CV2 Cases Flashcards
Case 12: 45 year old man with BP of 160/100 while self monitoring at home. obese sedentary lifestyle and smoker. pos for exertional dyspnea. Father died of AMI at 45.
DOC 2? other recommendations?
Stage II hypertension
DOC: ACE inhibitor and chlorthiadone
- low salt diet and emphasize lifestyle modification
- could consider putting him on one drug and then adding the second
what is the target dose for lisinopril?
40 mg
if newly diagnosed with HTN what are three things you want to check lab wise?
eGFR
creatinine
lipids
what is the general pathway a person follows when progressing to HF?
HTN
angina
HF
what are the three drugs you typically see a patient on in their 40s for HTN?
- chlorthidone or ACE
- ASA
- statin
what do you typically add for angina in their 50s to their clorthidone, ASA, and statin?
CCB (amlodipine usually first)
what do you typically add in the 70s for a patient with HF who is taking chlorthiadone, ASA, statin, CCB?
- BB
2. loop dieuretic
is there a genetic factor to HTN?
yes
if a pt is black, what should you go to for HTN instead of an ACE?
if patient is african american bypass the ACE and go to CCB because this is more effective for that population
what do ace inhibitors do? what do they prevent the reabsorption of?
decrease peripheral vascular resistance and also inhibit Na and H20 reabsorption
ace inhibitors reduce the retention of what two things?
Na and H2o
in the article we were supposed to read what was the main point?
the goal BP for everyone we are treating is to get it below 140/90
Case 13: 50 year old lady with a BP reading at health fair last week of 170/105, random glucose was 85. T2DM and hyperlipidemia. Metformin, atorvastatin. Current BP 172/106.
DOC?
- DOC1: linsinopril ACE since she is a diabetic and this can protect her kidneys and also treat peripheral neuropathy, have her come back in two weeks and check to see if she needs a diuretic
- DOC2: if in two weeks still elevated use a thiazide diuretic but increase monitoring of BS because thiazides can increase BS
BB can mask….
hypoglycemia
what are three tests you want to order on someone with HTN?
CMP
BNP
lipid panel
what do you need to be conscious of when giving lisinopril for the first time? so when should you take the first dose?
can cause first dose hypotension
so take the first dose at night when you are lying down
what class and what specific drug can mask hypoglycemia?
BB
propanolol so don’t use BB in diabetics
thiazides can cause an increase in what 2 other than BS? what percent? what happens to these levels?
increase in the concentration of total cholesterol and LDL 5-15%, but return to normal with long term use.
uric acid…can make the person more likely to get gout.
what should you suggest puts with elevated BP get?
a at home BP monitor….gives then more accurate readings than the ones we get at the doctors/clinic
a 70 year old man with BP 165/100 at last visit a week ago, in for BP follow up. has nocturnal dyspnea, nocturia, and exertional dyspnea. smoker. basilar rales, diminished heart sounds, dry cough, obese. A1C12. TNG prn.
DOC? 2
HTN but need to rule out if he has HF or COPD
- DOC ACE lisinopril since likely has diabetes with a1c of 12
- DOC2 furosemide to help get some of the fluid off
what do ACE inhibitors slow from happening to the heart?
remodeling
ace inhibitors are used for what three main conditions?
use for HF, CKD, DM
who ALWAYS gets a BB?
POST MI…..BB FOR EVERYTONE
decreases mortality in those folks post MI, specifically METROPOLIS SUCCINATE
what arteries do CCB dilate?
vasodilate the coronary arteries
case 15: 55 year old man with HTN who you started on tx last week. his initial BP was 170/105. sedentary and smoker. COPD. osteoarthritis. HCTZ 25 mg, Lisinopril 10 mg, ibuprofen 800 mg BID for OA.
DOC?
HTN secondary to ibuprofen use
DOC1: stop taking Ibuprofen…switch to acetaminophen or cortisone shots!
DOC2 if that doesn’t work: up the dose of lisinopril by 10 mg, target dose is 40 mg
explain how iburprofen uses causes an increase in BP?
this decreases the PROSTAGLANDIN A2 that dilates the renal artery and causes a retention in Na
without this the renal artery is more constricted so it activates the renin-system to increase BP
what can prasozin cause as a side effect?
POSTURAL HYPOTENSION because it decreases peripheral vascular resistance
does a reduction of even 5mmHg help a patient?
yes it does.
good job
what is the time frame you want to reach your goal BP in?
2-3 months
does ibuprofen counteract the effect of anti-HTN meds?
yes! because it decreases the amount of prostaglandin A2, this keeps the renal arteries dilated so without it they constrict
RAAS becomes activated and so you get retention of Na
Case 16: 35 year old lady with HTN started on a ACE developed a dry cough. pretreatment BP was 160/100. last mentral cycle was 2 months prior. Lisinopril and albuterol.
DOC? what do you need to do?
STOP THE MEDS!!! when was her last period? she might be pregnant!!
if pregnant: get OBGYN on the phone to consult because lisinopril is a tetragen category D, GO straight to OBYGN
if not pregnant: take her off the ACE and start on ARB
what is a side effect of ACE that would prevent you from taking this drug again?
angioedema
if you get angioedema on a ACE, are you able to take a ARB like losartan?
No, you have to take a CCB
are ACE inhibitors used during pregnancy?
NO it is a tetragen! esp in 1st trimester!!
what is the pregnancy rating for ARB losartan?
B
what are the absolute contraindications for using an ACE? 3
angioedema, cough, billateral renal stenosis
Case17: 30 year old african american male with BP 155/105 on three visits who declines tx because he has no money. stressful job as narcy. father died at 40 from MI.
DOC? and DOC based on cost?
- DOC: african american chlorthalidone, but this is expensive and he doesn’t want to spend money
- chlorthalidone is 2x as potent as hydrochlorothiazide, but HCTZis on $4 list so may be better option
THE DIFFERENCE BETWEEN THESE TWO ABOVE DRUGS FOR DOC IS BASED ON COST
explain what happens to the MOA of thiazide diuretics after two weeks? if the patient was black and it didn’t control their BP after two weeks, what would you next two options be?
before two weeks they act as DIURETIC
after two weeks they become a VASODILATOR
switch in MOA
If after two weeks the BP isn’t controlled and the pt is black, may consider uping the diuretic OR starting CCB
why is the DOC for HTN different between whites and blacks?
what is the DOC order for blacks?
different because blacks don’t rely on the RAAS system as much (this explains why ACEs don’t work for them)
Doc1: chlorthiadone
Doc2: CCB
what is the diuretic you want to use if you patient has a sulfa allergy?
ethycrinic acid
which drug should you avoid in a patient who has asthma/COPD?
Non-selective BB including propanolol and carvedilol
these effect B2 receptors and these are in the lung, so you don’t want to add this as a complicating factor!!
Case 17a: 45 year old white male with right shoulder pain from a car crash last week. no head trauma. BP 175/100 but no organ damage, headache, or changes in vision. his pain is killing him. eGFR is 110 ml/min
DOC? what should you ask him about? what is causing his HTN?
HTN due to pain since UA and eGFR wnl (suggests pain)
hydrocodone/acetaminophen 5/325 (vicodin)
ask this pt if he has been taking NSAIDS as well ibuprofen because it can increase BP so switch to acetaminophen if so
*treat his pain first then have him come back in a couple days and recheck his BP and reevaluate if he still needs meds!
case 17b: 70 year old caucasion main with HTN that has been well controlled on lisinopril 20 mg. he has gained 10 pounds over the last 6 months and his pain in his knees has gotten work and uses a OTC. his BP today is 175/105 with eGFR 30 ml/min. high sodium levels.
DOC?
he takes NSAID over the counter which decreases prostaglandin causing renal constriction and salt retention, switch to acetaminophen SNOWBALL, THE WORSE THEIR OA GETS THE MORE PAIN MEDS THEY TAKE THE WORSE THEIR BP GETS
DOC1: stop the ibuprophen switch to acetaminophen
*recheck him later and see how much it has effected his BP
if still elevated DOC2: increase his ACE lisinopril
if still elevated BP DOC3: start on CCB amlodipine
what drug can be used for migraine prophylaxsis?
propanolol (nonselective bb)
which drug is a B1, B2, and alpha blocker?
carvedilol
case 17c: 65 year old white main with HTN well controlled with amlodipine and chorthalidone. he doesn’t have enough money to cover meds and is concerned about this. he just came back from a cruise he won online. BP 170/105. no end organ damage.
what is the one recommendation you want to make to him? what two medication adjustments might you make in this patient?
- DOC 1: reduce diet, low salt diet since likely eating a lot
- DOC 2: if that doesn’t work then up chlorthalidone but for cost consider switching him to HCTZ since significantly cheaper
DOC 3: switch amlodipine for ACE lisinopril because it is less expensive
are thiazides ineffective in pts who have CKD?
yes they are if the pt has eGFR
can you used thiazides in diabetics even if they increase BS?
YES YOU CAN!!! since it only increase it a little bit, you just have to increase you BS monioring!!
if you see a diabetic with HTN….the first two drugs you should think of are?
thiazide and ACE
WHITES EXACT WORDS: THE DOC FOR HTN IN A DIABETIC PATIENT IS….
ACE!!! REMEMBER IT!
Case: pt with new afib WITHOUT VALVULAR disease whare are the two drugs you want to use in this patient in the primary care setting?
new anticoagulant dabigatran (ONLY ONE WITH ANTIDOTE) and BB
this prevents against stroke and also the BB adds rate control!!
Case: pt with new afib WITHOUT VALVULAR disease whare are the two drugs you want to use in this patient in the primary care setting? BUT THIS PATIENT HAS DIABETES?
DOC?
DOC1: dabigatran for stroke prevention since it is the only new anticoagulant that has a antedote!
DOC2: BB….but need to increase monitoring of BS because this can mask the effects of hypoglycemia!!!
case: Case: pt with new afib WITHOUT VALVULAR disease whare are the two drugs you want to use in this patient in the primary care setting? BUT THIS PATIENT HAS BRONCHOSPASM?
DOC1: dabigatran anticoagulant to prevent stroke
DOC2: NCCB verapamil or diltiazem for rate control (can’t use BB because of bronchospasm)
are the drug choices of dabigatran and BB/NDCCB the same for new afib, chronic afib, and paroxysmal afib?
YES!!
PSVT: what are the two most improtant things we would do in primary care?
- valsalva maneurver
- lifestyle changes
- possible NCCB diltizem/verapamil
what drug would be given in the ED if pt had PSVT?
adenosine or cardiovert
what are the two most common statin drugs that are given?
atorvastatine and rousuvastatin
what is the statin you would want to use in a alcoholic or someone with hepatic failure?
Pravastatin because it is not CYP450 metabolized
if a statin was completely contraindicated in someone what would be the next DOC?
the cholesterol absorption inhibitor EXETIMIBE
what are the 2 DOC for hypertriglyerceremia if trying to prevent pancreatitis?
DOC1: STILL STATIN….these have triglyceride lowering effects
DOC2 if can’t tolerate a statin: fibrinic acid gemfibrazil or fenofibrate
what triglyercide amount would indicated treatment to prevent pancreatitis?
750-800
Case: pt with new afib WITH VALVULAR disease whare are the two drugs you want to use in this patient in the primary care setting?
DOC1 is now warfarin instead of dabigatran, warfarin is indicated for people with valvular disease
DOC2 BB
can you use dabigatran in patient with afib AND valvular disease?
no must use warfarin
macrolides and fluorquinolones cause
QT prolongation
Rule of 6 when using statins
every time you double the dose, you can 6% increase in how much impact it has on LDL reduction….now life is more simple because you go to either high or moderate dose so this used to play a big role, but now not so much
majority of effect you get is in the first dose
what is the goal dosing for atorvastatin?
goal is to get to 80mg of atorvastin, but start at 40 mg and make sure they dont’ have any side effects and then work your way up to 80mg
case 18: 60 year old with HTN who returns for followup from having labs drawn to start HTN tx. COPD, Hyperlipidemia. cholesterol 250, LDL 140, TRI=all elevated.
DOC1:
- DOC: atorvastatin High dose: 40 mg
- risk calculation: 42.8%
what are the five symptoms you want to monitor for with statins?
Monitor for diarrhea, nausea, myalgias, rhabdomyolysis arthalgia
what should you take atorvastatin?
at night
which one is best at decreasing LDL and triglycerides?
atorvastatine
statins block…
block donovo synthesis of the enzyme
what do you want to check if a patient experience myalgia on statin?
CK and LFTs
when do you see maximum effect of statins?
4-6 weeks
case 19: 65 year old with hyperlipidemia, HTN, and angina. She now has afib and doesn’t want to be referred to cardiology because her health insurance doesn’t start till next month. TNG, Amlodipine, atorvastatin 10 mg.
DOC3?
- DOC 1: BB metoprolol tartrate BID rate controls for afib
- DOC 2: non valvular so use dabigatran anticoagulation
- DOC 3: up the dose of atorvastatin to 40 mg because she now has afib and this bumped her from primary prophylaxis to secondary prophylaxis
if patient has frank heart disease (arrythmia, MI any heart condition basicallyu) they go to ______ dose statin
high dose!
irregularally irregular pulse is indicative of …
afib
what dose ST Johns wart do to the concentration of statins?
DECREASE THE CONCENTRATION OF STATIN…so becareful if pt says they are taking herbal supplement
statins decrease the concentration of which drug?
decrease the concentration of dabigatran, keep in mind because many pts in afib are on this
case 20: 55 year old with newly discovered hyperlipidemia and PMH of alchoholism and cirrhosis. DOC?
- pravastatin 40 mg because of cirrhosis, this one isn’t metabolized by the CYP450 system
- 17.7% Risk score
what is a common SE of niacin? so what do you do about it?
flushing so can pretreat 30 mins before with ASA
will cause vasoconstriction so they are less likely to get flushing and itching associated with Niacin.
who should you not use fibrinic acid in?
billiary disease (gallbladder), it can increase their risk for obstruction with gallstones
what are the effect fibrinic acid has on triglyercides and HDL?
lower triglycerides and increase HDL
what are the 3 drugs that interact with fibrinic acids? so what do you have to tell your patient to do?
clopidigrel
repaglinide
warfarin
one hour or 4 hours after other prescriptions because it can interfere with other prescriptions being absorbed appropriately.
what is the MOA of exctimibe?
decreases absorption of cholesterol from intestine
Case21: 50 year old with hyperlipidemia who started taking atorvastin 40 mg and experienced myopathy and stopped the med. he wants to know what to do now?
DOC?
- DOC1: stop the drug till symptoms are gone, then start on low dose Atorvastatin 10mg
- if myopathy occurs again, doesn’t matter which drug you try next because they haven’t been proved to work…so just pick any of them
what is the only drug show to decrease lipid related mortality?
statins!! that is why they are far superior to all the others!
what can increase the number of triglycerides?
T2DM
what do you use to measure warfarin?
INR….warfarin increases this
Case 22: 50 year old with increase triglycerides that were accidently picked up on lab work. TRI=1150mg (normal 165). DOC?
- atorvastatin 10 mg to decrease risk of pancreatitis, risk of pancreatitis is >750-800
- if that didn’t work could SWITCH TO fibrinic acid/nitrate
why do we treat a persons triglycerides?
LOWERING TRIGLYERCIDES DONT’ KNOW IF IT HELPS WITH CV DISEASE, BUT WITH TRI HIGH THEY ARE AT RISK FOR PANCREATITIS SO TREAT FOR THIS
Case 23: 60 year old with pharyngitis and a fib. Anaphylaxis to PCN. DOC?
- clindamycin
- can’t use penicillin, cephalosporins (since anaphylaxis) macrolides and fluoroquinolones cause QT prolongation so can’t use these
-Ask about dental pain if the patient has taken cephalexin. If yes, try ceflex becaue the cost difference is substainial.
random!
case 24: a 75 year old lady with chronic a fib WITHOUT VALVULAR disease controlled with metoprolol 100 mg. denied cardioversion/ablation.
Doc2?
-RF 16.15% so put on
DOC1: atorvastatin 40 mg
DOC2: dabigatran anticoagulant because of nonvalvular afib
-qualifies for primary and secondary prevention (hyperlipidemia/afib)
if taking off dabigatran, must do so….
SLOWLY and taper!!
Case 25: 80 year old with afib not responsive to ablation. She has had a valve replacement. HTN. T2DM. COPD. Metoprolol Succinate. Lisinopril. Combivent. DOC?
since valve replacement
-DOC is warfarin because of valvular, monitor PTINR
why do you use an anticoagulant in a fib?
prevent against stroke
if someones INR is too high, what do you do?
-if INR is too high get the pt to eat green leafy vegetables, K decreases the INR closer to 1-2
what is a SE of warfarin/
bruising
when do you check the INR for warfarin?
check INR 1 week after initiating tx
case 26: 75 year old in clinic for lightheadedness and fatigue last week. she now has a irregularlly irregular HR. COPD. HTN. T2DM. CKD. Umeclidium, albuterol, amlodipine. DOC 2?
metoporlol succinate
dabigatran
what do you need to keep in mind when using digoxin?
narrow therapeutic range
when do you use amiodarone?
This can be indicated for unstable and complex patients with A fib, not used in primary care
if post MI with new onset afib in the ICU what would you use?
amiodarone
case 27: 85 year old male with episodic fatigue and lightheadedness over 6 months. he is asymptomatic in clinic. HTN. CKD3. Lisinopril.
what do you want to do for this patient? what would the DOC be if you found a positive result?
- event monitor to check for afib
- if afib: BB and dabigatran
most likely use metopolol succinate in this cause since likely Paroxysmal afib and is episodic and pt not symptomatic
what can beta blockers cause in diabetics?
hypoglycemia
so can use it but increase monitoring of BS
case 28: 40 year old seen in clinic for abrupt onset of fluttering in her chest. she drinks coffee and smokes. has rapid HR.
what would you try? and what would you do if that didn’t work?
suspect PSVT
- TRY THE VALSALVA FIRST IF THIS DOESN’T WORK TO CONVERT OR COMES BACK SHE SHOULD GO TO THE ED
- send her to the ED TO BE TREATED WITH ADENOSINE
what are two things that can contribute to a healthy person going into PSVT?
caffeine and nicotine
thaizide direutics increase the risk of ______ in diabetes
hyperglycemia….can still use it just need to monitor BS more! :)
if a patient developes a cough on a ACE what is the next DOC?
ARB
what are the 4 things that thiazides increase?
total cholesterol, LDL, BS, and UA
why don’t we use a fibric acid AND a statin together if a person can’t lower their LDL with just a statin?
what must you do?
because it increases the changes for myopathy if used together
take off the statin and put on a fibric acid
