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547 > Week 5 CVS Heme > Flashcards

Week 5 CVS Heme Flashcards

1
Q

Afib

Definition of paroxysmal AF

A

Paroxysmal AF

-continuous AF lasting >30 seconds, terminate within 7 days of onset

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2
Q

Afib

Definition of persistent AF

A

Persistent AF

-continuous AF lasting > 7 days, < 1 year

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3
Q

Afib

Definition of “longstanding” persistent AF

A

“longstanding” persistent AF

  • continuous AF > 1 year
  • rhythm control is being pursued
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4
Q

Afib

Definition of Permanent AF

A

Permanent AF

  • continuous AF
  • therapeutic decision NOT to pursue sinus rhythm restoration
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5
Q

Afib

Definition of valvular AF

A

Valvular AF

-AF in presence of mechanical heart valve
OR
-in presence of moderate to severe mitral stenosis

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6
Q

Afib

HATCH represents higher occurrence of Afib and higher risk of stroke

What does HATCH stand for?

A

A higher HATCH score correlates with higher occurrence of AF and a higher risk for stroke.

Hypertension
Age > 75 years
TIA previously or Stroke
COPD
Heart Failure
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7
Q

Afib

associated comorbidities?

A

Comorbidities:

  • HTN
  • DM2
  • hx of MI
  • valvular heart disease
  • OSA
  • obesity
  • HF
  • diastolic dysfunction
  • CAD
  • parenchymal lung disease

From weekly note: COPD is an independent predictor for major adverse cardiac events, and also for incidence of AFib

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8
Q

Afib

counselling for modifiable risk factors?

Modifiable risk factors:
ETOH: 
Smoking: 
Exercise: 
	• moderate intensity aerobic exercise 
	• Resistance exercise 
	• Flexibility exercise
Sleep Apnea: 
Weight: 
Diabetes: 
BP:
A

Modifiable risk factors:
ETOH: 0-1 drinks/day
Smoking: goal of abstinence
Exercise:
• moderate intensity aerobic exercise 30 min/day x 3-5 days/week (target >200 min/week)
• Resistance exercise 2-3 days/week
• Flexibility exercise 10 min per day 2 days/week if 65 and older
Sleep Apnea: CPAP if moderate OSA
Weight: weight loss >10% to keep BMI <27
Diabetes: target A1C 7.0% and under
BP: Target 130/80 or under at rest, 200/100 or under with peak exercise

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9
Q

Afib

Describe opportunistic screening

A

In adults 65+ at every medical encounter

Pulse-based:
-check pulse and BP

OR

Rhythm-based:
-single lead ECG

if afib suspected –> 12 lead

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10
Q

Afib

beta blockers

  • side effects?
  • contraindications?
A

Beta blockers

side effects: bradycardia, hypotension, fatigue, depression

CI: pre-excitation, bronchospasm

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11
Q

Afib

ND-CCB
eg diltiazem, verapamil

A

side effects: bradycardia, hypotension

verapamil: constipation
diltiazem: edema

CI: pre-excitation, CHF, LV dysfunction

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12
Q

Afib

CHADS

A 
CHF +1
HTN +1
Age > 65 +1
DM +1 
Stroke +2

if CHADS>1 or age 65 –> anticoagulate

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13
Q

Afib

CHA2DS2-VASC

A 
CHF (1)
HTN (1)
Age 75+ (2 points)
DM (1)
Stroke/TIA/TE (2 points)
Vascular disease (prior MI, PAD) (1)
Age 65-74 (1)
Sex (1 if female)
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14
Q

Afib

HASBLED

A 
HTN
Abnormal renal or liver function (1 point each)
Stroke
Bleeding
Labile INR
Elderly (65+)
Drug or alcohol (1 point each)

HTN = SBP >160
Abnormal renal: Cr >200
Abnormal liver: 2-3xULN
Labile INR = <60% time in therapeutic range
Drug = concurrent use of antiplatelet/ASA/NSAID

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15
Q

HF

presenting symptoms on history

in geriatrics?

A 
dyspnea at rest or with exertion (decreased exercise tolerance)
orthopnea
PND
palpitations
lower extremity edema
abdo distension
fatigue
weight gain

geriatrics:

  • worsening fatigue
  • decreased functional capacity
  • delirium/confusion
  • anorexia, nausea, abdo bloating
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16
Q

HF

what is the best way to assess volume status?

A

elevated JVP = fluid overload

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17
Q

Heart sounds in HF

extra heart sounds?

A

S3: L ventricular volume overload

  • systolic dysfunction
  • uncommon in HFpEF

S4: increased stiffness of L ventricle
*can be present with or without HF

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18
Q

Lower extremity edema can be sign of HF

other DDx?

A
  • meds (esp CCB)
  • venous insufficiency
  • kidney disease
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19
Q

HF

what will CXR show?

A

CXR: enlarged heart, perivascular edema, pulmonary edema

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20
Q

HF

initial workup if suspected on clinical history or physical exam?

A

CXR
ECG
Labs: CBC, ferritin, lytes, renal, U/A, glucose, TSH, troponin

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21
Q

True or false

BNP, NT pro-BNP and troponin are renally excreted and can be elevated in renal disease without overt HF or acute ischemia

A

true

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22
Q

Etiology of HF

FAILURES

A 
F: Forget to take medications
A: Arrhythmias, Anemia
I: Infection, Ischemia, Infarction
L: Lifestyle changes
U: Upregulators (thyroid, pregnancy)
R: Rheumatic heart disease and other valvular disease
E: Embolism
S: Stress (surgery)
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23
Q

BNP can be elevated in what other non-cardiac causes?

A

Conditions associated with elevated BNP other than CHF are as follows:

Acute renal failure and chronic renal failure

Hypertension (HTN)

Pulmonary diseases such as pulmonary hypertension, severe chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary embolism, adult respiratory distress syndrome (ARDS)

Cardiac causes -Myocardial infarction, atrial fibrillation, acute coronary syndrome, cardioversion, valvular heart disease, myocarditis

Older age

Female sex

Liver cirrhosis

Hyperthyroidism

Sepsis

Chemotherapy

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24
Q

common side effects with ACE-I?

A
  • postural hypotension
  • renal insufficiency
  • HYPERkalemia
  • dry cough (d/t bradykinin and substance P)
  • angioedema
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25
Q

why is cough and angioedema less common in ARB compared with ACE-I?

A

no effect on bradykinin

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26
Q

what are some contraindications with Beta blockers?

A

bradycardia, hypotension, severe lung disease, and or bronchospasm, acute decompensated HF

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27
Q

Mineralocorticoid receptor antagonists (MRA)

eg spironolactone

MOA?
Side effects?

A

MOA: blocks action of aldosterone (which acts to retain Na and water)
-aldosterone is UPREGULATED in HF

S/E:

  • hypotension
  • HYPERkalemia
  • worsening renal function
  • gynecomastia
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28
Q

HFpEF

-first line?
uj

A

first line: diuresis to decrease pulmonary congestion and venous pressures
**avoid overdiuresis* HFpEF patients are pre-load dependent to maintain cardiac output

BP and afib need to be adequately controlled

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29
Q

HF

risk factors?

A
  • HTN
  • Heart disease (ischemic or valvular)
  • DM
  • ETOH or substance use
  • Chemo or radiation
  • Family hx cardiomyopathy
  • Smoking
  • Hyperlipidemia
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30
Q

HF patient teaching

-warning signs

A

warning signs:

  • SOB with decreased tolerance, PND, orthopnea
  • SOB at rest
  • increased abdo swelling, pedal/leg edema
  • weight gain (>2 kg/2 days)
  • lightheaded/faint
  • palpitations
  • chest pain
  • confusion
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31
Q

HF patient teaching

lifestyle and risk factor management

A

HTN and DM: control
Smoking: stop
Obesity
Immunizations: flu, pneumococcal

DIET: Na restrict 2-3g/day
Daily weight if fluid retention

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32
Q

SGLT2 inhibitor

MOA

A

SGLT2 is transporter that REABSORBS glucose in renal tubules

SGLT2-I:

  • decrease reabsorption of glucose (increases excretion of glucose)
  • decrease reabsorption of sodium (osmotic diuresis, reduces SBP)
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33
Q

Standard therapies for HFrEF: symptomatic with LVEF <40%

A

ACEi/ARB –> ARNI
Beta blocker
MRA (spironolactone)
SGLT2 inhibitor

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34
Q

What is the most common micronutrient deficiency in older adults?

what is the most common cause?

A

IDA secondary to GI bleeding: older adults more likely to be on antiplatelets and anticoagulants
Primary GI disease: older adults more likely to have cancer, diverticulitis, gastritis

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35
Q

What are two potential causes of B12 deficiency in older adults?

A

use of PPIs

H pylori infection

36
Q

anemia from chronic inflammation

most common causes?

A

advanced cancer
infection
autoimmune diseases

other implicated chronic conditions: DM, CHF, obesity

*severity of anemia does not correlate with severity or progression of chronic underlying condition

37
Q

unexplained anemia of the elderly

etiology?

A 
1/3 of anemia in older adults
	• Not attributable to other causes
	• Typically mild (Hb 100-120), normocytic, low reticulocyte
	• Often multifactorial etiology
	• Declining testosterone
	• Decline in renal function and serum EPO
	• Occult chronic inflammation
	• Occult myelodysplasia
Monitor for progression to malignancy
38
Q

multiple myeloma

CRAB

A 
Calcium high (hypercalcemia)
Renal Failure (elevated creatinine and proteinuria)
Anemia
Bone Disease (bone pain)
39
Q

Iron deficiency anemia

Characteristics seen on labwork

A

microcytic anemia
hypochromic
decreased ferritin

*may be normocytic in early stages

40
Q

iron deficiency anemia

signs and symptoms:

A
  • fatigue
  • cold intolerance
  • headaches
  • restless legs
  • irritability/depression
  • nail changes (spoon nails)
  • angular cheilitis
  • pica
  • decreased aerobic work performance
  • hair loss
  • impaired immune system
41
Q

iron deficiency

cut off ranges

  • normal healthy adult?
  • chronic inflammatory condition
  • elderly
A

ferritin <30

<70-100 in chronic inflammatory conditions

<50 in elderly

42
Q

iron deficiency anemia

what to do if elevated ferritin?

A

ferritin is active phase reactant

-check CRP to see ferritin is elevated due to chronic disease, active inflammation or malignancy

43
Q

iron deficiency anemia

history?

A
  • diet
  • GTPAL if female
  • hx blood loss: GIB, hematuria, menorrhagia, blood donation
  • GI symptoms: change in bowel habits, abdo pain, dyspepsia, unexplained weight loss

Fam hx colorectal cancer

44
Q

what is the target ferritin for IDA?

A

target >100 ug/L

therapeutic range 100-200 mg elemental iron/day

45
Q

if CBC comes back with microcytic anemia, what is the next step?

A

check ferritin

  • do not treat with supplementation unless ferritin is confirmed to be low
  • low MCV and normal ferritin is seen in hemoglobinopathies
46
Q

Iron deficiency anemia

when to recheck CBC and ferritin?

A

check CBC in 2-4 weeks if moderate to severe anemia

Check CBC and ferritin in 3-6 months

47
Q

duration of treatment for IDA?

A

continue iron for 4-6 months after correction to replenish Fe stores

*may take 6 months

48
Q

PO iron supplement

patient counselling

A

Therapeutic dose range 100-200 mg elemental iron/day (consider lower dose for elderly)
Side effects: nausea, vomiting, dyspepsia, constipation, diarrhea, dark stools
Start at low dose, increase after 4-5 days
Take on empty stomach with vit C to increase absorption, but may have better tolerance if taken with food
Alternate day dosing
Avoid taking with multivit, calcium, antacid, tea, coffee, milk

49
Q

B12 deficiency

Etiology / risk factors

A

Dietary deficiency rare unless long term vegans
Food-bound cobalamin malabsorption in 20-40% of adults 60+ years old
• Lack of gastric acid
• H pylori infection
Long term rx: H2 blocker, PPI, metformin
Gastric resection
Pernicious anemia (autoimmune destruction of parietal cells, no IF)

50
Q

B12 deficiency is tied to long term use of which medications?

A

H2 receptor antagonists or PPI (12 months)

metformin (4 months)

51
Q

Sequelae of B12 deficiency

A

Megaloblastic anemia
Neuro symptoms: paresthesia, numbness, motor, memory/cognitive/personality change
neuro symptoms may be irreversible, early treatment is key*

52
Q

what is amaurosis fugax?

A

transient monocular vision loss

  • *Harbinger of stroke**red flag
  • *result of occlusion/internal carotid artery
  • *painless, unilateral
  • transient - 2 to 30 minutes
  • full or partial curtain/darkening
53
Q

Risk factors for carotid stenosis?

A

**TIA, stroke or amaurosis fugax in last 3 months

HTN
smoking
DM
CVD
CAD
dsylipidemia
age
54
Q

Medical management of carotid stenosis

A 
management of comorbidities:
HTN
DM
lipids
**high potency statin regardless of cholesterol level
ASA/clopidogrel

Smoking
Diet

55
Q

AAA

risk factors

A 
RISK FACTORS:
	• Smoking
	• Advanced age
	• CAD,
	• Atherosclerosis
	• High cholesterol
	• HTN
	• First-degree relative affected
	• Male gender
RISK FACTORS FOR EXPANSION:
	• Advanced age
	• Severe cardiac disease
	• Prior stroke
	• Tobacco use
RISK FACTORS FOR RUPTURE:
	• Female
	• Large initial diameter
	• Low FEV1
	• Current smoking
	• Elevated mean blood pressure
56
Q

Peripheral artery disease

symptoms

A
  • cramping/claudication in calves
  • claudication distance: pain with ambulation within known distance (2-3 blocks)
  • relieved within 5-10 min of rest
57
Q

Peripheral artery disease

physical exam

A

arterial ischemia lesions:

  • toes or distal foot
  • tend to be painful
  • loss of hair on toes and distal ankles

pedal pulses

58
Q

peripheral artery disease

diagnostic test?

A

doppler ABI

ankle brachial index

59
Q

peripheral artery disease

red flags?

A

pain at rest or at night
gangrenous wounds
pain relieved by hanging foot from bed
*critical limb ischemia

60
Q

peripheral artery disease

ABCDEs of medical treatment

A 
A: antiplatelet (ASA, plavix)
anticoagulate (if indicated)
ACE/ARB
B: BP target SBP <140, Beta blocker
C: cholesterol (statin), LDL <2, Cessation of smoking
D: Diabetes A1C <7, Diet
E: Exercise 3x/week, 20-30 min
61
Q

3 components of Virchow’s triad of thrombosis

A

-endothelial damage (dysfunction from smoking, HTN)
(damage from surgery, PICC, trauma)

-Hypercoagulation
(hereditary - factor V leiden, protein C+S deficiency)
(acquired - cancer, chemo, OCP/HRT, pregnancy, obesity, HIT)

-Stasis
(immobility, polycythemia)

62
Q

What two factors can influence BNP?

A

age

obesity

63
Q

Risk factors for CAD?

A

Elevated blood glucose

Smoking

HTN

Hyperlipidemia

Chronic renal disease

Family history CVD

Peripheral artery disease

64
Q

symptoms of unstable angina?

A

chest pain at rest
chest pain despite decreasing level of exertion
chest pain increasing in severity or frequency
chest pain pain following myocardial infarction

dyspnea, nausea, fatigue, diaphoresis, syncope, and epigastric, shoulder, arm or neck pain

chest pain is less likely, particularly in the older adult with diabetes

65
Q

medications recommended for asymptomatic stable ischemic heart disease?

A

ANTIPLATELET

ASA 81 mg daily for secondary prevention
Alternative: clopidogrel 75 mg daily

STATIN

Myopathy often dose dependent, try another statin if intolerant of one

Recommend LDL reduction proportional to estimated CV risk (eg aggressive if high CV risk)

66
Q

medications recommended for symptomatic stable ischemic heart disease/

A 
beta blocker (caution bradyarrhythmia, advanced AV block, sick sinus)
-may worsen fatigue

ACE-I or ARB for HTN

CCB

  • if angina not controlled with BB
  • smooth muscle relaxation
  • side effect: edema, palpitations, constipation

long action nitrates

  • in combo with BB and/or CCB
  • if angina not controlled with BB and/or CCB
  • side effect: headache, hypotension, reflex tachycardia
67
Q

SPRINT trail

side effects from aggressive SBP treatment to target under SBP 120?

A

higher rate of syncope, AKI, hypotension (but not injury from falls)

68
Q

symptoms of afib?

complications?

A

Fatigue
Palpitations
SOB
Lightheadedness

Older adults; falls, delirium, syncope

May also present with tachycardia, HF or stroke

COMPLICATIONS:
4-5x increased risk of stroke

69
Q

anticoagulation in afib

indications for warfarin?
doac?

A

DOAC: non-valvular AF
-contraindicated in renal impairment (CrCl <30)

warfarin: valvular AF (if mechanical valves and/or moderate/severe mitral stenosis)

70
Q

rate control for afib

  • indications
  • class of meds?
A

resting HR >100 bpm

beta blocker
CCB (diltiazem, verapamil)

cardioversion or ablation if poorly controlled

71
Q

pill in pocket approach to afib

-indications?

A
  • if symptomatic with sustained AF episodes (eg > 2 hours) less frequently than monthly
  • absence of severe symptoms during AF episode (chest pain, fainting, breathlessness)
  • ability to follow instructions
72
Q

pill in pocket approach to afib

instructions?
when to go to ER?

A
  • take AV node blocker (diltiazem 60 mg/verapamil 80 mg/metoprolol 25 mg) 30 min after onset
  • take antiarrhythmic (flecainide or propafenone) 30 min later
  • rest supine/seated x 4 hours or until resolved
  • go to ER if

AF does not terminate within 6-8 hours

Worsening or severe symptoms

Another episode within 24 hours (can only take PIP once in 24 hours)

73
Q

main cause of right heart failure?

A

left heart failure

if pulmonary cause: cor pulmonale

74
Q

what are beta blockers not used in decompensated heart failure?

A

decreased HR

decreased contractility

75
Q

what two classes of diabetes medications improve CV outcomes?

A

SGLT2-i

GLP-1 RA

76
Q

warfarin

initiation: when to recheck INR?
how long does it take for full anticoagulant effect?

A

check in 2 days after starting, adjust

check every 2-4 days until normal range for 2 values

once stable, check INR weekly

full effect 5-7 days

77
Q

MGUS (monoclonal gammopathy of undetermined significance) is a precursor to…..

A

multiple myeloma

78
Q

ferritin level is low/normal/high in anemia of chronic disease?

A

high (acute phase reactant)

decrease in serum iron and iron-binding capacity

79
Q

etiology of microcytic anemia

TAILS

A 
thalessemia
anemia of chronic disease
IDAD
lead poisoning
sideroblastic anemia
80
Q

CLL

patho?

diagnostic hallmark?

symptoms?

A

malignant B lymphocytes

isolated lymphocytosis total WBC count> 20x 109/L, up to several hundred thousand.
**often asymptomatic
lymphadenopathy (cervical and supraclavicular most commonly), hepatosplenomegaly, and constitutional symptoms (fatigue, fevers, nights sweats, weight loss and early satiety).

81
Q

CML

diagnostic hallmark?

symptoms?
triad?

A

leukocytosis with immature granulocytes, basophilia, eosinophilia

Symptoms are non-specific and include constitutional symptoms such as fatigue, weakness, anorexia, weight loss, night sweats, a sense of abdominal fullness particularly in LUQ, gouty arthritis

triad 
tinnitus, stupor, and urticaria

82
Q

risk factors for multiple myeloma?

A 
age (60+)
race (black >> white)
sex (slight M>F)
hx of radiation
MGUS
83
Q

MGUS (monocloanl gammopathy of undetermined significance) is diagnosed by…?

A

presence of M protein in blood or urine without evidence of MM

84
Q

presence of Bence Jones protein in urine (or serum) indicates….?

A

multiple myeloma

85
Q

unexplained anemia of the elderly

microcytic/normocytic/macrocytic?

A

normocytic

usually mild (Hb 100-120), low reticulocyte count

86
Q

unexplained anemia of the elderly

how often should CBC be checked?

A

q6 months to monitor progression and underlying pathology

*watch for progression to MGUS or MM

87
Q

when should investigation of anemia NOT be pursued in elderly?

A

if life expectancy if <1 year

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