm edema, Kerley B lines, effusions
Echo
EKG: deviation or underlying problem (acute MI, dysrhythmia)
PFT: for wheeze during exercise

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21
Q

heart failure: non-pharma mgmt x3

A

Na restriction
rest/activity balance
weight reduction

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22
Q

heart failure: pharm interventions x3

A

ACE inhibitors **

diuretics: furosemide (Lasix), thiazide
anticoagulation: for a fib

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23
Q

what is flash pulmonary edema?

A

aka acute pulmonary edema!

  • fluid moves into lung interstitium (space w/in alveolar septum btw alveolus + capillary)
  • d/t pulmonary capillary hydrostatic pressure
  • fluid flow out of capillaries exceeds lymph system ability to remove it
  • most common cause: LEFT-sided (acute) heart failure; also: acute MI, ↑ LV pressure
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24
Q

pulmonary edema: mgmt x7

A
  • O2 1 - 2 L/min + ABG
  • semi-Fowlers
  • morphine 2-4 mg IVP q20 - 30 mins PRN (stop if hypercapnic)
  • furosemide (Lasix) 40 mg IVP (repeat in 10 min if no response)
  • if severe: nitroprusside or hydralazine (reduce preload & afterload)
  • if CO/CI stays low: dobutamine 2.5 - 20 ug/kg/min (if SBP under 100 mmHg - dopamine 5 - 20 ug/kg/min)
  • if severe bronchospasm: albuterol (Proventil)
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25
Q

What are 2 meds used to reduce preload + afterload in the setting of pulmonary edema?

A

nitroprusside or hydralazine

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26
Q

What 2 meds are indicated for persistently low CO in the setting of pulmonary edema?

A

dobutamine 2.5-20 ug/kg/min

dopamine 5 - 20 ug/kg/min (SBP lt 100)

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27
Q

55 yo M w PMH significant for left-sided heart failure develops flash pulmonary edema. He has persistently low CO and is hypotensive at 88/46. What pharm intervention is indicated?

A

dopamine 5 - 20 ug/kg/min

dopamine ↑ SVR + SBP (∴ BP)

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28
Q

what is hypertension?

A

sustained SBP 140+
OR
DBP 90+

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29
Q

What is secondary hypertension? What is its most common cause?

A

1 = renal artery stenosis

hypertension secondary to other known causes

others: renal disease, pregnancy, estrogen use, endocrine disorders

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30
Q

What kind of headache occurs in severe hypertension?

A

sub-occipital (back of head) pulsating HA in early AM, resolves throughout the day

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31
Q

Your patient has hypertension. Name 3 labs you would order and your rationale (what causes are you ruling out?)

A
  • AM/PM cortisol levels: r/o Cushings
  • CXR: if cardiomegaly suspected
  • renovascular disease studies
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32
Q

JNC8 goal BP for patients under 60?

A

less than SBP 140

less than DBP 90

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33
Q

JNC8 goal BP for patients 60+?

A

less than SBP 150

less than DBP 90

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34
Q

What are the JNC 8 treatment recommendations for a non-black hypertension patient?

A

thiazide diuretic, CCB, ACE-inhibitor, ARB

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35
Q

What are the JNC 8 treatment recommendations for a black hypertension patient?

A

thiazide diuretic

CCB

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36
Q

What are the JNC 8 treatment recommendations for hypertension in adults 18+ with CKD?

A

ACE inhibitor OR ARB

REGARDLESS OF RACE/MEDICAL CONDITION

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37
Q

What are the JNC 8 treatment goals for hypertension? x5

A

initial treatment goal: 1 month; if not reached

  • first: increase dose
  • second: add second drug
  • refer to hypertensive specialist if 3+ drugs needed

assess monthly until goal reached
do not use ACE-i + ARB together

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38
Q

Per JNC 8 guidelines, how often do you assess BP until hypertension goal is reached?

A

MONTHLY

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39
Q

1 therapeutic lifestyle change necessary in HTN management?

A

Restrict sodium intake

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40
Q

67 yo. F presents to the clinic with no significant PMH. Initial BP read 168/92 with no other significant findings on physical exam. Before leaving - second BP read 158/88. You should?

A

Teach the patient about lifestyle changes - diet/exercise

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41
Q

What is a hypertensive urgency?

A

BP greater than 180/110 WITHOUT target end organ damage

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42
Q

hypertensive urgency: mgmt options x4

A 
PO!
clonidine (Catapres)
captopril (Capoten)
nifedipine (Procardia) 
furosemide (Lasix)
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43
Q

what is a hypertensive emergency?

A

BP greater than 180/120 WITH end target organ damage

requires IMMEDIATE intervention - in less than 1 hour

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44
Q

What are examples of end target organ damage associated with hypertensive emergency? x8

A 
malignant hypertension 
hypertensive encephalopathy
intracranial hemorrhage
acute MI
unstable angina
acute LV failure with pulmonary edema
dissecting AA
eclampsia
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45
Q

hypertensive emergency: mgmt x5

A

IMMEDIATE - less than 1 hour + ICU admit (art line + IV meds)

lower BP to SBP 160 - 180 OR under 105 DBP
- lower BP no more than 25% within 1 - 2 hrs then gradually over several days w PO tx

options:

  • nicardipine (Cardene) ** gold standard
  • nitroprusside (Nipride)
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46
Q

What are the parameters for lowering BP during a hypertensive emergency?

A

goal BP: SBP 160-180 / DBP under 105

do NOT lower more than 25% within 1 - 2 hrs

then lower gradually over several days with PO

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47
Q

What is the gold standard pharm intervention for hypertensive emergency?

A

IV nicardipine (Cardene)

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48
Q

angina: expected EKG findings

A

ST depression ** (most common)
T-wave peak or inversion

(DURING ATTACK)

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49
Q

What is angina? What is its pathophysiology?

A

characteristic chest discomfort lasting several minutes

↓ blood flow through vessel → TISSUE ISCHEMIA

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50
Q

What is stable angina?

A
  • aka classic aka chronic
  • predictable: pattern, onset, duration
    (4E: eating, exercise, exposure to cold, emotions)
  • exertional: most common
  • relieved by rest + nitroglycerin
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51
Q

What is Prinzmetal’s angina?

A
  • aka variant
  • intermittent, including at rest
  • patho: VASOSPASM d/t ↑ intracellular Ca, NOT r/t CAD
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52
Q

What is Levine’s Sign?

A

clenched first over precordium

90% diagnostic for angina

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53
Q

lipid panel goals: DM or CAD pts

A

LDL less than 70
HDL 40+
trigs less than 150

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54
Q

ideal total cholesterol

A

less than 200 mg/dL

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55
Q

What is the definitive diagnostic procedure for angina?

A

coronary angiography - but not indicated solely for diagnosis

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56
Q

Your obese 38 yo. patient has the following lipid panel:
Total Cholesterol 270
HDL 28
LDL 168
What is the most appropriate intervention at this time?

A

Start a statin

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57
Q

Which of the following lipid panels has 3 of the 4 values abnormal, warranting attention from the AG-ACNP?

a. cholesterol 170 LDL 80 TG 240 HDL 20
b. cholesterol 180 LDL 136 TG 160 HDL 29
c. cholesterol 210 LDL 182 TG 160 HDL 34

A

B. Cholesterol 180 LDL 136 TG 160 HDL 29

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58
Q

normal triglycerides

A

less than 150 mg/dL

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59
Q

optimal LDL

A

less than 100 mg/dL

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60
Q

ideal HDL

A

40 to 60
low = under 40
high = 60+

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61
Q

angina: non-pharm mgmt

A
  • reduction of risk factors
  • manage diet
    ↓ saturated fats
    then, ↓ unsaturated
    then, consider ↓ plant sterols (nuts, veg oils, etc)
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62
Q

angina: pharm mgmt

A

ASA 81 mg QD (enteric coated)
nitrates
beta blockers
calcium channel blockers

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63
Q

What is the leading cause of death in adults in the United States?

A

myocardial infarction

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64
Q

acute myocardial infarction: pathophys

A

↓ perfusion to myocardial tissue → infarction

- result: irreversible myocardial necrosis

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65
Q

When do most AMI occur?

A

@ rest

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66
Q

What three groups present with non-classic acute MI symptoms and how do they present?

A

women: fatigue; epigastric pain
elderly + diabetic: no pain
- in DM r/t neuropathy

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67
Q

acute MI: classic s/s x7

A

substernal chest pain: radiates to L arm + jaw
dyspnea
n/v
impending doom, syncope

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68
Q

Which heart sound is common in acute MI?

A

S4 r/t ventricular wall stiffness

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69
Q

acute MI: EKG findings

A

~ 30% have no initial changes
ST elevation gt 1 mm from baseline
peaked T waves
significant Q wave (gt25% height of R wave)

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70
Q

What two cardiac enzymes are cardioselective?

A

Troponin I

CK-MB

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71
Q

After acute MI, when do cardiac enzymes elevate and how long do they remain elevated?

A

elevate above normal w/n 4 - 6 hrs

remain elevated for days - 3 wks

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72
Q

ST change: I + aVL - indicative of what kind of MI?

A

LATERAL

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73
Q

ST changes: Leads II, III, + aVF - indicative of what kind of MI?

A

INFERIOR

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74
Q

ST changes: V leads/V3-V4 - indicative of what kind of MI?

A

ANTERIOR

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75
Q

anterior MI: EKG findings

A

ST elevation in V leads/V3-V4

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76
Q

acute MI: mgmt

A

MONA

  • O2
  • Morphine 2-4 mg IVP q30 min PRN
  • NTG SL q 5min x3
  • ASA 325 mg chewed
  • IVF @ KVO: large-bore PIV x3
  • 12 lead + cardiac monitor
  • if pulm edema: furosemide 40 mg IVP
  • metoprolol 5mg IV q2 min x 3 /THEN/ 15 min after last IV dose, 50mg PO q6 hrs
  • heparin vs Lovenox 1 mg/kg q12hrs + monitor coag
  • ACE Inhibitor: to prevent remodeling if HF or lg infarction
    • otherwise, only after fibrinolytics, ASA
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77
Q

acute MI: beta blocker of choice + dosage

A

metoprolol 5 mg IV q2min x 3

- then, 15 minutes after last IV dose: 50 mg PO q6hrs

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78
Q

What is the reversal agent for coumadin?

A

Vitamin K

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79
Q

indications for pharmacological revascularization in the setting of an AMI?

A

unrelieved chest pain 30 min - 6 hrs
/with/
ST elevation over 1mm in 2+ CONTIGUOUS leads

pharm revasc: fibrinolytics - tPA

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80
Q

acute STEMI: door to needle time? door to cath time?

A

door to needle - 30 minutes

door to cath - 90 minutes

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81
Q

Absolute contraindication for tPA.

A

Active bleeding or risk thereof including abn coags

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82
Q

acute MI: Lovenox doseage

A

SQ 1 mg/kg q12hrs

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83
Q

What is venous thrombosis?

A

partial or complete occlusion of vein by a thrombus with secondary inflammation to vessel wall
- superficial OR deep

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84
Q

venous thrombus: causes x5

A 
immobility
hypercoagulable state
endothelial damage
recent surgery 
PO contraceptives: esp if smoker
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85
Q

superficial thrombosis: s/s + exam findings x3

A

sudden onset pain
localized heat/erythema
low grade temp

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86
Q

DVT: s/s + exam findings x4

A

sudden onset pain, esp while walking
- may be dull ache or “tight” feeling

edema distal to occlusion
skin cool to touch
low grade temp

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87
Q

superficial venous thrombosis: mgmt

A

elevate extremity
warm compress
NSAID
d/c PO contraceptives

88
Q

What is peripheral vascular disease?

A

arteriosclerotic narrowing of arterial lumen → ↓ blood supply extremities

similar risk factors for CAD (hld, tobacco, DM)

89
Q

What is usually the first symptom of PVD?

A

calf pain (claudication)

90
Q

PVD: s/s x3

A

claudication
cool/numb extremity
progresses to pain at rest

91
Q

PVD: exam findings x6

A 
SHINY/HAIRLESS
dependent rubor
pallor, cyanosis
ulcerations
reduced pulses
92
Q

PVD: diagnostics

A

Arteriography: most definitive
Doppler US: eval flow
Ankle-Brachial Index (ABI)
XRays: may show calcification

93
Q

What is the most definitive diagnostic for PVD?

A

arteriography

94
Q

What is the priority intervention in the management of PVD?

A

Walking 1 hr/day to develop collateral circulation

95
Q

Your patient has a history of coagulapathy and is scheduled to go to the OR. What is the most appropriate intervention for this patient?

A

Pneumatic stockings. NOT Heparin; coumadin; or lovenox.

96
Q

A patient’s coags read: PT 29 INR 4.4. What would you do to the patient’s Coumadin dose?

A

Lower the coumadin. Goal INR 2.5-3.5

97
Q

Which of the following patients are most likely to develop a DVT:
a. 45 yo. liver failure pt
b. 30 yo. s/p ORIF R tib/fib
c. 59 yo. parapalegic, bedridden
d. 24 yo. F PO contraceptives

A

a. 45 yo. liver failure pt r/t high risk for bleeding

98
Q

Patient is admitted to telemetry floor with a history of atrial fibrillation and preserved LV function. What is the drug class of choice?

A

Beta Blocker

99
Q

Dependent rubor is a physical finding associated with what cardiovascular disease?

A

Peripheral Vascular Disease (arteriosclerotic occlusive disease)

100
Q

What is chronic venous insufficiency?

A

impaired VENOUS return d/t valve destruction, DVT, leg trauma, or sustained elevation of venous pressure (CHF)

more common in women

101
Q

Varicose veins are associated with what vascular disease?

A

Chronic venous insufficiency

102
Q

chronic venous insufficiency: s/s x3

A

LE aching relieved by elevation
Dependent edema
Night cramps in LE

103
Q

chronic venous insufficiency: PE findings

A

trophic (soft tissue) Δ + BROWNISH discoloration
edema, stasis leg ulcers, dermatitis
cool to touch

104
Q

What is the mainstay of chronic venous insufficiency management?

A

Heavy-duty elastic support stockings to increase venous return

105
Q

Acute weeping dermatitis is associated with what vascular disease?

A

Chronic venous insufficency

106
Q

acute weeping dermatitis: mgmt

A

wet compresses + 0.5% hydrocortisone

if bacterial infection is present: systemic abx

107
Q

Cardiac rehabilitation is an example of what type of prevention?

A

Tertiary prevention.

108
Q

What are appropriate medications for post-op a fib rate control?

A

digoxin
verapamil
metoprolol (Lopressor)

109
Q

What artery is associated with an Inferior MI?

A

right coronary artery (RCA)

110
Q

What class of medication should be used cautiously in a patient complaining of angina with reduced LV function?

A

Calcium Channel Blockers: may reduce LV fxn further

111
Q

What is the leading cause of new onset at fib?

A

Hyperthyroidism.

112
Q

Your patient is a 45 yo. F with new onset a fib. PMH is unremarkable. What medication would you start this patient on?

A

ASA

113
Q

What medication regimen would you initiate for a patient s/p AMI with reduced LV function of EF 10%?

A

Coumadin: indicated EF under 30%
ACE Inhibitor - prevent remodeling
Beta Blocker - prevent remodeling

114
Q

What routine lab is important to monitor with use of statins?

A

LFT: 3 - 6 mo

r/t risk for hepatic toxicity with statins

115
Q

What is pericarditis?

A

inflammation of the pericardium

116
Q

What is the most common cause of pericarditis?

A

Viral infection

117
Q

43 yo. M presents to ED with complaints of substernal chest pain that increases with inspiration; coughing and swallowing and decreases when he leans forward. He recently had fever; chills and loss of appetite. What is your primary differential?

A

Pericarditis

118
Q

pericarditis: s/s

A

very LOCALIZED, PLEURITIC retrosternal/precordial chest pain

  • worsens: deep inspiration, coughing, swallowing, recumbent position
  • decreases: leaning forward

SOB s/t inspiration pain

119
Q

What is the classic physical finding suggestive of pericarditis?

A

pericardial friction rub

120
Q

What two EKG findings are highly suggestive of pericarditis?*

A

ST segment elevation in ALL leads

PR depression: highly indicative

121
Q

What test do you order to confirm pericarditis?

A

Echocardiogram: will show pericardial fluid/inflammation

122
Q

What is the mainstay treatment for pericarditis?*

A

NSAIDS!!

  • ibuprofen (Advil) 400-600 mg PO q6-8 hrs
  • indomethacin (Indocin) 25 - 50 mg q8hrs x2 wks
123
Q

What major physiological complication is associated with pericarditis?

A

Cardiac tamponade.

Beck’s Triad:

  • distant heart sounds
  • distended jugular veins
  • decreased arterial pressure
124
Q

What is endocarditis?

A

infection: endothelial surface of the heart
- usually affects valves
- usually bacterial
- assoc w known valvular heart disease: rheumatic, AV/MV prolapse with significant regurg

125
Q

Endocarditis must be considered a differential for patients presenting with what 2 primary physical findings?

A

heart murmur

FUO

126
Q

What are Osler’s Nodes?

A

Endocarditis finding. Painful red nodules in distal phalanges.

127
Q

What are Janeway Lesions?

A

Endocarditis finding. RARE. Small, non-painful macules on palms + soles.

128
Q

What are Roth Spots?

A

Endocarditis finding. Small, white, retinal infarcts encircled by hemorrhage.

129
Q

What are splinter hemorrhages and what cardiac disease are they associated with?

A

Endocarditis finding. Linear, subunugal (finger/toe nail), splinter-appearance.

130
Q

What is the mainstay of diagnoses for endocarditis?

A

Blood culture x 3 at 3 different sites

131
Q

Bandemia is always present in what type of cardiovascular disorder?

A

Endocarditis. WBC always elevated with left shift.

132
Q

What is the treatment for endocarditis?

A

PCN G IV q4hrs in combination with gent

133
Q

What is the pharmacological intervention for PCN-resistant streptococci and MRSA endocarditis?

A

Vancomycin 12-15 mg/kg q12hrs via PICC line x6 weeks

134
Q

first time a fib in young vs older patients

A

young: ASA
older: coumadin

135
Q

Describe blood flow through the heart.

A

→ superior/inferior vena cava, R atrium, (tricuspid valve), R ventricle, (pulmonic valve), pulmonary artery, lungs, pulmonary veins, L atrium, (mitral valve), L ventricle, (aortic valve), aorta →

136
Q

Kentucky gallop is

A

S3

kentucky bourbon slushy

137
Q

Tennessee gallop is

A

S4

tenneseez-squeeze the kick against thick

138
Q

Describe grade I - VI heart murmurs.

A 
I: barely audible
II: faint
III: loud
IV: loud + thrill
V: very loud (one side of stethoscope off)
VI: loudest: no stethoscope needed
139
Q

How do you remember New York Heart Association (NYHA) Class III heart failure?

A

III = sleep with 3 pillows

140
Q

Describe mitral stenosis + where to auscultate it.

A

MS ARD: mid-diastolic murmur
- auscultate apex

S1 murmur, crescendo rumble

141
Q

Describe aortic stenosis + where to auscultate it.

A

MR ASS: systolic murmur
- auscultate 2nd R ICS

harsh “blowing” - radiates to NECK

142
Q

Describe mitral regurg + where to auscultate it.

A

MR ASS: systolic murmur
- auscultate apex

musical “blowing” - radiates to BASE or L AXILLA

143
Q

Describe aortic stenosis + where to auscultate it.

A

MS ARD: diastolic murmur
- auscultate 2nd L ICS

“blowing”

144
Q

which murmur radiates to base or L axilla during systole?

A

mitral regurg

145
Q

which murmur radiates to neck during systole?

A

aortic stenosis

146
Q

which murmurs radiate?

A

systolic (MR ASS)

147
Q

which murmur is a mid-diastolic rumble?

A

mitral stenosis

148
Q

Your patient with chronic atrial fibrillation now has an audible extra heart sound. What is it? What is your rationale?

A

S3/Kentucky. There is no atrial kick in a fib. (That kick is what creates S4.)

149
Q

What are Kerley B lines on CXR indicative of?

A

pulmonary edema

150
Q

What are 3 key pieces of information observed with an echocardiogram?

A
  • contractility
  • valve function
  • ejection fraction
151
Q

what is the physiologic basis of dependent pulmonary edema?

A

↑ capillary hydrostatic pressure

152
Q

nitroprusside class + MOA

A

class: vasodilator

↓ preload & afterload: via relaxation of vascular smooth muscle (d/t NO)
- immediate reduction of BP

dilation of coronary arteries

153
Q

hydralazine class + MOA

A

class: vasodilator

direct vasodilator: dilates arterioles + little effect on veins
- ↓ SVR = ↓ BP

154
Q

What heart sound is associated with hypertension? Rationale?

A

S4 - d/t LVH: myocardium is enlarged d/t the heart having to pump against ↑ SVR

155
Q

what lab findings do you expect with uncomplicated hypertension?

A

they are usually normal.

156
Q

hypertension: non-pharm mgmt

A
  • restrict dietary Na
  • weight loss
  • DASH diet
  • exercise
  • stress mgmt
  • reduce/eliminate EtOH
  • smoking cessation
  • adequate K, Ca, Mg intake !
157
Q

hypertension: general goal of pharmacologic mgmt

A

prescribe least # meds @ lowest dosage to attain acceptable BP
- decreases CV + renal morbidity/mortality

158
Q

first-line drug of choice for hypertension?

A

thiazide diuretics

159
Q

what allergy should you screen for before thiazide diuretic admin?

A

sulfa

160
Q

do not initiate an ACE-inhibitor or ARB with what K value?

A

greater than 5.5 mEq/L

161
Q

ACE-inhibitor or ARB use is contraindicated in what condition?

A

pregnancy

162
Q

What should you monitor with CCB admin?

A

HR, esp with verapamil or diltiazem

163
Q

In which population should you avoid beta blocker use?

A

asthma/COPD

164
Q

key administration consideration for alpha-1 antagonists

A

may cause first-dose syncope, take first dose at bedtime

165
Q

key administration consideration for alpha-2 agonists

A

do not discontinue use abruptly, as this may cause withdrawals and rebound hypertension

166
Q

How do age and gender impact response to anti-hypertensives?

A

They don’t.

167
Q

fundoscopic changes observed in malignant hypertension? x3

A

flame shaped retinal hemorrhages
soft exudates
papilledema (swelling of optic disk with blurred margins)

168
Q

What is unstable angina?

A
  • unrelieved by rest or nitro

- PRE-INFARCTION

169
Q

What is microvascular angina?

A

r/t metabolic syndrome

170
Q

What is exertional angina?

A
  • most common form of stable angina
  • precipitated by physical activity
  • subsides with rest
171
Q

What is the purpose of nitroglycerin in angina management?

A

shortens or prevents attacks

172
Q

What heart sound is associated with angina?

A

transient S4

173
Q

triglycerides are aka

A

VLDL

174
Q

ASCVD

A

atherosclerotic cardiovascular disease

175
Q

individuals who may benefit from statin therapy x4

A
  • clinical evidence of ASCVD
  • LDL-C 190+
  • DM 40 - 75 + LDL-C 70 - 189 + no clinical ASCVD
  • no ASCVD or DM + LDL-C 70 - 189 + est 10-yr risk ASCVD 7.5%+
176
Q

high-intensity statin therapy: indication

A

first-line in women + men under 75 who have clinical ASCVD (unless contraindicated)

LDL-C 190+ in 21+ (unless contraindicated)

DM + 7.5%+ est 10 yr ASCVD risk in 40 - 75

use moderate-intensity when high contraindicated or statin-associated AE

177
Q

statin therapy for ASCVD 75+

A

moderate or high-intensity, but eval potential for

  • risk-reduction benefits
  • AE
  • drug interactions
  • patient preferents
178
Q

what is a reasonable LDL-C reduction goal when intensifying statin therapy?

A

at least 50% LDL-C reduction

179
Q

high-intensity statin therapy: 2 examples + what is the effect?

A

daily dose lowers LDL-C on average by greater than 50%

atorvastatin (Lipitor) 40 - 80mg
rosuvastatin (Creator) 20 - 40mg

180
Q

mod-intensity statin therapy: 5 examples + what is the effect?

A

daily dose lowers LDL-C on average by 30 - 50%

atorvastatin (Lipitor) 10 - 20mg
rosuvastatin (Crestor) 5 - 10mg
simvastatin (Zocor) 20 - 40mg
pravastatin 40 - 80mg
lovastatin 40 mg
181
Q

low-intensity statin therapy: 3 examples + what is the effect?

A

daily dose lowers LDL-C on average by less than 30%

simvastatin (Zocor) 10mg
pravastatin 10 - 20mg
lovastatin 20 mg

182
Q

atorvastatin (Lipitor): high, mod, + low intensity therapy doses

A

40 - 80
10 - 20
10

183
Q

rosuvastatin (Crestor): high, mod, + low intensity therapy doses

A

20 - 40
5 - 10
none

184
Q

simvastatin: high, mod, + low intensity therapy doses

A

none
20 - 40
10

185
Q

statins are aka

A

HMG-CoA reductase inhibitors

186
Q

bile acid sequestrants x3 examples + effects

A

mostly ↓ LDL + may ↑ trigs
cholestyramine (Questran)
colesevelam (Welchol)
colestipol (Colestid)

lipid mgmt for angina tx

187
Q

fibrates: indication x2 examples

A

lipid mgmt for angina tx

gemfibrozil (Lopid)
fenofibrate (Tricor)

188
Q

cholesterol absorption inhibitor: indication + effects + name one

A

lipid mgmt for angina tx
use in combo + statin to ↓ LDL
ex: ezetimibe (Zetia)

189
Q

niacin: indication + effects

A

lipid mgmt for angina tx
↓ LDL + trigs
↑ HDL

190
Q

angina: 5 classes of drugs used for lipid mgmt

A 
HMG-CoA reductase inhibitors (statins)
bile acid sequestrants
fibrates
cholesterol absorption inhibitors
niacin
191
Q

acute MI: diagnostics to order

A

EKG
cardiac enzymes (Trop-T, Trop-I, CK-MB)
echo
CBC (leukocytosis 10 - 20 on day #2)

192
Q

INR: normal

A

0.8 - 1.2 seconds

193
Q

activated coagulation time (ACT): normal

A

70 - 120 seconds

194
Q

aPTT: normal

A

28 - 38 seconds

195
Q

PT: normal

A

11 - 16 seconds

196
Q

PTT: normal

A

60 - 90 seconds

197
Q

Virchow’s Triad

A

3 factors thought to contribute to thrombosis

  • venous stasis
  • endothelial damage
  • hypercoagulable state
198
Q

superficial thrombosis: diagnostics

A

none

199
Q

superficial thrombosis: diagnostics x3

A

US
D Dimer
venography

200
Q

DVT: mgmt x5

A
  • bed rest + elevated leg until local tenderness subsides (7 - 14 days)
  • reintroduce walking gradually
  • lovenox 1mg/kg q12 –OR– heparin infusion 7 - 10 days
  • coumadin therapy 12 wks
  • consult when anticoag therapy initiated
201
Q

PVD: mgmt x9

A
  • tobacco cessation
  • exercise: walk 1 hr/day to develop collaterals
  • vasodilators: pentoxifylline (Trental), cilostazol (Pletal)
  • weight reduction
  • manage DM, hld
  • angioplasty
  • bypass surgery
  • amputation
202
Q

In patients with chronic venous insufficiency: intervention to diminish chronic edema

A

bed rest with legs elevated

203
Q

chronic venous insufficiency: diagnostics

A

non-specifically diagnostic of CVI

r/o edema d/t HF + others

204
Q

pericarditis: mgmt x5

A
  • NSAIDS: mainstay (ibuprofen or indomethacin)
  • corticosteroids ONLY when total FAILURE of high-dose NSAIDs over weeks + relapsing pericarditis (dexamethasone, prednisone)
  • abx if bacterial infection
  • codeine 15 - 60mg PO QID: for pain
  • monitor for tamponade
205
Q

When are corticosteroids indicated for use in the mgmt of pericarditis? Which 2?

A

Only after total failure of high-dose NSAIDs (tx mainstay) over several weeks and relapsing pericarditis. (They can increase viral replication.)

  • dexamethasone 4 mg IV: can relieve pain in a few hours
  • prednisone 60 mg daily, then taper
206
Q

endocarditis: causes x11

A

USUALLY BACTERIAL

  • known valvular heart disease: rheumatic, AV/MV prolapse with significant regurg
  • congenital heart disease
  • recent dental/oropharyngeal surgery
  • GU instrumentation
  • resp tract surgery
  • prolonged use of IV or TPN
  • burns
  • HD
207
Q

endocarditis: s/s

A

very vague

fever, malaise, night sweats, weight loss, general “sick” feeling IS THAT NOT MALAISE GEEZ

208
Q

endocarditis: PE findings

A
  • murmur: absent in 30%, esp with R sided endocarditis
  • fever: med - high
  • Osler’s Nodes
  • Splinter hemorrhages
  • Janeway Lesions
  • Roth Spots
  • petechiae, purpura, pallor
209
Q

endocarditis: diagnostics x4

A
  • WBC: normal or elevated + ALWAYS left shift + bands
  • echo
  • blood culture: determine causative organism (3 cx @ 3 diff sites in 1 hour)
  • ESR: always elevated
210
Q

How do you order blood cultures for an endocarditis patient?

A

get 3 cultures @ 3 different sites in 1 hour

211
Q

endocarditis: mgmt

A
  • hold abx until blood cx available: only if not acutely ill, no s/s HF or major embolic events

all other pts: start EMPIRIC ABX, options:

  • pcn G 2 million units IV q4 hrs + gentamicin
  • nafcillin (Unipen) 2g IV q 4 hrs
  • vanc: if pcn resistant strep + MRSA
212
Q

You have a patient who presents suspected endocarditis, a history of significant mitral valve prolapse who has developed flash pulmonary edema. In regards to endocarditis mgmt, what is your plan for antibiotic therapy?

A

3 options

  • pcn G 2 million units IV q4 hrs + gentamicin
  • nafcillin (Unipen) 2g IV q 4 hrs
  • vanc: if pcn resistant strep + MRSA
213
Q

What happens to heart size in older adults?

A

Increase is possible, r/t LV and LA hypertrophy.

214
Q

What happens to HR in older adults?

A

Intrinsic and max decrease, resting and CO unaffected

215
Q

What is one normal physiologic change that can lead to the development of orthostatic hypotension in older adults?

A

diminished cardiac reserve

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