HTN, Dyslipidemia, Heart Failure Flashcards
Hypertensive retinopathy
- retinal vascular damage cused by poorly-controlled HTN
Grade1
* common in longstanding poorly controlled htn, reversible when treated
* narrowing of terminal arteriolar branches. No vision change or permanent findings
Grade2
* common in longstanding poorly controlled htn, reversible when treated
* narrowing of arterioles with severe local constriction
* no vision change or permanent findings
Grade 3
* Usually with DBP >110, implies HTN emergency
* preceding signs with flame-shapped hemorrhages
* potential for visual change and permannet retinal findings
* Complaints of dark spots in vision
Grade 4
* Usually DBP > 130, HTN emergency
* papilledema with preceding signs
* potential for visual change and permanent retinal findings (scar tissue develops)
1st line HTN treatment
JNC8 goal 140/90 for most pts (150/90 if >65)
AHA goal 130/80 for all
* Thiazide diuretic (HTZ, chlorthalidone)
* Calcium Channel Blocker (Amlodipine/diltiazem)
* ACE inhibitor or ARB (linsinopril/ losartan)
* If African american (thiazide and CCB, ACE/ARB not as effective)
* If CKD ACE/ARB
HTN testing with new Dx
- to facilitate CVD risk profile, establish a baseline for medication use and screen for secondary causes of HTN
- Fasting blood glucose/A1C
- CBC
- lipid profile
- serum creatinine with eGFR
- Serum sodium, potassium, calcium
- TSH
- urinalysis (looking for proteinuria)
- Electrocardiogram/Echo - evaluate heart, rhythm, and chamber size
- Urine albumin:creatinine ratio
Priority medications for HTN
Diuretic
* reduces vascualr resistance
* HCTZ, chlorthalidone (preferred)
* Na, K, Mg depleating, Ca sparing
* lower observed rate of fractures in womenwho are long-term thiazide diuretic users
ACEI (-pril suffix)
* Lisinopril, enalapril
ARB (-sartan suffix)
* Losartan, telmasartan
* reduces vascualr resistance
* K sparing, hyperkalemia risk
* ACEI - induced cough, use ARB as alternative
* ACEI <1% risk of angioedema, increased risk african, latino, hx of NSAID allergy
* priority med with DM
* Do not use with pregnancy
CCB
* decreases vascular resistance
* dihydropyridine (-ipine suffix): Amlodipine(Norvasc)
* non dihydropyridine: Diltiezem (cardizem)
* ankle edema with -ipines, usually dose dependednt
* avoid use/use with caution in presence of HF, renal or hepatic impairment
Secondary HTN medications
Beta Blocker (-lol suffix)
* Atenolol (tenoretic), metoprolol (toprol, lopressor), propranolol (inderal)
* decreases heart rate, and stroke volume
* not a 1st line med - decressed efect in select populations
* avoid non-cardioselective BB in lowe airway disease (propranolol). Lower dose cardioselective BB (metoprolol) usually acceptable if otherwise indicated (HF, difficult to control HTN)
Aldosterone antagonist
* Spironalactone (aldactone), eplerenone (Inspira)
* decresed vascular resistance
* potassium sparing diuretic
* hyperkalemia risk, particularly with ACEI/ARB use or volume depletion
* gynecomastia with prolonged use
* not a first line med
Hypertinsive Urgency Vs. Emergency
Urgency
* severe elevation in BP >180/>120
* stable without acute or impending change in HTN target organ dysfunction
* Ex. longstanding HTN who stopped or is non-adherant with HTN therapy, no lab or clinical evidence of rapidly progressing HTN TOD
* Intervention: No indication for in offce BP reduction with short acting hypertensive meds. No indication for referral to ED/hospitalization. Restart prior or intentensify standard HTN therapy
Emergency
* Severe elevation in BP >180/>120
* Evidence of impending or progressive HTN target organ dysfunction
* Ex: longstanding HTN, stopped/non-adherent to therapy, with evidence of rapidly progressing HTN TOD such as HF, pulmonary edema, high-grade HTN retinopathy, intracerebral hemorrhage
* Intervention: No indication for in offce BP reduction with short acting hypertensive meds. Immediate transfer to ED, usally with admission to ICU for parenteral antihypertensive tx.
Lipid Protein Profile
- used for dyslipidemia screening in detection particularly in the person with CV risk (DM, HTN, family Hx, obesity)
- TC - total cholesterol: NL <200
- LDL-c low density lipoprotien cholesterol: NL <100
- HDL-c High density lipoprotien cholesterol: NL > 40, >60 preferred
- TG triglycerides: NL <150 - can be performed fasting or not, If >400 repeat fasting
Statin therapy reccomendations
absolute indications for use
* LDL-c >190: high intesity statin
* DM and age 40-75: moderate intensity or add ASCVD risk assessment for high intesity therapy
* ASCVD score >20%
other indication for use based on ASCVD score
* <5% : low risk
* >5% - <7.5%: borderline risk - if risk enhancers present may start med-intensity statin
* >7.5 - <20%: if risk enhancers present start med-intensity statin
Statin Therapy
HMG-CoA reductase inhibitor: Statin used for LDL lowering
High intensity statin
* avoid with higher risk for statin ADE such as rabdo, age>75, impaired renal function, fraility, multiple comorbids, fibrate use
* LDL-C reduction of >50%
* atorvostatin, rosuvastatin
Medium intensity statin
* preferred in high risk for ADE
* LDL-C reduction of 33%
* Atorvastatin, rosuvistatin, simvastatin, pravastatin, lovastatin
- chek hepatic enzymes prior to initiation to establish baseline
- caution with grapefruit juice (CYP450 3A4 inhibitor)
- ADE: rhabdo, myositis, rare but most noted with higher dose
other LDL- lowering medications
Selective cholesterol absorption inhibitor
* Ezetimibe (Zetia)
* Lowers LDL-C up to 20%
* few adverse effects due to limited systemic absorption
* can be combined with simvastain
Protien convertase subtilisin/kexine type 9 inhibitor (PCSK9)
* Evolocumab, alirocumab
* monoclonal antibody
* lowers LDL-C >60%
* Injection only
* add on to satin for familial hypercholesterolemia and/or clinical athlerosclerosis when goal LDL cannot be met
ACL (adenosine triphosphate-citrate layse) inhibitor
* non-statin
* bempedoic acid (new drug)
* lowers LDL-C up to 33%
* adjunct to maximally-tolerated statin or ezetimbe therapy
* also used in statin intollerant
Triglyceride lowering agents
Omega 3 fatty acid by prescription
* 4g/d dose
* decrease in TG up to 30%
* adverse effect: increased risk of bleeding due to antiplatelet effect
Fibric acid dirivative (Fibrate)
* fenofibrate
* HDL increase of 20%
* TG decrease up to 50%
* Adverse effects: myopathy, including rhabdomyolysis, esp if taken with statin (do not give with satin)
Hypertriglyceridemia
TG <150
* mild 150-199
* mod 200-999
* severe 1000-1999
* mod/severe = risk for CVD
* Very severe <2000 - risk factor for CVD, acute pancreatitis
common causes of 2ndary hypertriglyceridemia
- DM with poor glycemic ctrl
- Untreated hypothyroidism
- Select medication use
1. 2nd gen atipsychotics
2. systemic corticosteroids
3. systemic estrogen supplements
4. systemic retinoid
lifestyle risk factors
* High carb diet
* excessive alcohol use
* sedentary lifestyle
* obesity
condition reverable with treatmetn of underlying cause
Pharmacologic tx of triglyceridemia
TG 199-499
* treat secondary cause
* statin therapy
TG >500
* treat secondary cause
* stain therapy
* Consider TG loering therapy with Omega 3 fatty acid or fibrate therapy
Heart failure etiology
- systolic left ventricular dysfuction (most frequent cause)
- Diastolic LV dysfunction
- Valvular disease
- congenitial HD
- pericardial disease
- endocardial disease
- rhythm/conduction disturbance
Heart failure Dx
Suspected
* dyspnea, fatigue, edema
Clincal Hx
* previous MI/ACE
* angina
* hypertension
* Valvualr disease/rhumatic fever
* palpitations
Clincial exam
* tachycardia
* increased JVP
* displaced apex beat
* S3 heart sound
* Murmur
* pulmonary crackles
* dependednt edema
Investigation directed by clinical presentation
* ECG
* CXR
* Echo
* Hemoglobin
* Blood chem
* Thyroid function
Stage A
at risk for HF
- at risk - get Bnp and use validated HF risk score
Conditions that increase risk
* HTN - control BP
* T2DM and CVD or high risk of CVD - SGLT2-I treatmetn (-gliflozin suffix) - dapagliflozin
* CVD - optimixe management
* Cardiotoxic exposure - multidiciplanary management
* 1st degree relative with genetic cardiomyopathy - genetic screen
Pre-Heart Failure
Stage B
- cardiology consult
- LVEF <40% with or without HX of MI/ACS - ACEI and Beta-blocker
- Recent MI or ACS - statin therapy
- LVEF <30% - implantable cardiodefibrilator
- nonischemic cardiomyopathy - genetic testing
Pysiologic Murmur
- GR1-3/6 early to mid systoloc murmur
- heard best at LSB but usualy audible over pericordium
- No radiation beyond pericordium
- softens or diapperas with standing
- increases with activity, fever, anemia
- S1, S2 intact, normal PMI
- Asymptomatic
- possibly heard in 80% of thin healthy adults
Aortic stenosis
*difficulty opening valve
* G1-4/6 harsh systolic murmur
* cresendo-decrescendo pattern
* heard best at 2nd RICS, apex, softens with standing
* radiates to coarotid, may have deminshed S2, slow filling carotid pulse, narrow pulse pressure
* Loud S4, heaving PMI
* in younger adults: congenital bicuspid valve
* In older: calcific rheumatic in nature
* Dizziness, syncope, ominous signs, pointing to severly decreased CO
Aortic sclerosis
- Gr 1-4/6 harsh sytolic ejection murmur
- heard best at 2nd RICS
- No S4, absence of symtoms
- Benign thickeneing and/or clacification of aortic valve leaflets
- no change in valve pressure
- “50 over 50” - found in 50% of people over 50
Aortic Regurgitation
*problem with valve closing
* G1-3/4 high pitched blowing diastolic murmur
* heard best at 3rd LICS
* may be enhanced by forced expiration, leaninf forward
* Usually with S3, wide pulse pressure, sustained thrusing apical impulse
* more common in men - rheumatic heart disease, tertiary syphilis
Mitral stenosis
- Left AV valve
- Grade 1-3/4 low pitched late diastolic murmur, heard best at apex, localized
- short crescendo-decrescendo rumble, like a bowling ball rolling
- often with opening snap, accentuated S1 in mitral area
- enhanced by left lateral decubutis position, squat cough, immediately post valsalva
- nearly all rhumatic in origin
- protracted latency period then gradual decrease in exercise tolerance leading to rapid downhill course due to low CO
- Afib common
Uncorrected Atrial septal defect
- G1-3/6 systoloc ejection murmur at pulmonic area
- widely split s2, right vericular heave
- typically without symptoms until middle age, then presenting with HF
Pulmonary HTN
- Narrow splitting S2, murmur of tricuspid regurgitation (right AV valve)
- report of SOB nearly universal
- Seen with RVH, RAH as identified by ECG, echo
Mitral regurgitation
- left AV valve
- Grade 1-4/6 high pitched blowing systolic murmur, often extending beyon S2
- sounds like long “haa”, “Hoo”
- heard best at RLSB
- radiates to axilla, often with laterally displaced PMI
- decreased with valsalva manuver
- increased by squat, hand grip
- found in ischemic HD, endocarditis, RHD, often with other valve abnormalities
Mitral Valve prolapse
- Grade 1-3/6 late systoloc crescendo murmur with honking quality
- heard best at apex
- murmur follow mid systolic click
- with valsalva or standing, click moves forward into earlier systole, resulting in longer sounding murmur
- with hand grasp, squat, click moves back resulting in shourter murmur
- often seen with minor thoracic deformities
Conditions for dental procedure ABX endocarditis prophylaxis
- prosthetic cardiac valve replacement with. prosthetic material
- Previous endocarditis
- Unrepaired cyanotic congenital heard disease, including paliative shunts nd conduits
- Completely repaired congenital heard defect with prosthetic material/device during the 1st 6 months after surgery
- repaired congenital heart disease with residual defects at the site or adjacent to the site repaired with prosthetic material
- cardiac transplant where cariac valvulopathy has developed.
ABx for prevention of endocarditis with dental, oral, respritory or esopogeal procedures
- give once 30-60 min prior to procedure
- Amoxiicillin 2 g po
unable to take orals
* ampicillin 2g IM/IV
* cefazolin/ceftriaxone IM/IV
if pen allergy
* cephalexin
* doxycycline
* azthromycin/clarithromycin
if pen allergry and can’t take po
cefazolin/ceftriaxone IM/IV
