FamMed PPP w/ Rosh Flashcards
What are the two etiologies for hyperlipidemia
What two PE findings are suggestive of this Dx
When are screening initiated for wo/men
HyperCholesterol/Triglyceridemia
Xanthomas: accumulation on Achilles
Xanthelasmas: eyelid plaques
High risk (smoking, HTN, FamHx)- M: 20-25, F: 30-35 Low risk- M: 35, F: 45
National Cholesterol Education Program recommends screening all adults at ? age regardless of RFs
What are the 5 populations that need to have hyperlipidemia Tx
? lab order is needed if Pt develops body aches after starting statin therapy
20y/o
Diabetics between 40-75y/o
Atherosclerotic dz/ASCVD risk ≥7.5%
≥21y/o w/ LDL ≥190
<19y/o w/ familial hypercholesterolemia
Creatinine kinase
Best med for lowering elevated LDL
Best meds for lowering triglycerides
Best meds to increase HDL
DM2 get ? two meds
Statins, Bile acid sequestrants
Fibrates, Niacin
Niacin, Fibrates
Statins, Fibrates
MOA of statins
Two possible adverse outcomes
Pt education for taking these meds
Inhibit HMG-CoA reductase, inc LDL clearance
Rhabdo, Myositis
Take at night (Atorva/Rosuva- anytime of day)
MOA of Niacin
Adverse effect of use
C/i to use
Inc HDL levels by decreasing clearance
Inc prostaglandins= flushing/warm skin; Pre-Tx w/ NSAID/ASA 30min prior
PUD, Liver Dz
MOA of Fibrates
Adverse effects of use
C/i to use
Dec triglyceride synthesis w/ inc lipoprotein catabolism
Increased gallstones
Hepatobiliary Dz, Breastfeeding
What is the only Fibrate approved for co-use w/ a Statin
Genfibrozil can’t be used w/ ? meglitinide
How is the pruritus associated w/ biliary obstruction Tx
Fenofibric acid
Repaglinide
Cholestyramine
MOA of Bile Acid Sequestrants
Adverse effects of use
C/i to use
Binds to bile acids preventing absorption and dec LDL
Inc triglycerides
Impairs medication/fat soluble vitamin absorption
Sev hypertriglycerides, Complete biliary obstruction
MOA of Ezetimibe
What are the indications for use
What are the adverse effects of use
Inhibits intestinal cholesterol absorption
Combo use w/ statin to dec LDLs
Inc LFTs, HA/D
High intensity statins
Mod intensity statins
Low intensity statins
Atrova 40-80mg
Rosuva 20-40mg
Atorva 10 Rosuva 10 Simva 20-40 Prava 40 Lova 40 Fluva 40 Fluva 80 Pita 2-4mg
Simva 10 Prava 10-20 Lova 20 Fluva 20-40 Pita 1mg
Ranges for Normal, Elevated, Stage 1 and Stage 2 HTN
MCC of Essential HTN
MCC of Secondary HTN
N: <120/80 and <80
E: 120-129 and <80
1: 130-39 or 80-89
2: ≥140/≥90
Idiopathic
Renovascular
? are the two MCC of end stage renal dz in USA
What are the ACC/AHA HTN targets
What are the JNC-8 HTN targets
DM then HTN
<130/80
<60y/o/CKDz/DM: <140/90
≥60y/o: <150/90
? is the only ARB that doesn’t cause hyperuricemia
MOA of Thiazide diuretics (including Metolazone)
S/e of use
Losartan
Dec reabsorption and Ca excretion at distal tubule
HypoNa/K, HyperUr/Ca/Glucose
MOA of Loop Diuretics
Adverse effects of use
C/i in ? population
Inhibit water transport across LoH
HypoK/Na/Ca
Sulfa allergy
MOA of K-sparing diuretics
S/e of use
C/i to use
Inhibit Na/water absorption, most useful combo use w/ Loops
HyperK, metabolic acidosis
Renal failure, HypoNa
MOA of ACEI
Adverse effects of use
C/i to use
Dec pre/after load, inc vasodilation and insulin action
1st dose HOTN, HyperK Cough Angioedema
Pregnancy
MOA of ARBS
Adverse effect of use
C/i to use
Binds/blocks angiotensin two receptors w/out increasing bradykinin levels
HyperK
Pregnancy
MOA of Non-Dihydro CCBs
MOA of Dihydro CCBs
S/e of use
C/i to use
Vasodilators w/out cardiac effect
Affect contractility/conduction along w/ vasodilation
HA Edema Consitpaion- Verapamil
CHF, 2/3 blocks
MOA of BB
Adverse effects of use
Ci to use
Catecholamine inhibitor, blocks adrenergic renin release
Impotence, HypoGlycemia
HOTN, HR <50, Asthma/COPD
MOA of A-blockers
Beneficial use for ? population
Adverse effects to use
Blockade leads to arterial dilation
HTN w/ BPH
1st dose syncope, HA, weakness
When do USPSTF screening begin and when are f/u needed
Criteria for HTN Urgency
MC c/c Sx
18y/o: q12mon,
q6mon if SBP 120-129
SBP >180 or DBP >120 w/out end organ damage
HA
How are HTN Urgency Tx
What is the BP goal for Tx
PO Meds: Clonidine: A2 agonist Captopirl Furosemide Labetalol Nicardipine
≤160/100
Define HTN Emergency
How quickly is BP lowered
What are the three exceptions to lowering BP
SBP >180 or DBP >120 w/ end organ damage
MAP dec 10-20% first hour
5-15% over 23hrs
Acute phase ischemic stroke
Aortic dissection
intracerebral HTN
What meds are used during HTn Emergencies
What causes angina
Sxs begin to occur when ?% occlusion is present
Nicard/Clevidi-pine
Labetalol
Fenoldopam
Na Nitroprusside
Dec perfusion: inc demand along w/ dec supply
≥70%
Time frame for angina pectoris
What are anginal equivalents
Who is more likely to develop an equivalent
<30min, resolves <5min w/ rest or Nitro
Dyspnea, Epigastric/Shoulder pain
Elderly Diabetic Obese Women
What is the initial step for Dx Angina Pectoris
What is the most important non-invasive test
What is the definitive Dx method
EKG w/ ST depression
Stress test w Bruce protocol
Angiography
How is Angina Pectoris managed outpatient
What are the two revascularization techniques and what determines the method
ASA BB Nitro Statin
PCI: 1 or 2 vessel Dz in non-DM w/out LAD involvement and normal EF
CABG: L-main or 3 vessel Dz, or two vessel Dz in diabetics, or Pts w/ EF <40%
What are the four NYHA classifications of angina
? is the most useful non-invasive test in the Dx of CADz
What are the indications to order this test
1: ASx, no limitations
2: Sx w/ mod activity
3: Sx w/ mild activity
4: Sx at rest
Stress test
Baseline EKG is normal
What two meds are used for a chemical stress test for Pts unable to exercise
Pts need to d/c ? two meds prior to test
What two meds are used for stress Echos
Adenosine: dec AV conduction
Dipyridamole: dec platelet aggregation, coronary artery dilation
Theophylline: adenosine receptor antagonist
Caffeine
Dopamine or Dobutamine (c/i w/ AS, MI <3 days or HTN)
What can trigger Rest Angina
What medication may be used during angiography to aid w/ Dx
How are these Pts managed and what is avoided
Prinzmetal: cocaine, pseudophedrine
Ergonovine
CCBs, then Nitro;
No BBs
Check ? leads for P-wave morphology
How is a sinus rhythm determined
Normal PR interval
2, V1
Upright 1, 2, aVF;
Neg in aVR
.12-.2 (3-5 boxes)
How is L atria enlargement assessed
How is R atria enlargement assessed
Normal QRS length is ? but if shortened ? step is skipped
M-shaped in lead 2
Biphasic in V1 w/ larger terminal component
Tall in lead two ≥3mm
Biphasic in V1 w/ larger initial component
RVH criteria
LVH Criterias
V1 R>S or R >7mm
Sokolow-Lyon:
V1 S + V5 R >35 (>30 women)
Cornell:
aVL R + V3 S >28mm (>20mm women)
Heart moves ? infarct and ? hypertrophy
Define Sinus Arrhythmia
If Sx, how are these Pts Tx
Away from infarct, Towards hypertrophy
Beat to beat variation: inc w/ inspiration, dec w/ expiration
Brady w/ Atropine first, then:
Trans-pace, Epi, Dopamine
Criteria for Sinus Tach
What med is used for persistent sinus tach during ACS
Criteria for Sinus Brady and how are Pts w/ Sxs Tx
> 100bpm w/ P-waves
Metoprolol
<60bpm w/ P-waves;
Atropine then Epi/Trans-pacing
MCC of SSS
How does this condition present and how is it Dx
If unstable, how are Pts Tx
How are Pts Tx long term
Sinus node fibrosis
Episodic brady/tachy;
EKG or Holter
Atropine then,
Trans-pace, Epi, Dopamine
Pacemaker
How does A-flutter appear on EKG
How are stable Pts managed
How are unstable Pts managed
Identical saw-tooth waves at 250-350 bpms
Vagal, Rate: BB/CCBs
Sync’d conversion
Definitive Tx for A-flutter
? class anti-arrhythmics can be used
What are the four types of Afib
Ablation
1A, 1C or 3
Paroxysmal: <7days
Persistent: >7days
Permanent: >12mon, refractory to conversion or no attempts
Lone: no heart Dz
? syndrome can occur during Afib
How are stable Pts Tx
How are unstable Pts Tx
Ashman: aberrant conduction beats w/ wide QRS after short R-R cycles
Rate: BB or Non-Di CCBs, Digoxin if BB/CCB c/i
Synch’d conversion
How are Afib Pts definitively Tx
Anticoagulate ? long prior and after conversion
What are the two types of PSVT
Ablation, MAZE surgery
3wks prior, 4wks after
ANRT: one normal, one accessory path within AV node; MC type
AVRT: one normal, one accessory outside AV node (WPW, LGL syndrome)
What are the two different EKG presentations of PSVTs
How are the two Tx
Orthodromic: narrow complex tachycardia
Antidromic: regular, wide complex tachycardia
Stable, narrow: vagal, Adenosine, BB CCB Digoxin
Stable, Wide:
Amiodarone, Procainamide
Unstable: Synch’d conversion
What is the difference between WAP and MAT
MAT frequently co-exists w/ ? other d/o
How is MAT Tx in this population
WAP: <100bpm
MAP: >100bpm
COPD
Verapamil;
BB if LV function preserved
WPW is a AVRT variant w/ accessory pathway located ?
What are the 3 EKG findings
How is this wide complex Tx
Bundle of Kent
Short PR
Wide QRS
D-wave
Procainamide/Amiodarone
Synch’d conversion
Ablation
What EKG finding suggest AV junctional rhythms
What EKG finding suggest PVCs
MCC of Vtach
Inverted P-wave 1, 2, aVF
Post P-wave aVR
T-wave opposite direction of QRS w/ compensatory pause
Ischemic heart dz
Along w/ low E+, what medication toxicity can cause V-tach
How is stable, sustained Vtach Tx
MCC of Vfib
Digoxin
Amiodarone Lidocaine Procainamide
ischemic heart Dz
Class 1 Anti-arrythmic drugs
Na channel blockers: dec Na conduction and AV node automaticity leading to membrane stabilization
1A: Procainamide Quinidine Disopyramide;
Prolong repolarization and action potential
1b: Lidocaine, Tocainide;
Dec conduction velocity and shortens repolarization;
C/i: narrow SVT
1c: Flecainide Propafenone Ecainide;
Inc QRS prolongation and dec conduction velocity w/ affecting action potential
Class 2 Anti-arrhythmic drugs
Cardio sel: AME-olol
Non-Sel B1, B2: PS-olol
Non-sel A, B1,2: LC-olol
Dec SA/AV node conduction
Non-sels can cause bronchospasms in asthma/COPD
Toxicity Tx w/ glucagon
Class 3 anti-arrhythmics
Sotalol Amiodarone Ibutilide Dofetilide
Prolongs action potential
Amiodarone: characteristics of Class 1-4 meds w/ s/e of pulm fibrosis and thyroid d/o
Class 4 anti-arrhythmics
Class 5 anti-arrhythmics
Class 1 and 3 antiarrhythmics are used for while Class 2 and 4 are used for
Verapamil, Diltiazem
Slows SA/AV conduction to inc PR interval and refractory period
Digoxin- cardiac glycoside, dec ATP-ase
1/3: rhythm, 2/4: rate
MCC of syncope
Harsh/Rumbling murmur indicates ?
Blowing murmur indicates ?
Vasovagal: prodrome of dizzy, light headed, tunnel vision
Stenosis
Regurg
Increasing venous return to the heart increases the intensity of ALL murmurs except ? two
What two murmurs radiate
What positions accentuate aortic and mitral murmurs
HOCM, MVP
MR: axilla AS: carotid
Aortic: sit, lean forward
Mitral: lay on side
What does hand grip do for heart murmurs
This murmur increases ? murmurs
What effect does Amyl nitrate have on murmurs
Inc after load, dec LV emptying
Outflow: AS, HOCM, MVP
Dec afterload, inc LV emptying; inc AR/MR murmurs; this is why after load reducers (ACEI) are used
? is the MC valvular Dz
What are the two MCC by age
What would be seen on PE indicating this murmur
AS- preload depended
> 70: age degeneration <70: bicuspid valve
Pulsus parvus et tardus: weak, delayed carotid pulse w/ narrow pulse pressure
How are Pts w/ AS managed until surgical correction
What additional murmur can be heard w/ AR
What two additional PE findings aid w/ Dx AR
Avoid exertion and neg inotropes: BBs, CCBs
Austin Flint: Mid-late diastolic rumble at apex d/t regurg from LA into LV
Bounding pulses, Wide pulse pressure
What are the 8 types of wide pulse pressures seen w/ AR
Water Hammer: rapid up/down of radial pulse
Corrigan: water hammer in carotid artery
Hill’s: SBP popliteal > brachial, most sensitive
Duroziez: femoral artery pressure= bruit
Traubes: double sound at femoral w/ compression
De Musset: head bob w/ pulse
Muller’s: pulsations seen in uvula
Quincke’s: finger nail pulsations
How is AR Dx
How are Pts managed until surgery
MCC of MS
Echo w/ cath
Dec afterload: ACEI/ARB
Rheumatic heart dz
What facial changes are seen on PE in Pts w/ MS
What ENT syndrome can this cause
What will be heard on exam
Mitral facies: flushed cheeks w/ facial pallor d/t hypoxia
Ortners- recurrent nerve plasy d/t LA dilation
Loud S1 (MV closure) w/ opening snap
MCC of MVP
What does this sound like on PE
What makes this click occur sooner/later
USA: MVP
Developing: rheumatic heart dz
Widely split S2 w/ displaced PMI
Soon: dec preload, Late: inc preload
What med is used during MVP w/ Sxs
Do Pts need endocarditis prophylaxis
What causes PS
BBs
No
Congenital Rubella Syndrome
What additional murmur is heard w/ PR
Define Carvallos Sign
? lab result makes a Dx of CHF more likely
Graham Steel: early diastolic decrescendo at LUSB, accentuated w/ inc venous return/dec w/ dec return
Inc murmur w/ inspiration w/ pulsatile liver= TR
BNP >100; LMOP:
Fuorsemide Morphine Nitrates O2 Position- sit and dangle legs over bed to dec preload/venous return
What are the two MCC of pericarditis
How is pericarditis Dx
How is this Tx based on etiology
Infection: Coxsackie, Echovirus
Dresslers
EKG: diffuse, precordial ST elevation/PR depression, opposite in aVR
NSAID/ASA; Dressler: ASA/Colchicine (avoid NSAID)
? size of abdominal aorta is considered an aneurysm
What is the MC location
How do un/ruptured aneurysms present
> 3cm
Infrarenal
Un: Flank pain, abdominal bruit, pulsatile mass
Rup: Flank pain w/ echymosis, HOTN, mass
How are AAA Dx
When are screenings performed
What sizes are indicative of repair/referral
Stable: CT w/ contrast Unstable: bedside US
All men 65-75y/o w/ smoking Hx
> 5.4 or expands >0.5cm/6mon
4.5cm: refer
4-4.5cm: US q6mon
3-4cm: US q12mon
