Lecture 3 - common systemic diseases Flashcards
what is the most common cause for hospitalization and is the leading cause of death in the elderly?
cardiovascular conditions = HTN, coronary artery disease, calcified aortic stenosis, atrial fibrillation, congestive heart failure and anemia
what are normal cardiovascular aging changes?
decrease in cardiac functional reserve capacity, limited physical activity, and less ability to tolerate stress
what are abnormal cardiovascular aging changes?
hypercholesterolemia, HTN, coronary artery disease, carotid artery disease, vertebrobasilar insufficiency, peripheral vascular disease, heart failure, atrial fibrillation, and valvular heart disease
what are the cardiovascular lab tests?
lipid profile (total cholesterol, HDL, LDL, triglycerides), CBC, CBC with differential, ESR and CPR
what does a CBC with differential measure?
percentage of WBC components - maker of inflammation, immune response, allergic reaction and hematologic
what does ESR measure?
non-specific inflammation, infection and neoplasm (elevated in GCA, vasculitis, waldenstrom macroglobulinemia, metastatic cancer and chronic infection)
what does CRP measure?
general marker of inflammation and inflammation secondary to infection (also lymphoma, immune system diseases and GCA) - significant association with cardiovascular disease (atherosclerosis and risk of cardiovascular events)
what is atherosclerosis the leading cause of?
heart disease, stroke, and renal failure
what causes atherosclerosis?
blood vessel stenosis, thrombus and emboli
what are some risk factors for atherosclerosis?
high blood lipid levels, DM dyslipidemia, HTN, low HDL, central fat retention, elevated homocysteine levels, tobacco and male gender
what are the symptoms of atherosclerosis?
none initially - later affects the organs
what is the location of atherosclerosis?
intima of blood vessels - often at bifurcations
what is an atheroma?
an accumulation of lipoproteins (cholesterol) and cellular debris - center becomes necrotic and forms foam cell and has a fibrous cap
what is the composition of an atheroma?
necrotic core, abnormal smooth muscle cells, immune cells (monocytes, macrophages, mast cells), fibrous cap
what is the composition of a thrombus or embolus?
fibrin, platelet, red blood cells
how does a thrombus form from an atheroma?
the atheroma starts to cause stenosis/thinning and causes more stress on the endothelial cells = fibrous cap bursts creating a thrombus
what are the 3 types of emboli?
blood (thromboembolism), cholesterol pieces, and calcium pieces
how do you diagnose atherosclerosis?
blood cholesterol levels
what is the management for atherosclerosis?
prevention (modify risk factors), control lipid levels (statins, fibrates, nicotinic acid, fish oil, folic acid), lifestyle changes (weight loss, exercise, reduce fat/sugar, stop smoking/alcohol)
what are 2 causes of hypertension?
lifestyle factors and comorbidities
what are the 2 types of hypertension?
essential (idiopathic/primary) and secondary (renal disease, aldosteronism, cushing’s, pheochromocytoma, pre-eclampsia)
what is the definition of hypertension?
systolic BP of 120mmHg or greater and/or diastolic BP of 80mmHg or greater (measured on 2 or more clinical occasions after initial screen)
what are some risk factors for HTN?
age, genetics, obesity, race, male gender, hypercholesteremia, DM, physical inactivity, salt sensitivity, smoking, excessive alcohol and low vitamin D levels
what organs are affected in HTN?
heart (increases workload), brain, kidney, and retina
what are the symptoms of HTN?
none
what are the JNC 8 guidelines for patients under 30-60?
diastolic less than 90mmHg
what are the JNC 8 guidelines for patients over age 60?
systolic less than 150 and diastolic less than 90 unless (tolerating treatment at lower level, has chronic kidney disease, or has DM)
what is the clinical approach to treating HTN?
diuretics - if no improvement add beta-blocker/ACE inhibitor/angiotensin receptor agonist
if cannot tolerate diuretic use calcium channel blocker - if calcium channel blocker doesn’t work add ACE inhibitor or beta-blocker
what are the 2 types of coronary artery disease?
atherosclerosis of coronary arteries = ischemic heart disease and acute myocardial infarction
what are the risk factors for coronary artery disease?
atherosclerosis, HTN, smoking and anemia
what are the characteristics of ischemic heart disease?
chronic, caused by atherosclerosis, symptomatic, risk for MI, normal EKG and treatment is prevention of vessel ischemia
what are the characteristics of acute myocardial infarction?
acute, caused by atherosclerosis/thrombosis/embolism, may be asymptomatic, at risk for another MI, abnormal EKG, treatment is to open vessels and break thrombus down
what is the work-up for ischemic heart disease?
electrocardiogram, stress tests, echocardiogram, coronary arteriography
what is the treatment of ischemic heart disease?
treat atherosclerosis, medications (vasodilators/nitrates, beta-blockers, ASA) and surgery (CABG)
what are the symptoms of MI?
pain in center of chest, nausea/vomiting, anxiety, shortness of breath, feelings of impending doom
what is the work-up for MI?
appearance (pale skin, sweating, cool extremities), physical (pulse/BP normal, positive heart sounds), ECG-ST elevation with production of Q waves, echocardiogram
what is the treatment for MI?
defibrillation, ASA, nitroglycerin (pain), medications (antithrombolytic agents, beta-blockers, ACE inhibitors, long-term ASA, heparin, plavix) or surgery (angioplasty or CABG)
what is carotid artery disease?
blockage of the carotid artery - high risk for transient ischemic attack, stroke, CRAO = caused by atherosclerosis or thrombus
what is the work-up for carotid artery disease?
carotid duplex scan and cerebral antiography
what is the treatment for carotid artery disease?
atherosclerosis management, medication (anti-platelet agents = ASA, plavix) and surgical (carotid endarterectomy or carotid stent)
what is vertebrobasilar insufficiency?
atheroma or occlusion may block basilar and/or vertebral artery = causes TIA or CVA
what is peripheral vascular disease?
segmental occlusion of the medium/large arteries, including aorta, iliac, femoral, popliteal, tibial, peroneal
what causes peripheral vascular disease?
atherosclerosis, DM, HTN, hyperlipidemia, smokers, and elderly
what are the symptoms of peripheral vascular disease?
pain/fatigue in leg muscles (intermittent claudication) worse with exercise, relieved by rest
what is the work up for peripheral vascular disease?
absent pulses distal to the obstruction, may be bruit over site of obstruction, hair loss, thickened nails, doppler flow studies, duplex ultrasound and stress test
what is the treatment for peripheral vascular disease?
treatment of underlying conditions, ASA, revascularization with stents, and bypass
what causes heart failure?
DM, coronary artery disease, HTN, myocardial infarction, aortic valve stenosis, smoking
what is the diagnostic test for heart failure?
echocardiogram
what is the treatment for heart failure?
treat underlying condition
what causes atrial fibrillation?
electrophysiological changes in the heart (tachycardia = >100bpm - causes decreased ejection of the atrial chamber of the heart
what are people with atrial fibrillation at greater risk for?
stroke or ocular embolism
what are the signs/symptoms of atrial fibrillation?
angina, syncope, embolization, fatigue, palpitations, and anxiety
how do you diagnose atrial fibrillation?
ECG (3 or more abnormal readings)
what is the treatment for atrial fibrillation?
treat underlying factors, restore normal sinus rhythm by electrical cardioconversion, slow ventricular rate (beta-blockers, calcium channel antagonists) and anticoagulants to prevent clots (warfarin, ASA)
what are bradyarrhythmias?
caused by electrophysiological changes in the heart (bradycardia =
what causes bradyarrhythmias?
drugs (sympathetic decreased - beta-adrenergic receptors or parasympathetic increased - muscarinic receptors) = can cause heart block or death
what are the symptoms of bradyarrhythmias?
dizziness, fatigue, syncope
what is the treatment for bradyarrhythmias?
IV atropine, isoproterenol, pacemaker
what is valvular heart disease?
calcification of the valves (common) and endocarditis from mitral valve prolapse (rare)
what can valvular heart disease cause?
MI, CVA, ocular embolism
what are the diagnostic tests for valvular heart disease?
echocardiogram and CT scan
what is the treatment for valvular heart disease?
surgical, if infectious give antibiotics
what are the diagnostic tests for cardiovascular disease?
BP, heart rate, electrocardiogram, echocardiogram, carotid doppler
what is an ECG (electrocardiogram)?
provides graphical representation of electrical impulses that the heart generates during the cardiac cycle = used to determine cardiac electrical problems
when is an ECG (electrocardiogram) used?
arrhythmias (MI, conduction problems, pulmonary embolis)
what is an echocardiogram?
heart ultrasound to evaluate structure and function of heart = used to determine if structural problems are present
when is an echocardiogram used?
valve problems, thrombi present, chamber problems
what is a carotid doppler?
ultrasound of the carotid arteries
when is a carotid doppler used?
to diagnose carotid plaques or stenosis
if a patient is taking 81mg ASA what should you ask about?
if they have had a stroke or heart attack = common for prevention or for maintenance after MI/CVA
how is cancer related to aging?
increase in prevalence with age = cancer biology directly linked to cellular aging (genetic mutations/instability, telomere shortening, chemical mutations, radiation exposure, free radical development, reduced immune response, chronic inflammation, virus exposure)
what is a major cause of mortality and morbidity in the elderly?
cardiovascular accident (CVA/stroke)
what are the 2 types of cardiovascular accidents?
ischemic (2/3) = lack of blood flow to area (thrombus/emboli)
hemorrhagic (1/3) = bleed in brain
what are the risk factors for cardiovascular accidents?
HTN, hyperlipidemia, atrial fibrillation, DM, carotid stenosis, smoking, temporal arteritis
what are the sudden signs of a stroke?
FAST = face drooping, arm weakness, speech difficulty, and time to call 911 (time is very important)
what is a transient ischemic attack (TIA)?
episode that indicates a stroke but only lasts 30 minutes - if recur it is likely brain thrombosis, if recur but different symptoms likely extracranial (heart) emboli
what is the work up for an acute stroke?
stroke work up, urgent CT or MRI, lab tests
what is the treatment for an acute stroke?
immediate fibrinolytic therapy
what is the secondary preventative therapy for a stroke?
antiplatelet therapy (ASA, plavix, dipyridamole)
what is the cause if the transient vision loss is monocular during a stroke/TIA?
carotid disease
what is the cause if the transient vision loss is binocular during a stroke/TIA?
vertebrobasilar insufficiency
what are the causes of ocular signs during a stroke/TIA?
any condition that causes an emboli to go to the brain/centers of vision, atherosclerosis = vascular insufficiency, cardiac arrhythmia
what are the diagnostic tests for a stroke/TIA that causes ocular signs?
blood work if suspect GCA, blood work to rule out other causes, carotid doppler scan, echocardiogram
diagnostic testing then eye exam
what is the cause of the stroke/TIA if there is diplopia present?
verebrobasilar insufficiency
what is the difference between a mass and a stroke?
both are acute - stroke is sudden and has clear signs vs. a mass which is gradual with unclear signs
both need imaging and a neurology consult
what is the most common lung disease in the elderly?
COPD = inflammation of the airways - mucous plugs obstruct airway
what is the symptom of COPD?
dyspnea = shortness of breath advanced = weight loss, muscle loss, decreased strength
what is the difference between emphysema and chronic bronchitis?
emphysema = permanently enlarged airspaces
chronic bronchitis = productive, persistent cough
what are the causes of COPD?
dust, smoking, air pollution, toxic gases, pulmonary infections, reduced antioxidant intake, genetic predisposition
what are the treatments for COPD?
smoking cessation, bronchodilators, inhaled corticosteroids, rarely systemic corticosteroids, oxygen supplementation
what is obstructive sleep apnea?
recurrent collapse of the airway during sleep = cessation of airflow (apnea/hyponea), intermittent disturbances in gas exchange, fragmented sleep
what are the risk factors for sleep apnea?
older age, male, obesity, craniofacial or upper airway soft tissue abnormalities, daytime congestion problems, cardiovascular problems, metabolic syndrome
what is the treatment for sleep apnea?
weight loss, CPAP machine
why should you be worried if the PPD test is negative in the elderly?
most causes of TB are elderly and the PPD test is less sensitive - if high suspicion, retest in 2 weeks (signs may be different)
how does penumonia/influenza cause mortality in the elderly?
usually due to secondary complications = other infections, worsening of other chronic disease (congestive heart failure or COPD)
what are the symptoms of pneumonia?
fever, cough, dyspnea
how do you diagnose pneumonia? what is the treatment?
chest x-ray, sputum culture, blood cultures
antibiotics
what is metabolic syndrome?
obesity, impaired glucose tolerance, high BP, high triglycerides, risk of developing DM
what are the symptoms of DM in the elderly?
no polyuria or polydipsia (increased threshold for glucose in kidney), falls, failure to thrive, urinary incontinence, delerium
what does the initial presentation of DM look like in the elderly?
often based on lab work - concurrent with other findings (MI/stroke, vision changes, retinal hemes in routine eye exam)
what are some complications in untreated hypothyroidism?
heart problems, thyroid eye disease
what are some complications in untreated hyperthyroidism?
congestive heart failure, stroke, infection, thyroid eye disease
what are some symptoms of thyroid disease in the elderly?
fatigue, muscle weakness, weight loss and atrial arrhythmias (not = heat intolerance, sinus tachycardia, sweating, tremor)
what tests are included in thyroid panel?
THS - T4 (total or free) - T3 (total or free), anti-thyroid antibodies
what are the treatments for thyroid disease?
hypothyroid = levothyroxine hyperthyroid = beta-blockers or thionamides
what is osteoporosis?
low bone mass as a result of aging - higher rates in women after menopause
how do you diagnose osteoporosis and what is the treatment?
diagnosis = bone density scan (DEXA) treatment = exercise, calcium, bisphosphates, estrogen, calcitonin
what is osteoarthritis?
degenerative joint disease - idiopathic or secondary
what is the treatment for osteoarthritis?
palliative not curative = exercise, weight loss, patient education, acetaminophen, NSAID, capsaicin, glucocorticoid injections
what is the treatment for benign prostate hyperplasia (BPH)?
alpha-1 antagonists = relax neck of bladder
5-alpha-reductase inhibitors
PDE-5 inhibitors or antimuscarinics
what are the risk factors for BPH?
age, smoking, co-morbidities
