CV ( primary and secondary HTN) Flashcards
What is the 1st line dx test for murmurs?
echo w/ doppler
Systolic Murmurs
MR ASS is a MVP
- mid to late holosystolic
- MR - mitral regurg
- AS - aortic stenosis
- S - systole
- MVP - mitral valve prolapse –> will become MR , will hear a “click”
MR
blowing or high-pitched
May radiate to the LEFT AXILLA
location: apex, apical area, mitral area, 5th ICS by mid-clavicular line
Aortic Stenosis
systolic ejection murmur
May radiate to the NECK
end stage - heart failure, syncope, agina, high risk for sudden death
Location:
- aortic area , at the “base” of heart
MVP
mid-systolic click with late systolic murmur at the mitral area
sx: usually asymptomatic or may complain of palpitations chest discomfort, dixxy, sob
labs: echo, TEE
Loacation : “ apex” apical area
Diastolic Murmurs
MS ARDe
MS: mitral stenosis
AR - Aortic regurgitation
e; erbs point ( AR can be heard here
- always indicative of heart disease*
MS
low pitched - diastolic rumbling murmur that is loudest at the apex (use bell)
sy: DOE, dypnea *, afibb *
location: apex, apical area, mitral area,
When to use the bell of stethescope
MS and listening for extra heart sounds
AR
early diastolic decresendo blowing murmur. Aterial pulses could be abnormal
location: 3rd 4th ICS at the left sternal border ( erbs point)
Heart sounds
S1, S2,
s1 = systole s2 = diastole
S3
early Diastole “ ventricular gallop”
- normal in pregnancy
- more common in children and young adults
- Abnormal if found after age 40 , may indicate heart failure
S4
Late diastole ( atrial kick)
LVH ( stiff)
can be a normal finding in elderly
Grading Murmurs
Grades 1-3 ( no thrill)
Grade 4 - first time thrill is palpated
Grade 5-6 - heard thrill)
A-fibb
can be paroxysmal or persistent
its a reduction in cardiac output and increased risk of emboli formation
key to evaluate pt need for antithrombotic therapy ( heart valve abnormality raises risk)
A- fibb presentation , dx, tx, avoid
complains of sudden onset heart palpitations, accomplanied by weakness, dizziness, fatigue, dyspnea.
may have rapid pulse and hypotension
dx: EKG ( no discrete P waves, irregularly irregular)
refer to cards
avoid: caffiene, nicotine, decongestants, alchol
What is the CHA2DS2- VASC score
assess for afibb stroke/emboli score
what are the two biggest risk factors in developing a stroke/ emboli
- hx of a stroke/TIA/thromboemolism
- 75 or older
what is first line anticoagulation therapy for people with valvular abnormalities? what are the drug interactions?
warfarin
- Sulfa drugs
- Macrolides
- NSAIDS
what is first line anticoagulation therapy for people with NO valvular abnormalities? what are the drug interactions?
Factor Xa inhibitors
PPI, antacids, H2 blockers, NSAIDS, clopidogrel
How long does it take on warfarin for the INR to change?
2-3 days
Pt education for warfarin
eat the same amount of vitamin K rich food daily
too much will decrease INR
high vitamin K foods: green-leafy vegetables, broccoli, brussel sprouts, cabbage, mayonnaise
What is the INR goal for anticaogulation?
2-3
what to do if INR is 3.1-4.0
check for any presence of bleeding
decrease maintaince dose 10% per week
what to do if INR is 4.1-5.0
check for bleeding
hold one dose. decrease weekly dose by 10
Length of therapy for first episode of provoked ( surgury) / unprovoked ( venous thromboembolism)
minimum 3 months
When will a pt be on anticoagulation for life?
with recurrent VTE, VTE w/ risk factors, unprovoked isolated distala DVT, VTE w/ malignacy
Pulse deficit
count the apical and radial pulses at the same time then subtract the difference
Pulsus Paradoxus
a decrease in the systolic BP of > 10 during inspiration ( must be more than 10,
causes: cardiac tamponade, pericardial effusion, acute MI, constrictive pericarditis
pulmonary causes: asthma, tension pnuemo, emphysema
Othrostatic hypotension
a decrease in the systolic BP of at least 20 or the diastolic of 10 in 3 min
best ways to check bp : supine then standing
Impending AAA rupture presentation
elderly man who is a smoker, complains of sudden onset of severe abdominal pain accompanied by severe low back pain, will appear shock like or incidental finding on cxr
What is the most common cause of sudden death in young healthy athletes?
Hypertrophic Cardiomyopathy as it causes VT
- want to ask about congential CVD in sports phsycials
Acute Infective Endocarditis ( bacterial) presenation
fevers, chills, weight loss, heart murmur w/ petechie, splinter hemmorages, janeway lesions, oslers nodes,
Acute Infective Endocarditis ( bacterial) PE
splinter hemmorages : non blanching reddish lines on nailbed
NONtender erythematous macules on the palms and soles ( jameaway lesions)
subcutaneous TENDER violaceous nodules on the pads of fingers and toes (oslers nodes)
hemmorahagic lesions on retina w/ pale centers ( roth spots)
Endocarditits prophaylsis
Amox 2 gm 1 -hour prior to procedure
if PCN allergy - Keflex
who is at high risk for endocarfitis
prosethic heart valve
hx of infectious endocarditis
cyanotic congetial heart dx, CHF
what are the high risk procedures?
dental work, colonoscopy, bronchocopy w/ biopsy, TTE
What is HTN a major risk factor for?
stroke, MI, Vascular disease, CKD
What is the most common cause of secondary HTN
renal artery stenosis - renovascular
What is end organ damage in HTN
Heart failure Carotid plaques PVD/PAD LVH Kidney UA
Heart Failure end organ damage
s3, s4, dyspnea, edema, rales, elevated JVD
Carotid plaques end organ damage
carotid bruits, high risk CAD
PVD/PAD end organ damage
decreased or absent peripheral pulses
LVH end organ damage
left ventricular heave, or increased size of PMI
Kidney end organ damage
hypertensive nueropathy
UA end organ damage
may show RBC, protein
Renal artery Stenosis
cause of secondary HTN, called also Polycystic kidney dx
- will hear a bruit in upper abdomen or will have englarged kidneys
doesnt mean they have CKD
dont use an ACE
Other causes of secondary HTN
- Hyperthyroidism
- Pheochromocytoma ( tumor on adrenal gland)
- Primary Hyperaldosteronism ( HTN w/ low K, and elevated NA)
- Cushing syndrome
- Addisions ( will see HYPO)
- Coactation of aorta ( picked in infancy
- sleep apnea
Pheochromocytoma
tumor on adrenal gland
triad of : headache, sweating and tachy w/ hypertension. the severe HTN will resolve in hours
Labs: 24 urine for metanephrines, and catecholamines
Primary Hyperaldosteronism
HTN w/ hypokalemia and slightly hypernaturemia
Labs: plasma renin activiation and aldosterone concentration in AM
Cushing syndrome
too much cortisol
- abdominal obesity, with skinny arms , round face with acne, straie red to purple color in breasts, dorsal hump
labs: lare night salivary cortisol and 24 hour urine free cortisol
normal caused by steroid use
Addison disease
adrenal insufficency , hypo corticolism
craving of salty foods, diffuse hyperpigmentation on face,
low BP
labs will show elevated K, low NA ,
DX; morning cortisol levels
Other factors that affect BP
NSAIDS
Estrogens
Stimulents
Diet
what type of decongestants increase BP
pseeudophedrine / sudafed
what is a cough supressent?
Dextromethorphan
What is a normal BP
120/80 or less
what is the biggest difference in the guidelines
the stages and the amounts
how should you measure BP
emptied bladder,
support arm on a table,
measure in both arms use higher reading arm for measurement.
take 2 readers per visit one to two minute apart and average the readings
How to dx HTN
two readings at least one min apart (average)
taken on two or three separate visits
if above 130/80 = HTN
can use out-of office self monitoring BP to confirm dx and for the titration of medication or if you suspect white coat
what is the goal BP
130/80
what is first line tx for HTN
lifestyle
- weight loss
- DASH ( can lower 11 off SBP)
- sodium restriction
- potassium increse
- reduce alchol
- 150 min of aerobic activity per week
which pts get lifestyle + meds
DM< CKD< MI
what drugs to avoid in people with HTN, CAD, SZ, mania
Decongestants : OTC cold and sinus drugs
Methylxanthines : theophylline , caffiene
Amphetamines
Appetitie Supressants : sibutramine
what is goal for healthy older adult over 60
150/90
goal BP for CKD or DM over 60
140/90
first line tx for CKD
include ACEI or ARB
First line tx for DM (ALL)
include ACEI or ARB
first line tx for blacks
CCB and thiazide diuretic
first line tx for non-blacks
Thiazide diuretic ACE, ARB or CCB
when to recheck BP for goal of therapy
1 month
goal for people with CV dx and ASCVD 10% or more
130/80
goal for people with HFpEF
130/80 and start with and ACE / ARB or BB
first line tx for people with Afibb
ARB
first line tx for pregnancy
methyldopa, nifedipine, labetolol
avoid ACE ARB and aliskiren
Examples of Thiazide diuretics
chlorthalidone ( highest potency)
HCTZ
indapamide
exmaples of CCB
amilodipine, diltizem ER, nitredipine
examples of ACE
catopril enalapril, lisinopril
examples of ARB
eprosartan, losrtan, calsartan, candesarten
Thiazide MOA
works on kidneys by increasing secretion of NA and chloride , loss of K, MG and decreases urinary calcium excretion
Thiazide S/e
” think HYPER VS HYPO”
hyperglycemia ( don’t give to DM)
hyper triglyceridemia / hyper cholestrol
Hyperuriecemia
hypokalemia
hyponaturmia
hypomag
caution w/ people with severe sulfa allergy
contraindication: gout
Give to people with osteopenia/osteoporosis as it slows down urinary secretion of calcium. can decrease risk of hip fractures
Loop diuretics
quick and potent ( lasix, Bumex)
dont give to people who are lithium - can increase kidney damage
na depletion
Potassium sparing diuretics
interferes with the sodium-potassium exhange in the distal tube of kidneys
- spironoactone, amiloride, triamterene
- causes hyperkalemia ( dont combine with ACE-ARBS
side effects of spironoactone
hirtisum
Galactorrhea, hyperkalemia, GI effects
ACE and ARBS
preferred in DM, CKD
Adverse: dry cough , hyperkalemia
Beta blockers
decreases vasomotor activity and cardiac output and inhibits norepinephrine release
B1 = heart and kidney
B2: - lungs, GI, uterus, vascular smooth muscles
Do not discontinue abruptly, wean
beta blockers a/e and contraindications
Adverse effects:
- broncospasm
- bradycardia, HF,
- PAD exacerbations
- depression, sexual dysfucntion
- avoid if they have chronic lung disease
contraindiaction;
- heart failure , 2nd or 3 rd heart block, bradycardia,
DM - can blunt or worsen hypoglycemia response
CCB what type
blocks calcium channels in the heart and arterioles causing vasodilations depresses AV node
First line for blacks, raynaud’s dx
Dihydropyrdines : “pine” more potent, no negative effect on the cardiac contractility or conduction. use for HTN and stable angina
Non-dihydropyridines - more effect on the cardiac conduction and contractility. Less potent vasodilator. used for HTN, chronic stable angina, arrythmias
CCB contraindiactions and a/e
grapefruit juice ( it will increase serum level causing toxcity)
2nd 3rd heart block, CHF
Adverse :
- headache flushing, ankle edema, constipation
Alpha-blockers
blocks alpha receptors in peripheral arterioles resulting in profound vasodilation
- terazosin (hystrin) / doxasozin (cardura) - can work for both BPH and HTN
