DIT Flashcards
pathogenesis of atherosclerosis
- endothelial damage
- Lipoprotein accumulation (LDL) in vessel wall
- Adhesion of monocytes and foam cells (macrophages)
- Factor release (puts, macrophages, inflammatory mediators, cytokines)
- Smooth muscle infiltration
- Lipid accumulation
How to dx PAD?
ABI < 0.9
Meds associated with HLD
- thiazide diuretics
- bblockers
- atypical antipsychotics
- protease inhibitors
- oral estrogens
Who needs statin therapy?
- clinical ASCVD (ACS, MI, Stroke/TIA, PAD, revascularizaiton)
- anyone LDL>190
- DM 40-75
- 10 year risk >7.5% age 40-75
MOA and target of statins
HMG-Coa reductase inhibitor
BEST drug to lower LDL
side effects and what labs to get before starting statin
myopathy/inhibits coenzyme q10 (increased CK, myalgia, cramping)
hepatic dysfunction
get LFTs before starting but not routinely
MOA and target ezetimibe
impairs dietary and biliary cholesterol at brush border
primarily lowers LDL
Side effects ezetimibe
myalgia and increased LFTs (like statin)
MOA and target of fibrates
decrease hepatic secretion of VLDL
primary effect on TRIGLYCERIDES
VLDL = triglycerides
side effects fibrates
same as statins and ezetimibe (myalgia LFT elevation)
Name some bile acid sequestrants
cholestyramine, colestipol, colesevelam
bile acid sequestrates target what?
LDL (but only lower 10%…statins more effective)
side effects bile acid sequestrants
GI side effects (bloating, cramping), LFT elevaiton
Which cholesterol med is best for increasing HDL
niacin
side effect niacin and how to rx
facial flushing
improves with ASA or NSAID, and time
target of omega 3 fatty acids (fish oil)
TGs
which cholesterol med can be used as an adjunct treatment of cdiff?
cholestyramine
what new heart sounds can you get during MI?
new systolic murmur
S3
S4
What additional finding besides ST changes can indicate STEMI?
new LBBB
After MI when does troponin elevate
elevates in 1-4 hours
stays elevated up to 1-2 weeks
When do Q waves (dipping before R wave) appear during MI?
appears within hours, deepens over 1-2 days and persists until weeks later
How doe ST segment and T waves change during MI
ST elevates hours after MI but is normal days after
T wave inverts after Day 1-2 returns to normal weeks later
ST changes in V2,3,4,5
anterior MI
LAD
ST changes V1, V2, V3
septal wall MI
LAD
ST changes II, III, avF
inferior wall MI
PDA
ST changes I, aVL, V5, V6
lateral wall MI
LAD/circumflex
MOA dobutamine
primary B1 agonist - increases HR and contractility
best pressor for cardiogenic shock
dobutamine
MOA epinephrine
ALL AROUND AGONIST (a1,a2,b1,b2)
low dose - b1 increases CO
high dose - a1 vasoconstriction
best pressor for septic shock
norepi
best pressor for anaphylactic shock
epi
MOA norepi
a1 agonist - vasoconstriction
b1 agonist
if norepinephrine doesn’t work for septic shock, what are 2 ok 2nd line drugs
epi
phenylephrine
vasopressin
complications of using pressor like norepinephrine for extended period of time
finger/toe ischemia and necrosis
mesenteric ischemia
renal insufficiency
if dobutamine doesn’t work for cardiogenic shock, what’s a good 2nd line
dopamine
also good adjuvant pressor
MOA phenylephrine
a1 agonist (vasoconstriction)
MOA dopamine
low dose - b1
high dose - a1
when does Dressler syndrome occur?
2-4 weeks post MI
bacterial infection most commonly associated with acute pericarditis
TB
what drugs can cause pericarditis
isoniazid, procainamide, hydralazine
Which viral infection can cause pericarditis
HIV
Patient with CKD presents with pleuritic chest pain and friction rub with diffuse ST elevation…?
uremic pericarditis
rx acute pericarditis
usually NSAIDs and colchicine
also treat underlying cause if you can find one
Echo finding in acute pericarditis
pericardial effusion
physical exam findings tamponade
Beck’s triad (hypotension, JVD, muffled heart sounds)
pulses paradoxus
what is pulsus paradoxus
SBP decreases >10 mmhg during inspiration
usually due to poor LV capacitance
pulsus paradoxus vs kussmaul sign
pulsus - poor LV capacitance
kussmaul - poor RV capcitance
what is kussmaul sign and what conditions is it usually found in?
anything that restricts RV filling
- chronic constrictive pericarditis
- RV infarction
- massive PE
- R CHF
- tricuspid stenosis
- restrictive cardiomyopathy
What is kussmaul sign (not breathing)?
JVD with inspiration
Physical exam finding left atrial myxoma
early DIASTOLIC sound (“tumor plop”)…rare finding
what are the classes of antiarrythmics
1 - Na channel blockers
2 - beta blockers
3- potassium channel blockers
4 - Ca channel blockers
“No BadBoys Keep Clean”
Name class 1a antiarrhythmics
“the Queen Proclaims Diso’s pyramid”
Quinidine
Procainamide
Disopyramide
Name the class 1c antiarrhythmics
“can I have Fries Please?”
Flecanide
Propafenone
Name the class 1b antiarrhytmics
“Liddy’s Mexican Tacos”
Lidocaine
Mexiletine
Tocanide
also phenytoin
Which antiarrhythmics widen QRS?
Class 1
Which anti arrhythmic is associated with drug induced lupus?
procainamide
Which class of antiarrhythmics are best post MI?
class Ib (since they lower AP, lower ERP, and shorten QT) unlike other class 1 drugs which prolong QRS and QT
Name the class III antiarrhythmics
"AIDS" Amiodarone Ibulitide Dofelitide Sotaolol (sounds like beta blocker but it aint)
Which class of antiarrhythmics prolong QT?
class III K channel blockers
watch out for torsades!
Adverse effects of amiodarone
pulmonary fibrosis (check PFTs, c/I lung dx)
hepatotoxicity (check LFTs)
hypo/hyperthyroidism (check TSH)
blue/gray skin deposits, corneal deposits
PVCs are wide or narrow QRS complexes?
wide
Cardiac index, SVR, and LVEDV in systolic CHF?
Cardiac index - decreased
SVR - increased (activation of RAAS system)
LVEDV - increased (secondary to RAAS system to increase preload, even if there is a mitral regurg)
MCC cause secondary HTN
renal artery stenosis
atherosclerosis/fibromuscular dysplasia
What med to avoid if bilateral renal artery stenosis?
ACEI/ARB (constricts efferent arteriole -> rapidly fucks up GFR)
HTN, hypokalemia, metabolic alkalosis
Conn syndrome (primary hyperaldosteronism)
How to dx primary hyperaldosteronism
plasma aldosterone:plasma renin activity
aldosterone to renin ratio
How to manage BP in hypertensive urgency
reduce BP to 160/100 initially
don’t decrease MAP more than 25%
Name some fast acting and titratable meds appropriate for hypertensive urgency
nitroprusside enalapril captopril clonidine labetalol nicardipine
3 ways to calculate MAP
- CO x TPR
- 1/3SBP + 2/3DBP
- DBP + 1/3PP (pulse pressure = SBP-DBP)
HTN med causes hyperkalemia and renal insufficiency
ACEI/ARBs
(even though these are renal protective) , they will dilate efferent arteriole which will decrease GFR and increase BUN and Cr)
HTN meds associated with reflex tachycardia cardia
arterial vasodilators (hydrazine, minoxidil)
HTN med that can cause inappropriate hair growth/treat baldness
minoxidil
HTN med that causes hypokalemia, hyponatremia, and hypercalcemia
thiazides
which HTN to avoid in asthma or COPD
non selective beta blockers (M-P +labetolol, carvedilol)
HTN med that can cause headache, constipation, GERD,
CCBs
HTN med that can cause peripheral edema
CCB
HTN med that can cause bradycardia
nondihydropyridines (diltiazem, verapamil)
metabolic side effects beta blockers
reduce HDL, increase TGLs
which HTN med can mask symptoms of hypoglycemia
Beta blockers
Which HTN med is associated with positive antihistone abs?
drug induced lupus
HYDRALAZINE
also watch out for in class 1a antiarrythmic procainamide
Which HTN meds safe in pregnancy?
“Hypertensive mothers love nifedipine”
- hydralazine
- methyldopa
- labetolol
- nifedipine
Which HTN meds c/I pregnancy
ACEI
ARBs
direct renin inhibitors
HTN med with rebound HTN, dry mouth, sedation
clonidine
HTN med associated with orthostatic hypotension
a1 blockers (prazosin, doxazosin)
name 2 thiazides
- hctz
- chlorthalidone
indication for surgical repair of aortic dissecction
stanford type A (ascending aorta dissection)
type B (descending) only needs medical management
first line BP med for aortic dissection
BB
indications for AAA repair
- AAA>5.5 cm in men and 5 cm in women
- symptomatic (tenderness, abdominal pain)
- increase in diameter more than 0.5 cm in 6 month interval
Best management for PAD
conservative! -smoking cessation - daily exercises -glucose BP control aspirin/statin
pharmacologic treatment for leg claudication
cilostazol - improves blood flow to LE and decreases claudication
Best rx for varicose veins
lifestyle modification (weight reduction, avoid prolonged standing, leg elevation)
meds that reduce morbidity and mortality in patients with known CAD
- bb
- statin
- DUAL anti platelet (asa + p2y12 receptor blocker like clopidogrel, ticragrelor)
- aldosterone antag (spiriniolactone, eplenerone)
- ACEI/ARB
patient with pacemaker presents with right sided heart failure, JVD, hepatomegaly, abdominal dissension, lower extremity edema
Tricuspid regurg (adverse effect of implantable pacemaker/defib) since it can damage tricuspid leaflets
GCA associated with what other rheum disease
PMR (polymyalgia reumatica)
Physical exam finding takayasu
poor pulses in UE (“pulseless dx”)
What specific vessel does takayasu tend to effect
aorta (specifically the arch)
Kawasaki criteria
CRASH and burn
4/5 (Conjunctivitis, rash, adenopathy cervical, strawberry tongue, hand/feet changes/desquamation)
+
fever >104 for more than 5 days
treatment Kawasaki
IVIG
high dose ASA
Which vasculitis is ANCA negative?
polyarteritis nodosa
What organs does PAN affect?
usually, kidneys, GI, SPARES lungs
asthma patient with skin findings, lung and upper airway dx with positive p-ANCA
eosinophilic granulomatosis polyangitis
Lung involvement, upper airway, kidney, c-ANCA positive
granulomatosis with polyangitis (Wegner’s)
How to differentiate Wegner’s (gran with polyangitis) and Churg Strauss (eosinophilic gran)
Wegner - c-ANCA
Churg strauss - p-ANCA
HCV patient comes in with palpable purport, weakness, and joint pain) with some renal involvement
mixed cryoglobulinemia
treatment for thromboangitis obliterans
smoking cessation (prevents autoamputation of digits)
Rx HSP
supportive therapy
rx AML
m3 variant
vit a
all trans retinoic acid
if not m3, chemo
rx CML
imantinib
how to dx AML/ALL
bone marrow biopsy
>20% blasts
blast cell with auer rods
AML
rx with vit A if m3 variant
age of ALL
kids, age 7
+Tdt
ALL
t 9;22
phiadelphia chromosome
BCR-ABL
CML!!!!!!
tyrosine kinase causing overactivity and expressing cancer
BCR ABL
rx
t 9;22
CML
tyrosine kinase inhibitor (imantinib)
CML + blast crisis
AML
complication CLL
hyperviscosity syndrome from so many cells
myeloperoxidase
AML
CML can turn into…?
AML
4 year old, bone pain, pancytopenia (bleeding/pallor/infections)
ALL
