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Block 3 - Cardio > Clin Med - Cardio 1 > Flashcards

Clin Med - Cardio 1 Flashcards

1
Q

What is systolic pressure?

A

arterial pressure when the LV contracts

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2
Q

What is diastolic pressure?

A

arterial pressure when the LV relaxes

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3
Q

What is primary essential HTN?

A

combo of genetic & environment factors
- no specific underlying cause

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4
Q

What is secondary HTN?

A

identifiable underlying cause

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5
Q

Examples of causes of secondary HTN

A
  • genetic
  • kidney dz
  • primary hyperaldosteronism
  • Cushing syndrome
  • pregnancy
  • estrogen use
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6
Q

Complication of untreated HTN

A
  • hypertensive CV dz (HF)
  • hypertensive cerebrovascular disease (stroke)
  • hypertensive kidney dx (kidney failure)
  • Aortic dissection
  • Atherosclerotic complications (MI)
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7
Q

Describe how untreated HTN causes hypertensive cardiovascular dz (HF).

A

heart contracts against increased pressure; heart gets fatigued

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8
Q

Describe how untreated HTN causes hypertensive kidney dz (KF)

A
  • kidneys are constantly under high pressure
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9
Q

Define primary essential HTN

A

sustained elevation of systemic arterial BP

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10
Q

What values are commonly defined as primary essential HTN?

A
  • SBP >/= 130mmHg
    and/or
  • DBP >/= 80mmHg
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11
Q

What is the onset age of primary essential HTN?

A

20-50 yo, but prevalence increases w/ age

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12
Q

Percentage of HTN that is primary essential

A

90-95%

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13
Q

Gender prevalence of primary essential HTN

A

Men (50%) > Women (44%)

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14
Q

What region of the US have primary essential HTN?

A

Southeast

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15
Q

RFs for HTN w/ good evidence

A
  • high-normal BP
  • elevated BP during medical care
  • obesity & weight gain
  • alcohol uses
  • FHx
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16
Q

Possible RFs for HTN w/ limited evidence

A
  • elevated urinary Na+ excretion
  • high red meat intake
  • Hx of kidney stones
  • psoriasis
  • frequent analgesic use
  • OCP
  • increased lead levels
  • sleep duration ≤ 5 hours/night
  • hostility & anger traits
  • low occupational status
  • increased dietary phosphate
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17
Q

Primary essential HTN pathophys

A

Increased sympathetic nervous system output
- B1 receptors in heart
- A1 receptors in BVs
- JG cells in kidney

Age effect on kidneys
Increased Na+/Na+ retention

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18
Q

Explain how B1 receptors in the heart affect BP

A

Incr epi/norepi output–> incr HR/contractility–> incr SV–> incr BP

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19
Q

Explain how A1 receptors in the BVs affect BP

A

causes vasoconstriction which incr BP

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20
Q

Explain how JG cells in the kidney affect BP

A

release renin–> angiotensin system–> incr BP

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21
Q

Explain how age effect on the kidneys affects BP

A

incr collagen–> makes vessels less compliant

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22
Q

Explain how increased Na+/Na+ retention affects BP

A

water follows Na+–> incr BV–> incr BP

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23
Q

Is primary essential HTN usually symptomatic or asymptomatic?

A

asymptomatic

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24
Q

What percentage of US adults are unaware of HTN?

A

30%

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25
Q

What prescription & OTC meds may cause HTN?

A
  • Antidepressants
  • Amphetamines
  • Corticosteroids
  • Contraceptives
  • Cocaine
  • Decongestants (pseudoephedrine)
  • Methamphetamines
  • NSAIDS* metabolized in kidneys
  • St. John’s wart
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26
Q

Medical conditions that can cause HTN.

A
  • hyperthyroidism
  • renal dz
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27
Q

Other cardiac RFs

A
  • DM
  • CAD
  • HF
  • Obesity
  • Hyperlipidemia
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28
Q

True or False: FHx can play a role in the development of HTN.

A

True

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29
Q

Social RFs pertaining to primary essential HTN

A
  • dietary habits
  • stress
  • smoking
  • alcohol intake
  • activity level
  • drug use such as cocaine
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30
Q

Primary Essential HTN: Eye PE

A

hypertensive retinopathy

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31
Q

Primary Essential HTN: Neck PE

A
  • carotid bruits
  • thyroid enlargement (hyperthyroidism)
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32
Q

Primary Essential HTN: Cardiac PE

A
  • PMI displaced laterally in LV hypertrophy
  • S4 (one of the earliest PE findings of HTN, if physical finding are present)
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33
Q

What is one of the earliest physical findings of HTN, if physical finding are present?

A

S4

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34
Q

Primary Essential HTN: Abdomen PE

A
  • AAA
  • Abdominal bruits (suggest renovascular HTN)
  • Hepatomegaly
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35
Q

What does AAA stand for?

A

Abdominal Aortic Aneurysm

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36
Q

UpToDate/ACC BP screening recommendations

A

At minimum
- adults w/ normal BP should have reassessment every year

  • adults should be evaluated every 6 months if they have RFs for HTN or their previously measured SBP was 120-129
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37
Q

APP recommendation for pediatric BP screening

A

screen all pts for HTN annually & high RF pts at each visit beginning at 3yo

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38
Q

Key steps for proper BP measurements

A
  1. Properly prepare the patient
  2. Use proper technique for BP measurements
  3. Take the proper measurements needed for dx & tx of elevated BP/HTN
  4. Proper documentation
  5. Average the reading
  6. Provide BP readings to patient (verbal & in writing)
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39
Q

What is the gold stand for BP measurement?

A

ambulatory BP monitor

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40
Q

In adults, use ___ BP readings on __ occasions meeting threshold definition for SBP and/or DBP

A

> /= 2
/= 2

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41
Q

If suspicion of white coat HTN, what do you do?

A

can use ambulatory BP monitoring

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42
Q

Normal BP

A

SBP < 120
and
DBP <80

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43
Q

Elevated BP

A

SBP: 120-129
and
DBP: <80

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44
Q

High BP (HTN Stage 1)

A

SBP: 130 -139
or
DBP: 80 - 89

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45
Q

High BP (Stage 2)

A

SBP: 140 or higher
or
DBP: 90 or higher

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46
Q

Hypertensive Urgency

A

SBP: higher than 180
and/or
DBP: higher than 120

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47
Q

Reasons to do initial testing when dx stage 1 HTN

A
  • to look for any underlying causes of BP
  • look for additional cardiac RFs
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48
Q

Primary Essential HTN: Initial testing Labs

A
  • electrolytes (Ca+) & serum Cr (for GFR)
  • fasting glucose
  • UA
  • CBC
  • TSH
  • Lipid profile
  • EKG
  • Calculate 10-year atherosclerotic CVD risk
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49
Q

What does EKG finding is indicative of HTN?

A

LV hypertrophy

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50
Q

If unusual presentation or very young/very old pt or suspected 2ndary HTN: what additional things do you order?

A
  • echo (assess EF)
  • Renal US
  • Test for renal artery stenosis
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51
Q

Why order labs initially for primary essential HTN?

A
  1. look for any underlying causes of high BP
  2. look for additional cardiac RFs
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52
Q

Lifestyle changes that can tx HTN.

A
  • weight reduction
  • DASH eating plan
  • Na+ reduced
  • Exercise
  • Alcohol reduction
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53
Q

What does DASH stand for?

A

Dietary Approach to Stop HTN

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54
Q

Recommended Na+ amount/day

A

<2000 (<1500)

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55
Q

Who should be treated w/ meds for primary essential HTN?

A
  • out-of-office BP >/= 135 and/or >/= 85
  • average office BP >/= 140 and/or >/= 90 if out-of-office readings are not available
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56
Q

Primary Essential HTN: Should be given meds if; >/=130 and/or >/=80 who have 1 or more of the following features?

A
  • established clinical CVD
  • Type 2 DM
  • Chronic kidney dz
  • Age 65yrs or older
  • estimated 10-year risk of atherosclerotic CVD of at least 10%
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57
Q

What is considered an established clinical CVD?

A
  • any CAD
  • HF
  • any kind of carotid dz
  • previous stroke
  • known PAD
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58
Q

Describe the incidence reduction of treated HTN for HF, stroke, MIs.

A
  • HF reduction: 50%
  • Stroke reduction: 30-40%
  • MIs reduction: 20-25%
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59
Q

What is the goal BP w/ treatment?

A

< 130/80

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60
Q

Stage 1 HTN: initiate one drug. List them

A
  • angiotensin-converting enzyme (ACE) inhibitor
    -    angiotensin receptor blocker (ARB)
  • Ca+ channel blocker
  • Thiazide diuretic
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61
Q

Which drugs are considered 1st line tx for stage 1 HTN?

A
  • ACE inhibitor
  • Angiotensin receptor blocker (ARB)

NEVER GIVE THESE IN COMBONATION

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62
Q

Stage 2 HTN: initiate 2 drubs (combo preferred)

A
  • ACE + CCB preferred, but some patients may benefit from a thiazide diuretic
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63
Q

What is resistant HTN?

A

the failure to reach blood pressure control in patients who are adherent to full doses of an appropriate three-drug regimen

  • start to think about 2ndary HTN
64
Q

What are the two types of hypertensive crisis?

A
  • hypertensive urgency
  • hypertensive emergency
65
Q

What is hypertensive urgency defined as?

A

> 180 systolic and/or 120 diastolic

  • no end organ damage, may have a HA (exclude end organ damage w/ PE & labs
66
Q

How do you lower hypertensive urgency?

A

over hours to days

67
Q

What is the initial target for hypertensive urgency?

A

<160/100, then further reduction

68
Q

Commonly used fast acting drugs:

A
  • Clonidine
  • Captopril
  • Nifedipine
69
Q

What is hypertensive emergency defined as?

A

> 180 systolic and/or 120 diastolic

evidence of end organ damage

70
Q

How do you lower hypertensive emegency?

A

reduced within 1 hour

71
Q

What is the initial target for hypertensie emergency?

A

25% reduction in 1 hr, then 160/100 in 3-6hrs

72
Q

What is the main goal of a Hypertensive emergency?

A

prevention of further end organ damage

73
Q

Commonly used-drugs for a hypertensive emergency

A
  • Nicardipine
  • Labetalol
  • Hydralazine
  • Nitroprusside
74
Q

List end organ damage

A
  • Myocardial ischemia & infarction
  • Acute kidney injury
  • Aortic dissection
  • Pulmonary edema
  • Ischemic stroke
  • Intracerebral hemorrhage
  • Preeclampsia/eclampsia in pregnancy
75
Q

What is eclampsia?

A

preeclampsia + seizure

76
Q

Suspect 2ndary HTN if:

A
  • severe or resistant hypertension
  • acute rise or liability in BP in a pt w/ previously stable values
  • Age less than 30, non obese patient, no FHx
  • unable to control BP w/ 3 meds
77
Q

Common causes of 2ndary HTN

A
  • Renovascular HTN due to renal artery stenosis (most common)
  • sleep apnea
78
Q

Less common causes of 2ndary HTN

A
  • oral contraceptives
  • pheochromocytoma
  • Cushing’s syndrome
79
Q

What test should be ran to assess renovascular dz?

A

CT or MR angiography

80
Q

What test should be ran to assess primary kidney dz?

81
Q

What test should be ran to assess pheochromocytoma?

A
  • plasma & urine catecholamines
  • MRI or
  • CT
82
Q

When does HF occur?

A

occurs if the heart cannot pump (systolic) or fill (diastolic) adequately

83
Q

What is the long term effects seem of HF?

A

blood backs up into the lungs & lower extremities

84
Q

What is the most common cause of HF?

85
Q

RFs of HF

A
  • advanced age
  • female sex
  • obesity
  • HTN
  • smoking
  • DM
  • CAD
  • valvular heart disease
  • Afib
86
Q

What is happening during systolic HF?

A

heart can’t pump enough blood out

87
Q

Systolic HF is also known as:

A

HF w/ decreased EF

88
Q

4 factors that govern systolic function

A
  • contractile state of the myocardium (strength)
  • Preload
  • Afterload
  • HR
89
Q

Systolic HF: Pathophys

A

LV dysfunction–> decr EF–> body compensatory mechanisms–> fluid retention & vasoconstriction–> ventricular remodeling–> LV dilation

90
Q

Define EF

A

% of blood the LV pumps out with each contraction

91
Q

Normal range for for EF

92
Q

What is happening during diastolic HF?

A

heart can’t relax enough

93
Q

Diastolic HF is also known as:

A

HF w/ preserved EF

94
Q

Diastolic HF: pathophys

A

ventricle is stiff & unable to relax–> less blood fills the ventricle–> decr SV–> decr CO

95
Q

What causes high output HF?

A

caused by the body’s need for incr blood & oxygen

96
Q

HF: Hx

A
  • Dyspnea
  • Orthopnea
  • PND (paroxysmal nocutural dyspnea)
  • Palpitations
  • Fatigue
  • Lower extremity edema
  • cough
  • weight gain
  • abdominal swelling
97
Q

HF: PE

A

Cardiac
- distended neck veins
- Lateral PMI
- S3 and/or S4 gallop
- Mitral regurg

Noncardiac
- crackles in lungs
- distended and/or pulsatile liver
- edema/dependent edema

98
Q

HF: Dx and labs

A
  • EKG
  • Elevated BNP
  • CBC
  • Serum electrolytes
  • Kidney/liver function
  • CXR
  • Echo
99
Q

NYHA Stage I classification

A

Cardiac dz + no symptoms, no limitations in normal physical activity

100
Q

NYHA Stage II classification

A

Mild symptoms & slight limitation during activity

101
Q

NYHA Stage III classification

A

significant limitation in activity due to symptoms. okay at rest

102
Q

NYHA Stage IV classification

A

Severe limitations. symptoms at rest

103
Q

Treatment of Chronic HF

A
  • Correction/management of revisable causes (HTN, hypothyroidism, arrhythmias)
  • Decr dz burden: stop smoking, stop drinking, decr salt intake, limit fluids
  • Pharmocologic tx
  • cardiac rehab
104
Q

Meds used in CHF w/ decr EF

A
  • ARNI
  • ACEI
  • BB
  • Diuretic (loop diuretic)
  • SGLT2 inhibitors
105
Q

Meds used for CHF w/ preserved EF

A
  • SGLT2 inhibitors
  • mineralocorticoid receptor antagonist
106
Q

Common loop diuretic used in chronic HF

A

furosemide [Lasix]

107
Q

SGLT2 inhibitors were first used for:

A

DM, but can be used for other Dz

108
Q

Less commonly uses therapies for Chronic HF

A

LVAD
- LV assist devices

109
Q

Preferred renin-angiotensin system inhibitors/nephrilysin inhibitors meds for CHF

A
  • Sacubitril-valsartan
110
Q

Preferred beta blocker meds for CHF

A
  • Carvedilol
  • Metoprolol succinate CR
  • Bisoprolol
111
Q

Preferred mineralocorticoid receptor meds for CHF

A
  • Spironolactone
  • Eplerenone
112
Q

Preferred SGLT2 medications for CHF

A
  • Dapagliflozin
  • Empagliflozin
113
Q

Acute HF is usually due to:

A
  • discontinuation of meds
  • excessive salt intake/excessive fluid intake
  • myocardial ischemia
  • tachyarrhythmias
114
Q

Acute HF: S/S

A
  • Acute onset or worsening of dyspnea at rest.
  • Tachycardia, diaphoresis
  • Pulm rales, rhonchi; expiratory wheezing.
  • Pink, frothy sputum
  • Hypoxemia
115
Q

What would CXR show for acute HF?

A

shows interstitial and alveolar edema with or without cardiomegaly.

116
Q

Name diuretics used for acute HF

A
  • furosemide or bumetanide
117
Q

What is the mainstay tx for acute HF?

A

initiate diuretic therapy w/o delay to relieve congestive/fluid overload

118
Q

Describe hypertrophic cardiomyopathy.

A

myocardium becomes thick & hypercontractile
- less blood can fill the ventricle

119
Q

Hypertrophic cardiomyopathy eventually causes…

A

diastolic HF

120
Q

What measurement is considered a thick LV wall on echo?

121
Q

Hypertrophic cardiomyopathy can lead to what in young athletes?

A

sudden cardiac death

122
Q

40-60% of hypertrophic cardiomyopathy are due to…

123
Q

Hypertrophic cardiomyopathy: Pathophys

A

thicken ventricular walls–> small LV–> turbulent blood flow

124
Q

Hypertrophic cardiomyopathy: S/S

A
  • majority of pts are asymptomatic, may be noticed due to murmur on exam or abnormal EKG
  • dyspnea (most common)
  • syncope/presyncope
  • palpitations
  • CHF
125
Q

Hypertrophic Cardiomyopathy: PE (could have all or none)

A
  • Crescendo-decrescendo murmur heard at the left sternal border
  • Bifid pulse (AKA biphasic pulse)
  • S4
  • Lateral displacement of point of maximal intensity
126
Q

Hypertrophic cardiomyopathy: Dx Labs

A

EKG
- mostly normal, but can have signs of LVH
CXR
- LV enlargement
Echo
- LV >1.5cm

127
Q

Hypertrophic cardiomyopathy: Tx

A
  • BB
  • Verapamil
  • ICD
  • heart transplant
  • Myomectomy
  • EHTOL induced
128
Q

Describe what happens during restrictive cardiomyopathy

A

myocardium becomes stiff & less compliant
- less blood can fill the ventricle

129
Q

Restrictive cardiomyopathy eventually causes:

A

diastolic HF

130
Q

Most causes of restrictive cardiomyopathy are:

A

idiopathic, but some underlying dz may be identified

131
Q

Some causes for restrictive cardiomyopathy

A
  • amyloidosis (most common)
  • sarcoidosis
  • haematochromatosis
  • radiation
132
Q

Restrictive Cardiomyopathy: Pathophys

A

Very stiff muscle–> high pressure in ventricles & atria–> less blood supply to body–> buildup of fluid in lungs

133
Q

Restrictive Cardiomyopathy: S/S

A
  • usually presents as HF w/ PHTN
  • dyspnea
  • lower extremity edema
134
Q

Restrictive Cardiomyopathy: PE

A

S4 heart sound

135
Q

Restrictive Cardiomyopathy: Dx & labs

A

EKG
- small amplitude QRS complexes
Echo
- impaired ventricle filling

136
Q

Restrictive cardiomyopathy: Tx

A
  • aimed to reduce pulmonary congestion–> diuretics
  • treat underlying illness if identifiable
137
Q

What is the most common type of cardiomyopathy?

138
Q

What parts of the heart are affected with dilated cardiomyopathy?

A

can affect all chambers of the heart

139
Q

In dilated cardiomyopathy myocardium gets very weak & this can cause:

A
  • low CO
  • Systolic HF
  • valves stretch, causing MV & TV regurg
  • can cause arrhythmias
140
Q

Dilated cardiomyopathy can be categorized as:

A
  • ischemic or non-ischemic
141
Q

The most common cause of dilated cardiomyopathy

A

idiopathic

142
Q

What defiicnecy is seen in alcholics that can cause dilated cardiomyopathy?

143
Q

What percentage of dilate cardiomyopathy is genetic related?

144
Q

Dilated cardiomyopathy: Pathophys

A

overstretched muscle–> Incr ventricular size–> reduced squeeze ability–> less blood supply to body–> fluid buildup in lungs

145
Q

Dilated cardiomyopathy: S/S

A

HF
- edema
- dyspnea on exertion
- orthopnea

146
Q

Where is S3 heard in relation to normal heart sounds?

147
Q

Where is S4 heard in relation to normal heart sounds?

148
Q

Dilated cardiomyopathy: PE

A
  • cardiomegaly
  • S3
  • JVD
  • rales
149
Q

What does JVD mean?

A

jugular vein distention

150
Q

Dilated cardiomyopathy: Dx labs

A
  • echo (LV dilation)
  • CXR w/ LV enlargement
  • EKG (may have none, some, or all)
    –> atrial and/or ventricular hypertrophy
    –> conduction delays (LBBB)
151
Q

Dilated cardiomyopathy: Tx

A
  • tx underlying condition if possible
  • Beta blockers
  • ACE inhibitors
  • LVAD
  • ICD helps to prevent sudden death
  • heart transplant
152
Q

What does ICD stand for?

A

implantable cardioverter defibrillator

153
Q

Which patients should be evaluated for heart transplant?

A

All LVAD patients

154
Q

General indications for LVAD

A
  • LV EF < 25%
  • NYHA Class III or IV functional status despite guideline-directed medical therapy
  • high predicted mortality w/n 1-2 yrs or dependence on continuous parenteral inotropic support
155
Q

What is (+) inotropic?

A

increases contraction of the heart

156
Q

What is (+) chronotropic?

A

increases HR

Block 3 - Cardio (13 decks)

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