HTN, HF, Carditis, hypotension, syncope Flashcards
1
Q
Difference between essential (primary) and secondary HTN
A
Essential-Onset between 25-50
95% of HTN
Exacerbating factors (obesity, NSAIDS, sleep apnea, Increased Na+, Excessive ETOH, Smoking, Polycythemia)
Secondary causes think someone, not between 20-50, had well controlled and now has an increase, refractory HTN on multiple meds
Causes(OCPs, NSAIDs, decongestants, SSRIs and tricyclic, glucocorticoids, weight loss meds, erythropoietin, illicit drugs, Primary renal disease(most comon cause) renal artery stenosis, hyper/hypothyroid, pregnancy, coarctation of aorta(children))
2
Q
Metabolic Syndrome
A
Abdominal Obesity Triglycerides >150mg/dL HDL <40mg/dL in Men HDL <50mg/dL in women Systolic BP >130 or diastolic BP >85 Fasting BGL >100mg/dL
3
Q
Hypertensive urgency
A
Severe HTN in asymptomatic Pt no evidence of EOD
SBP>180
DBP>120
4
Q
Hypertensive Emergency
A
Severe HTN with evidence of acute EOD
Life threatening needs immediate treatment
SBP>180
DBP>120
5
Q
Lab tests for R/O secondary HTN
A
TSH-thyroid issues UA-checking for protein Renal artery bruits-stenosis Polysomnography-sleep apnea Excessive cortisol, moon face, obesity-bushings UA- illicit drugs
6
Q
120-129/80
A
JNC 7-preHTN
2017 elevated
7
Q
130-139/80-89
A
JNC 7-preHTN
2017 Stage 1 HTN
8
Q
140-159/90-99
A
JNC-7-Stage 1 HTN
2017-Stage 2 HTN
9
Q
> 160/>100
A
JNC7-STage 2 HTN
2017-Stage 2 HTN
10
Q
HTN screening
A
Over 40 or with risk factors yearly
11
Q
Ambulatory BP monitoring
A
24 hr BP monitoring, expensive
Preferred method for confirming the diagnosis oHTN/white coat HTN
12
Q
How to diagnose HTN
A
Pt presents with HTN urgency or emergency
initial screening of >160/100 with target EOD
13
Q
2ndary HTN causes
A
Sleep apnea Drug induced/related CKD Primary aldosteronism renovascular disease longterm corticosteroid use/ bushings syndrome pheochromocytoma coarctation of aorta thyroid/parathyroid
14
Q
Think 2ndary HTN in Pt
A
Less than 20 older than 50
well controlled HTN with spike
HTN refractory to multiple treatments
15
Q
Meds that causes 2ndary HTN
A
OCP, NSAIDs, Decongestants, Antidepressants, Glucocorticoids, Weight loss meds, EPO, Cyclosporine, stimulants
16
Q
Most common cause of 2ndary HTN
A
Primary Renal disease
17
Q
Complications of Untreated HTN
A
ESKD,
Strokes,
dementia/alzheimers
CVD-LVH, HF, arrhythmias, MI, sudden death
18
Q
End Organ Damage(EOD)
A
LVH(early finding) CHF- AMI/CAD Demand ischemia Stroke Aortic dissection retinal hemorrhage
19
Q
EOD on fundoscopy
A
optic disc swelling, cotton wool patches, hard exudates
20
Q
HTN Pt clinical presentation
A
Asymptomatic for years-nonspecific headaches
21
Q
Hypertensive Encephalopathy
A
HTN with somnolence, confusion, visual disturbances, N/V
EMERGENCY
22
Q
Goal of initial assessment
A
Determine extent of EOD
Determine overall CVD risk
RO identifiable 2nd causes/often curable causes of 2nd HTN
23
Q
Nonpharm approach
A
Weight reduction DASH diet Na reduction physical activity decrease alcohol/smoking
24
Q
JNC 8 HTN goals >60 no DM or CKD
A
<150/90
Black-Thiazide or CCB
Nonblack-thiazide, ACE, ARB or CCB
25
JNC 8 HTN goals<60 no DM/CKD
<140/90
Black-Thiazide or CCB
Nonblack-thiazide, ACE, ARB or CCB
26
JNC 8 HTN goals DM or CKD
<140/90
DM no CKD
Black-Thiazide or CCB
Nonblack-thiazide, ACE, ARB or CCB
CKD- ACE or ARB along with another class
27
Hypotension-BP criteria
BP<90/60 MAP <65
28
Shock-definition
state of cell and tissue hypoxia due to a decrease in O2 delivery
Hypoperfusion state
29
Features of Hypotension
```
Tachycardia
oliguria
hyperlactatemia
AMS
Tachypnea
Cool/clammy
Cyanosis-Perioral cyanosis
metabolic acidosis
```
30
Orthostatic/postural hypotension
After 5 min of lying down, delay of the normal compensatory mechanism of ANS
31
Clinical presentation of orthostatic hypotension
SBP drops >20mmHg
| DBP drops>10mmHg
32
Orthostatic Hypotension-etiology
```
Drop in blood volume
Drop in cardiac output
Arrhythmia
Medications
endocrine, neurological or metabolic disorders
```
33
Orthostatic Hypo initial work up
CBC, BMP, ECG,
| Consider- tilt test, echo, neuro and cardiology consults
34
Management of orthostatic hypotension
```
treat underlying cause
asymptomatic pt may not need treatment
D/C causative med
IV or PO fluid
treat infection, arrhythmia, anemia
```
35
Orthostatic hypotension Pt ed
Stand up slowly, maintain hydration, increase Na+ intake, raising head of bed, compression socks, reduce alcohol, increase caffine
36
Vasovagal hypotension
Stimulation of vagus nerve causes drop in BP and HR(stimulation of parasympathetic nervous system)
37
DVT etiology
prolonged immobilization, thrombophilia, neoplasm, Fhx, increases with age
38
DVT clinical finding
swelling of leg or calf, warmth and erythema
| pain increasing with standing or walking
39
DVT diagnosis
H&P Hollman's test, ultrasound, can do d Dimer
40
DVT treatment
Depends on location
Fem-pop or more distal- determine if provoked or unprovoked- Anticoag with warfarin or DOAC/NOAC-
Ileofemoral- refer for mechanical thrombectomy vs thrombolysis
41
chronic Arterial occlusive disease etiology/pathology
chronic and progressive- atherosclerotic plaques, stenosis, ruptured plaques(emboli)
42
chronic arterial occlusive disease- clinical findings
typically chronic and progressive-claudication, collateral circulation
PAD is normally asymptomatic-can progress to become life-threatening if risk factors are not treated
43
chronic Arterial occlusive disease- Dx
H&P, specific pattern Pt has with Sx development,
Ankle-brachial index
imaging if indicated
44
Chronic arterial occlusive disease treatment
Tx risk factors- Especially statins and controlling DM. Walking program can help to create collateral circulation and train muscles to depend on less O2.
45
acute arterial occlusive disease treatment
emergency(NPO) discuss anticoag with surgeon(heparin) Angiogram, open embolectomy vs endovascular
46
Acute arterial occlusive disease -Dx
Cardiac exam, abdominal exam, pulse exam, imaging -CT
47
acute arterial occlusive disease clinical findings
cold leg, painful, no collateral flow
48
acute arterial occlusive disease etiology
result of clot
49
phlebitis/thrombophlebitis-eti
a clot formed in superficial venous return-no risk of DVT
50
phlebitis/thrombophlebitis clinical findings
pain, redness, and inflammation (locally not to entire lower limb as with DVT)
51
phlebitis/thrombophlebitis Dx
Clinical, use duplex ultrasound if suspicious for DVT
52
phlebitis/thrombophlebitis treatment
NSAIDs and localized heat
53
Chronic venous insufficiency etiology/pathology
MC FMHx, then DVT and trauma, occurs in men and women equally-rarely congenital
Venous insufficiency, reflux of blood flow through valves
54
Chronic venous insufficiency clinical findings
spider or reticular telangiectasia, varicose veins, edema, skin changes, ulceration, thrombophlebitis
-pain edema, aching, throbbing fatigue-consider venous stasis ulcer
55
chronic venous insufficiency Dx
Ultrasound can measure size and flow (antegrade/retrograde)-reflux is retrograde flow for more than 500ms
56
chronic venous insufficiency Tx
lifestyle modifications- elevation and compression socks
minimally invasive techniques- ablation
invasive- vein stripping
57
varicose veins pathology
venous insufficiency- causing dilation of veins and blood pooling
58
Varicose veins clinical findings
squishy +/-painful veins
59
Varicose veins Dx and Tx
Ultrasound- minimally invasive (ablation) to invasive(vein stripping)
60
Venous ulceration EPI/Patho
the result of venous insufficiency
61
Venous ulceration clinical /Dx
typically on medial malleolus, will have swelling, will have a palpable pulse
62
Reynaud's disease Epi/
F>M, FMHx, smoking, autoimmune disease, some meds
63
Reynaud's pathology
vasospastic disorder
64
Reynaud's clinical and Dx
pallor, cyanosis, hyperemia
| H&P Sx
65
Reynaud's treatment
Lifestyle changes-gloves and socks-smoking cessation, D/C BB if HTN and give CCB
66
Temporal arteritis EPI/ETI
Autoimmune vasculitisF>M 4:1
| caucasions
67
temporal arteritis clinical findings
HA, malaise/fatigue, some fever and neck/jaw claudication
68
Temporal arteritis Dx
ESR/CRP- Rheumatology referral
69
Temporal arteritis Tx
temporal artery biopsy, Oral corticosteroids (PO Prednisone)
70
Aortic Aneurysm Epi/Eti
M>F >60yo, Caucasians, Hx of smoking, FMHx
71
Aortic Aneurysm Clinical findings
Usually none - can cause back and abd pain
can embolize to legs
RUPTURE- very rapidly becomes hemodynamically unstable
Pulsatile mass in abd
72
Aortic Aneurysm Dx
Imaging or ultrasound
73
Aortic Aneurysm Tx
```
Treat HTN (BB) antiplatlets and statins(prevent emboli and further stenosis)
Endovascular repair: stent graft EVAR
or open repair
```
74
Aortic Dissection Epi/Eti
Trauma, penetrating atherosclerotic plaque, HTN
75
Aortic Dissection Patho
Fenestrated intima allows blood into other layers of the blood vessel creating a false lumen
76
Aortic Dissection Clinical findings
Ripping, tearing pain in back, depending on location can have unequal BP(check bilateral BP)
77
Aortic Dissection Dx
Imaging
78
Aortic Dissection Tx
BP management, may need endovascular or open repair if causing end organ damage
79
HF NYHA Class I
Pt with heart disease w/o limitation of physical activity-no signs of HF
80
HF NYHA Class II
Pt with heart Disease resulting in slight limitation of physical activity-Symptoms of HF develop with activity but go away with rest
81
HF NYHA class III
Pt with heart disease resulting in marked limitation of physical activity, Symptoms develop w/ less than ordinary physical activity- no symptoms at rest
82
HF NYHA Class IV
Symptoms of HF at rest
83
HF AHA Stage A
At high risk for HF no structural damage and no Sx of HF
84
HF AHA Stage B
Structural HD w/o signs or symptoms of HF,
85
HF AHA Stage C
Structural HD w/ prior or current signs and symptoms of HF
86
HF AHA Stage D
Refractory HF requiring specialized intervention
87
HFpEF
Diastolic HF-enlarged muscle doesn't allow enough blood into the ventricle, Ejection fraction is normal but Cardiac output is decreased-dizziness, orthostatic hypotension
88
HFrEF
Systolic HF- weak ventricular muscle is not able to push out causing a decrease in CO and EF
89
Left-sided HF
SOB, pulmonary edema
| Can have right sided failure symptoms as well due to the severity of HF
90
Right Sided HF
Systemic edema-JVD-
| Can have Left sided symptoms as well depending on the severity
91
HF ECHO
Can monitor proper contraction and movement of heart and valves- can give an EF and determine which part of the heart is damaged
92
HF Brain Natriuretic peptide(BNP)
Is released from the ventricle in response to increases in ventricular stretch
93
Acute HF
Decompensated HF
94
Chronic HF
Stable- treat underlying causes
95
Treatment approach to Chronic HF
1-ACE, ARB or ARNI
2-BB-carvedilol or metoporlol ER
3-Aldosterone Antagonist-Spironolactone
96
ACE/ARB-MOA
afterload reducers
97
ARNI-moa
potentiate ARB effects
98
Aldosterone antagonist MOA
Diuretic
99
BB moa
decrease afterload and myocardial O2 demand
100
Loop diuretics
Symptom relief
101
Digoxin moa
positive inotrope and negative chronotrope
102
Non pharm treatments of HF
```
ICD-
BiVentricular pacing
Case management- daily weigh-ins
Coronary revascularization
LVAD
Transplants
```
103
Treatment of acute HF
O2, BiPAP-CPAP
Vascular support- MSO4-venodilation, Nitrates-venodilation, Diuretics-excrete fluid, Dobutamine-increase inotropy, Slowly reintroduce ACE, BB and other meds once stablized
104
S1
Closure of the AV valves-beginning of systole
105
S2
Closure of the Semilunar valves- the beginning of diastole
106
S3
Extra sound- HF or dilated cardiomyopathy-blood rushing into the ventricle "Ken Tuck Y"
Gallop
107
S4
Extra heart sound- immediately precedes S1- stiff ventricle, infiltrate-HFpRF
"Ten es see"
Gallop
108
Systolic murmurs
Aortic stenosis
Pulmonic Stenosis
Mitral/tricuspid insufficiency/regurge
Mitral valve prolapse
109
Diastolic murmurs
Always pathologic
Aortic/pulmonic insufficiency/regurge
mitral/tricuspid stenosis
110
Aortic Stenosis murmur
Harsh crescendo/decrescendo over aortic region
111
Aortic Stenosis eti/
MC valve disease, degeneration due to calcification
| RHD, congenital bicuspid aortic valve, atherosclerosis, elderly-radiation/collagen diseases(rare)
112
Aortic stenosis signs
rales- cool extremities, angina, syncope-Life expectancy decreases rapidly when symptoms arise
113
Aortic stenosis Dx
Murmur heard best with Pt leaning forward, decreased w/volume reduction(standing) and increased with volume increase(squating)
114
Aortic stenosis grading
Normal-3-4cm^2
Mod 1.15cm^2
Severe<1cm^2
115
Aortic stenosis Tx
Valve replacement or repair
116
Aortic stenosis management
Avoid Negative inotropes
Observe yearly w/echo-asymptomatic every 2-5 years
Replacement for severe(10-30y expectancy)
117
Aortic stenosis Pt ed
Pt needs to tolerate elevated BP to maintain CO
118
Pulmonic stenosis murmur
crescendo/decrescendo over pulmonic area
| with Pt leaning forward and with the release of Valsalva
119
Pulmonic stenosis ETI
heart surgery or congenital MC
| Tetralogy of Fallot
120
Mitral insufficiency/ regurge murmur
Best heard at apex-radiates to axilla
systolic murmur-opening snap blowing holosystolic murmur
increases with increased peripheral resistance
121
Mitral regurge insufficiency ETI
leaflet, annulus chordae tendonae/papillary muscle abnormalities
122
Mitral regurge Sx
Asymptomatic ---exercise intolerance, IHD(angina), severe dyspnea(L HFrEF) afib
123
Mitral regurge management
yearly echo, avoid atrial remodeling
124
Mitral valve prolapse murmur
late systolic click with a crescendo murmur
| click will occur sooner when standing, later with squatting
125
Tricuspid regurge murmur
difficult to hear-use bell when standing
126
tricuspid regurge eti
pulmonary HTN leading to HF
| infective endocarditis, Epstein barr, pacemaker leads, Rheumatic fever
127
Aortic insufficiency/regurge
Quiet blowing decrescendo heard on left sternal border, increases with peripheral resistance
128
Aortic insufficiency ETI
congenital leaflet-bicuspid aortic valve
| endocarditis, marfans, Rheumatic HD, dilation of aortic root, rarely syphilis
129
Aortic insufficiency sings/sx
exercise intolerance, dyspnea, orthopnea, CHF, angina, bounding peripheral pulses
130
Aortic stenosis tx/management
yearly echos
| replacement
131
Mitral valve stenosis murmur
Opening snap, diastolic murmur, rumbling decrescendo low pitch heard best at apex with bell in left recumbent
132
Mitral valve stenosis ETI
second most common murmur-
Rheumatic fever, 4x more males-females have more symptoms
endocarditis
133
Mitral valve stenosis sx/signs
rales, cool extremities, subtle exercise intolerance, palpitations, chf, hoarsness, a fib
134
Mitral valve stenosis Dx
EKG, Echo, CBC, BMP, Mg++, TSH, CXR, BNP
135
Mitral valve stenosis grading
Normal 4-5 cm^2
mild <2.5cm^2
Critical<1 cm^2
136
Mitral valve stenosis Tx and Management
Replacement
prevent clots, control HR(BB, CCB), prophylaxis against endocarditis(dental procedures)
Yearly echo
137
Pulmonic regurge murmur
caused by pulmonary HTN MC
| quiet murmur low flow- Descrescendo best heard in pulmonic area increases with release of valsalva
138
Tricuspid stenosis murmur
Pan diastolic at L sternal border
| increases with exercise(increased venous return to heart
139
Dilated cardiomyopathy
MC type- ischemia, HTN, thick ventricular walls with dialation inside then becomes thin and weak
140
Hypertrophic cardiomyopathy HOCM
think sudden cardiac death by athlete, inborn deffect of left ventricle hypertrophy near the outflow track into the aorta
need exercise restriction(can have surgery to remove portion(Septal myomectomy)
ICD and BB
141
Restrictive cardiomyopathy-
rare -deposits of things in the heart muscle, amylooidosis-plaques heart muscle causing issues with conduction and contraction
142
tako tsubo cardiomyopathy
broken heart-after catecholamine discharge dilation and ballooning of LV-mainly postmenopausal women
143
EKG findings in cardiomyopathy
50% sensitive 90% specific
Criteria for LVH
V1 S+V5/6 R >35mm(7big boxes)
144
Radiology findings in cardiomyopathy
CXR- gives an indication of an enlarged heart but no cause
Echo can calculate EF and specify which part of Heart is affected
Cardiac MRI-expensive and slow-more detailed than echo
145
Lab studies in cardiomyopathy
BNP/Nt-ProBNP-higher the BNP the more stretch of the ventricles- causes vasodilation-drop in BP
Causes decrease in renin causing more diuresis decreasing blood volume
146
Endocarditis
Patho-Infection/inflammation of valve or prosthetic valve
ETI-TB, mycobacteria, HACEK, Staph and Strep
Risks-indwelling catheters, central lines, iv drug users, prolonged infections
S/S- fever, malaise, splinter hemorrhages, Osler nodes(painful) Janeway lesions(not painful), new murmur, sepsis
Dx-blood culture(3 separate locations), echo
Tx-based on blood culture results, replace valve if damaged
147
Myocarditis
Patho-inflammation/infection of muscle
ETI- HX recent uri, febrile illness, drugs, vaccination
Dx- Echo, MRI, myocardial biopsy
Tx- typically self limiting, if not treat as HF and treat cause
148
Pericarditis
Patho- inflammation/ infection of pericardial sac
ETI- viral infection, systemic disease, infrections, autoimmune, drugs, uremia
Clinical pres- pericardial friction rub, fever, tamponade, tachypnea, tachycardia, narrow pulse pressure, pulsus pardoxus, diffuse ST elevation, pleuritic chest pt increases in supine position decreases when leaning forward
Dx- elevated erythrocyte sediment rate(ESR) and c reactive protein(CRP)
Tx NSAIDs, ASA, colchicine(post MI), ABX for infective, dialysis for uremic
Consideration- Colchicine can cause severe ADE, effusion vs tamponade
149
Rheumatic heart disease tx
PCN, Tx chorea, CHF management, surgery to replace valves
150
Endocarditis prophlylaxis
Dental procedures, respiratory tract procedures, procedures on infected skin/tissue -prosthetic cardiac valve, previous infective endocarditis, Congenital heart disease, cardiac transplants
