Green PANCE book Flashcards
Primary (essential) hypertension causes ___% of cases of elevated BP
90 to 95%
More prevalent with increased age and in blacks
Hypertension
Parenchymal renal dz Renal artery stenosis Coarctation of aorta, Pheochromocytoma Cushing Syndrome, hyperthyroidism primary hyperaldosteronism chronic steroid therapy, estrogen use NSAID use, sleep apnea
Secondary causes of HTN
Essential HTN is exacerbated in…
Males
Blacks
Sedentary individuals
Smokers
BP persistently elevated higher than 220 mmHg systolic or higher than 125 mmHg diastolic or accompanied by complications
Hypertensive urgencies!! Must be reduced within hours
Encephalopathy, nephropathy, intracranial hemorrhage, aortic dissections, pulmonary edema, unstable angina, or MI in the presence of strikingly elevated pressures defines…
Hypertensive emergency
must be reduced within 1 hour
HTN is diagnosed when the pt has elevated BP of over 140 mmHg systolic and/or 90 mmHg diastolic during..
at least 2 visits
a BP reading 120-139 mmHg systolic and/or 80-89 mmHg diastolic
Prehypertension
What abnormality might you see on an EKG in a patient with HTN
left ventricular hypertrophy
Once HTN is diagnosed, the treatment goal should be to achieve a BP reading of less than…
140/90 mmHg
in a pt w diabetes or CKD, 130/80
Low saturated fat, cholesterol, total fat describes what kind of diet?
DASH
Dietary Approaches to Stop Hypertension
(includes fruits, veggies, fat free or low fat milk products, increased fiber)
Initial therapy for essential HTN?
Diuretics
Thiazide diuretics most consistently effective
Clinical syndrome characterized by abnormal retention of water and sodium. Resulting venous congestion causes typical symptoms such as dyspnea and edema
CHF
Results from pathologic changes in one or more of the following: myocardial contractility, structural integrity of valves, preload or after load of the ventricle, HR
CHF
CHF adversely affects left atrial pressure and…
cardiac output
….causes exertional pulmonary vascular congestion leading to exertional dyspnea plus cough, fatigue, orthopnea, PND, basilar rales, gallops and exercise intolerance
Left sided failure
…causes systemic vascular congestion and is characterized by distended neck veins, tender or non tender hepatic congestion, decreased appetite/nausea and dependent pitting edema
Right sided failure
Predominant features of R sided failure
Peripheral edema
Hepatomegaly
Most common cause of R sided HF
L sided HF
CXR may show:
cardiomegaly and bilateral or R sided pulmonary effusions, perivascular or interstitial edema (Kerley B lines), venous dilation and cephalization and alveolar fluid
CHF
ECG may show:
non specific changes (i.e. low voltage), underlying arrhythmias, intraventricular conduction defects, left ventricular hypertrophy, non specific depolarization changes, new or old MI
CHF
What is the most useful diagnostic in CHF?
Echocardiography
*it is able to assess size and function of the chambers, valve abnormalities, pericardial effusion, shunting and segmental wall abnormalities
Echocardiography can measure…
Ejection fraction (EF)
What is a key diagnostic and prognostic indicator in CHF?
Ejection fraction (EF)
When is cardiac catheterization indicated?
if atherosclerosis is suspected
initial therapy of most CHF patients chinless early initiation of…
ACE inhibitors
*have been shown to decrease L ventricular wall stress and slow myocardial remodeling and fibrosis
Ca channel blockers are used to treat associated..
angina or HTN
When the ejection fraction falls below 35, what can be implemented?
Implantable cardioverter-defibrillators (ICD)
…is characterized by insufficient oxygen supply to cardiac muscle, most commonly caused by atherosclerotic narrowing and less often by constriction f coronary arteries
Ischemic heart disease
Levine sign, which is a clenched fist over the stern, and clenches teeth when describing chest pain may be seen in patients with…
Ischemia
Stable angina lasts for less than…
3 minutes
What is the most sensitive clinical sign of angina seen on an ECG?
horizontal or downsloping ST segment depression
1/5 of MI patients will die of..
V fib
MIs in…women, diabetics, elderly…
more likely to have atypical symptoms
..includes pericarditis, fever, leukocytosis and pericardial or pleural effusion usually 1-2 weeks post MI
Dressler syndrome (post MI syndrome)
Most specific marker myocardial damage?
Troponin
This scoring system is the quickest and easiest and can be completed at bedside. One point is given for each:
- 65 yo plus
- 3 or more risk factors of CAD
- use of ASA in last 7 days
- known CAD with stenosis 50% or more
- more than 1 episode of rest angina within last 24 hours
- ST segment deviation
- elevated cardiac markers
**score of 3 or more=high risk
TIMI (Thrombolysis In Myocardial Infarction)
More complex scoring method..
age, gender, vital signs, ST segment changes, and historical factors are included to predict 6 mo risk of death after discharge
GRACE (Global Registry of Acute Coronary Events)
Which drugs should be given at once to a pt with an acute STEMI
Aspirin and clopidogrel
What should be done within 90 minutes in an MI patient
Angiography
______ cardiomyopathies are the most common type and are associated with reduced strength of ventricular contraction, resulting in dilation of the L ventricle
Dilated
This cardiomyopathy demonstrates massive hypertrophy (particularly of the septum), small left ventricle, systolic anterior mitral motion and diastolic dysfunction
Hypertrophic cardiomyopathy
This cardiomyopathy results from fibrosis or infiltration of the ventricular wall because of colleges-defect diseases, most commonly: amyloidosis, radiation, postoperative changes, diabetes and endomyocardial fibrosis
Restrictive cardiomyopathy
Most common presentation of dilated cardiomyopathy
Dyspnea
Acute pericarditis is most commonly..
idiopathic or due to viral infection
Pericardial effusion (secondary to pericarditis, uremia, or cardiac trauma) produces restrictive pressure on..
the heart
primary presenting symptom of acute pericarditis is sharp, pleuritic substernal radiation chest pain often relived by sitting upright and leaning forward; a cardiac friction rub is characteristic
Acute pericarditis
this occurs when fluid compromises cardiac filling and impairs cardiac output
Cardiac tamponade
this presents with slowly progressive dyspnea, fatigue and weakness accompanied by edema, hepatomegaly and ascites
constrictive pericarditis
typically presents with tachycardia, tachypnea, narrow pulse pressure, jugular venous distention and pulsus paradxus
cardiac tamponade
which diagnostics are useful in determining the extent of cardiac effusion
chest radiography
echocardiography
Most cases of native valve infective endocarditis are…
S. viridans
S. aureus
enterococci
Most common bacteria and valve involved in drug users with endocarditis
S. aureus, tricuspid valve
Prosthetic valve endocarditis most often caused by…
S. aureus
gram negative organisms or fungi cause endocarditis if the disease develops during the first…
2 months after implantation
later dz due to strep or staph
Most patients present with: fever (although may be absent in elderly) and non specific symptoms (i.e. cough, dyspnea, arthralgia, back or flank pain, GI complaints)
endocarditis
aprox 90% of endocarditis patients will have a stable murmur, but this may be absent in..
R sided infections
25% of patients have…palatal, conjunctival or subungal petechiae; splinter hemorrhages; olser nodes; janeway lesions and roth spots
Endocarditis
painful, violaceous, raised lesions of the fingers, toes or feet
Olser nodes
endocarditis
painless red lesions of the palms or soles
Janeway lesions
endocarditis
exudative lesions in the retina
Roth spots
endocarditis
pallor and splenomegaly are common; strokes and emboli may occur
endocarditis
3 sets of blood cultures at least 1 hour apart should be obtained before…
starting antibiotics
_____ is essential to make the diagnosis of infective endocarditis and identify the specific valves involved
Echocardiography
The presence of ______ is diagnostic for infective endocarditis
vegetation
Which echocardiography is best for endocarditis dx
Transesophageal echo (TEE)
- 2 positive blood cultures of a typical causative microorganism
- echocardiographic evidence of endocardial involvement, including new valvular regurgitation
Major Criteria for endocarditis
- predisposing factors (i.e. drug use, abnormal valves)
- fever higher than 100.4 F (38 C)
- vascular phenomena (ie embolic dz or pulmonary infarction)
- immunologic phenomena (ie glomerulonephritis, olser nodes, roth spots)
- positive blood cultures not meeting major critera
Minor criteria for endocarditis
Gentamicin with ceftriaxone or vancomycin is appropriate initial therapy for pts with suspected..
infective endocarditis
valve replacement, especially of the ____ valve may be necessary if endocarditis does not resolve w antibiotic therapy
aortic
systemic immune response occurring usually 2-3 weeks following a beta-hemolytic strep pharyngitis
*most common in recent immigrants
Rheumatic fever
Major criteria: carditis, erythema marginatum, subcutaneous nodules, chorea, and polyarthritis
rheumatic fever
Minor criteria: fever, polyathralgias, reversible prolongation of the PR interval, rapid ESR or CRP
rheumatic fever
ECG change most commonly associated with acute pericarditis
diffuse ST segment elevation
