CVD Flashcards
Causes of 2ndry HTN
Renal/renovascular (e.g. stenosis) – most common cause
Endocrine –hyperaldo, thyroid, or parathyroid, Chusings, Pheo, acromegaly
Meds–OCPS, decongestants, estrogen, steroids, TCAs, NSAIDS
Coarctation of aorta
Cocaine/stimulants
Sleep apnea
Evaluation of pt with HTN
- Look for 2ndry causes
- Assess end organ damage (heart, kidneys, eyes, CNS)
- Assess overall CV risk (Urinalysis, Cem, fasting glucose, lipid panel, ECG)
- make therapeutic decisions
HTN thresholds
BP >140/90 in general pop BP > 130/80 in diabetes/renal disease PreHTN: 120-139/80-89 Stage I: 140-159/90-99 (lifestyle, drug) Stage II: >160/>100 (lifestyle, likely 2 drugs
Pregnancy and HTN
- always get a hCG before initiating therapy
- Thiazides, ACEis, CCBs, ARBs are bad
- BBs and hydralazine are safe
General Tx HTN
- Lifestyle: Salt, BMI (esp central obesity), Alcohol (pressor), Exercise, low saturated fat, unnecessary meds, stress management
- Goal: ideal is 120/80, 135/85 minimum for diabetes/renal insuff, 140/90 general threshold
- All agents are roughly equivalent, but ppl respond differently. Thiazides, CCBs, ACEis, ARBs used as initial monotherapy. BBs have adverse CV effects in the elderly
- ACCOMPLISH trial: ACEi (benazepril) + CCB (amlodipine) > ACEi + diuretic
- If one agent not successful, switch, then add a second if needed
Thiazides in HTN
- “salt-sensitive” HTN more common in African Americans, so diuretic is good initial choice (unless comorbid diabetes –> ACEi)
- Check K regularly (hypokalemia can be exacerbated by decreased salt intake)
- SEs: hypokalemia, hyperuricemia, hyperglycemia, dyslipidemia, metabolic alkalosis, hypomagnesemia
BBs in HTN
- Decrease HR and CO, decrease renin release
- SEs: bradycardia, bronchospasm, insomnia, fatigue, may increase TGs and decrease HFL, depression, sedation.
- not initial Tx in elderly bc of CV effects
ACEis in HTN
inhibit RAAS and bradykinin degradation
- Preferred in diabetes because protective of kidney
- SEs: acute renal failure, hyperkalemia, dry cough angioedema, skin rash, dysgusia, contraindicated in pregnancy
ARBs in HTN
similarly beneficial to kidneys as ACEis
Contraindicated in pregnancy
CCBs in HTN
cause vasodilation of arteriolar vasculature
Contraindicated in pregnancy
alpha blockers in HTN
- decrease arteriolar resistance
- may benefit pts with BPH, but not first or second line agents
hydralazine minoxidil in HTN
- Vasodilators
- Not typically given, but can be used with BBs and diuretics in pts with refractory HTN
Type I HLD
- Exogenous
- Chylomicrons
- Tx: Diet
Type IIa HLD
- Familial
- LDL
- Tx: Statins, Niacin, Cholestyramine
Type IIb HLD
- Combined
- LDL + VLDL
- Tx: Tatins, Niacin, Gemfibrozil
Type III HLD
- Familial dysbetalipoproteinemia
- IDL
- Tx: Gemfibrozil + Niacin
Type IV HLD
- Endogenous
- VLDL
- Tx: Niacin, Gemfibrozil Statins
Type V HLD
- Familial hyperTG
- VLDL + chylomicrons
- Tx: Niacin, Gemfibrozil
2ndry causes of HLD
- Endocrine: hypothyroid, DM, Chushing’s
- Renal: nephrotic sydrome, uremia
- Chronic liver disease
- Meds: glucocorticoids, estrogen, thiazides, BBs
- Pregnancy
Threshold lvls for HLD (Total, LDL, TGs)
Total: Ideal: 240
LDL: Ideal 160
TGs: Ideal 250
HDL and CAD risk
- For every 10 inc, CAD risk decreases by 50%
- Low HDL 60) is a “negative” risk factor
TGs and CAD risk
-elevated TGs are associated w/ risk, but uncertain whether lowering TG lvls reduces risk
Total-to-HDL ratio and CAD
Desirable: <4.5
5 = avg
10 = double risk
20 = triple risk
LDL goals/Tx thresholds
-DM + CAD: goal = 2 RFs: Goal <160, lifestyle at 160, drug Tx at 190.
Xanthelesma
yellow plaques on eyelids from HLD
Xanthoma
hard, yellowish masses on tendons from HLD
Screening/workup for HLD
- screen: total and HDL (nonfasting OK)
- If abnormal, full lipid profile (TG and calculated LDL–fasting)
- Workup for secondary causes: TSH, LFT, BUN, Cr, Glucose
Risk factors for CAD in evaluation of HLD
- Current cigarette smoking (dose dependent)
- HTN
- DM
- Low HDL (60) is a negative RF
- Male >45
- Female >55
- Male (don’t double-count with age)
- FHx of premature CAD (first degree male relative MI/sudden death <65 yo)
Statin Potencies
- increasing order (cost increases too):
- fluvastatin (Lescol) < lovastatin (Mevacor) and pravastatin (Pravachol) < simvastatin (Zocor) and atorvastatin (Lipitor).
Lifestyle changes in HLD
- Dietary: <300 mg/day cholesterol. Can reduce LDL by 10%
- Exercise and weight loss
Tx elevated TGs
- limited data
- first line in lifestyle
- Meds: fibrates, nictonic acid, fish oil
- Statins should be considered (cardioprotective independent of LDL lowering)
Lx in statins
- monitor LFTs (monthly for 3 months, then every 3-6 months)
- harmless elevation in CPK can occur
Niacin
- lowers TG + LDL
- Increases HDL
- do not use in diabetics
- Can cause flushing/pruritus.
- Check LFTs/CPK
Cholestyramine
- Bile acid-binding resin
- Lowers LDL, increases TGs
- effective when combined with statins/niacin in high-risk pts
- Adverse GI side effects
Fibrates (gemfibrozil
- Lowers VLDL and TG, increases HDL
- Primarily for TG levels
- GI side effects
- abnormal LFTs, gynecomastia, gallstones, weight gain, myopathies
