cholesterol and HTN Flashcards
what is the normal total cholesterol?
< 200
we initiate statin therapy when the ASCVD risk is
> 7.5
normal triglyceride level
<150
normal HDL level
40-60 the higher the better
normal LDL
< 100
when is the routine time to do a lipid profile on a patient?
every 5 years unless risk factors are present even increased BMI is a risk factor
clinical signs of high cholesterol
Arcus senilis
Xanthelasma (younger people- more benign in elderly)
Arcus senilis
Arcus senilis is common in older adults. It’s caused by fat (lipid) deposits deep in the edge of the cornea. Arcus senilis doesn’t affect vision, nor does it require treatment.A person with arcus senilis may notice a white, gray, or blue circle or arc around the cornea of the eye. The circle or arc will have a sharp outer border
Xanthelasma
Xanthelasma is a harmless, yellow growth that appears on or by the corners of your eyelids next to your nose. Cholesterol deposits build up under your skin to form a xanthelasma. Having xanthelasmas could be a sign of another condition, such as: Diabetes
Before we do statins
simple lifestyle modifications
2 high intensity statins that we will use as go to treatment for hyperlipidemia
atorvastatin
rousouvastatin
at higher doses
signs and symptoms to be cautious with when people are starting statins
any new muscle pain or signs and symptoms of jaundice
what statin would we use for a patient who has an elevated cholesterol and whose dad died of a cardiovascular issue at 45?
A high-risk patient is definitely at risk for a cardiovascular event so we want to use a high
intensity statin for that type of patient.
If they have new muscle pain after starting a statin what might be going on?
Rhabdomyolysis
If we suspect Rhabdomyolysis what lab level we need to order?
A creatine kinase (CK) test measures the amount of creatine kinase in your blood. Elevated CK levels may indicate skeletal muscle, heart or brain damage or degeneration — either chronic (long-term) or acute (short-term). Other names for a creatine kinase test include: CK total. CK creatine.
In someone who is experiencing Rhabdomyolysis the CK level is going to be how high?
5 times the normal limit. So, we need to stop the statin.
What if the patient comes in with jaundice after starting a new statin? For that patient what lab would you draw?
That can definitely be
some acute drug induced hepatitis.
LFT’s
If a patient is in Rhabdomyolysis and we do not discontinue their statin, what might happen?
ACUTE RENAL FAILURE ***** (you absolutely need to know this)
Usually the KEY distinguishing symptom between possibly rhabdomyolysis and acute drug
induced hepatitis is what?
that we see that intense muscle pain with rhabdomyolysis specifically, we don’t usually see that with the hepatitis side.
What should a patient not ingest if they are taking a STATIN?
Grapefruit juice
What is a CK level?
A creatine kinase (CK) test measures the amount of creatine kinase in your blood. Elevated CK levels may indicate skeletal muscle, heart or brain damage or degeneration — either chronic (long-term) or acute (short-term). Other names for a creatine kinase test include: CK total. CK creatine.
What medication do we want to use if the trigylcerides are greater than 500?
Use Fenofibrate if triglycerides > 500
a normal level of triglycerides is
under 150, but if it’s greater than 500 what might happen in our patient?
Pancreatitis
After 500 they are pretty much at a high risk;
after 1000 it is almost inevitable that they will
develop pancreatitis.
What are those two possible clinical signs that we might see on a patient with necrotizing pancreatitis?
Cullen’s and Turner’s sign.
Cullen’s sign
Cullen sign is superficial bruising in the subcutaneous fat around the umbilicus. It has been described in acute pancreatitis, rectus sheath hematoma, splenic rupture, perforated ulcer, intra-abdominal cancer, and ruptured ectopic pregnancy, and as a complication of anticoagulation.
Turner’s sign.
Grey Turner sign is a discoloration of the left flank associated with acute hemorrhagic pancreatitis.
AHA guidelines states BP should be less than
130/80
Now, in the JNC8 guidelines we are going to initiate blood pressure medication management in
those who are older than 60 when their blood pressure is?
> 150/90.
For those less than age 60 or
have chronic kidney disease or DM the cut off for BP is going to be?
140/90.
ideally with any pt with
HTN we are still going to be doing what?
lifestyle modification,
home BP logs,
and then we can
advance into medication after that point.
Which Herbal Supplement is good for the heart?
Coenzyme 10 (CoQ-10)
modifiable risk factors
we can change
smoking
obesity
poor diet
sedentary lifestyle
non-modifiable risk factors
increasing age
african american
male
family history
new c/o HTN s/sx
need to be investigated
H/A
fatigue
vision changes
normal BP
<120/80
stage 1 HTN
130-139/80-89
stage 2 HTN
> 140 or > 90
why have HTN guidelines changed?
to try to prevent longterm side effects of HTN
What if pt is hypertensive when they come to office?
3-6 months of lifestyle modifications then come back
for further evaluation with BP log
stage 1 HTN 130-139/80-89 treat?
Assess ASCVD risk to determine whether to start medication.
if ASCVD > 10% (HTN has the word TEN) go ahead and treat that BP with antiHTN meds
Goal BP when treating HTN
< 130/80
No matter what BP is, we need to address what?
1 lifestyle changes
diet
exercise
smoking cessation
When we give BP meds, what are our go-to medications?
ACE inhibitors/ ARBs
thiazide diuretics
calcium channel blockers
What are our go-to meds for African Americans?
CCBs or thiazide diuretics
ACE inhibitors end in what?
pril
Side effects of ACE inhibitors?
Use during pregnancy?
Use with kidneys?
dry, hacking cough
possible angioedema (even after 10 years)
Risk for hyperkalemia- watch potassium
Nephroprotective for MOST patient
drug of choice for stage 3 kidney patients
May see a slight worsening of the kidney function- if > 30% increase in creatinine you should DISCONTINUE
CAT X during pregnancy
Thiazide diuretics examples
HCTZ
chlorathiadone
Thiazide diuretic side effects
May increase uric acid, triglycerides, and glucose
What are some patients that may not be able to take thiazide diuretics?
Gout patients
triglyceride patients
maybe diabetic patient
severe renal dysfunction with GFR< 30
Which thiazide diuretic decreases cardiovascular risk?
chlorothiadone
Which BP meds are wonderful for patients with osteoporosis?
thiazide diuretics because they are known to hold on to that calcium, and this is better for osteoporosis patients.
What are the classes of calcium channel blockers
There are two distinct chemical classes of CCBs: the dihydropyridines (such as nifedipine and amlodipine) and the nondihydropyridines (diltiazem and verapamil).
What if a patient comes to the office with two elevated BPs and they are already on a medication?
first assess COMPLIANCE to MEDICATION, did
they have side effects that they did not tell you about, did they stop taking the medication
on their own, do they forget to take it, are they taking it?
2- If they tell you they are taking it every day and they are very diligent about it, that is
when we start to investigate another med.
With ACE inhibitors what labs do we want to monitor in our patients?
Renal fxn (BUN, and
creatinine) and also look at POTASSIUM, since they will be at a risk of hyperkalemia.
What medication will we switch to if the patient experiences that life threatening effects of
angioedema with an ACE?
ARB (angiotensin receptor blocker) ex: losartan, valsartan.
Why do we always try to start patients on an ACE first?
because ACE inhibitors specifically have been found to decrease cardiovascular events and overall mortality.
ARBs do NOT.
Who should we avoid thiazides in?
think about those patients who will NOT benefit from an increase in triglycerides, increase in uric acid or an increase in glucose; anyone having issues
with those things, probably will not be an ideal candidate for thiazides.
What comorbidity are thiazides great for?
OSTEOPOROSIS because they stimulate
those osteoblasts to make bone and they also help the body retain more calcium.
Calcium Channel Blockers; who do we want to avoid from getting these meds?
GERD patients because that vasodilation of the CCB relaxes that lower esophageal sphincter, which
allows for that stomach acid to come up out of the stomach easier, so all of their symptoms will
be worsened.
When do we use beta blockers for HTN patients?
Beta Blockers are NOT a first line medication treatment, but can be used if a person has had an
MI or something like that.
What BP med do we prefer in African Americans?
Thiazides and CCBs.
*** With CCB, what signs and symptoms do we see the patient coming complaining of ?
Ankle
edema and headache ***
For HTN what should we look for in the eyes?
we should look for Copper wire arteries and AV nicking
Copper wire arteries is when arteries begin to look red and copper in nature
AV nicking is when an artery crosses a vein and it causes it to bulge
** both of these are caused by HTN so ideally, we need to strictly control their blood pressure
and ensure it is being managed.
We can also see flame hemorrhages specifically with HTN.
Cooper wiring and AV nicking- what are these and where are they?
Silver wiring or copper wiring is where the walls of the arterioles become thickened and sclerosed causing increased reflection of the light. Arteriovenous nicking is where the arterioles cause compression of the veins where they cross. This is again due to sclerosis and hardening of the arterioles.
flame hemorrhages
Flame hemorrhages are a subset of retinal hemorrhages occurring within the retinal nerve fiber layer. They are typically in diseases affecting superficial retinal capillary plexus secondary to arterial diseases like hypertension, blood dyscrasias, and anemias.
occipital headache
typically occurs upon awakening,
This is a HYPERTENSION headache. Tx; give antihypertensives or if they are already on them
then adjust doses.
What are the three medications in pregnant women for BP control?
“New Little Mama” mnemonic
* Nifedipine
* Labetalol
* Methyldopa
Meds that are Category X in pregnant women?
ACEs and ARBs
Statins
DMARDs (methotrexate)
HLD verses HTN with ASCVD risk
HTN ASCVD> 10% HTN has the word ten in it
HLD ASCVD> 7.5%
What is out “go-to” medication for patients that have HTN and DM?
ACEs and ARBs because these meds are renal protective and we also know that HTN and DM
are the two leading causes of Kidney disease.
A patient with HTN and diabetes will likely
have metabolic syndrome as well and so what medication are we not going to give this patient?
Thiazides because we know thiazides can increase glucose levels and our patient already has
diabetes, so is definitely not a good choice.
Two leading causes of chronic kidney disease?
HTN and DM
Why is it that the elderly population is so prone to developing HTN ?
as people grow older their
arteries begin to stiffen and there is less elasticity which makes it a lot easier for HTN to
develop.
If a patient has isolated systolic HTN, what is the preferred BP med for this condition?
Calcium
channel blockers.
What is going on with our patient if there is a variance in their heart rate between inspiration and expiration?
This is called Respiratory Sinus Arrhythmia. In what patients do we normally see this? Young
healthy athlete. Is this going to be something that needs further intervention and treatment?
NOPE
What about pulsus paradoxus?
Pulsus paradoxus is when there is a 10 pnt drop in the systolic blood pressure upon inspiration. This usually indicates that there is something going on.
Pulsus Paradoxus we are thinking Cardiac Tamponade, Status Asthmaticus, something serious
is going on and we need to investigate it and treat it.
What are some diagnostic tests we could do for CHF?
We can do a BNP (lab),
EKG
echocardiogram.
What is the ejection fraction going to be on an echocardiogram if a patient has heart
failure?
There is a little bit of a grey area here between 40-50% but definitely anything lower
than 40% EJ = HEART FAILURE.
What are some medications Heart Failure patients might be on?
Diuretics (Lasix), blood pressure meds, potassium
replacement.
Difference between left-sided and right-sided heart failure?
In left-sided heart failure, the left side of the heart is weakened and results in reduced ability for the heart to pump blood into the body. In right-sided heart failure, the right side of the heart is weakened and results in fluid in your veins, causing swelling in the legs, ankles, and liver.
What if the patient has diabetes, HTN, and HF, what meds would you give ?
ACE, Beta Blocker
in the right patient.
What if a Heart Failure patient is on diuretics, and potassium supplements when they left the
hospital after having an exacerbation and all of a sudden, a few wks later they show up with an
exacerbation again and its only been like 2 wks?
This is another time where we need to do an
investigation and make sure they are taking their medications like they were actually prescribed.
Then, after that, if they were taking it like they were supposed to, that is when we start
manipulating the medications and doses.
If your HF patient gains how much weight? in how much time? when should they report it to
you?
2 kg in one day. They need to go ahead and call you so that you can go ahead and increase
the diuretic and maybe increase the potassium along that.
What is going to be an extra heart sound that we hear in fluid overload?
S3 is heard in heart failure
When is another time in the lifetime where we have a lot of extra fluid circulating around and we
might hear S3 as well?
Pregnancy
What diabetes medication should be AVOIDED at ALL COST in a Heart failure patient?
TZDs (thiazolidinediones) (pioglitazone, actos) because they cause EDEMA and our HF patient’s already have way too much fluid and edema.
What about an OTC medication a heart failure patient should avoid?
NSAIDs because they will increase sodium and fluid retention and we don’t want to throw the patient into
an exacerbation again.
HTN treatment for patients with
Asthma ?
- Ace Inhibitors are generally safe.
- Avoid Beta blockers.
HTN treatment for children?
ACE inhibitor or a CCB but there is more research with ACE thus first choice.
Which murmurs are pathologic?
Murmurs and abnormal heart sounds may be detected on physical examination. Although systolic murmurs are often “innocent” or physiologic, diastolic murmurs are virtually always pathologic.
Afib
atria are quivering
What are Afib patients at risk for?
bloodclot
What meds to Afib patients need to be on?
anticoagulent
Afib rhythm
ireegularly irregular- no Pwave
What medication can you give to your afib patient for rate control?
metoprolol
What rhythm strip is most often tested?
Afib
warfarin
anticoagulant that can be given for Afib
What lab do we look at to see if Warfarin is effective?
INR
Normal INR not on anticoagulant?
approximately 1
In a patient taking warfarin, what do we want with their blood and their INR?
We want their blood to be a little thinner because of their afib so the ideal INR should be 2-3
How can you think about INR?
The higher the INR the thinner your blood is.
What is the antidote to warfarin?
Vitamin K
When do you know to administer vitamin K to warfarin patients?
If they are actively bleeding and what their INR actually is
Where is the base and apex of the heart?
Base is at the top and apex is at the bottom
mneumonic to remember heart valves
all people take money
All people take money
aortic pulmonic tricuspid mitral
when do we hear S1 heart sound?
Closure of AV valves mitral and tricuspid
AV valves
mitral and tricuspid
when do we hear S2 heart sound?
Closure of semilunar valves aortic and pulmonic
semilunar valves
aortic and pulmonic
When do we hear S3 sounds?
extra fluid heart failure
pregnancy
When do we typically hear an S4 heart sound?
uncontrolled HTN
left ventricular hypertrophy
What if we hear a split S2 during inspiration and expiration?
REFER REFER REFER
The only time a split S2 is normal is?
when you can only hear it during inspiration
What heart sound will we hear at the base?
S2
Where would you hear S1 and the additional sounds?
At the apex
Two types of murmurs
systolic and diastolic
- Diastolic murmurs =
Doom and need to be REFERRED
- Only murmurs that radiate are
systolic murmurs
which are
Mitral regurgitation
aortic stenosis
mitral valve prolapse
Diastolic murmur mneumonic
MS. ARD
Mitral stenosis
aortic regurgitation diastolic
what are our diastolic murmurs?
mitral stenosis
aortic regurgitation
DOOM
systolic murmur mneumonic
MR. PASS MVP
Mitral regurgitation
physiologic
aortic stenosis systolic
mitral valve prolapse
where does aortic stenosis radiate to?
neck
*Where does mitral regurgitation radiate?
armpit
What is special about mitral valve prolapse?
A systolic murmur in which we hear a click
When is mitral valve prolapse with a click commonly seen?
Marfan’s syndrome
What grade of murmur are we going to feel a palpable thrill?
Grade IV or higher
A patient comes in and legs are purple and shiny, they have decreased blood flow, they tell you that pain is relieved with rest and dangling, and they have this ulcer on their toe. What is going on here?
This is PERIPHERAL ARTERIAL DISEASE.
Pain with activity that is relieved with rest is called?
Intermittent claudication
Treatment when people have intermittent claudication?
we will have these patients to try their very best to continue walking and just taking breaks as needed for their Peripheral Arterial Disease.
How do we diagnose Peripheral arterial disease?
We do an ABI (Ankle brachial index)
What score on and ankle brachial index indicates peripheral arterial disease?
Less than 0.9
How is that ABI calculated?
Individually for each leg. Divide the blood pressure in the artery in the ankle by the blood pressure in the artery in the arm.
What is going to be are absolute biggest risk factor for peripheral arterial disease?
smoking
WE got reddish brown discoloration in the patient’s skin of lower extremities, looks edematous,
= Chronic venous insufficiency.
In a patient with Chronic venous insufficiency what are they at biggest risk for?
CLOTS (DVt)
Well with Chronic Venous Insufficiency we do not have that good venous return back to the heart anymore, and then the blood starts to pool.
So, if we see Chronic venous insufficiency symptoms or varicose vein, who will we refer to?
Vascular
When we suspect a deep vein thrombosis, what will it look like? signs and symptoms?
Localized swelling at the site, localized erythema, a lot of type they come in with that stereotypical calf pain;
DVT dx
VENOUS DOPPLER or a D-dimer but doppler is the best option.
What if they have all the stereotypical signs of a DVT but a negative HOMAN sign, are we still going to do a venous doppler?
ABSOLUTELY, because Homan sign is no longer specific enough.
Raynaud’s phenomenon
This is a disorder that causes decreased blood flow to the fingers,
what usually leads to this Raynaud’s phenomenon?
Typically, exposure to cold and stress
how is Raynaud’s typically treated?
Usually with Calcium channel blockers is an option and definitely we want out patient to avoid any known triggers as well.
Virchow’s Triad is what and tells what?
DVT….
Alterations in blood flow/stasis of flow
Vascular injury/intravascular vessel wall damage
Presence of a hypercoagulable state
Dx of DVT
US extremities
Inability to compress venous segment
Risk factors of DVT
Immobility
Travel (esp, > 4 hours)
Pregnancy/post-partum
OCP/Hormone therapies
Smoking
Assessment of DVT
Pain, warmth, erythema
Unilateral edema
Homans sign (not always reliable)
Treatment of DVT
Hospitalization
Assess bleeding risk prior to beginning treatment
Initial treatment: subq or parenteral anticoagulation
* Heparin
* Overlap with an oral anti-coagulation agent for at least 5 days
* Avoid Coumadin in pregnant patients
Patient will remain on oral anti-coagulation for 3-12 months
Use compression stockings for 1-2 years
F/U in office
papilledema-
swelling of the optic nerve can be seen in HTN
- Lifestyle modifications-1st Line of treatment for HTN
Weight reductions (10-20 lbs)
* BMI > 25=Overweight; BMI >30 = Obese
DASH (Dietary Approaches to Stop Hypertension) eating plan
* Fruits, veggies, whole grains, low-fat dairy products, lean meats, reduced fat, foods higher potassium, calcium and magnesium
Sodium restrictions (< 1500mg /day)
Increase potassium intake (3,500-5,000 mg/day)
Physical activity (90-150 minutes/week)
Alcohol: limit to 1 drink/day (women), 2 drinks/day (men)
Stress reduction
Non-dihydropyridine CCBs
o Ex-Diltiazem
o BP control and renal protection
o can reduce HR
o D/t blocking of calcium (which allows for muscle contractions), pts may experience urinary incontinence
o Inhibits the movement of calcium ions across the cell membrane and vascular smooth muscles; this depresses myocardial contractility and increases
- Dihydropyridine (“-pine”) CCB’s
o Ex-amlodipine
o *1st line treatment for African Americans (along with thiazide diuretics)
o A potent vasodilator
o Useful in patients with stubborn hypertension
o Side effect: May have lower extremity and pedal edema
o do not use in patients with heart failure
o Inhibits the movement of calcium ions across the cell membrane and vascular smooth muscle; This depresses myocardial contractility and increases cardiac blood flow
o does not cause bradycardia
o monitor for hypotension and worsening of heart failure or ankle edema
assessment of DVT
- Assessment
Pain, warmth, erythema
Unilateral edema
Homans sign (not always reliable)
risk factors of DVT
- Risk factors
Immobility
Travel (esp, > 4 hours)
Pregnancy/post-partum
OCP/Hormone therapies
Smoking
Dx of DVT
- Dx
US extremities
Inability to compress venous segment
treatment of DVT
- Treatment
Hospitalization
Assess bleeding risk prior to beginning treatment
Initial treatment: subq or parenteral anticoagulation - Heparin
- Overlap with an oral anti-coagulation agent for at least 5 days
- Avoid Coumadin in pregnant patients
Patient will remain on oral anti-coagulation for 3-12 months
Use compression stockings for 1-2 years
F/U in office
Aortic Stenosis
Obstruction of blood flow across the aortic valve
Aortic Stenosis risk factors,
Risk factors: HTN, high cholesterol, smoking
Aortic Stenosis signs, symptoms,
S/S: Angina, dizziness/syncope, dyspnea, fatigue, palpitations
* Physical findings: Murmur, Heaving PMI below MCL, slowly rising carotid pulse, split S2, prominent S4; pt resting, leaning forward, breath held in full expiration; CXR=LVH
Aortic Stenosis treatment plan
Treatment: NO vasodilators; surgery (TAVR)
- Mitral regurgitation
Backflow of blood through the mitral valve due to damage to the valve/supporting structures
* Can lead to LVH
Mitral regurgitation risk factors,
Risks factors: endocarditis, Rheumatic fever, myocarditis, mitral valve prolapse
Mitral regurgitation signs, symptoms,
S/S: Murmrs, dyspnea when lying, edema, palpitations, exercise intolerance; can be asymptomatic for 10 years; leads to LVH and HF
Mitral regurgitation treatment plan
Treatment: ACEI, Beta-blockers, surgery
- Mitral valve prolapse
When the left AV valve does not function properly causing the valve to bulge into the atrium; sometimes causing back flow of the blood into the atrium
Mitral valve prolapse risk factors,
Risk factors: genetic, connective tissue diseases (MD, Graves, Marfan’s, Ehlers-Danlos)
Mitral valve prolapse signs, symptoms,
S/S: dizziness, fatigue, chest pain, Murmur
Mitral valve prolapse treatment plan
Treatment: ASA, Beta-blockers, or surgery (pig valves)
Myocardial infarction signs, symptoms,
S/S: chest pain unrelieved by rest, heaviness, pressure, jaw/back pain, dyspnea, fatigue
Myocardial infarction treatment plan
Treatment: NTG, ASA, Beta blockers, TPA, cath
* After MI, pts should be on: antiplatelets (ASA/Plavix), Statin, Beta blocker, ACEI
PAD (peripheral arterial disease)
Ex: stenosis or occlusion of the arteries in the limbs that impedes blood flow
* Lower extremities occur more commonly than the upper extremities
Peripheral artery disease Dx
DX-Resting ankle-brachial index (ABI)
Ratio of ankle systolic BP/brachial systolic BP
Measured using a doppler probe
Normal= >0.9-1.3
Gold standard for diagnosing= contrast angiography/PCTA
PAD risk factors and education
Risks factors: smoking, diabetes, obesity, metabolic syndrome, age
Encourage lifestyle modification (75% patients will improve with this)
Encourage exercise (strengthens collateral vessels)
* Walk 3 x week
Avoid salts and animal fats (encourage vegetarian)
PAD signs, symptoms,
Hallmark signs:
*Pain in legs after walking/exercise/stairs (intermittent claudication)
*Relief with rest
Lack of hair growth on legs
Pale, cool extremities
Thickened toenails
Dependent rubor (erythema or discoloration of lower limbs)
Diminished pulses
Peripheral artery treatment plan
- Pharm management
*ASA, Plavix, *Pletal (vasodilator) - effectiveness of PLETAL is increased with exercise
- Avoid ASA/Plavix in patients with GI bleeds
- Refer to vascular surgeon
Persistent symptoms
Limb Ischemia
Non-healing ulcer
- Which blood pressure medications should be avoided in asthmatic patients?
- Beta blockers can cause airway narrowing
creatine vs creatinine
Creatine exists in a steady state with a similar compound named creatinine that can be measured in lab tests as a marker of kidney function. It is passed out of your body in the urine. This means your body must release stored creatine each day to keep normal levels, the amount depending on your muscle mass.
arterial and venous insufficiency
Despite their similar symptoms and characteristics, arterial and venous insufficiency are actually quite different. A breakdown in blood flow causes vein insufficiency, while poor circulation causes arterial insufficiency. In addition, venous insufficiency can cause swelling near the ankles and lower legs. The hallmark presentation of acute ischemia suggestive of limb jeopardy include the 5 P’s: pain, paralysis, pallor, paresthesia, and pulselessness.
