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Chapter 7 & 14 - Cardiovascular Disorders Flashcards

1
Q

What are target organs and their outcomes in hypertensive target organ dysfunction?

A
  • Brain - Stroke, vascular (multi-infarct) dementia
  • Cardiovascular system - Atherosclerosis, MI, left ventricular hypertrophy, heart failure
  • Kidney - Hypertensive nephropathy, renal failure
  • Eye - Hypertensive retinopathy with risk of blindness
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2
Q

Lifestyle Modification recommendations for HTN and dyslipidemia

A
  • Weight reduction
  • DASH diet – high in fruits and veggies, low-fat dairy products; reduced fat
  • Dietary sodium reduction – reduce Na intake to < 2.4 g Na or < 6 g NaCl
  • Aerobic physical activity – moderate-vigorous activity at least 40 minutes 3-4x/week
  • Moderation of alcohol consumption - < 2 drinks/day for men, < 1 drink/day for women
  • All patients need to receive education on this
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3
Q

MOA of ACEs and ARBs

A
  • They are similar in the fact that they work with RAAS
  • ACE - Stop conversion of angiotensin I to angiotensin II (angiotensin II causes vasoconstriction and fluid retention)
  • ARB - Blocks the receptors where angiotensin II wants to bind
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4
Q

Medications for HTN and other cardiac medications – drug classes

A
  • Diuretic (thiazide)
  • ACE inhibitors
  • ARBs
  • Calcium channel blockers
  • Beta-blockers (not first-line for HTN)
  • Aldosterone antagonist (not first-line for HTN)
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5
Q

HTN Meds – diuretic (thiazide)

A
  • Examples: HCTZ (HydroDiuril), chlorthalidone (Hygroton)
  • How does it work: lowers PVR; BP = HR x SV x PVR↓
  • Na, K, and Mg depleting
  • Calcium-sparing: lower rates of fractures in women
  • Less effective in GFRs < 30 but Loops remain effective in lower GFRs
  • Works for all ethnicities
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6
Q

HTN Meds – ACE inhibitors and ARBs

A
  • Examples of ACEs: Lisinopril (Prinivil), enalapril (Vasotec), (-pril)
  • Examples of ARBs: Losartan (Cozaar), telmisartan (Micardis) (-sartan)
  • How do they work: lowers PVR; BP = HR x SV x PVR↓
  • K sparing: hyperkalemia risk with inadequate fluid intake, renal impairment, and when used with aldosterone antagonist
  • ACE-I induced cough – use ARB as alternative
  • ACE-I induced angioedema in ≤ 1% of population; risk factors = Black, Latino, hx of NSAID allergy
  • Per ADA, not priority HTN med in DM
  • Not nearly as effective in Black population
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7
Q

HTN Meds – Calcium channel blockers

A
  • Examples of dihydropyridine (DPH) CCBs: amlodipine (Norvasc), (-pine)
  • Examples non-DPH CCBs: diltiazem (Cardizem)
  • How do they work: lowers PVR; BP = HR x SV x PVR↓
  • Ankle edema, particularly in DPH CCBs, usually does-dependent
  • Avoid use or use with caution in HF, renal failure, or renal impairment
  • Works for all ethnicities
  • DPH CCBs are more for HTN; non-DPH CCBs are more for rate/rhythm control
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8
Q

HTN Meds – beta-blockers

A
  • Examples: atenolol (Tenoretic), metoprolol (Toprol, Lopressor), (-lol)
  • How does it work: lowers HR and SV; BP = HR↓ x SV↓ x PVR
  • Lower-dose cardioselective BB (propranolol, nadolol) usually okay in COPD and asthma
  • Not first-line for HTN
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9
Q

HTN Meds – aldosterone antagonist

A
  • Examples: spironolactone (Aldactone), eplerenone (Inspra)
  • How does it work: lowers PVR; BP = HR x SV x PVR↓
  • Gynecomastia risk with prolonged use
  • Hyperkalemia risk, especially with ACEs and ARBs, and in volume depletion
  • Not first-line medication d/t adverse effect profile
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10
Q

Classification of BP

A
  • Elevated: SBP 120-129 mmHg and DBP /<80
  • Stage 2 HTN: SBP ≥ 140 mmHg or DBP ≥ 90 mmHg
  • Hypertensive emergency: SBP < 180 mmHg and/or DBP > 120 mmHg
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11
Q

HTN Treatment Recommendations

A
  • Elevated: non-pharmacologic therapy, reassess BP in 3-6 months
  • Stage 2 HTN: non-pharm therapy and BP-lower meds – 2 first-line agents of different classes (thiazide diuretics (HCTZ), CCBs (amlodipine, diltiazem), and ACE (-pril) or ARB (-sartan)
  • Simultaneous use of ACE and ARB is potentially harmful and not recommended
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12
Q

Hypertensive Urgency vs. Emergency – pathophysiologic and s/s

A
  • Urgency: SBP > 180 mmHg and/or DBP > 120 mmHg; minimal or no acute target end organ damage, can be asymptomatic
  • Emergency: HTN (of any degree) with acute target end organ ischemia and damage – neuro (encephalopathy, strokes, papilledema), cardiovascular (ACS, HF, pulmonary edema, aortic dissection), renal (proteinuria, hematuria, acute renal failure)
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13
Q

Hypertensive urgency vs. emergency – general treatment recommendations

A
  • Monitor for ↓ urine output, ↑ creatinine, and ↓ mental status – may be an indication that lower BPs cannot be tolerated or that the BP is dropping too quickly
  • Tailor therapy based on etiology and clinical context
  • Urgency – lower BP over a few hours with ORAL antihypertensive agents, goal is to return BP to normal within 1-2 days
  • Emergency – ↓ MAP by approximately 25% within minutes to 2 hours with IV agents, consider arterial line, goal is a DBP < 110 within 2-6 hours as tolerated
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14
Q

IV therapy for hypertensive emergency

A
  • Nitroprusside 0.25-10 mcg/kg/min
  • Labetalol 20-80 mg IV push q10min or 0.5-2 mg/minute
  • Nicardipine 5-15 mg/hr
  • Nitroglycerin 5-1000 mcg/min
  • Esmolol 0.5 mg/kg loading dose then 0.05-0.2 mg/kg/min
  • Hydralazine 10-20 mg every 20-30 minutes
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15
Q

Oral therapy for hypertensive urgency

A
  • Captopril 12.5-100 mg 3x daily
  • Labetalol 200-800 mg 3x daily
  • Clonidine 0.2 mg loading dose then 0.1 mg every hour
  • *Trending to treat with normal antihypertensives, treating them like primary care HTN
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16
Q

Pathophysiology and etiology of CAD and MI

A
  • CAD develops d/t several factors causing endothelial damage and infiltration of fatty deposits:
  • Elevated LDL
  • Endothelial dysfunction
  • Vascular inflammation
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17
Q

Gender prevalence of CAD/MI

A
  • < 70 years of age – male:female ratio is 4:1

* ≥ 70 years of age – male:female ratio is 1:1

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18
Q

General medical management of CAD

A

• Centers around decreasing myocardial workload or increasing oxygen supply

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19
Q

Differentiate angina from MI

A
  • Change from typical angina pattern
  • Presence of associated symptoms
  • Characteristic ECG changes; regional abnormality
  • Troponin enzyme determinations
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20
Q

Common s/s of CAD or acute cardiac disease

A
  • Substernal chest pain (pressure) with a typical pattern of radiation, nausea/vomiting, SOB, and diaphoresis
  • Atypical presentations: women (chest pain is less common), diabetics (may not have chest pain, may have neuropathy), and heart transplant patients (severe the nerves so no chest pain); may also experience epigastric pain
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21
Q

CAD & Treatment: stable angina

A
  • Description: The earliest stages of clinically significant CAD
  • Symptom description: Symptoms typically occur with activity and is relieved with rest and/or nitrates
  • Diagnostic findings: No cardiac enzyme elevation, may see signs of ischemia on 12-lead (rare)
  • Treatment: Prophylactic therapy – lower lipids, nitrates, ASA, lifestyle modifications; outpatient testing, if indicated
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22
Q

CAD & Treatment: Unstable angina (UA)

A
  • Description: subtotal coronary thrombosis
  • Symptom description: Symptoms typically occur with activity and/or at rest and is not easily relieved with rest and/or nitrates (lasting < 30 minutes)
  • Diagnostic findings: No cardiac enzyme elevation, may have signs of ischemia on 12-lead (ST depression, TWI) during symptomatic episode
  • Treatment: same for UA and NSTEMI
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23
Q

CAD & Treatment: NSTEMI

A
  • Description: Subtotal coronary thrombosis with partial thickness infarction of myocardial wall
  • Symptom description: Symptoms typically occur with activity and/or at rest and is not relieved with rest and/or nitrates (lasting > 30 minutes)
  • Diagnostic findings: Cardiac enzyme elevation, signs of ischemia on 12-lead (ST depression, TWI)
  • Treatment: same for UA and NSTEMI
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24
Q

Treatment for UA and NSTEMI

A

• Treatment is the same for UA/NSTEMI (invasive vs. conservative strategy based on TIMI score)
• Nitrates (SL, PO, topical, IV)
• Beta blockers (PO), use IV if ongoing pain or HTN
o Use CCB if patient cannot tolerate BB secondary to bronchospasm
• ACE or ARB if HF or EF < 40% and SBP > 100
• Morphine for resistant symptoms or if pulmonary edema is present
• Oxygen (titrate to sat of > 90%)
• Aspirin (non-enteric coated) 162-324 mg (crushed) x1 dose then 81 mg PO daily
• ADP-receptor blocker (clopidogrel, prasugrel, or ticagrelor) in addition to ASA
• Heparin therapy, if admitted
• Cardiology consult

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25
Q

CAD & Treatment: STEMI

A
  • Description: total coronary thrombosis with full thickness infarction of myocardial wall
  • Symptom description: Symptoms typically occur at rest and is not relieved with rest, may improve with high doses of nitrates
  • Diagnostic findings: Cardiac enzyme elevation, signs of infarction on 12-lead (regional ST elevations)
  • Treatment: ASA 325 mg PO x 1 doss, nitrates SL or IV, beta blockade, antiplatelet therapy, heparin therapy, cardiac catheterization/PCI, fibrinolysis (if delayed PCI)
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26
Q

TIMI Scoring for UA/NSTEMI

A
  • Score 0-2: low risk

* Score 3-7: high risk

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27
Q

Fibrinolysis initiation guidelines

A

• Symptoms > 15 minutes but < 12 hours
• Delayed PCI
o Goal (if presenting to a PCI facility) is door to balloon < 90 minutes
o Goal (if presenting to a non-PCI facility) is door to balloon < 120 minutes
• If fibrinolysis therapy is chosen, the goal is < 30 minutes to hospital presentation

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28
Q

Indications for Fibrinolysis treatment in STEMI

A
  • ST-segment elevation > 0.1 mV in 2 or more leads
  • Chest pain and ST elevation not relieved by SL NTG
  • < 80 years old
  • Patient is AAO or a person who knows patient’s health history is present
  • There are no contraindications
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29
Q

Absolute contraindications to fibrinolysis in STEMI

A
  • Hx of any cerebrovascular event (ICH, intracranial neoplasm, aneurysm, AVM)
  • Non-hemorrhagic stroke or head trauma ≤ 3 months ago
  • Cranial or spinal trauma < 2 months ago
  • Known bleeding diathesis
  • Active internal bleeding
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30
Q

Acute Coronary syndrome post-hospital care per AHA

A
  • A – aspirin, anticoagulants, ACEI/ARB, aldosterone antagonist as advisable
  • B – beta blockers, BP control
  • C – cholesterol control, cigarettes (smoking cessation)
  • D – diet, diabetes control
  • E – education, exercise/increased physical activity
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31
Q

Regional ECG Changes in UA/NSTEMI/STEMI: septal

A
  • Leads: V1 and V2

* Coronary artery: proximal LAD

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32
Q

Regional ECG Changes in UA/NSTEMI/STEMI: anterior

A
  • Leads: V3 and V4

* Coronary artery: LAD

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33
Q

Regional ECG Changes in UA/NSTEMI/STEMI: apical

A
  • Leads: V5 and V6

* Coronary artery: distal LAD, LCx, RCA

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34
Q

Regional ECG Changes in UA/NSTEMI/STEMI: lateral

A
  • Leads: I and aVL

* Coronary artery: LCx

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35
Q

Regional ECG Changes in UA/NSTEMI/STEMI: inferior

A
  • Leads: II, III, and aVF

* Coronary artery: RCA or LCx

36
Q

Regional ECG Changes in UA/NSTEMI/STEMI: right ventricular

A
  • Leads: V1, V2, V4R

* Coronary artery: proximal RCA

37
Q

Regional ECG Changes in UA/NSTEMI/STEMI: posterior

A
  • Leads: ST depression V1 and V3; ST elevation V7-V9

* Coronary artery: RCA or LCx

38
Q

Acute Heart Failure Key Points: left vs. right-sided HF

A
  • Left – involvement of left ventricle, pulmonary symptoms most common (i.e., SOB, DOE, pulmonary edema, etc.)
  • Right – involvement of right ventricle, systemic symptoms most common (i.e., hepatosplenomegaly, edema, etc.)
39
Q

Acute Heart Failure Key Points: systolic vs. diastolic HF

A
  • Systolic – decreased forcefulness of contractions, decreased ejection fraction
  • Diastolic – inability of full relaxation, normal ejection fraction
40
Q

Acute decompensated HF: warm vs. cold; dry vs. wet

A
  • No congestion, good perfusion: dry and warm
  • No congestion, poor perfusion: dry and cold
  • Congestion, good perfusion: wet and warm
  • Congestion, poor perfusion: wet and cold
41
Q

General HF treatment strategies based off of congestion and perfusion

A
  • No congestion, good perfusion – outpatient treatment
  • No congestion, poor perfusion – inpatient treatment, inotropes
  • Congestion, good perfusion – inpatient treatment, diuresis
  • Congestion, poor perfusion – ICU admission, diuresis, inotropes, and/or vasodilators
42
Q

HF treatment for congestion: “LMNOP”

A
  • L – Lasix (give IV at 1-2.5x total daily PO dose, monitor UO)
  • M – morphine (for refractory symptoms like SOB and/or pleural effusion, decreases symptoms, causes vasodilation)
  • N – nitrates (causes vasodilation)
  • O – oxygen (decreases symptoms)
  • P – position (upright with legs over the side of the bed, decreases afterload)
43
Q

HF treatment for poor perfusion

A

• IV vasodilators [Nitroglycerin, nitroprusside (Nipride), nesiritide (Natrecor)]
• Inotropic agents [dobutamine, milrinone (Primacor)]
• Ultrafiltration
• Mechanical circulatory support
o IABP – inflates in diastole and deflates in systole → ↓ impedance of LV ejection, ↓ myocardial O2 demand, and ↑ coronary perfusion
o Ventricular assist device (LVAD and/or RVAD) – bridge to recovery or transplant
• Cardiac transplant (15-20% mortality after 1 year, overall 10-year median survival)

44
Q

ACC/AHA Stages of HF

A
  • Stage A – high risk of HF without the presence of structural changes or symptoms
  • Stage B – structural risk of HF without the presence of structural changes or symptoms
  • Stage C – structural risk of HF without the presence of structural changes or symptoms
  • Stage D – refractory HF, risk of HF without the presence of structural changes or symptoms
45
Q

NYHA Symptom Classification of HF

A
  • Class I – no limitations on physical activity and no overt symptoms
  • Class II – slight physical activity limitation. Comfortable at rest, but normal physical activity causes symptoms
  • Class III – marked physical activity limitation. Comfortable at rest, but less than normal physical activity causes symptoms
  • Class IV – unable to perform any activity without the presence of symptoms. Presence of symptoms at rest
46
Q

Pericarditis vs. Endocarditis: pericarditis

A
  • Inflammation of the pericardium
  • Usually d/t viral infection; wide variety of other causes include other infection, post-MI, autoimmune, uremia
  • Characterized by non-radiating, sharp, stabbing, knife-like chest pain over the PMI
  • Friction rub may be present
  • 12-lead ECG may reveal global concave ST elevations
  • Pain is relieved by leaning forward to relieve pressure from the pericardium
  • Symptomatic treatment with NSAIDs for mild forms; corticosteroids for more severe cases
47
Q

Pericarditis vs. Endocarditis: endocarditis

A
  • Inflammation of the endocardium
  • Caused by bacteria or fungi
  • Highest risk of patients include those with valvular disease and increased risk of pathogen introduction
  • Changing cardiac murmur is diagnostically significant but the exception rather than the rule
  • Physical exam typically reveals acutely septic patient
  • Additional findings may include Osler’s nodes, Janeway lesions, splinter hemorrhages
  • Treatment must include coverage of Gram+ organisms
48
Q

Cardiac Rehab Phases

A
  • Phase I – in hospital, getting out of bed, moving around
  • Phase II – at rehab facility, goal is to challenge the heart to work above baseline to get the heart stronger. Get HR above baseline but below level of ischemic change
  • Phase III – rest of life, healthy lifestyle
49
Q

Hydrostatic vs. oncotic pressure

A
  • Hydrostatic – pushes fluid into the interstitium from vasculature
  • Oncotic – pulls fluid from interstitium into vasculature
50
Q

Ankle-Brachial index (ABI) scores

A
  • ≤ 0.9: significant for peripheral arterial disease
  • 0.91-0.99: borderline PAD
  • 1.0-1.4: negative for PAD
  • > 1.4: test is no longer reliable
51
Q

What is the tamponade triad (Beck’s triad)?

A
  • Increased JVP
  • Distant, muffled heart sounds
  • Hypotension
52
Q

A 45-year-old male is sent from the local urgent care to the ER for a BP of 190/101. The patient complains of a headache. A 12-lead-ECG, lab studies including cardiac enzymes, and a physical exam are all unremarkable. Which of the following would be the most appropriate treatment for this patient?

a. Nitroprusside (Nipride) infusion and admit to ICU
b. Nifedipine 10 mg sublingual and discharge home
c. Captopril (Capoten) 25 mg PO and re-evaluate BP
d. Clonidine (Catapress) 0.4 mg PO and re-evaluate BP

A

c. Captopril (Capoten) 25 mg PO and re-evaluate BP

C is correct because: This is a hypertensive urgency, can treat with orals

A is incorrect because: Not appropriate, this is not a hypertensive emergency

B is incorrect because: this is an old recommendation

D is incorrect because: Old recommendation, unpredictable drug, too high of dose

53
Q

A 48-year-old female presents to the ER for evaluation and treatment of a 6-hour history of sudden-onset throbbing headache. She reports taking 2 prescription-strength doses of ibuprofen without improvement. She admits to not filling her antihypertensive prescription, and her BP is now 200/125. She is beginning to demonstrate some confusion and loss of alertness. On physical exam, you note a new S3 heart sound. The patient now reports SOB and on physical exam you note crackles in bilateral lung bases. Lab analysis is significant for an acute rise in the patient’s creatinine from her last ED visit. The next step in her care would be to administer:

a. IV nicardipine (Cardene)
b. IV digoxin (Lanoxin)
c. Oral labetalol (Normodyne)
d. Oral clonidine (Catapres)

A

a. IV nicardipine (Cardene)

A is correct because: this is a hypertensive emergency, need IV meds

B is incorrect because: this option doesn’t make sense

C is incorrect because: this patient needs an IV agent

D is incorrect because: this patient needs an IV agent

54
Q

Mr. Jones, a 52-year-old African American man with a hx of HTN and DM, was admitted to the hospital for pneumonia. As you are preparing his discharge you note the following lab values: A1C = 7.3%, GFR = 106. Physical exam findings including the following: BMI = 46.4, no S3, no S, no murmur, PMI at 5th ICS MCL. Funduscopic exam is WNL. He is currently taking a calcium channel blocker for the past 2 months to treat his HTN. His BP today is 160/94 mmHg bilaterally. The next step is to:

a. Add an ACE-I and have the patient follow-up with this PCP in 2 weeks
b. Discontinue the calcium channel blocker and start an aldosterone antagonist
c. Advise Mr. Jones that his BP is in an acceptable range and he should follow-up with his PCP in approximately 2 months
d. Prescribe a thiazide diuretic and advise a 1 month follow-up

A

d. Prescribe a thiazide diuretic and advise a 1 month follow-up

A is incorrect because: ACEs probably won’t be effective since he is African American

B is incorrect because: Don’t want to stop their current treatment

C is incorrect because: BP is not in acceptable range

55
Q

A 68-year-old female of Italian ancestry with no PMH was admitted for a chest pain evaluation, which was determined to be musculoskeletal in nature. The patient was in the hospital for 72 hours and was consistently hypertensive with a SBP range of 158-170 and a DBP range of 95-106. Recent lab analysis reveals the following: A1C = 5.3%, GFR = 98. Physical exam findings are as follows: BMI = 46.4, no S3, no S4, no murmur, PMI at 5th ICS MCL. Funduscopic exam is WNL. The patient was started on a thiazide diuretic during the admission, which as shown improvement in her BP. The patient is medically clear for discharge. Which of the following represent(s) the best discharge interventions? (select all that apply)

a. Start beta blocker therapy
b. Continue pharmacotherapy with a thiazide diuretic
c. Encourage weight reduction
d. Switch the thiazide diuretic to an ACE-I
e. Set up an appointment with the patient’s PCP to follow-up on discharge

A

b. Continue pharmacotherapy with a thiazide diuretic
c. Encourage weight reduction
e. Set up an appointment with the patient’s PCP to follow-up on discharge

B is correct because: it seems to be working so don’t stop it

C is correct because: you should always encourage lifestyle modifications

D is incorrect because: there is no indication to switch to an ACE

56
Q

Which of the following medications can be used in a patent with poorly-controlled HTN who asks, “What medications can I take when I have a cold?”

a. Dextromethorphan
b. Chlorpheniramine
c. Pseudoephedrine
d. Guaifenesin

A

d. Guaifenesin

57
Q

A 52-year-old male is 3 days post MI in the MICU. He has been complaining of chest pain and is convinced he is having another heart attack. He reports sharp, stabbing pains on the left side of his chest, starting about 30 minutes ago, that worsens with coughing or breathing deeply. The pain eases somewhat when he sits up and leans forward. On exam he is tachycardic, tachypneic, and normotensive. Additional findings will likely include:

a. Hypoxemia by ABG
b. ST depression in ECG leads I, II, and III
c. Non-specific ST elevations in all 12 leads
d. Elevated leukocytosis and fever

A

c. Non-specific ST elevations in all 12 leads

A is incorrect because: there is no reason for him to be hypoxemic

D is incorrect because: this fits more with endocarditis

58
Q

A 68-year-old patient with a history of an ischemic stroke 4 years ago presents with nausea, diaphoresis, and SOB. A 12-lead ECG is significant for new-onset ST depressions in leads I and aVL. A troponin is resulted at 1.2 ng/ml. Her BP is 160/88. Why is thrombolytic therapy currently contraindicated for this patient?

a. Age
b. Current BP
c. 12-lead ECG findings
d. History of stroke

A

c. 12-lead ECG findings

C is correct because: she has ST depressions, not elevations

59
Q

Which among the following is the most important unmodifiable risk factor for coronary artery disease?

a. Family history
b. Age
c. Dyslipidemia
d. Ethnicity

A

a. Family history

60
Q

Your patient is a 45-year-old male recovering from a STEMI. He is being referred to Phase II cardiac rehab. Exercise testing showed ischemic changes at a heart rate of 132. Resting heart rate is 82. What should his target heart rate be?

a. 80-100
b. 82-110
c. 105-150
d. 112-125

A

d. 112-125

A and B are incorrect because: the range doesn’t start above his 82 baseline

C is incorrect because: this range is higher than level of ischemic change

61
Q

A 61-year-old female with aortic stenosis is now experiencing syncopal episodes, which is most likely a result of:

a. Increased SVR
b. Decreased CO
c. Decreased PaO2
d. Decreased PAOP

A

b. Decreased CO

B is correct because: aortic valve isn’t opening and severe aortic stenosis can lead to a decreased CO

62
Q

Your 76-year-old male patient is in CHF NYHA Class III. The lower extremity edema he has is most likely a pathophysiologic result of:

a. Increase in oncotic pressure
b. Decrease in oncotic pressure
c. Increase in hydrostatic pressure
d. Decrease in hydrostatic pressure

A

c. Increase in hydrostatic pressure

C is incorrect because: this is d/t fluid overload which pushes fluid into the interstitial spaces

63
Q

A 62-year-old female patient is being managed on warfarin (Coumadin) therapy for emboli prophylaxis d/t her atrial fibrillation. Her PT is 29 seconds and INR 4.4. Your best action would be to:

a. Lower the warfarin dose
b. Continue the same dose
c. Have the PT rechecked in 1 week
d. Instruct the patient to take a daily high-dose vitamin K supplement

A

a. Lower the warfarin dose

A is correct because: the INR for atrial fibrillation should be 2-3

64
Q

Stasis dermatitis is a common complication of chronic venous insufficiency. For the patient with stasis dermatitis, your therapy should include:

a. No specific intervention other than observation
b. Bacitracin (Neosporin) and H2O2 irrigation
c. Elevate the leg and compression therapy
d. Topical triamcinolone

A

c. Elevate the leg and compression therapy

65
Q

Which of the following situations is a contraindication to ACE inhibitor use?

a. Mild-to-moderate renal insufficiency
b. Bilateral renal artery stenosis
c. Hepatic impairment
d. Concomitant treatment with an SSRI

A

b. Bilateral renal artery stenosis

66
Q

Your patient is s/p STEMI, day 3. He is a 50-pack-yaer smoker and has a hx of HTN. He is now complaining of pain in the hips and lower extremities with activity and a foot ulcer that is heeling poorly. The patient has cool lower extremities and describes paresthesia and an inability to feel soft touch in both lower extremities. The most appropriate diagnostic study for the patient to make a diagnosis would be:

a. An ankle-brachial-index (ABI)
b. A lower extremity ultrasound with Doppler
c. A CT scan of the head
d. A fasting lipid profile

A

a. An ankle-brachial-index (ABI)

A is correct because: the patient probably has PAD

67
Q

You are the NP on a cardiology service and precepting a first semester NP student. a patient requires statin therapy for HLD. When questioning the student about the goal for therapy, which of the following would indicate a correct response?

a. “The initial goal is to lower the overall cardiovascular risk.”
b. “The initial goal is to increase HDL”
c. “The initial goal is to decrease triglycerides”
d. “The initial goal is to decrease the total cholesterol”

A

a. “The initial goal is to lower the overall cardiovascular risk.”

68
Q

You are evaluating a 35-year-old female patient for severe body aches and discover the patient started a statin (HMG-CaA inhibitor) medication for HLD 2 weeks ago. The patient reports dark urine and a CK of 12,000 is noted. What is your priority intervention?

a. Order a loop diuretic
b. Order IV isotonic fluids
c. Review the BMP
d. Decrease the dose of the statin medication

A

b. Order IV isotonic fluids

B is correct because: the patient is experiencing rhabdo

C is incorrect because: this won’t do anything for the patient

D is incorrect because: we need to discontinue the statin

69
Q

A 16-year-old male patient presents toe the ED after sustaining blunt force trauma to the chest. Which of the following s/s would be most specific for recognizing cardiac tamponade? (select all the apply)

a. Elevated JVP
b. Dyspnea
c. Distant heart sounds
d. Hypotension
e. Bradycardia

A

a. Elevated JVP
c. Distant heart sounds
d. Hypotension

70
Q

A 50-year-old female patient presnts to the ER awake and alert with palpitations. Vitals signs are as follows: HR 220, RR 20, BP 110/86, POx 98% on RA. The NP notes the following rhythm: v-tach. The patient’s BP drops to 75/40, she is becoming increasingly lethargic and progresses to unresponsiveness. The priorty intervention is to:

a. Administer propofol 20 mg IV
b. Perform synchronized cardioversion
c. Administer amiodarone (Coradone) 150 mg IV
d. Perform cardiac massage

A

b. Perform synchronized cardioversion

71
Q

You are treating a patient in acute decompensated HF and determine that the patient needs positive-inotropic pharmacotherapy. When comparing dobutamine to Milrinone, which of the following does the AGACNP need to consider?

a. Dobutamine does not have a significant effect on the patient’s heart rate
b. Milrinone has the potential to cause significant hypotension
c. Dobutamine causes a decrease in myocardial oxygen consumption
d. Milrinone has a short half-life

A

b. Milrinone has the potential to cause significant hypotension

A is incorrect because: dobutamine increases HR

C is incorrect because: dopamine causes an increase in O2 consumption

D is incorrect because: milrinone has a long half-life

72
Q

The AGACNP is called to evaluate a 65-year-old male patient in acute decompensated HF. The patint initially presented with SOB and increasing lower extremity edema. At home he is on Lasix 20 mg PO twice daily, Lisinopril 10 mg PO daily, metoprolol succinate 25 mg PO daily, aspirin 81 mg PO daily, and metformin 500 mg PO daily. Lab studies reveal a BNP of 950, Na 133, K 3.7. Current vital signs are as follows: HR 115, RR 22, BP 147/98, POx 93% on RA. On physical exam you note a patient who appears mildly short of breath with warm skin and 4+ pitting edema in the lower extremities. Which of the following interventions would be most appropriate?

a. Lasix 40 mg IV
b. Lasix 80 mg IV
c. Milrinone 0.50 mcg/kg IV loading dose
d. Milrinone 50 mcg/kg IV loading dose

A

b. Lasix 80 mg IV

B is correct because: Patient is “warm and wet” – congested but good perfusion and so diuresis is treatment. Patient takes Lasix 20 mg twice daily PO (40 mg) which means we want to give twice the home dose = 80 mg

C and D are incorrect because: Patient doesn’t have signs of poor perfusion

73
Q

The AGACNP is called to the telemetry unit via a rapid response from a patient with an acute change in mental status. Upon arrival the AGACNP is notified that the patient was admitted for a syncopal episode last evening and during their morning evaluation the nurse noted an acute change in mental status and a weak central pulse. The patient has been in sinus bradycardia and you are provided the following rhythm strip: 3rd degree heart block. What would be the definitive treatment for this patient?

a. Transcutaneous pacemaker
b. Atropine 0.5 mg IV every 3-5 minutes
c. Transvenous pacemaker
d. Atropine IV infusion at 0.5 mg per hour

A

c. Transvenous pacemaker

74
Q

A 54-year-old female is brought to the ER after a suicide attempt. The patient reports she overdose on her beta blocker earlier today. The patient arrives with the following vital signs: HF 28, RR 14, BP 75/46, POx 99% on RA. The patient is pale, the skin is warm and dry, and the patient is awake, alert, and oriented. The ECG shows sinus bradycardia without ectopy. Which of the following interventions would the AGACNP order?

a. NS 1000 ml IV bolus
b. Protamine sulfate 40 mg IV push over 10 minutes
c. Atropine 3 mg IV push
d. Glucagon 50 mcg/kg IV push over 1 minute

A

d. Glucagon 50 mcg/kg IV push over 1 minute

D is correct because: this is the reversal agent for beta blockers

B is incorrect because: this is the reversal agent for unfractionated heparin

75
Q

What does a pathologic S3 heart sound signify?

A
  • Marker of ventricular overload and/or systolic dysfunction
  • For diagnosis of HF, must correlate it with additional findings like crackles, dyspnea, etc.
  • Findings can resolve with treatment of the underlying condition
76
Q

What does a S4 heart sound signify?

A
  • Poor diastolic function, often found in uncontrolled HTN or recurrent myocardial ischemia
  • Can resolve with treatment of the underlying condition
77
Q

What murmurs are systolic?

A
  • MR. ASS wins the MVP
  • Mitral regurg (holosystolic)
  • Aortic Stenosis Systolic
  • Mitral Valve Prolapse
78
Q

What murmurs are diastolic?

A
  • MS. ARD
  • Mitral Stenosis
  • Aortic Regurg Diastolic
79
Q

Characteristics of a physiologic/benign murmur

A
  • No cardiac history
  • Low grade
  • S1 and S2 are intact
  • No heave, thrill, or radiation beyond precordium
  • Normal PMI
  • Softens or disappears with supine to standing position change
80
Q

Characteristics of pathologic (non-benign) murmurs

A
  • Abnormal history
  • Higher grade
  • Radiation beyond precordium
  • S1 or S2 obliterated
  • Heave or thrill
  • Increased intensity with supine to standing position
  • Considered pathologic if any one of these characteristics are present; echo is next step in evaluation
81
Q

A 78-year-old woman with a 30-year history of HTN and dyslipidemia and a 10-year history of type 2 DM presents with suspected acute coronary syndrome. She is most likely to report a recent onset of:

a. Retrosternal chest pain with radiation to the left arm
b. Syncope
c. Unusual fatigue
d. Nausea and vomiting

A

c. Unusual fatigue

82
Q

Raymond is an 18-year-old high school basketball player. He is in for a sports clearance physical exam and denies activity intolerance, chest pain, and syncope. Today’s assessment reveals the following: 74” (188 cm), 220 lb. (99.8 kg), Tanner Stage 5. Both heart sounds intact, a grade 2/6 harsh systolic murmur with radiation to the neck, loudest along USB, softer towards axilla, somewhat softer with position change from supine to standing, no delay in carotid upstroke, other pulses intact. Raymond’s findings are most likely the result of:

a. Aortic stenosis
b. Aortic regurgitation
c. Mitral valve prolapse
d. Physiologic murmur

A

a. Aortic stenosis

B is incorrect because: aortic regurg is a diastolic murmur

C is incorrect because: mitral valve prolapse is best heard in the mitral region is not holosystolic

83
Q

Mrs. Rivera is an 82-year-old woman with infrequent contact with her HCP. She presents for a sick visit with the following chief complaint, “I get really dizzy when I walk up a flight of stairs.” She denies chest pain, agrees that she feels “a bit winded” when physically active; this symptom resolves quickly with cessation of trigger activity. Physical examination reveals the following: BP 110/90, grade 2/6 harsh systolic murmur with radiation to the neck, loudest along USB, softer towards axilla, both heart sounds preserved, no S3 or S4, no neck vein distention, no carotid bruit, delayed carotid upstroke (the carotid pulse should be felt essentially simultaneously with the S1 heart sound) . Her clinical presentation is most consistent with the presence of:

a. Mitral stenosis
b. Carotid artery dissection
c. Systolic heart disease
d. Calcific aortic stenosis

A

d. Calcific aortic stenosis

D is correct because: aortic stenosis is a systolic murmur and symptomatology is consistent with difficulty getting blood out of the heart

A is incorrect because: mitral stenosis is a diastolic murmur

B is incorrect because: this a true emergency situation

C is incorrect because: it is too general of a term

84
Q

Richard is a 62-year-old man with HTN, heart disease, or HF. He presents today for follow-up and is without new symptoms. Physical exam reveals the following: PMI @ 5th ICS AAL with a sustained impulse, grade 3/6 blowing holosystolic murmur with radiation to axilla. The murmur accentuated by rolling patient onto left side, softens when going from supine to standing position, louder with hand grip, 2nd heart sound not preserved, and full carotid upstroke bilaterally is noted. These findings are most consistent with:

a. Mitral valve prolapse
b. Aortic stenosis
c. Pulmonic stenosis
d. Mitral regurgitation

A

d. Mitral regurgitation

D is correct because: mitral regurg is systolic, radiates towards the axilla, and holosystolic is classic

A is incorrect because: the holosystolic characteristic is classic of mitral regurg

B and C and incorrect because: these murmurs would not radiate towards the axilla

85
Q

Jane is a 27-year-old woman who presents for a “pap test”. She is new to your practice, has no significant health history and reports excellent exercise tolerance, running up to 5 miles 5-7 days a week and recently was 1st place in her age division in a 6k road race. Jane reports taking a low-dose combined oral contraceptive and a daily multivitamin. Physical exam reveals a BMI 22.1 kg/m2, mild pectus excavatum (common in women with mitral valve prolapse), PMI WNL with both heart sounds intact. There is a mid-systolic click with late systolic murmur (this is classic mitral valve prolapse) and the murmur moves forward with position change from supine to stand. The rest of her physical exam is unremarkable. The next most appropriate step in her care is to:

a. Prescribe an antibiotic that she should take prior to dental work
b. Inform her that she should curtail her running program
c. Advise Jane that she should discontinue the use of a combined oral contraceptive immediately
d. Inform Jane that obtaining an echocardiogram is a prudent next step

A

d. Inform Jane that obtaining an echocardiogram is a prudent next step

D is correct because: need to make a diagnosis before going forward with a plan

A is incorrect because: people with MVP don’t need this

B is incorrect because: nothing in her hx tells us she has a dangerous cardiac condition

C is incorrect because: women with MVP can take birth control

86
Q

Jack is a 16-year-old varsity basketball player who presents for a sports clearance physical exam. His health history is unremarkable and reports excellent activity tolerance. Which of the following would be a finding on Jack’s cardiac exam that would warrant immediate evaluation?

a. A split second heart sound that increases on inspiration and closes on expiration accompanied by a PMI at the 5th ICS MCL
b. A grade 2/6 mid-systolic murmur that increases in intensity with position change from supine to standing accompanied by a loud S4
c. PMI with palpable single impulse at the 5th ICS accompanied by S1 louder than S2 at the apex
d. A grade 2/6 systolic murmur noted over the precordium without radiation that disappears with position change from supine to standing accompanied by S2 louder than S1 at the base – describing a physiologic murmur

A

b. A grade 2/6 mid-systolic murmur that increases in intensity with position change from supine to standing accompanied by a loud S4

B is correct because: a healthy teen should not have a loud S4

A is incorrect because: it is describing a physiologic split of the S2 and a normal PMI

C is incorrect because: this is a normal PMI

D is incorrect because: it is describing a physiologic murmur

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