Clin Med - Cardio 1 Flashcards
1
Q
What is systolic pressure?
A
arterial pressure when the LV contracts
2
Q
What is diastolic pressure?
A
arterial pressure when the LV relaxes
3
Q
What is primary essential HTN?
A
combo of genetic & environment factors
- no specific underlying cause
4
Q
What is secondary HTN?
A
identifiable underlying cause
5
Q
Examples of causes of secondary HTN
A
- genetic
- kidney dz
- primary hyperaldosteronism
- Cushing syndrome
- pregnancy
- estrogen use
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)
7
Q
Describe how untreated HTN causes hypertensive cardiovascular dz (HF).
A
heart contracts against increased pressure; heart gets fatigued
8
Q
Describe how untreated HTN causes hypertensive kidney dz (KF)
A
- kidneys are constantly under high pressure
9
Q
Define primary essential HTN
A
sustained elevation of systemic arterial BP
10
Q
What values are commonly defined as primary essential HTN?
A
- SBP >/= 130mmHg
and/or - DBP >/= 80mmHg
11
Q
What is the onset age of primary essential HTN?
A
20-50 yo, but prevalence increases w/ age
12
Q
Percentage of HTN that is primary essential
A
90-95%
13
Q
Gender prevalence of primary essential HTN
A
Men (50%) > Women (44%)
14
Q
What region of the US have primary essential HTN?
A
Southeast
15
Q
RFs for HTN w/ good evidence
A
- high-normal BP
- elevated BP during medical care
- obesity & weight gain
- alcohol uses
- FHx
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
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
18
Q
Explain how B1 receptors in the heart affect BP
A
Incr epi/norepi output–> incr HR/contractility–> incr SV–> incr BP
19
Q
Explain how A1 receptors in the BVs affect BP
A
causes vasoconstriction which incr BP
20
Q
Explain how JG cells in the kidney affect BP
A
release renin–> angiotensin system–> incr BP
21
Q
Explain how age effect on the kidneys affects BP
A
incr collagen–> makes vessels less compliant
22
Q
Explain how increased Na+/Na+ retention affects BP
A
water follows Na+–> incr BV–> incr BP
23
Q
Is primary essential HTN usually symptomatic or asymptomatic?
A
asymptomatic
24
Q
What percentage of US adults are unaware of HTN?
A
30%
25
What prescription & OTC meds may cause HTN?
- Antidepressants
- Amphetamines
- Corticosteroids
- Contraceptives
- Cocaine
- Decongestants (pseudoephedrine)
- Methamphetamines
- NSAIDS* metabolized in kidneys
- St. John’s wart
26
Medical conditions that can cause HTN.
- hyperthyroidism
- renal dz
27
Other cardiac RFs
- DM
- CAD
- HF
- Obesity
- Hyperlipidemia
28
True or False: FHx can play a role in the development of HTN.
True
29
Social RFs pertaining to primary essential HTN
- dietary habits
- stress
- smoking
- alcohol intake
- activity level
- drug use such as cocaine
30
Primary Essential HTN: Eye PE
hypertensive retinopathy
31
Primary Essential HTN: Neck PE
- carotid bruits
- thyroid enlargement (hyperthyroidism)
32
Primary Essential HTN: Cardiac PE
- PMI displaced laterally in LV hypertrophy
- S4 (one of the earliest PE findings of HTN, if physical finding are present)
33
What is one of the earliest physical findings of HTN, if physical finding are present?
S4
34
Primary Essential HTN: Abdomen PE
- AAA
- Abdominal bruits (suggest renovascular HTN)
- Hepatomegaly
35
What does AAA stand for?
Abdominal Aortic Aneurysm
36
UpToDate/ACC BP screening recommendations
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
37
APP recommendation for pediatric BP screening
screen all pts for HTN annually & high RF pts at each visit beginning at 3yo
38
Key steps for proper BP measurements
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)
39
What is the gold stand for BP measurement?
ambulatory BP monitor
40
In adults, use ___ BP readings on __ occasions meeting threshold definition for SBP and/or DBP
>/= 2
>/= 2
41
If suspicion of white coat HTN, what do you do?
can use ambulatory BP monitoring
42
Normal BP
SBP < 120
and
DBP <80
43
Elevated BP
SBP: 120-129
and
DBP: <80
44
High BP (HTN Stage 1)
SBP: 130 -139
or
DBP: 80 - 89
45
High BP (Stage 2)
SBP: 140 or higher
or
DBP: 90 or higher
46
Hypertensive Urgency
SBP: higher than 180
and/or
DBP: higher than 120
47
Reasons to do initial testing when dx stage 1 HTN
- to look for any underlying causes of BP
- look for additional cardiac RFs
48
Primary Essential HTN: Initial testing Labs
- electrolytes (Ca+) & serum Cr (for GFR)
- fasting glucose
- UA
- CBC
- TSH
- Lipid profile
- EKG
- Calculate 10-year atherosclerotic CVD risk
49
What does EKG finding is indicative of HTN?
LV hypertrophy
50
If unusual presentation or very young/very old pt or suspected 2ndary HTN: what additional things do you order?
- echo (assess EF)
- Renal US
- Test for renal artery stenosis
51
Why order labs initially for primary essential HTN?
1. look for any underlying causes of high BP
2. look for additional cardiac RFs
52
Lifestyle changes that can tx HTN.
- weight reduction
- DASH eating plan
- Na+ reduced
- Exercise
- Alcohol reduction
53
What does DASH stand for?
Dietary Approach to Stop HTN
54
Recommended Na+ amount/day
<2000 (<1500)
55
Who should be treated w/ meds for primary essential HTN?
- out-of-office BP >/= 135 and/or >/= 85
- average office BP >/= 140 and/or >/= 90 if out-of-office readings are not available
56
Primary Essential HTN: Should be given meds if; >/=130 and/or >/=80 who have 1 or more of the following features?
- established clinical CVD
- Type 2 DM
- Chronic kidney dz
- Age 65yrs or older
- estimated 10-year risk of atherosclerotic CVD of at least 10%
57
What is considered an established clinical CVD?
- any CAD
- HF
- any kind of carotid dz
- previous stroke
- known PAD
58
Describe the incidence reduction of treated HTN for HF, stroke, MIs.
- HF reduction: 50%
- Stroke reduction: 30-40%
- MIs reduction: 20-25%
59
What is the goal BP w/ treatment?
< 130/80
60
Stage 1 HTN: initiate one drug. List them
- *angiotensin-converting enzyme (ACE) inhibitor
-*angiotensin receptor blocker (ARB)
- Ca+ channel blocker
- Thiazide diuretic
61
Which drugs are considered 1st line tx for stage 1 HTN?
- ACE inhibitor
- Angiotensin receptor blocker (ARB)
NEVER GIVE THESE IN COMBONATION
62
Stage 2 HTN: initiate 2 drubs (combo preferred)
- ACE + CCB preferred, but some patients may benefit from a thiazide diuretic
63
What is resistant HTN?
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
What are the two types of hypertensive crisis?
- hypertensive urgency
- hypertensive emergency
65
What is hypertensive urgency defined as?
>180 systolic and/or 120 diastolic
- no end organ damage, may have a HA (exclude end organ damage w/ PE & labs
66
How do you lower hypertensive urgency?
over hours to days
67
What is the initial target for hypertensive urgency?
<160/100, then further reduction
68
Commonly used fast acting drugs:
- Clonidine
- Captopril
- Nifedipine
69
What is hypertensive emergency defined as?
> 180 systolic and/or 120 diastolic
evidence of end organ damage
70
How do you lower hypertensive emegency?
reduced within 1 hour
71
What is the initial target for hypertensie emergency?
25% reduction in 1 hr, then 160/100 in 3-6hrs
72
What is the main goal of a Hypertensive emergency?
prevention of further end organ damage
73
Commonly used-drugs for a hypertensive emergency
- Nicardipine
- Labetalol
- Hydralazine
- Nitroprusside
74
List end organ damage
- Myocardial ischemia & infarction
- Acute kidney injury
- Aortic dissection
- Pulmonary edema
- Ischemic stroke
- Intracerebral hemorrhage
- Preeclampsia/eclampsia in pregnancy
75
What is eclampsia?
preeclampsia + seizure
76
Suspect 2ndary HTN if:
- 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
Common causes of 2ndary HTN
- Renovascular HTN due to renal artery stenosis (most common)
- sleep apnea
78
Less common causes of 2ndary HTN
- oral contraceptives
- pheochromocytoma
- Cushing's syndrome
79
What test should be ran to assess renovascular dz?
CT or MR angiography
80
What test should be ran to assess primary kidney dz?
BUN/Cr
81
What test should be ran to assess pheochromocytoma?
- plasma & urine catecholamines
- MRI or
- CT
82
When does HF occur?
occurs if the heart cannot pump (systolic) or fill (diastolic) adequately
83
What is the long term effects seem of HF?
blood backs up into the lungs & lower extremities
84
What is the most common cause of HF?
HTN
85
RFs of HF
- advanced age
- female sex
- obesity
- HTN
- smoking
- DM
- CAD
- valvular heart disease
- Afib
86
What is happening during systolic HF?
heart can't pump enough blood out
87
Systolic HF is also known as:
HF w/ decreased EF
88
4 factors that govern systolic function
- contractile state of the myocardium (strength)
- Preload
- Afterload
- HR
89
Systolic HF: Pathophys
LV dysfunction--> decr EF--> body compensatory mechanisms--> fluid retention & vasoconstriction--> ventricular remodeling--> LV dilation
90
Define EF
% of blood the LV pumps out with each contraction
91
Normal range for for EF
55-70%
92
What is happening during diastolic HF?
heart can't relax enough
93
Diastolic HF is also known as:
HF w/ preserved EF
94
Diastolic HF: pathophys
ventricle is stiff & unable to relax--> less blood fills the ventricle--> decr SV--> decr CO
95
What causes high output HF?
caused by the body's need for incr blood & oxygen
96
HF: Hx
- Dyspnea
- Orthopnea
- PND (paroxysmal nocutural dyspnea)
- Palpitations
- Fatigue
- Lower extremity edema
- cough
- weight gain
- abdominal swelling
97
HF: PE
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
HF: Dx and labs
- EKG
- Elevated BNP
- CBC
- Serum electrolytes
- Kidney/liver function
- CXR
- Echo
99
NYHA Stage I classification
Cardiac dz + no symptoms, no limitations in normal physical activity
100
NYHA Stage II classification
Mild symptoms & slight limitation during activity
101
NYHA Stage III classification
significant limitation in activity due to symptoms. okay at rest
102
NYHA Stage IV classification
Severe limitations. symptoms at rest
103
Treatment of Chronic HF
- 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
Meds used in CHF w/ decr EF
- ARNI
- ACEI
- BB
- Diuretic (loop diuretic)
- SGLT2 inhibitors
105
Meds used for CHF w/ preserved EF
- SGLT2 inhibitors
- mineralocorticoid receptor antagonist
106
Common loop diuretic used in chronic HF
furosemide [Lasix]
107
SGLT2 inhibitors were first used for:
DM, but can be used for other Dz
108
Less commonly uses therapies for Chronic HF
LVAD
- LV assist devices
109
Preferred renin-angiotensin system inhibitors/nephrilysin inhibitors meds for CHF
- Sacubitril-valsartan
110
Preferred beta blocker meds for CHF
- Carvedilol
- Metoprolol succinate CR
- Bisoprolol
111
Preferred mineralocorticoid receptor meds for CHF
- Spironolactone
- Eplerenone
112
Preferred SGLT2 medications for CHF
- Dapagliflozin
- Empagliflozin
113
Acute HF is usually due to:
- discontinuation of meds
- excessive salt intake/excessive fluid intake
- myocardial ischemia
- tachyarrhythmias
114
Acute HF: S/S
- Acute onset or worsening of dyspnea at rest.
- Tachycardia, diaphoresis
- Pulm rales, rhonchi; expiratory wheezing.
- Pink, frothy sputum
- Hypoxemia
115
What would CXR show for acute HF?
shows interstitial and alveolar edema with or without cardiomegaly.
116
Name diuretics used for acute HF
- furosemide or bumetanide
117
What is the mainstay tx for acute HF?
initiate diuretic therapy w/o delay to relieve congestive/fluid overload
118
Describe hypertrophic cardiomyopathy.
myocardium becomes thick & hypercontractile
- less blood can fill the ventricle
119
Hypertrophic cardiomyopathy eventually causes...
diastolic HF
120
What measurement is considered a thick LV wall on echo?
1.5 cm
121
Hypertrophic cardiomyopathy can lead to what in young athletes?
sudden cardiac death
122
40-60% of hypertrophic cardiomyopathy are due to...
genetics
123
Hypertrophic cardiomyopathy: Pathophys
thicken ventricular walls--> small LV--> turbulent blood flow
124
Hypertrophic cardiomyopathy: S/S
- majority of pts are asymptomatic, may be noticed due to murmur on exam or abnormal EKG
- dyspnea (most common)
- syncope/presyncope
- palpitations
- CHF
125
Hypertrophic Cardiomyopathy: PE (could have all or none)
- Crescendo-decrescendo murmur heard at the left sternal border
- Bifid pulse (AKA biphasic pulse)
- S4
- Lateral displacement of point of maximal intensity
126
Hypertrophic cardiomyopathy: Dx Labs
EKG
- mostly normal, but can have signs of LVH
CXR
- LV enlargement
Echo
- LV >1.5cm
127
Hypertrophic cardiomyopathy: Tx
- BB
- Verapamil
- ICD
- heart transplant
- Myomectomy
- EHTOL induced
128
Describe what happens during restrictive cardiomyopathy
myocardium becomes stiff & less compliant
- less blood can fill the ventricle
129
Restrictive cardiomyopathy eventually causes:
diastolic HF
130
Most causes of restrictive cardiomyopathy are:
idiopathic, but some underlying dz may be identified
131
Some causes for restrictive cardiomyopathy
- amyloidosis (most common)
- sarcoidosis
- haematochromatosis
- radiation
132
Restrictive Cardiomyopathy: Pathophys
Very stiff muscle--> high pressure in ventricles & atria--> less blood supply to body--> buildup of fluid in lungs
133
Restrictive Cardiomyopathy: S/S
- usually presents as HF w/ PHTN
- dyspnea
- lower extremity edema
134
Restrictive Cardiomyopathy: PE
S4 heart sound
135
Restrictive Cardiomyopathy: Dx & labs
EKG
- small amplitude QRS complexes
Echo
- impaired ventricle filling
136
Restrictive cardiomyopathy: Tx
- aimed to reduce pulmonary congestion--> diuretics
- treat underlying illness if identifiable
137
What is the most common type of cardiomyopathy?
dilated
138
What parts of the heart are affected with dilated cardiomyopathy?
can affect all chambers of the heart
139
In dilated cardiomyopathy myocardium gets very weak & this can cause:
- low CO
- Systolic HF
- valves stretch, causing MV & TV regurg
- can cause arrhythmias
140
Dilated cardiomyopathy can be categorized as:
- ischemic or non-ischemic
141
The most common cause of dilated cardiomyopathy
idiopathic
142
What defiicnecy is seen in alcholics that can cause dilated cardiomyopathy?
Thymine
143
What percentage of dilate cardiomyopathy is genetic related?
20-30%
144
Dilated cardiomyopathy: Pathophys
overstretched muscle--> Incr ventricular size--> reduced squeeze ability--> less blood supply to body--> fluid buildup in lungs
145
Dilated cardiomyopathy: S/S
HF
- edema
- dyspnea on exertion
- orthopnea
146
Where is S3 heard in relation to normal heart sounds?
after S2
147
Where is S4 heard in relation to normal heart sounds?
before S1
148
Dilated cardiomyopathy: PE
- cardiomegaly
- S3
- JVD
- rales
149
What does JVD mean?
jugular vein distention
150
Dilated cardiomyopathy: Dx labs
- echo (LV dilation)
- CXR w/ LV enlargement
- EKG (may have none, some, or all)
--> atrial and/or ventricular hypertrophy
--> conduction delays (LBBB)
151
Dilated cardiomyopathy: Tx
- tx underlying condition if possible
- Beta blockers
- ACE inhibitors
- LVAD
- ICD helps to prevent sudden death
- heart transplant
152
What does ICD stand for?
implantable cardioverter defibrillator
153
Which patients should be evaluated for heart transplant?
All LVAD patients
154
General indications for LVAD
- 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
What is (+) inotropic?
increases contraction of the heart
156
What is (+) chronotropic?
increases HR
