Week 5 CVS Flashcards
In patients without CVD, lipid testing is suggested in men age ______ and women age _______.
men 40 and up
women 50 and up
Testing can be considered earlier for patients with known traditional CVD risk factors including but not limited to hypertension, family history of premature CVD, chronic kidney disease, diabetes, and smoking.
When reassessing CVD risk in patients not taking lipid-lowering therapy, how often is it suggested to reassess lipid levels?
no more than every 5 years and preferably 10 years, unless risk factors change.
High-intensity statins are recommended when your 10 yr CVD risk score is _____ or higher.
20%
Moderate-intensity statins are recommended when your 10 yr CVD risk score is _____.
10-19%
What are the recommendations when your 10 yr CVD risk score is less than 10%?
Retest lipids in 5 -10 yrs (10 is preferred).
If your patient is on max statin therapy and still needs some help to decrease CVD risk, which meds are recommended?
Ezetimibe or PCSK9 inhibitors.
At what age is it recommended that we stop testing our patients’ lipid levels and assessing risk using a CVD risk calculator?
75 years old.
Statins are not recommended for primary prevention in patients 75+ yrs old.
True or false?
True, but it is still reasonable to so discuss risks vs benefits if your patient’s overall health status is good.
If your patient has a cardiovascular event but is older the age of 75, you should not recommend starting a statin.
True or false?
False. The CFP guideline recommends encouraging your patient to start statin therapy after reviewing risks and benefits.
If your patient is on a statin and tolerating it well, it should not be stopped simply because your patient reaches the age of 75.
True or false?
True.
What should you recommend if your patient cannot tolerate a statin due to non-severe muscle cramps?
Statin therapy > non-statin therapy. Try switching med, lower dose, or alternate daily dosing.
For primary prevention in patients unable to tolerate any
statin use, should you recommend non-statin use?
What about in secondary prevention?
Not in primary prevention.
In secondary prevention, it is suggested in the CFP guideline to explore non-statin meds like ezitimibe, fibrates or PCSK9 inhibitors
When should you repeat lipid testing once your patient starts lipid-lowering therapy?
The CFP guideline recommends against repeat testing, and against cholesterol targets.
What is the big red flag adverse reaction to statins to make sure you counsel your patients on?
Rhabdo! I heard my preceptor counsel about cola-coloured urine and I thought that was a good way to make sure they knew what to watch for.
Some patient teachings when you prescribe a statin?
May cause muscle cramping, low incidence of 5% or less.
Serious possible A/E: rhabdo, may increase your blood glucose and contribute to DMT2, and may cause memory loss or confusion.
Avoid grapefruit juice.
What is Afib and why is it a problem?
Atrial fibrillation (AF) is the irregular and rapid heart rhythm caused by abnormal electrical impulse formation and/or propagation. These impulses make the atria beat irregularly and in a dyssynchronous manner with the ventricles, causing blood pooling and poor systemic circulation
How do you classify Afib based on duration?
(paroxysmal vs persistent vs longstanding, permanent)
Paroxysmal = episodes last longer than 30 seconds but less than 7 days
Persistent = episodes last longer than 7 days but less than 1 year
Longstanding persistent = continuous AF for more than 1 year but rhythm control is still being pursued
Permanent = continuous AF where the decision is made to not pursue sinus rhythm restoration
What is the difference between valvular and non-valvular Afib?
Valvular = AF in the presence of a mechanical valve or moderate-severe mitral stenosis
Non-Valvular = AF in all patients who do not fit the valvular classification
Who most typically gets Afib?
Increased age (12% inover 75)
Male
Caucasian
What does Afib look like on an ECG?
irregular rhythm with no discernible, distinct P waves, lasting at least 30 seconds.
Why does a patient’s AFib become increasingly unlikely to restore (convert to sinus rhythm) the longer it goes on?
The presence of AF leads to structural and electrical re-modelling of the atria that over time, advances the severity from paroxysmal –> persistent –> permanent. Thus, the longer a patient has been in continuous AF, the less likely it is to terminate spontaneously, and harder it is to restore and maintain sinus rhythm.
S&S of AF?
- Palpitations
- Irregular, tachycardic, pounding/fluttering heartbeat
- Fatigue
- Weakness
- Dizziness/Light-headedness
- Dyspnea at rest or on exertion
- Potential angina
- Potential syncope
How do we diagnose Afib?
ECG (Sensitivity > 92% and Specificity > 90%) is the gold standard
Holter monitor
Echocardiogram (
o Assess for structural concerns related to valvular AF such as mitral valve stenosis
What are the 3 main pillars of management plan for AF?
1) lifestyle - managing modifiable risk factors & comorbidities
2) anticoagulation for stroke/systemic embolism prevention
3) rate/rhythm control
What bloodwork needs to be done prior to starting a DOAC?
ALT, AST, GGT, bilirubin (as per BC Guidelines)
CBC, CrCl (apparently do not use GFR)
T/F most patients with AF will require and benefit from OAC therapy
True!
An oral anticoagulant is NOT recommended in what group with AF?
OAC is not recommended for NVAF patients < 65 years with none of the CHADS2 risk factors because the risk of stroke is very low in this group
A patient has valvular AF and a mechanical valve. Do you start them on a DOAC or warfarin?
Warfarin only!
***Direct oral anticoagulants (DOACs) are contraindicated in patients with valvular AF
A patient has valvular AF and moderate/severe mitral stenosis. Do you start them on a DOAC or warfarin?
Warfarin only!
A patient has nonvalvular AF and is 65 years or older. What do you do?
Start a DOAC
**For patients with NVAF, use the CCS Algorithm (CHADS-65) to determine the optimal antithrombotic therapy.
A patient has nonvalvular AF and is 60 years old. They have HTN. What do you do?
DOAC
- Although they are younger than 65, they have one of the CHADS risk factors so they should be started on an anticoagulant
Name the 4 CHADS risk factors
1) Prior stroke or TIA
2) HTN
3) Heart failure
4) DM
**Regardless of age, if anyone has nonvalvular AF and any of these risk factors, they are recommended to start on a DOAC
A patient with CAD or PAD should be started on what therapy?
Antiplatelet!
**Note – the antiplatelet therapy is provided primarily for the management of concomitant vascular disease and not as a stroke preventative therapy per se
Why do we choose DOACs over warfarin when we can?
DOACs are preferred over warfarin in NVAF because pooled data from randomized trials have shown that the risks of stroke/ systemic embolism, intracranial bleed and all-cause mortality are significantly reduced with DOAC compared with warfarin
T/F A patient has Afib but no symptoms. They don’t require anticoagulation.
FALLLLSSEEEEEEE
Absence of symptoms (e.g., in subclinical AF) does not change management (according to BC guidelines).
According to the CCS pocket guide: We suggest that it is reasonable to prescribe OAC for patients with AF who are aged ≥65 years or with a CHADS2
score ≥1 who have episodes
of subclinical AF lasting >24 continuous hours
Your patient is newly diagnosed with valvular AF. They state their symptoms have been present for a couple of months.
T/F you should refer them for immediate cardioversion.
NO! Risk of throwing clot
OAC for a minimum of 3 weeks is needed BEFORE planned cardioversion in the following patients:
- Valvular AF
- NVAF episode duration < 12 hour and recent (< 6 months) stroke or transient ischemic attack (TIA)
- NVAF episode duration 12 – 48 hours and CHADS2 score > 2
- NVAF episode duration > 48 hours
You patient was cardioverted in hospital 2 weeks ago. You notice they’re still on a anticoagulant. You can stop it…right?
NO!
OAC for a minimum of 4 weeks is needed AFTER cardioversion and then long-term anticoagulation should be managed according to CHADS-65
Your patient is a frail 98 year old and tends to fall a few times per year. T/F: falls are a contraindication for anticoagulation and you should stop their DOAC or warfarin.
FALSE
It is estimated that patients with AF taking warfarin have to fall more than 295 times in 1 year for the risks of warfarin to outweigh its benefits. Fall risk alone should therefore not be a reason to withhold anticoagulation
In the outpatient setting, choosing rate vs rhythm control is dependent on what factors?
1) type of AF (paroxysmal vs persistent),
2) duration of AF,
3) LV function
4) patient symptoms and preferences.
In what situations is rhythm control preffered over rate control for AF?
1) recently diagnosed AF (within 1 year)
2) Highly symptomatic or significant QOL impairment
3) Multiple recurrences
4) Difficulty to achieve rate control
5) Arrythmia-induced cardiomyopathy
FYI: In those patients with recently diagnosed AF (within 1 year), an initial strategy of rhythm control is preferred as the first treatment strategy because it is associated with reduced cardiovascular death and reduced rates of stroke.11 However, antiarrhythmic drugs have not been associated with a beneficial effect on mortality and many have significant adverse effects.
In those patients with established AF (duration > 1 year), RCTs have shown no significant difference in cardiovascular outcomes between patients treated with a strategy with rate control vs rhythm control.
Longterm rate control: Titrate rate-controlling agents to achieve a target heart rate of ≤ ______ bpm at rest.
100
How do you choose rate control agents in relation to the person’s LVF?
If you start some rate control agent and have inadequate symptoms or heart rate control, what might be the next steps?
LVEF 40% or less: bisoprolol, carvedilol, or metoprolol
LVEF >40%: beta blocker, diltiazem or verapamil
May need to add digoxin or another agent (but this is again dependent on the LVEF….see the handy dandy algorithms in the BC Guidline for AF)
T/F the purpose of long-term rhythm control is to eliminate ALL AF episodes.
False - The focus of rhythm control is on symptom relief, improving functional capacity and quality of life, and reducing health care utilization, and not necessarily the elimination of all AF episodes
T/F we should consult a specialist if considering rhythm control
True
In what kind of AF patient might it be appropriate to have a “pill in pocket” method for treatment? What is this?
For symptomatic AF episodes (e.g. ≥2hrs) occurring less than monthly,
flecainide or propafenone can be taken intermittently (PRN) or as a
booster dose as an outpatient (pill-in-the-pocket).
Generally used in paroxysmal Afib
According to CCS pocket guide, appropriate candidates are:
1) symptomatic patients with sustained AF episodes (e.g. ≥2 hours) that
occur less frequently than monthly
2) absence of severe or disabling symptoms during an AF episode (e.g.
fainting, severe chest pain, or breathlessness)
3) ability to comply with instructions, and proper medication use
**The first time a patient does it has to be closely supervised in the hospital to monitor for AEs
What guidance should you give your patient with AF regarding alcohol and tobacco use?
Limit to 2 standard drinks/week (or none!)
Abstinence from tobacco
According to the BC guidelines, what is the BP target for someone with AF?
130/80 at rest and 200/100 at peak exercise.
What exercise recommendations will you give your patient with Afib?
BC guidelines:
200 or more minutes of moderate intensity aerobic exercise (30mins x 3-5 days)
Resistance exercise 2-3 days/week
Flexibility exercises at least 10 minutes per day x 2 days/week in those >65yrs old
**Rx files says to AVOID INTENSE EXERCISE
What is the SAF score?
Severity of AF
OUtlines symptoms and effect on QOL
Rated class 0-4
Tell me again how we define paroxysmal AF?
Continuous AF episode lasting longer than 30 seconds but terminating within 7 days of onset
Tell me again how we define persistent AF?
Continuous AF episode lasting longer than 7 days but less than 1 year.
Differentiate “longstanding persistent AF” and “permanent AF”
Both are continuous AF >1 year
In longstanding persistent, rhythm control management is still being pursued. In permanent, have stopped persuing sinus rhythm.
Risk factors for AF
Advancing age
* Male sex
* Hypertension
* HF with reduced ejection fraction
* Valvular heart disease
* Overt thyroid disease
* Obstructive sleep apnea
* Obesity
* Excessive alcohol intake
* Congenital heart disease (e.g. early
repair of atrial septal defect)
What are some triggers for AF episodes?
- Stimulants
- Alcohol
- Sleep deprivation
- Emotional Stress
- Physical Exertion
- Sleep/Nocturnal
- Digestive
What are some reversible causes of Af?
- surgery
- Acute cardiac pathology
- Acute pulmonary pathology
- Acute infection
- Thyrotoxicosis
- Alcohol
- Pharmacologic agents (e.g. Ibrutinib)
- Supraventricular tachycardia
- Ventricular pacing
What is the weight loss target for someone with AF?
Target a weight loss of ≥10% to a
BMI of less than 27 kg/m2
.
What other treatments beyond pharmacologic rate/rhythm control and cardioversion might be used for AF?
pacemaker implantation and AVJ Ablation
What are common adverse effects of beta blockers?
bradycardia, hypotension, fatigue, and
depression
A/E of digoxin?
GI upset, blurred vision, proarrhythmia
Name some DOACs
apixaban, dabigatran, edoxaban, or rivaroxaban
T/F DOACs need to be adjusted based on renal function
True - there’s nice summary on pg. 24 of the pocket guide. Looks like apixaban is 5mg for anything over CrCl of 30mL/min. But the others require renal dosing
What does HAS BLED stand for?
HTN
Abnormal renal and liver function
Stroke hx
Bleeding
Labile INRs
Elderly (age >65)
Drugs of alcohol
OSA is a major risk factor for AF. What treatment is therefore imperative for someone with OSA and AF?
Ensure using CPAP!
Why is quitting smoking important in AF?
Smoking raises blood pressure and heart rate, both of which are risk factors for AF episodes
Is digoxin considered rate or rhythm control?
Rate
Which meds are rhythm control?
Amiodarone
Dronedrone
Flecainide
Propafenone
Sotalol
What does the CHA2DS2-VASc criteria stand for?
Congestive HF
Hypertension
Age ≥ 75 years
Diabetes mellitus
Stroke / TIA / TE
Vascular MI, PAD, aortic plaque
Age 65-74
Sex – female
A CHA2DS2-VASc score of ____ for men and women does NOT indicate a need for anticoagulation
males: = 0, females: = 1
What are two ways that we classify heart failure?
Based on symptoms
Based on EF
LVEF of ______ = HF with preserved EF (HFpEF)
50% or greater
LVEF of ______ = HF with mid-range EF (HFmEF)
41-49%
LVEF of ______ = HF with reducedEF (HFrEF)
less than or equal to 40%
What classification system is used for HF based on symptoms?
NYHA (New York Heart Association)
Outline NYHA Class I and II (Don hinted that we will be tested on these!)
I - NO symptoms
2 - Mild symptoms: symptoms with ordinary activity
Outline NYHA Class III and IV
III: moderate symptoms - symptoms with less than ordinary activity
IV: severe symptoms: symptoms at rest or with minimal activity
Risk factors for HF
- Hypertension
- Ischemic heart disease (IHD)
- Valvular heart disease
- Diabetes mellitus
- Heavy alcohol or substance use
- Chemotherapy or radiation
therapy - Family history of cardiomyopathy
- Smoking
- Hyperlipidemia
S&S of HF
Breathlessness
Fatigue
Leg swelling
Confusion (especially in elderly)
Orthopnea
Paroxysmal nocturnal
dyspnea
- Lung crackles
- Elevated Jugular Venous Pressure (JVP)
- Positive Abdominal jugular reflux (AJR)
- Peripheral edema
- Displaced apex
- 3rd heart sound, 4th heart sound (S3
, S4) - Heart murmur
- Low blood pressure (BP)
- Heart rate > 100 BPM
What might you find on an ECG with someone with HF?
- Q Waves
- Left Ventricular Hypertrophy (LVH)
- Left Bundle Branch Block (LBBB)
- Tachycardia
- Atrial Fibrillation
At what values of BNP is HF unlikely, possible, and likely? (this is BNP not proBNP!)
< 100 pg/ml - HF unlikely
= 100-400 pg/ml - HF possible but other diagnoses need to be considered
> 400 pg/ml - HF likely
In HF, what might you seen on an echo?
- Decreased left ventricular (LV) ejection fraction (EF)
- Increased LV end-systolic and end-diastolic diameter
- LVH
- Wall motion abnormalities and diastolic dysfunction
- Increased right ventricular (RV) size and/or
RV dysfunction - Valve dysfunction
- Elevated pulmonary arterial pressures (PAP)
Key physical exam components to do with someone with HF
Vital signs
Weight
Volume status
Heart
Lung
Abdomen
Peripheral Vascular
Initial investigations to do if suspecting HF?
CXR
ECG
Lab work (CBC, electrolytes, renal function,
urinalysis, glucose, thyroid function)
….then if still suspecting HF: Echo, BNP
What are some red flags for worsening HF? (things to tell your patient should prompt them to return to care)
Dyspnea
- With less exertion
- During sleep
- When lying flat
ï Fatigue with progressively less exertion
ï Increased abdominal swelling or
pedal and leg edema
ï Dyspnea at rest
ï Weight gain (eg. > 2kg in 2 days)
ï Lightheaded/faint
ï Prolonged palpitations
ï Confusion
ï Chest pain that does not go away
with rest or with medicine or is
worsening
A sodium restriction of ____ to ____g/day is reasonable for a patient with HF
2g-3g/day
Tx for most patients with HFrEF requires quadruple therapy. What are the 4 categories of medications your patient will be on?
1) ACEi (or ARB) or ARNI
2) Beta blocker
3) MRA (such as spironolactone)
4) SGLT2 inhibitor
T/F when treating HFrEF, we titrate medications to achieve a target BP.
False - we are treating to target DOSES (as long as they are tolerated)
Why do we treat with a beta blocker in HF?
Reduce O2 demand, allow longer time for myocardial relaxation and subsequent blood into the myocardium
When do you NOT use a beta blockers in HF?
DO NOT USE IN ACUTE VOLUME OVERLOAD (will dramatically exacerbate the hear failure)
How does an SGLT2 benefit a person with HF?
Reduces sodium & glucose reuptake, causing diuresis
How do you advise a person with HF on the level of activity that is acceptable?
If they are not having symptoms then the activity is likely okay for them to do.
What are the exercise recommendations for someone with NYHA Class I - III HF?
Flexibility exercises
Resistance exercises 2-3 days/week
Aerobic exercises
- moderate intensity may be incorporated for some (65%-85% HRmax)
- walk, treadmill, ergocycle, swimming
- start with 2-3 days/week, work up to 5
- Start with 10-15mins, work up to 30
exercise recommendations for Class IV HF
Aerobic exercises recommended for selected population only & under Supervision by an expert team
- flexibility exercises recommended
What is the general goal for diuretic use in HF?
Minimum effective diuretic dose to maintain euvolemia
How is HFpEF treated?
My understanding is that a preserved EF means they don’t necessary need to be on full quad therapy, but they made need most of the same agents depending on the situation?
CCS pocket book says:
- Treat hypertension according to current hypertension guidelines
- Usually loop diuretics are needed, renal function may be very volume dependant
- In most cases, an indication for ACEi, ARB and/or BB is present
- Patients with atrial fibrillation should be anticoagulated unless
there is a contraindication
- Individuals with HFpEF, serum potassium < 5.0 mmol/L and
eGFR >30mL/min, an MRA like spironolactone should be
considered
According to BC guidleines:
To improve outcomes:
Initiate an SGLT2i (e.g., empagliflozin and dapagliflozin). SGLT2i therapy reduces hospitalizations as well as all- cause and cardiovascular mortality across age, sex, race, HF and EF classification.5,19,20
Consider MRA (in all eligible patients) to reduce HF hospitalization.21
In select patients, consider initiating an angiotensin receptor-neprilysin inhibitor (ARNI)
Spironolactone is a potassium ______ diuretic (wasting/sparing)
Spironolactone is a potassium-sparing diuretic
What NYHA classes should you consider for hospital admission/
III and IV
(also consider O2 sats, BP, HR, RR, ECG findings etc)
T/F Furosemide is generally just for symptomatic tx in HF (not actually improving the HF)
True according to Don’s lecture.
If a patient is needing frequent PRN lasix, need to look and see if you can optimize other treatments.
Rx files says:
use diuretics for congestion at any stage
adjust diuretic dose to euvolemic state
combine diuretics if persistent fluid retention
(e.g. furosemide + metolazone or acetazolamide)
What are the current Canadian Task Force Preventative Health Care (CTFPHC) Screening recommendations for AAA.
One time screening with US for AAA for men aged 65-80.
* For men 80+, potential benefit is reduced bc more likely to experience medical conditions that increase risk of AE from elective procedures to repair AAA
* Women have very low rates of AAA and greater risk of mortality following AAA procedure which reduces the likelihood of benefit from screening
How should a patient with heart failure be advised to weight themself? how often? What kind of weight gain is concerning?
daily morning weight in the nude & after
voiding, especially if fluid retention, congestion, or
renal dysfunction;
encourage patients to report rapid
weight gain (i.e. ~2lbs / 2 days or 5lbs / week)
What general fluid intake restrictions are appropriate for a patient with HF?
limit to 1.5-2L / day if fluid retention
or congestion not easily controlled with diuretics, or
renal dysfunction or hyponatremia.
Consider all
liquids e.g. beverages, soups.
In older adults, what is the recommended BP target according to BC guidelines?
For adults aged 60 and above desirable BP reading of AOBP < 145/85 is recommended.
Also keep in mind that BP targets in older adults should be individualized based on a person’s frailty, comorbid conditions, and tolerability of the medications and adverse effects (falls).
What type of murmur does AS create?
Systolic ejection murmur, crescendo-decrescendo, with a click
What is mitral regurgitation (MR)?
Leakage of blood across the mitral valve from the LV into the LA; can be primary or secondary.
Reduced CO → increased LV and LA pressure → LV and LA dilatation → and pulmonary HTN
What type of murmur does MR cause?
Holosystolic or pansystolic murmur - lasts in the entirety of systole - but is a flat murmur b/c the intensity remains the same.
- During systolic contraction, blood regurgitates from the LV into the LA across the incompetent mitral valve resulting in a short but audible holosystolic murmur between S1 and S2. The portion of left ventricular end diastolic volume that regurgitates into the LA myocardium increases left atrial pressures resulting in a tall V-wave (in the JVP). Severe, acute MR usually results in acute hemodynamic decompensation.
Where is AS murmur heard most loudly?
aortic area
Can the AS murmur radiate to the neck or carotids?
Yes. Murmur is occurring in the aorta and one of the first branches off of the aorta are the carotid arteries. Hear the murmur up resonating thru the carotid in the neck.
Where would the MR murmur be best heard?
mitral area or apex
What are some lifestyle recommendations to help manage hypertension?
Dash diet
Healthy weight
<2,000 mg of sodium per day
Smoking cessation
Reduced etoh intake <2 drinks per day.
Physical activity of 30-40 min 4-7 days a week
Smoking cessation
Stress reduction
For newly diagnosed hypertension, what should you focus on your physical examination?
Weight, height, waist circumference, dilated fundoscopy, central and peripheral cardiovascular examination, and abdominal examination.
What labwork would you order in newly diagnosed hypertension?
Urinalysis - albumin to creatinine ratio (ACR), hematuria
Blood chemistry - potassium, sodium, creatinine/estimated glomerular filtration rate (eGFR)
Fasting blood glucose or hemoglobin A1c level
Blood lipids – non-HDL cholesterol and triglycerides (non-fasting is acceptable)
Electrocardiogram (ECG)
What are risk factors (modifiable, non-modifiable, medications) for hypertension?
Modifiable: smoking; high alcohol consumption; low physical activity levels/sedentary lifestyle; unhealthy eating (such as high sodium intake and low vegetable and fruit intake); body composition (e.g., high body weight, high body mass index, waist circumference); poor sleep; poor psychological factors (e.g., stress levels).
Non-modifiable: age; family history
Prescription drugs (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, decongestants, oral contraceptive use); others (e.g., alcohol, stimulants, sodium).
What follow up is necessary when managing hypertension?
-Two weeks after initiating antihypertensive medications, follow-up with an eGFR to monitor kidney function and monitor for adherence to medications.
-Then, follow-up with the patient at monthly intervals until BP is in a desired range for two consecutive visits.
-Review every 3 - 6 months (as long as the patient remains stable)
Where can the MR murmur radiate?
To the l. axilla
What are the symptoms of MR?
- Dyspnea
- peripheral edema
- decreased exercise tolerance
- SOBOE
- PND
- orthopnea
- palpitations
What are the symptoms of AS?
- Exertional angina
- PND
- peripheral edema
- exertional dyspnea
- HF symptoms
- syncope
- dyspnea
- orthopnea
- decreased exercise tolerance
- presyncope
Name the murmur: Grade I
Faintest murmur that can be heard.
Name the murmur: Grade II
Soft murmur that is readily detectable.
Name the murmur: Grade III
Louder than grade II but without a palpable precordial thrill.
Name the murmur: Grade IV
Loud murmur associated with a palpable precordial thrill.
Name the murmur: Grade V
Very loud murmur; audible with the stethoscope placed lightly on the chest; occurs with a palpable precordial thrill.
Name the murmur: Grade VI
Loudest murmur; audible with the stethoscope off the chest; occurs with a palpable precordial thrill.
Which murmur would there be an apical thrill?
MR
what type of Investigations is needed for possible AS and planning to refer?
ECG, CXR, Echo, Stress Test (contraindicated if symptomatic)
What are common causes of secondary HTN?
Renal insufficiency
* Renovascular disease
Primary hyperaldosteronism * Thyroid disease
Pheochromocytoma and other rare endocrine causes
Obstructive sleep apnea
what type of Investigations is needed for possible MR and planning to refer?
ECG, CXR, echo/ TTE, TEE, cardiac cath, exercise stress testing, serum biomarkers of LV function
Describe the epidemiology of peripheral arterial disease (PAD).
15% incidence in patients 70+
Risk factors: similar to CAD; older age, smoking, HTN, male, known atherosclerosis to other sites, fhx PAD, DM, hyperlipidemia, homocysteinemia
Describe the pathophysiology of PAD
-Narrowing of peripheral arteries d/t plaque deposition
-Lack of blood flow to the musculature relative to its metabolism, which results in pain in the affected muscle groups
What is the pathognomonic feature of PAD?
Intermittent claudication = a reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest (as O2 demand changes).
* Cramping or aching
* Primarily in the calves
* Relieved within 10 min of activity cessation
Describe S&S of PAD.
-Often asymptomatic
-Severity of symptoms depends on degree of arterial narrowing, # of arteries affected, activity level of patient
-Aching leg/ foot pain (calf most common, can also occur in thigh, butt, forefoot)
-Intermittent claudication (cramping with exercise, relieved by rest)
-Can also have pain at rest (i.e., pain waking from sleep)- that goes away when leg is lowered into dependant position (bc increases blood supply)
-Ischemic pain will NOT be readily controlled by analgesics
-Foot pallor with elevation and then rubor (or cyanosis) in dependant position
-Non healing wounds/ ulcers/ gangrene (usually tips of toes, lateral malleolus, metatarsal heads; dry, punched out, painful but bleed little)
-lack of pedal pusles
-Skin changes- cool, thin, dry, shiny, hairless
-Nail changes- brittle, hypertrophic, ridged
Describe the stereotypical ulcers seen in PAD
-tips of toes, lateral malleolus, metatarsal heads
-DRY
-punched out
-painful
-bleed little
Assessment for PAD?
Focussed history of ambulation is able to confirm the dx of claudication with most patients
-Vitals
-Cardiac & abdo assess
-Assess for S&S of infection if open wounds
-inspection of the skin of the extremities
-All peripheral pulses
-auscultation for bruits
-extremity neurologic examination.
-If can’t palpate pulse, use doppler
* The vascular examination in patients with PAD commonly reveals diminished or absent pulses below the level of arterial obstruction with occasional bruits over stenotic lesions and evidence of poor wound healing in the area of diminished perfusion
How to diagnose PAD?
Ankle brachial index. Uses doppler analysis, and is diagnostic for arterial obstruction if <0.9
Measures ankle BP (usually a bit higher) over brachial BP
How do we differentiate intermittent claudication from PAD from the neurogenic claudication of spinal stenosis?
IC- exercise induced, usually had predictable onset (i.e., always happens after walking 10 min or always happens after walking 250m ,etc.), pain primarily in calves, relieved by rest almost immediately (and definitely within 10 min)
NC- variable distance to onset, pain in calves/ posterior thigh and buttock, relieved by bending over or sitting down or using assistive/ mobility devices, takes 15 min to hours to relieve pain, usually associated with low back pain
In PAD, what indicators may suggest need for early surgical intervention for limb salvage?
ischemic pain
ulceration
Refer to vascular specialist for revascularization
* Indicated for those with significant or disabling symptoms of claudication unresponsive to lifestyle adjustment and pharmacologic therapy
* For patients with chronic limb-threatening ischemia (eg, rest pain, ulceration), revascularization is a priority to improve arterial blood flow
* Endovascular approach (angioplasty), open repair (surgical bypass of occluded/ stenotic segment)
What is the pharm and non pharm management of PAD?
Non pharm
-Regular exercise (walking regime) & weight reduction important
-Involves combo of CVD risk reduction: smoking cessation, tx CV risk factors (i.e., HTN, dyslipidemia)
Pharm:
- antiplatelets (ASA, clopidogrel)
-statin
What are the top three causes of anemia in older adults
1/3 - anemia of chronic disease/chronic inflammation
1/3 nutritional deficiencies (usually iron)
1/3 unexplained
**Don lists anemia of chronic disease as the most common anemia in older adults
Explain the patho of anemia of chronic disease
Chronic inflammation/inflammatory cytokines:
- Leads to decreased erythropoietin production in the kidneys and erythropoietin response of erythroid progenitor cells, decreasing production of RBCs.
- Increases hepcidin. Hepcidin is produced by the liver, it reduces gut iron absorption and iron release from macrophages that have consumed dead RBCs. This causes a functional iron deficiency where serum iron is low and insufficient, but overall iron stores are adequate. Normally, macrophage release of recycled iron accounts for 90-95% of daily body iron requirement.
- Enhances erythrophagocytosis by splenic and hepatic macrophages, leading to decreased survival time of erythrocytes.
What are some medical conditions that can contribute to anemia of chronic disease?
- Classically: advanced cancer, infection and autoimmune diseases (IBD, RA, sarcoidosis, SLE, vasculitis)
- Others: diabetes, congestive heart failure, COPD, pulmonary hypertension, obesity, chronic kidney disease, liver disease, hypothyroidism, critical illness and trauma
T/F: Anemia of chronic disease is a macrocytic normochromic anemia
False:
Anemia of chronic disease is a normocytic normochromic anemia
(in can occasionally be microcytic in more severe cases)
How do you treat anemia of chronic disease?
Treat the underlying condition
In hypertension, when should you refer to a hypertension specialist?
Refer if BP is still not controlled after treatment with three antihypertensive medications
Pick the true statements
a) Long-acting diuretics like indapamide and chlorthalidone are preferred over shorter acting diuretics like hydrochlorothiazide
b) When prescribing combination therapy, an ACE inhibitor plus a long-acting CCB is preferable to an ACE inhibitor plus a thiazide or thiazide-like diuretic.
c) Short-acting nifedipine or amlodipine are examples of CCBs used to tx HTN.
d) Prescribing single-pill combination therapy is an effective way to manage HTN; a common combination is ramipril and losartan .
A and B are true per Hypertension Canada
C is false–it is not reccomended to use short term CCBs.
D- Do not combine ARBs with ACEi.
Which classes of medications are recommended for isolated systolic hypertension without other compelling indications?
Thiazide/thiazide-like diuretics, ARBs or long-acting dihydropyridine CCBs.
For which classes of medications should you monitor creatinine and potassium?
Potassium sparing diuretics, ACE inhibitors and ARBs.
