deck 4 Flashcards
behavioral change shown to improve function significantly with heart fialure
discontinuing alcohol
management of refractory edema
add second diuretic (metalozone) - spironolactone can be used but usually only considered for NYHA class III or IV patients
only evidence for dual ARB + ACE inhibitor therapy
can reduce hospitalizations in CHF patients
strongest RF for developing alzheimer’s
increasing age, FH second
early signs of alzheimer’s
- memory disturbance, word-finding difficulty, decreased ability to recognize and draw complex figures, loss of ability to calculate.
- social behavior remains strikingly preserved until late in the illness
evidence for cholinesterase inhibitors in AD?
- associated with modest improvements in cognition, behavior, activities of daily living, and global measurements of functioning. However, they do not change the progression of neurodegeneration.
drug shown to have statistically significant benefit in advanced cases of dementia?
memantine
screening test used for diabetes?
fasting glucose
diabetes diagnosis
Two separate random glucose measurements more than 200 mg/dL with classic signs of diabetes (polydipsia, polyuria, polyphagia, weight loss), a fasting glucose greater than 126 mg/dL, or a glucose reading greater than 200 mg/dL 2 hours after a 75-g glucose load.
leading cause of blindness in the US
diabetic retinopathy
diabetic retinopathy risk correlated with…
increasing hbA1c
indication for ACE inhibitor in diabets
all diabetics with systolic BP greater than 100
ACE inhibitors and creatinine?
can be used irrespective of creatinine levels
effect of fibrates
lower triglycerides and raise HDL, but have minimal effects on LDL.
diet changes in diabetics?
Glycemic control is dependent on the total caloric intake, not the type of calorie taken in. Low-carbohydrate and high-protein diets have not been shown to improve glucose control more than weight loss from other methods. Sucrose does not need to be eliminated, but it may raise blood sugar more quickly after ingestion. Formal dietary programs are not more likely to produce long-term sustainable results unless exercise is a large component of the plan. Increased fiber does improve glycemic control.
oral therapy for type 2 diabetes
No evidence supports changing sulfonylureas when one is not adequately controlling glucose levels. Biguanides act to decrease glucose output from the liver, and can decrease hemoglobin A1C by 1.5% to 2%. However, biguanides should not be used if creatinine is higher than 1.5 mg/dL. Meglitinides increase insulin secretion and should only be taken before meals. They can reduce the hemoglobin A1C by 0.5% to 2% and are most valuable if fasting sugar is adequate, but postprandial sugars are high. Since they increase insulin levels, they are more effective when used in combination with a medication that has a different mechanism of action. They are excreted in the liver, therefore are safe in renal failure. Thiazolidinediones decrease insulin resistance and are an excellent choice for those with insulin insensitivity. α-Glucosidase inhibitors inhibit the absorption of carbohydrates in the gut and can decrease the hemoglobin A1C by 0.7% to 1%. They should be avoided if creatinine more than 2.0 mg/dL.
GLP-1 agonists mechanism
gut-derived incretin hormone that stimulates insulin and suppresses glucagon secretion, delays gastric emptying, and reduces appetite and food intake
DPP-4 inhibitor mechanism
prolongs the activity of endogenously released GLP-1
NPH (neural protamine hadedorn) length of action
10-20 hours
long-acting insulin preparations
lantus and levemir (24 hours)
lipid treatment goal for patients with known CAD
less than or equal to 70 mg/dL
lipid goal estimation
If a patient has no known coronary disease, the 10-year risk for coronary disease should be estimated using a readily available National Cholesterol Education Program (NCEP) risk calculator (available online). If the 10-year risk is greater than 20%, the LDL treatment goal should be less than or equal to 100 mg/dL. If the risk is between 10% and 20%, the LDL treatment goal should be less than 130 mg/dL. If the risk is less than 10%, the treatment goal should be less than 160 mg/dL.
interventions for increasing HDL
- exercising is most effective.
- moderate alcohol raises HDL
- weight loss + smoking have similar effect
single best predictor of adverse outcomes of all lipid values
- low HDL
affect of smoking on lipid levels
increases HDL by 5-10 but does not affect LDL, VLDL, or triglycerides
how to decrease facial flushing with niacin
take it with aspirin
fish oil mechanism
decreases secretion of triglycerides by the liver
fibrate mechanism
changes hepatic metabolism of lipoprotein
ezetemibe MOA
lowers cholesterol by interfering with absorption of cholesterol in the gut
ezetemibe effects
Used alone, it lowers LDL and triglycerides only modestly. When added to a low-dose statin, the combination lowers LDL as much as the maximum statin dose, but its combined use with a low-dose statin may produce fewer adverse effects.
niacin effects
- significantly raises HDL
- moderately decreases LDL
- moderately decreases triglycerides
best test to rule out acute HIV
Plasma HIV RNA (but low level viremia may represent false-positive)
HIV window period
several weeks to 4 months
pap testing in HIV patients
every 6 months
HIV and prophylaxis
Prophylaxis against M avium complex (MAC) should be instituted once the patient’s CD4 count drops less than 75
to 100 lymphocytes/mm3. Prophylaxis against Pneumocystis pneumonia should be considered once the CD4 count drops less than 200 lymphocytes/mm3 . Prophylaxis for fungal disease has been studied, but there was no benefit in the group that had prophylaxis with regard to mortality. Prophylaxis for herpes simplex and herpes zoster is not generally done. CMV prophylaxis can be instituted in those with CMV IgG positivity and with CD4 counts less than 50 lymphocytes/mm^ , but it is generally not done because ganciclovir (the primary prophylactic agent) can cause neutropenia.
pneumocystis pneumonia treatment
TMP-SMX for 3 weeks + steroids
lifestyle modifications for managing HTN
Weight reduction is most beneficial, and systolic blood pressure can fall from up to 20 mm Hg for each 10 lb of weight lost. A DASH diet can lower blood pressure between 8 and 14 mm Hg. Dietary sodium reduction, increased exercise and moderation of alcohol can be expected to lower systolic blood pressure less than 10 mm Hg.
HTN management
lifestyle modifications –> pharmacotherapy
stage 2 HTN
systolic BP greater than 160 or diastolic greater than 90
management of stage 2 HTN
thiazide with either ACE/ARB/b-blocker/or CCB
routine testing for new ddx of HTN
Need to assess end-organ damage + identify patients at high risk for cardiovascular complications…
- hemoglobin and hematocrit
- potassium
- creatinine
- fasting glucose
- fasting lipid
- UA
- resting ECG
abdominal bruit suggests…
renal artery stenosis
renal artery stenosis workup
- renal angiography or ACE-inhibitor renal scan
BP management to prevent stroke recurrence
ACE inhibitor + diuretic in combination
BP management
Persons younger than 55 years who are not black start an ACE inhibitor as first-line therapy (A). β-Blockers (B) can be used in this group, but are no longer considered ideal first-line therapy. In persons who are older than 55 years or black, the first-line therapy is either a calcium channel blocker (C) or a diuretic (D). If one medication does not control the blood pressure, the next step is to add an agent from the other category. For example, if you have an “A” or “B” medication, add a “C” or “D” medication. If that still doesn’t control the blood pressure, use A (or B) + C + D. Those still resistant should consider an α-blocker or other agent.
atypical angina
patient experiences pain that has the quality and characteristics of angina, or occurs with exertion, but not both.
anginal equivalent
dyspnea is sole or major manifestation
major concern with prescribing nitrates
Tolerance is the most significant issue to consider when using nitrates for stable angina. Tolerance develops rapidly when long-acting nitrates are given. When using a patch, it is important to have intervals of 10 to 12 hours without the patch to retain the antianginal effect. Headache and fatigue may be important side effects, but are more of a nuisance than an important consideration. The medications can be used with β-blockers and calcium channel blockers.
beta-blocker dosing
adjust dose to achieve a HR of 50-60 beats/min
obesity workup
- history and physical most important
- lab assessment to assess medical consequences, including fasting glucose, lipid panel
