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Clin Therapeutics 1 > Exam 3 - HTN & ACS > Flashcards

Exam 3 - HTN & ACS Flashcards

1
Q

What is the goal BP for someone under 60 with no DM or CKD?

A

140/90 or less

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2
Q

What is the goal BP for someone over 60 with no DM or CKD?

A

150/90 or less

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3
Q

What is goal BP for someone with DM or CKD?

A

140/90 or less. Age doesn’t matter.

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4
Q

Initial HTN meds in black population? (+/- DM)

A

Thiazide-type diuretic or CCB

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5
Q

What is the goal BP for a patient older than 18 with DM?

A

140/90 or less

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6
Q

What is the goal BP for a patient older than 18 with CKD?

A

Less than 140/90

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7
Q

What is the goal BP for someone over 18 with DM?

A

140/90 or less

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8
Q

What is the goal BP for someone over 18 with CKD?

A

140/90 or less

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9
Q

Why do ACEi/ARBs not work as well in the black population?

A

Low plasma renin levels and increased sodium/fluid loading?

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10
Q

Which HTN meds does the black population respond particularly well to?

A

Diuretics and Na+ restriction

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11
Q

What are the 4 first-line HTN meds for the general population? Non-black, +/- DM.

A

ACEi, ARB, CCB, Thiazide-type diuretic

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12
Q

Initial HTN meds if have CKD? (Even if black, DM, or have proteinuria.)

A

ACEi or ARB

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13
Q

Which two meds are most effective in improving cerebrovascular, heart failure, and combined CV outcomes in the black population?

A

Diuretics and CCBs

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14
Q

Some studies have shown an increased stroke risk with which HTN med in the black population?

A

ACEi

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15
Q

If goal BP not met on one agent within one month of initiating treatment what is next step? (Hint: 2 options)

A
  1. Increase dose, or

2. Add 2nd agent from a different class

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16
Q

If goal BP not met on 2 drugs?

A

Add 3rd from different class (Ex: ACEi + CCB + Thiazide diuretic)

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17
Q

Which two class of HTN drugs should not be used in combo?

A

ACEi + ARB

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18
Q

The ACCOMPLISH trial found significantly less CV mortality with what combo?

A

CCB + ACEI

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19
Q

If goal BP can’t be reached with combo of three first-line meds what to do before 4th agent?

A

Ensure dose optimization and med compliance. Consider referral to HTN specialist.

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20
Q

What did the HYVET trial find for elderly over 80 y/o?

A

Diuretic +/- ACEi trend toward reduced rates of fatal/nonfatal stroke.
Secondary outcome: significant reduction in secondary outcomes (fatal stroke, all-cause mortality, CV outcomes)

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21
Q

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?

A

Goal BP < 140/90 mmHg; thiazide-type diuretic or CCB

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22
Q

What to monitor with Thiazide diuretics? (HInt: 5 things)

A

Hypokalemia, Ca, uric acid, glucose, SCr

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23
Q

What is the CrCl where Thiazide diuretics no longer work?

A

Under 30mL/min. Use look diuretics. Metolazone OK if under 30.

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24
Q

Which minteral to monitor with ACE-inhibitors and ARBs?

A

Hyperkalemia

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25
Q

ACE-I and ARB beneficial for what protein issue?

A

Beneficial for proteinuria (DM/CKD)

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26
Q

ACE-I and ARB rating in 1st term preggers? 2nd and 3rd term preggers?

A

1st term=C

2 and 3rd=D

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27
Q

Which ARB is a uricosuric? What does that even mean?

A

Lorsartan. Excrete uric acid from blood into urine. good for gout.

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28
Q

2 big side-effects of ACE-Inhibitors?

A
  1. Cough (switch to ARB)

2. Angioedema (can get real serious real fast)

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29
Q

Where do Dihydropyradine CCBs work? Name ends in?

A

“-dipine”.

Work in vascular smooth muscle causing peripheral vasodilation.

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30
Q

2 big side-effects from Dihydropyradine CCBs?

A
  1. Peripheral edema

2. Reflex tachycardia

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31
Q

Amlodipine and Simvastatin 20?

A

Drug-drug interaction

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32
Q

Diltiazem/Verapamil + Simvastatin 10?

A

Drug-drug interaction

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33
Q

Where do the non-DI-CCBs work?

A

Cardiac smooth muscle. Reduce HR and heart contractility (negative chronotrope and negative inotrope).

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34
Q

Side effects of non-DI-CCBs? (Hint: ß-blockers and LVD/HF)

A

Constipation.
ß-blockers=risk of AV block.
Don’t use in LVD/HF!

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35
Q

Spironolactone and Eplerenone are examples of which diuretic?

A

Aldosterone-antagonist/Potassium-sparing

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36
Q

Potassium-sparing diuretic and ACEi/ARB caution when used together?

A

Can cause hyperK and arrythmias

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37
Q

Spironolactone can do what to men?

A

Anti-androgen effect. Gynecomastia.

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38
Q

When is Eplerenone contraindicated? (hint: 2 cases)

A
  1. CrCl less than 50

2. DM + proteinuria

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39
Q

Which K-sparing diuretic CI’d if PT has CrCl less than 50?

A

Eplerenone

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40
Q

Which K-sparing diuretic CI’d if PT has DM w/proteinuria.

A

Eplerenone

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41
Q

Eplerenone and potssium?

A

Use precaution. 3A4.

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42
Q

When to consider use of ß-blockers?

A

In cormorbid CHF or CVD (angina/MI)

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43
Q

Carvedilol and Labetelol have added effects to what channel?

A

Added alpha blockade

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44
Q

Which ß-blocker requires renal dosing?

A

Atenolol

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45
Q

What can ß-blockers mask?

A

Hypoglycemia

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46
Q

ß-blockers might have reduced efficacy in which population?

A

Black population

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47
Q

Alpha-1-blockers end in what?

A

“-zosin”

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48
Q

Alpha-1-blockers good for relief of what?

A

BPH

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49
Q

Alpha-1-blocker side effects?

A

Orthostatic hypotension, reflex tachy, dizzy, drowsy, increased risk of peripheral edema

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50
Q

What are the three centrally-acting agents?

A

Clonidine, Methyldopa, Reserprine

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51
Q

How is Clonidine administered?

A

Once a week patch

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52
Q

Which centrally acting HTN agent is safe in preggers?

A

Methyldopa

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53
Q

What can happen if d/c centrally acting HTN agent? Worse with what other med?

A

Rebound HTN. Worse with ß-blocker.

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54
Q

Centrally acting agent side-effects?

A

Drowsy, dizzy, sedation, dry mouth, impotence

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55
Q

What are the 2 Direct Vasodilators?

A
  1. Minoxidil

2. Hydralazine

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56
Q

How to minimize reflex tachycardia with Direct Vasodilators?

A

Add ß-blocker or central agent

57
Q

Hydralazine has an added benefit with which other heart dz?

A

HF

58
Q

Minoxidil can do what to fluids?

A

Cause fluid retention

59
Q

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.

A

Yes

60
Q

Define Resistant HTN

A

BP that remains above goal inspite of using 3 anti-HTN agents of different classes at optimal doses

61
Q

Percent of PTs with Resistant HTN?

A

10%

62
Q

What’s important to do before labeling a PT with resistant HTN?

A

Consider/rule-out secondary causes of resistance

63
Q

What is a common secondary cause of HTN?

A

Pseudoresisance

64
Q

What can cause Pseudoresisance?

A
  1. Faulty BP machine or technique
  2. White coat syndrome or aggravation
  3. Non-adherence
65
Q

What is the #1 cause of Pseudoresisance?

A

Non-adherence of BP meds. Up to 40% of patients stop taking meds in first year.

66
Q

How to improve adherence of BP meds?

A

Assess if PT understands dz. Use adhereance aids. Link meds with daily activities. Provide multi-disciplinary support. Recognize socio-behavioral issues. Simplify med regimen.

67
Q

What are frequent Secondary Causes of HTN?

A

Sleep apnea, primary aldosteronism, CKD (CrCl 30 or less), renal artery stenosis, volume overload, alcohol intake, obesity, meds (NSAIDS, COX-2-inhibitors)

68
Q

Uncommon causes of Secondary HTN?

A

Pheochromocytoma, Cushing’s dz, Hyperparathyroidism, Incracranal tumor

69
Q

Secondary HTN due to which meds? (hint: may be illegal or herbal)

A

NSAIDS/COX-2-inhib, stimulants, cocaine, sympathomimetics (decongestants, diet pills), OCPs, cyclosporins, tacrolimus, steroids, erythropoietin, natural licorice, herbals like ephedra and bitter orange

70
Q

How to treat Resistant HTN patients?

A

Compliance with meds, combo agents to reduce pull burden, chronotherapeutics (give one at night, NOT a diuretic)

71
Q

Which class is a good option for 4th line HTN agent? What are its effects on BP and LV?

A

K-sparing diuretics (spironolactone, eplerenone, amiloride). Reduce SBP 5-20, reduce DBP 5-10, improve LV size.

72
Q

When do use an Alpha-1-blocker with Resistant HTN?

A

If PT has low HR +/- BPH

73
Q

What HR to use ß-blockers above?

A

Above 80

74
Q

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)

A

FALSE

75
Q

What BP for PT with DM2?

A

140/90 or below

76
Q

When to follow up with pre-HTN patients using non-pharm approach?

A

1 year

77
Q

When to follow up with Stage 1 HTN patients w/o major risk factors using non-pharm approach?

A

1-6 months

78
Q

When to follow up with Stage 1 HTN patients w/o major risk factors using who failed non-pharm approach?

A

1-6 months

79
Q

CAD risk factors?

A
  • 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)
80
Q

What age a 1st degree relative with “premature” MI?

A

Men under 55

Women under 65

81
Q

According to the AHA guidelines how soon upon arrival should an ECG for chest pain be done?

A

10 minutes

82
Q

Is a T wave inversion in lead III normal or not?

A

Normal variant

83
Q

What does marked twave inversion >2mm suggest

A

Ischemia

84
Q

What does nitroglycerin to do preload and afterload?

A

Decrease preload and decreased afterload

85
Q

How should the orders for nitroglycerin be prescribed for the patient in the ED?

A

Nitroglycerin 0.4mg Q 5 minutes x3

86
Q 
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

A. Ibuprofen

87
Q

What form should Aspirin be given? Dose?

A

Chewable 324mg

88
Q

When to hold NTG?

A

BP less than 100/50

89
Q

How much Morphine and when to hold?

A

Morphine 2-4mg PRN. Hold BP less than 100/50.

90
Q

Which type of xray would you like to order for ACS patient?

A

Portable chest

91
Q

What is the portable CXR view?

A

AP

92
Q

If a patient who has relief of pain from Nitroglycerin, this indicates a cardiac process?
A.True
B.False

A

False. Nitro does GI relaxation so relief might not be strictly cardiac.

93
Q

How often to repeat EKG in first hour when initial EKG is nondiagnostic?

A

every 15-30min

94
Q

How often to measure Troponins?

A

Every 3-6h

95
Q

Which leads for right sided EKG?

A

V7-V9

96
Q

What are the 3 types of ACS?

A
  1. Unstable angina
  2. nSTEMI
  3. STEMI
97
Q

TIMI score of 0-2, 3-4, and 5-7 represent what?

A

0-2=low risk of CAD

98
Q

What is the TIMI score? Which ACS is it better at? What does it not use?

A

Can be used to help risk stratify patients with angina symptoms
(unstable angina, non-STEMI). Doesn’t use Troponins.

99
Q

What is the Heart Score?

A

Measures undifferentiated PTs with possible ACS. Undifferentiated chest pain or angina equivalents.

100
Q

What trumps all in ACS?

A

Story

101
Q

What type of antithrombotic are the ADP Receptor Antagonists?

A

Antiplatelet

102
Q

What are the three ADP Receptor Antagonists?

A
  1. Clopidogrel
  2. Prasugrel
  3. Ticagrelor
103
Q

The ADP receptor antagonists work on which receptor to prevent platelet aggregation?

A

P2Y12

104
Q

Where is the HEART tool only used?

A

ED

105
Q

What does the PURSUIT score predict?

A

Risk of Death or MI at 30 days after admission

106
Q

What does the TIMI score predict?

A

Risk of all cause mortality, MI and severe recurrent ischemia requiring urgent revascularization within 14 days after admission

107
Q

What does the GRACE score predict?

A

Risk of hospital death and post-discharge death at 6 months

108
Q

What does the HEART score predict?

A

Prediction of combined endpoint of MI, PCI, CABG, or death within 6 weeks after presentation

109
Q

Enoxaparin, Fondaparinux, and UFH are what sorts of drugs?

A

Anticoagulants

110
Q

Enoxaparin, Fondaparinux, and UFH duration

A

UFH=first 48h or until PCI

Enox and Fonda=duration of hospital stay or until PCI

111
Q

When are the IIb/IIIa inhibitors given?

A

Given during coronary angioplasty or stent placement in patients with ACS

112
Q

What is the primary ADR of anticoagulants?

A

Bleeding risk

113
Q

Which three are the Indirect thrombin inhibitors which inactivate Factor Xa?

A

Heparin/Enoxoparin/Fondaparinux

114
Q

Must monitor what UFH? Concern for what?

A

Must monitor PTT; concern for HIT

115
Q

UFH route and onset?

A

IV. Rapid onset.

116
Q

Which has a greater bleeding risk between LMWH and UFH?

A

UFH

117
Q

Route of LMWH? Monitoring aPTT required?

A

SQ (good for outpatient). No aPTT monitoring required.

118
Q

UFH and kidneys?

A

OK even if CrCl less than 30

119
Q

LMWH and kidneys?

A

Can’t give below CrCl 30 unless reduce dose by 50%

120
Q

If CrCl less than 30 can give LMWH?

A

Either reduce dose by 50% of switch to UFH.

121
Q

Fonda (arixtra) CI’ed with what CrCl?

A

Below 30

122
Q

UFH or LMWH has simpler dose?

A

LMWH

123
Q

UFH dosed by which weight?

A

Ideal weight

124
Q

LMWH dosed by which weight?

A

LMWH is actual weight

125
Q

What two things must be negative to stress test a patient?

A

EKG and biomarkers negative

126
Q

If stress test shows stable angina what will the PT need?

A

PCI

127
Q

When to give PT dual anti-platelet therapt + anticoagulation?

A

When dx with ACS (positive cardiac biomarkers or EKG changes)

128
Q

Can give Clopidogrel (Plavix) with liver dz?

A

No!

129
Q

If PT has had HIT how long until give UFH or LMWH again?

A

100 days

130
Q

NTG and elevated ICP?

A

Don’t give!

131
Q

Area of heart and coronary artery if STEMI in Leads V2, V3, V4?

A

Anterior MI.

Left anterior descending artery (LAD)

132
Q

Clopidogrel (Plavix) and Prozac ok together?

A

NO.

and other CYP3A4/2C19 DDI.

133
Q

NSAIDs after MI ok?

A

No!!!!!

134
Q

OK to give NTG if PT on Viagra?

A

NoooooooOOoOoooo!!

135
Q

STEMI in leads I, aVL, V5, V6. Heart region and which artery?

A

Left lateral MI.

LCx artery

136
Q

STEMI in leads II, III, aVF. Which heart region? Artery?

A

Inferior MI.

RCA.

137
Q

STEMI in aVR, V1. Heart region and artery?

A

Right ventricular. RCA.

138
Q

ST depressions in V2-V4. Heart region and artery?

A

Posterior MI.

RCA.

Clin Therapeutics 1 (12 decks)

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