Exam 3 - HTN & ACS Flashcards
What is the goal BP for someone under 60 with no DM or CKD?
140/90 or less
What is the goal BP for someone over 60 with no DM or CKD?
150/90 or less
What is goal BP for someone with DM or CKD?
140/90 or less. Age doesn’t matter.
Initial HTN meds in black population? (+/- DM)
Thiazide-type diuretic or CCB
What is the goal BP for a patient older than 18 with DM?
140/90 or less
What is the goal BP for a patient older than 18 with CKD?
Less than 140/90
What is the goal BP for someone over 18 with DM?
140/90 or less
What is the goal BP for someone over 18 with CKD?
140/90 or less
Why do ACEi/ARBs not work as well in the black population?
Low plasma renin levels and increased sodium/fluid loading?
Which HTN meds does the black population respond particularly well to?
Diuretics and Na+ restriction
What are the 4 first-line HTN meds for the general population? Non-black, +/- DM.
ACEi, ARB, CCB, Thiazide-type diuretic
Initial HTN meds if have CKD? (Even if black, DM, or have proteinuria.)
ACEi or ARB
Which two meds are most effective in improving cerebrovascular, heart failure, and combined CV outcomes in the black population?
Diuretics and CCBs
Some studies have shown an increased stroke risk with which HTN med in the black population?
ACEi
If goal BP not met on one agent within one month of initiating treatment what is next step? (Hint: 2 options)
- Increase dose, or
2. Add 2nd agent from a different class
If goal BP not met on 2 drugs?
Add 3rd from different class (Ex: ACEi + CCB + Thiazide diuretic)
Which two class of HTN drugs should not be used in combo?
ACEi + ARB
The ACCOMPLISH trial found significantly less CV mortality with what combo?
CCB + ACEI
If goal BP can’t be reached with combo of three first-line meds what to do before 4th agent?
Ensure dose optimization and med compliance. Consider referral to HTN specialist.
What did the HYVET trial find for elderly over 80 y/o?
Diuretic +/- ACEi trend toward reduced rates of fatal/nonfatal stroke.
Secondary outcome: significant reduction in secondary outcomes (fatal stroke, all-cause mortality, CV outcomes)
According to the recent JNC-8 hypertension guidelines, what is the goal blood pressure and initial first-line agent for a 45 y/o African-American patient with hypertension, diabetes, and hyperlipidemia?
Goal BP < 140/90 mmHg; thiazide-type diuretic or CCB
What to monitor with Thiazide diuretics? (HInt: 5 things)
Hypokalemia, Ca, uric acid, glucose, SCr
What is the CrCl where Thiazide diuretics no longer work?
Under 30mL/min. Use look diuretics. Metolazone OK if under 30.
Which minteral to monitor with ACE-inhibitors and ARBs?
Hyperkalemia
ACE-I and ARB beneficial for what protein issue?
Beneficial for proteinuria (DM/CKD)
ACE-I and ARB rating in 1st term preggers? 2nd and 3rd term preggers?
1st term=C
2 and 3rd=D
Which ARB is a uricosuric? What does that even mean?
Lorsartan. Excrete uric acid from blood into urine. good for gout.
2 big side-effects of ACE-Inhibitors?
- Cough (switch to ARB)
2. Angioedema (can get real serious real fast)
Where do Dihydropyradine CCBs work? Name ends in?
“-dipine”.
Work in vascular smooth muscle causing peripheral vasodilation.
2 big side-effects from Dihydropyradine CCBs?
- Peripheral edema
2. Reflex tachycardia
Amlodipine and Simvastatin 20?
Drug-drug interaction
Diltiazem/Verapamil + Simvastatin 10?
Drug-drug interaction
Where do the non-DI-CCBs work?
Cardiac smooth muscle. Reduce HR and heart contractility (negative chronotrope and negative inotrope).
Side effects of non-DI-CCBs? (Hint: ß-blockers and LVD/HF)
Constipation.
ß-blockers=risk of AV block.
Don’t use in LVD/HF!
Spironolactone and Eplerenone are examples of which diuretic?
Aldosterone-antagonist/Potassium-sparing
Potassium-sparing diuretic and ACEi/ARB caution when used together?
Can cause hyperK and arrythmias
Spironolactone can do what to men?
Anti-androgen effect. Gynecomastia.
When is Eplerenone contraindicated? (hint: 2 cases)
- CrCl less than 50
2. DM + proteinuria
Which K-sparing diuretic CI’d if PT has CrCl less than 50?
Eplerenone
Which K-sparing diuretic CI’d if PT has DM w/proteinuria.
Eplerenone
Eplerenone and potssium?
Use precaution. 3A4.
When to consider use of ß-blockers?
In cormorbid CHF or CVD (angina/MI)
Carvedilol and Labetelol have added effects to what channel?
Added alpha blockade
Which ß-blocker requires renal dosing?
Atenolol
What can ß-blockers mask?
Hypoglycemia
ß-blockers might have reduced efficacy in which population?
Black population
Alpha-1-blockers end in what?
“-zosin”
Alpha-1-blockers good for relief of what?
BPH
Alpha-1-blocker side effects?
Orthostatic hypotension, reflex tachy, dizzy, drowsy, increased risk of peripheral edema
What are the three centrally-acting agents?
Clonidine, Methyldopa, Reserprine
How is Clonidine administered?
Once a week patch
Which centrally acting HTN agent is safe in preggers?
Methyldopa
What can happen if d/c centrally acting HTN agent? Worse with what other med?
Rebound HTN. Worse with ß-blocker.
Centrally acting agent side-effects?
Drowsy, dizzy, sedation, dry mouth, impotence
What are the 2 Direct Vasodilators?
- Minoxidil
2. Hydralazine
How to minimize reflex tachycardia with Direct Vasodilators?
Add ß-blocker or central agent
Hydralazine has an added benefit with which other heart dz?
HF
Minoxidil can do what to fluids?
Cause fluid retention
True or False: In a patient with co-morbid hypertension and cardiovascular disease (CVD; history of angina or prior MI) who is not at goal BP and whose medications solely include HCTZ, lisinopril, and amlodipine, a beta-blocker should be considered as the next agent.
Yes
Define Resistant HTN
BP that remains above goal inspite of using 3 anti-HTN agents of different classes at optimal doses
Percent of PTs with Resistant HTN?
10%
What’s important to do before labeling a PT with resistant HTN?
Consider/rule-out secondary causes of resistance
What is a common secondary cause of HTN?
Pseudoresisance
What can cause Pseudoresisance?
- Faulty BP machine or technique
- White coat syndrome or aggravation
- Non-adherence
What is the #1 cause of Pseudoresisance?
Non-adherence of BP meds. Up to 40% of patients stop taking meds in first year.
How to improve adherence of BP meds?
Assess if PT understands dz. Use adhereance aids. Link meds with daily activities. Provide multi-disciplinary support. Recognize socio-behavioral issues. Simplify med regimen.
What are frequent Secondary Causes of HTN?
Sleep apnea, primary aldosteronism, CKD (CrCl 30 or less), renal artery stenosis, volume overload, alcohol intake, obesity, meds (NSAIDS, COX-2-inhibitors)
Uncommon causes of Secondary HTN?
Pheochromocytoma, Cushing’s dz, Hyperparathyroidism, Incracranal tumor
Secondary HTN due to which meds? (hint: may be illegal or herbal)
NSAIDS/COX-2-inhib, stimulants, cocaine, sympathomimetics (decongestants, diet pills), OCPs, cyclosporins, tacrolimus, steroids, erythropoietin, natural licorice, herbals like ephedra and bitter orange
How to treat Resistant HTN patients?
Compliance with meds, combo agents to reduce pull burden, chronotherapeutics (give one at night, NOT a diuretic)
Which class is a good option for 4th line HTN agent? What are its effects on BP and LV?
K-sparing diuretics (spironolactone, eplerenone, amiloride). Reduce SBP 5-20, reduce DBP 5-10, improve LV size.
When do use an Alpha-1-blocker with Resistant HTN?
If PT has low HR +/- BPH
What HR to use ß-blockers above?
Above 80
True or False: Potassium-sparing diuretics, beta-blockers, and
alpha blockers are considered equally efficacious as add-on considerations in resistant hypertension (classic triad: thiazide, ACEI or ARB, and CCB)
FALSE
What BP for PT with DM2?
140/90 or below
When to follow up with pre-HTN patients using non-pharm approach?
1 year
When to follow up with Stage 1 HTN patients w/o major risk factors using non-pharm approach?
1-6 months
When to follow up with Stage 1 HTN patients w/o major risk factors using who failed non-pharm approach?
1-6 months
CAD risk factors?
- Age >65, male>female
- Smoking, dyslipidemia, HTN DM, abd obesity/central obesity
- family hx of 1st degree relative with premature MI (men <55, women <65)
- cocaine use (don’t give metoprolol d/t unopposed alpha!!! i think you can give labetolol)
What age a 1st degree relative with “premature” MI?
Men under 55
Women under 65
According to the AHA guidelines how soon upon arrival should an ECG for chest pain be done?
10 minutes
Is a T wave inversion in lead III normal or not?
Normal variant
What does marked twave inversion >2mm suggest
Ischemia
What does nitroglycerin to do preload and afterload?
Decrease preload and decreased afterload
How should the orders for nitroglycerin be prescribed for the patient in the ED?
Nitroglycerin 0.4mg Q 5 minutes x3
Which of the following medications should NOT be given in potential ACS/NSTEMI patients? A. Ibuprofen B. Clopidogrel C. Metoprolol D. Prasugrel E. Baby Aspirin
A. Ibuprofen
What form should Aspirin be given? Dose?
Chewable 324mg
When to hold NTG?
BP less than 100/50
How much Morphine and when to hold?
Morphine 2-4mg PRN. Hold BP less than 100/50.
Which type of xray would you like to order for ACS patient?
Portable chest
What is the portable CXR view?
AP
If a patient who has relief of pain from Nitroglycerin, this indicates a cardiac process?
A.True
B.False
False. Nitro does GI relaxation so relief might not be strictly cardiac.
How often to repeat EKG in first hour when initial EKG is nondiagnostic?
every 15-30min
How often to measure Troponins?
Every 3-6h
Which leads for right sided EKG?
V7-V9
What are the 3 types of ACS?
- Unstable angina
- nSTEMI
- STEMI
TIMI score of 0-2, 3-4, and 5-7 represent what?
0-2=low risk of CAD
What is the TIMI score? Which ACS is it better at? What does it not use?
Can be used to help risk stratify patients with angina symptoms
(unstable angina, non-STEMI). Doesn’t use Troponins.
What is the Heart Score?
Measures undifferentiated PTs with possible ACS. Undifferentiated chest pain or angina equivalents.
What trumps all in ACS?
Story
What type of antithrombotic are the ADP Receptor Antagonists?
Antiplatelet
What are the three ADP Receptor Antagonists?
- Clopidogrel
- Prasugrel
- Ticagrelor
The ADP receptor antagonists work on which receptor to prevent platelet aggregation?
P2Y12
Where is the HEART tool only used?
ED
What does the PURSUIT score predict?
Risk of Death or MI at 30 days after admission
What does the TIMI score predict?
Risk of all cause mortality, MI and severe recurrent ischemia requiring urgent revascularization within 14 days after admission
What does the GRACE score predict?
Risk of hospital death and post-discharge death at 6 months
What does the HEART score predict?
Prediction of combined endpoint of MI, PCI, CABG, or death within 6 weeks after presentation
Enoxaparin, Fondaparinux, and UFH are what sorts of drugs?
Anticoagulants
Enoxaparin, Fondaparinux, and UFH duration
UFH=first 48h or until PCI
Enox and Fonda=duration of hospital stay or until PCI
When are the IIb/IIIa inhibitors given?
Given during coronary angioplasty or stent placement in patients with ACS
What is the primary ADR of anticoagulants?
Bleeding risk
Which three are the Indirect thrombin inhibitors which inactivate Factor Xa?
Heparin/Enoxoparin/Fondaparinux
Must monitor what UFH? Concern for what?
Must monitor PTT; concern for HIT
UFH route and onset?
IV. Rapid onset.
Which has a greater bleeding risk between LMWH and UFH?
UFH
Route of LMWH? Monitoring aPTT required?
SQ (good for outpatient). No aPTT monitoring required.
UFH and kidneys?
OK even if CrCl less than 30
LMWH and kidneys?
Can’t give below CrCl 30 unless reduce dose by 50%
If CrCl less than 30 can give LMWH?
Either reduce dose by 50% of switch to UFH.
Fonda (arixtra) CI’ed with what CrCl?
Below 30
UFH or LMWH has simpler dose?
LMWH
UFH dosed by which weight?
Ideal weight
LMWH dosed by which weight?
LMWH is actual weight
What two things must be negative to stress test a patient?
EKG and biomarkers negative
If stress test shows stable angina what will the PT need?
PCI
When to give PT dual anti-platelet therapt + anticoagulation?
When dx with ACS (positive cardiac biomarkers or EKG changes)
Can give Clopidogrel (Plavix) with liver dz?
No!
If PT has had HIT how long until give UFH or LMWH again?
100 days
NTG and elevated ICP?
Don’t give!
Area of heart and coronary artery if STEMI in Leads V2, V3, V4?
Anterior MI.
Left anterior descending artery (LAD)
Clopidogrel (Plavix) and Prozac ok together?
NO.
and other CYP3A4/2C19 DDI.
NSAIDs after MI ok?
No!!!!!
OK to give NTG if PT on Viagra?
NoooooooOOoOoooo!!
STEMI in leads I, aVL, V5, V6. Heart region and which artery?
Left lateral MI.
LCx artery
STEMI in leads II, III, aVF. Which heart region? Artery?
Inferior MI.
RCA.
STEMI in aVR, V1. Heart region and artery?
Right ventricular. RCA.
ST depressions in V2-V4. Heart region and artery?
Posterior MI.
RCA.
