HTN Cardiomyopathy CHF Flashcards

Question

hypertensive emergency tx

Answer 1

-Reduce mean arterial pressure (MAP) by 25% in 1-2hrs* -Quick reduction of BP can lead to ischemic CVA** IV agents: -Esmolol, Labetolol -Hydralazine -Nitroglycerine -Nitroprusside

Answer 2

MAP = average blood pressure during a single cardiac cycle: -Cardiac output -systemic vascular resistance -central venous pressure “preload”

Answer 3

Definition: consistently elevated office blood pressure readings with out of office readings that do not meet criteria for hypertension - In office elevated bp but then out of office they dont meet criteria for HTN -Difficult to differentiate -Increased risk of developing hypertension -Ambulatory and home blood pressure monitoring

Answer 4

-Systolic BP < 90 mm Hg and/or diastolic BP < 60 mm Hg -Significant if symptoms are present

Answer 5

Medications: -Beta-blockers -Alpha-blockers -Calcium channel blockers -Nitrates Hypovolemia: -Blood loss -Excessive diuretic use -Dehydration -Anemia Low cardiac output: -Myocardial infarction -Bradycardia -Heart failure

Answer 6

-Dizziness/lightheadedness -if they are getting up fast or bending down and getting lightheaded -> not vasoconstricting enough to compensate when they move quick -> are they on a vasodilator? -Fatigue -Weakness -Syncope -Shortness of breath -Exertion dyspnea -Chest pain -Palpitations -Headache -Cough- compensation to increase preload -Seizures- no blood flow to brain

Answer 7

Decrease in BP upon standing: >20 Systolic >10 Diastolic

Answer 8

-Cardiac Arrhythmias -Dehydration* -Parkinson’s -Diabetes -Endocrine disorders -Hypoaldosterosterism -Hypothyroidism -Anemia --------- "A DROP": Arrhythmias Dehydration Regulatory problems (Parkinson's) Other Endocrine disorders (like hypoaldosteronism and hypothyroidism) Poor blood volume (Anemia) ----- meds: -alpha blockers -diuretics -narcotics - MAOIs - TIAs

Answer 9

-Alpha-blockers: Terazosin, tamsulosin, doxazosin -> vasodilators! -Diuretics: Furosemide, hydrochlorathiazide -Nacrotics: Morphine -MAOIs: Rasagiline -TIAs: amitriptyline

Answer 10

Dx- blood pressure measurements -> lying, sitting, standing Tx: -Increase oral HYDRATION and salt INTAKE -Slow positional changes- pump legs before you stand -> muscular pump -Compression stockings -Exercise -Treat underlying cause Medication tx: -Fludrocortisone- glucocorticosteroid -Midodrine- alpha agonist (dont give to HTN pt) -Droxidopa (dont need to know) give "FLUDRO and MIDODRINE"

Answer 11

-Definition: Cardiovascular failure causing loss of tissue perfusion -End-organ tissue lack of perfusion -Hypotension refractory to volume resuscitation -Systolic BP < 90 mm Hg - urine output < 20mL/hr

Answer 12

-Acute MI - MC cause** -Cardiac tamponade -Pneumothorax -Arrhythmias -PE -Cardiomyopathies -Heart failure -Cardiac contusion -Valvular and septal abnormalities "youre so cute you SHOCKED me" - aCUTE MI = cardiogenic SHOCK"

Answer 13

-Hypotension! -Oliguria/anuria! -Tachycardia! -Altered mental status! -Cool extremities- organs not perfused -Decreased capillary refill -Weak peripheral pulses -Jugular venous distension- volume overload or right HF -Pulmonary congestion

Answer 14

First step for all patient with shock = ABCs ** -Airway, breathing, circulation - 2 large bore needles, central line arterial line Vasopressors: positive ionotropic agents -Dopamine -Dobutamine -Norepinephrine* -Intra-aortic balloon pump Identify and treat underlying cause -Acute MI: -Aspirin, heparin, nitrates, etc -Emergent revascularization – coronary angiogram -bypass, stent -Cardiac tamponade- Pericardiocentisis, pericardial window -Arrhythmias: ACLS protocol

Answer 15

-CHRONIC and PROGRESSIVE disease in which the heart is unable to meet the body circulatory demands -Results in abnormal RETENTION OF FLUID due to reduced efficiency of the heart - venous congestion due to a pathologic change

Answer 16

High output vs. low output (CO) Diastolic vs. systolic - systolic: decrease in LV ejection fracture (<45%) -diastolic: normal LVEF but cannot RELAX myocardium Right sided vs. left sided - right sided: periphery and systemic backup - left sided: pulmonary vascular congestion

Answer 17

"the PATH to be a PA is high workload (high output)" - Pregnancy - Anemia - Thyrotoxicosis - Hemachromatosis - Paget's ds - AV Fistula -High-output: Increase in cardiac output -this is not usually problem with heart -> more compensation for something else ---- -Anemia (anemic pts compensate -> increase HR, hypertrophy) -Thyrotoxicosis - excess of thyroid hormones -Hemachromatosis - iron metabolism issue -Pregnancy -Wet beriberi (dont need to know) -Paget’s disease of the bone -AV fistulas

Answer 18

Low-output: decrease in cardiac output - MC compared to high output - cant contract, cant fill, or the valves are injured Causes: -Decrease in myocardial contractility -Cardiomyopathies - heart diseases -Valvular disease- stenosis -> back flow -> improper filling -Diastolic dysfunction

Answer 19

Issue: -Difficulty with myocardial contractility -> Failure to contract -Reduced left ventricular ejection fraction (LVEF) -45% or less* -> dx with HF Causes: -MC- Coronary artery disease** -> Post MI (weakened heart cant contract) -HTN -Valvular disease -Myocarditis -Alcohol abuse -Radiation treatment "THink why can the heart not squeeze? - CAD - not enough blood and post-MI makes it weak - HTN - alcohol or radiation - myocarditis - valvular issue -> hard to push out blood

Answer 20

-Preserve LVEF with impaired ventricular filling -Difficulty with relaxation myocardium -Failure to relax Causes: -Left ventricular hypertrophy: MC cause of diastolic dysfunction** (chronic HTN could cause LVH) -Valvular disease -Restrictive cardiomyopathy: heart wall stiffens ( -osis diseases) -Amyloidosis- fat deposits in heart tissue -Sarcoidosis- inflammatory -Hemachromatosis

Answer 21

main issue: Pulmonary vascular congestion -Dyspnea -Orthopnea -Paroxysmal nocturnal dyspnea -Cough- frothy clear fluid -Confusion -Fatigue Signs: -Rales, decreased breath sounds at bases -> sometimes nothing -Tachypnea -S3 heart sound – ventricular gallop Tx- lower volume

Answer 22

-Systemic vascular congestion Sx: based on liver dysfunction and congestion -Anorexia- volume compressing stomach -Nausea/Vomiting -Jugular venous distention -> JVD reflex -Hepatomegaly -Ascities -Peripheral pitting edema -ABSENCE OF LUNG FLUID IF ONLY RIGHT SIDED -Left heart failure is the most common cause of right*

Answer 23

CLINICAL DIAGNOSIS! Labs: -CBC, CMP, TFTs, -B-type natriuretic peptide (BNP)- Released from the ventricles: volume OVERLOAD or EXPANSION Chest radiography: -Cardiomegaly -Kerley B lines – interstitial edema- Horizontal lines at periphery of lungs -Pulmonary dilations -Pleural effusions- Blunting of costophrenic angles

Answer 24

EKG – nonspecific Echocardiogram: -reduced LVEF -Valvular abnormalities -Pericardial effusion Stress test – identification of ischemia Cardiac angiogram

Answer 25

-pleuthoric state of congestion with blood: there is NO IVC MOVEMENT -hypotensive pt -> check IVC sniff test -> HF pt with overload will have NO IVC collapse -pt with dehydration: IVC will completely COLLAPSE -normal- 50% collapse during inspiration -if you assume the pt with hypotension needs volume and they are really in HF -> you make it worse...

Answer 26

BNP will increase in anything that makes it feel like it has too much volume Cardiac conditions: - HF - valvular heart disease -CAD - HTN Pulmonary ds: - acute pulmonary embolism - pulm HTN - obstructive sleep apnea Neurologic: - stroke critical illness: - sepsis -cirrhosis toxins - chemo - snake bites Others: -renal insufficiency - anemia -hyperaldosteronism

Answer 27

A/1: - no cardiovascular ds -no sx of limitations with activity B/2: - minimal CVD - slight limiations with physical activity - GOING UP STAIRS, carrying heavy packages - no sx with rest C/3: - mod-servere CVD - marked limitation with physical activity - DOING ACTIVITIES (GETTING DRESSED, walking across a room ETC) - only comfortable w rest D/4: - severe CVD - SYMPTOMS AT REST, END STAGE HEART FAILURE. sitting in a chair -<45% EF -> classify HF -classification is based of symptoms -> tx is based on EF

Answer 28

-Treat any underlying cause - GET THE annual INFLUENZA and PNEUMOCOCCAL vaccines** Lifestyle modifications -Low sodium diet- <1800 mg -Fluid restriction- volume overload -Weight loss -Alcohol reduction -Smoking cessation -Exercise programs -Monitor daily weights

Answer 29

Diuretics: - most effective sx relief (loop); thiazides more for HTN - aldosterone antagonists: potassium sparring; good for advance stages ACE inhibitors - REDUCE MORTALITY - all pts must be on it Beta blockers: - decrease mortality with post-MI HF - must give to pts with atherosclerotic ds Digoxin: - severe Afib or reduced EF pt - second line tx last resort: other inotropes - mildirone, dobutamine sacubitril-vasartan (ARB) - for systolic HF pts; class II-IV - blocks Neprilysin -> increases BNP

Answer 30

Diuretics- most effective with symptomatic relief -Loop diuretics: Furosemide (Lasix)- MOST POTENT -Thiazide diuretics: Hydrochlorothiazide (not really HF, just keep volume a little lower) -Aldosterone antagonist: Spironolactone, eplerenone -Potassium sparing -Effective in more advanced stages

Answer 31

-2. ACE inhibitors – REDUCE MORTALITY -if you have HF YOU NEED TO BE ON THIS -Decrease LV stress – decrease preload and afterload -Slow remodeling- All patient with systolic heart failure should be on ACE inhibitor -monitor K -Angiotensin II receptors blockers (ARBs) can be used if a pt is intolerant of ACE inhibitors MOA: -Causes atrial and venous dilation ADR: -Hyperkalermia* - angioedema* - cough*- due to bradykinin production other treatment: diuretics - most effective for symptomatic relief

Answer 32

-tell pt to check weight every morning and night -tell pt to check weight when they are having symptoms -tell them to take an extra diuretic if symptomatic and weight increased by about 3 lbs -> shows that symptoms are due to volume overload

Answer 33

Beta-blockers – proven to decrease mortality with post-MI HF -Hx of atherosclerotic ds: have to give Beta-blockers MOA: -Decreases remodeling -Slows HR -> decreases the rate of O2 consumption -Antiarrhythmic and anti-ischemic properties Drugs: - metoprolol (Toprolol): beta 1 - carvediolol (Coreg): alpha and beta -COMET TRIAL showed significant improvement in survival with carvedilol -> especially prior MI Contraindications: - caution in patient with pulmonary disease - Bronchial spams - could cause drop in BP -> slowly taper up

Answer 34

-useful with patients with reduced EF or severe Afib -Positive inotropic affects- Increase cardiac contractility -Has not been shown to decrease mortality -> last resort/ Second-line treatment -need to check digoxin levels -Narrow therapeutic range Signs of digoxin toxicity: -Green halos around lights* (board question) -Nausea, vomiting, anorexia -AV blocks, ventricular arrhythmias -Disorientation, memory impairment .

Answer 35

-Neprilysin inhibitor which increases levels of natriuretic peptide -increases BNP -> encourages to reduce volume status -Increasing vasodilation and decreases volume through sodium excretion -For systolic heart failure patients - With class II-IV heart failure -Decreases mortality and hospitalizations

Answer 36

-Prevention of sudden death (MC cause of death in CHF pts -indicicated when LVEF <35% -PPM-AICD options -> combined pacemaker-defib

Answer 37

-pt who require frequent hospitalization -bridge to cardiac transplant* or destination therapy while pts wait for a heart -need anticoagulation therapy -very last resort

Answer 38

-monitor pulmonary artery pressures for titration of diuretics

Answer 39

-Dilation of the ventricles/atria causing a reduction in strength and contraction -Most common cardiomyopathy (95%) -Men > females

Answer 40

-Alcohol* -Ischemia*** - CAD* -Idiopathic -Genetic -Chemotherapy toxicity -Post-partum state -Myocarditis -Thyroid disease -Lyme disease -Diabetes -Arrythmias -Cocaine "CARDIOMYOPAthy" -CAD/ISCHEMIA* -Alchohol -R = genetics lol - Diabetes - Idiopathic - Myocarditis - Y: ThYroid - other toxins - chemo - Post-infection Lyme ds - Arrythmias - -toxins - cocaine

Answer 41

Symptoms/Signs: -Heart failure signs and symptoms -S3 and S4: S3 = volume overload; S4 = noncompliant ventricles -Cardiomegaly -Sudden death Dx: --Echocardiogram – diagnostic test of choice** -Chest x-ray -Genetic testing

Answer 42

-Hypertrophy of the left VENTRICULAR SEPTUM -Blockage of blood flow out of the left ventricle = hypertrophic obstructive cardiomyopathy (HOCM) -Men = women -Common cause of sudden death in people younger than 30 years*

Answer 43

Systolic ejection murmur at Lower left Sternal Border:** -Decreases squatting, lying down -Increases with Valsalva and standing -Increased carotid pulse (bisferious pulse/ biphasic peaks during systole) Other sx: -Dyspnea -Chest pain -Palpitations -Arrhythmias -Syncope -Sudden death

Answer 44

-echocardiogram- dx of choice* -EKG -genetic testing

Answer 45

-Collagen defect infiltrating the VENTRICULAR wall causing reduced relaxation -“stiffening” of the ventricle -Impedes ventricular filling

Answer 46

Cause: anything that increases fibrosis of cardiac muscles -Amyloidosis -Sarcoidosis -Hemochromatosis -Scleroderma -Carcinoid Syndrome -post-radiation/chemotherapy fibrosis -Idiopathic

Answer 47

Sx: -dyspnea -exercise intolerance -RIGHT sided heart failure S&S: peripheral congestion Dx: -EKG: low voltage (low amplitude) -echocardiogram -endomyocardial bx

Answer 48

Dilated and restrictive tx: -Treat underlying cause -Supportive treatment of congestive heart failure -defibrillator Hypertrophic: -Avoid strenuous activity -Beta-blockers or calcium channel blockers:to improve diastolic filling -Septal myomectomy - remove thickened septum -Alcohol septal ablation - inject alc to cause local necrosis and reduce obstruction All cardiomyopathies: -AICD: automatic implantable cardioverter-defib -Cardiac transplantation