Wk 6: Cardio + pulmonary Flashcards
Karl, a 20-year-old otherwise healthy male, presents to your primary care clinic for an annual well visit. As part of his routine physical, you check his blood pressure and BMI, and order some screening labs, including a fasting serum lipid profile, shown below.
How should you counsel the patient regarding his lipid profile results?
a) “Your lipid tests look great! You are healthy as a horse.”
b) “It would be best for your long-term health if you can increase your LDL-C and lower your HDL-C.”
c) “We need to talk about some lifestyle and possibly medication options to help bring all four of your lipid profile values back within normal ranges.”
d) “Your triglycerides are so high you could develop pancreatitis at any moment!”
c) “We need to talk about some lifestyle and possibly medication options to help bring all four of your lipid profile values back within normal ranges.”
1) What do cholesterol + triglycerides equal?
2) What do lipoproteins do?
3) What do lipoproteins include?
1) Important lipids (fatty substances) in blood, lymph, CSF, and extracellular fluid
2) Transport cholesterol and triglycerides throughout these fluids and into cells (lipids by themselves are insoluble in plasma)
3) HDL, IDL, LDL, VLDL, lipoprotein(a), chylomicrons
1) What are Apolipoproteins (apo)?
2) What is their importance?
3) Where can plaques form and what can they lead to?
1) Proteins that bind lipids to form lipoproteins
2) Lipoproteins and apolipoproteins are an accurate predictor of atherosclerotic cardiovascular disease (ASCVD)*
3) In blood vessels; can occlude the vessels or embolize leading to CVA/MI
List 4 things included in a lipid profile
1) Total cholesterol (TC)
2) Triglycerides (TGs)
3) High-Density Lipoprotein Cholesterol (HDL-C)
4) Low-Density Lipoprotein Cholesterol (LDL-C)
Lipid profile:
1) When is it ideally drawn?
2) What do reference ranges depend on?
3) What is it used for?
4) What can specific tests of lipid profiles be used for?
1) When pt is fasting
2) Age and sex
3) Help ID pts at risk of ASCVD
4) To calculate future ASCVD risk and guide medication selection/management
What is a desirable cholesterol value? Why?
<200 mg/dL; lower ASCVD risk
Cholesterol is a steroid lipid carried as a lipoprotein (bound to LDLs, HDLs, etc.). What 4 things is it needed for?
1) Cell membranes
2) Bile acids
3) Hormones
4) Gluco/mineralocorticoids
1) What are the sources of cholesterol?
2) How do you calculate total cholesterol?
1) Liver produces cholesterol; levels can also be increased through dietary intake (e.g., oral animal products)
2) Total cholesterol = HDL-C + LDL-C + 20% of triglyceride level
High Density Lipoprotein Cholesterol (HDL-C):
1) Is this good or bad cholesterol?
2) What does it do?
3) What are high levels associated with?
4) What can raise levels?
1) “Good cholesterol”
2) HDL removes lipids from endothelium and carries excess cholesterol to liver for elimination
3) High levels (>60 mg/dL) are protective
4) Exercise, weight loss (if overweight), smoking cessation, and substitution of monounsaturated for saturated fatty acids
1) Low levels of HDL-C associated with increased ASCVD risk; what is considered “low”?
2) What do low levels often occur in association with?
1) Females: <50 mg/dL
Males: <40 mg/dL
2) Hypertriglyceridemia
Low Density Lipoprotein Cholesterol (LDL-C):
1) Is this good or bad cholesterol?
2) Where is most cholesterol carried by it taken?
3) What are high levels associated with?
4) What is a normal value?
1) “Bad cholesterol”
2) Most cholesterol carried by LDL is deposited into the lining of blood vessels
Atherogenic (promotes vessel plaque formation)
3) Increased ASCVD risk
4) “Normal” value is <130 mg/dL; however, the lower the better to reduce ASCVD risk
Low Density Lipoprotein Cholesterol (LDL-C):
1) What are the goal values in avg and high risk patients?
2) Where does the value come from? Explain the accuracy
1) <100 mg/dL in normal risk patients
<70 mg/dL in high-risk patients
2) Often a calculated value based on formulas using other lipid profile values (sometimes directly measured)
-High triglyceride levels (e.g., ≥400 mg/dL) can make LDL calculations inaccurate
Triglycerides (TGs):
1) What is it?
2) What carries it?
3) What happens to extra TGs?
1) Form of fat in the bloodstream (storage source for energy), produced by liver
2) VLDLs and LDLs
3) Deposited as droplets in adipose tissue
Triglycerides (TGs):
1) What is the goal dose?
2) What can cause acute pancreatitis?
1) <150 mg/dL
2) Severe hypertriglyceridemia (>500 mg/dL)
1) Sum up the good lab values (lower ASCVD risk)
2) Sum up the (higher ASCVD risk)
1) High HDL-C; low TC, TGs, LDL-C; low TC:HDL ratio; low non-HDL cholesterol
2) Low HDL-C; high TC, TGs, LDL-C; high TC:HDL ratio; high non-HDL cholesterol
List the approximate desirable values for most pts (mg/dL):
1) Total cholesterol
2) Triglycerides
3) LDL-C
4) HDL-C
1) Total cholesterol: <200
2) Triglycerides: <150
3) LDL-C: <100
4) HDL-C: >60
Cardiac Enzymes (Cardiac Biomarkers):
1) When are they released into blood?
2) What are they used to assess?
3) What are some also used for?
1) When heart is damaged
2) Acute coronary syndromes (ACS)/cardiac ischemia
3) In diagnosis of skeletal muscle disease/injury
What 3 things are included in cardiac enzymes/ biomarkers?
1) Creatine (phospho)kinase (CK, CPK)
2) Myoglobin
3) Troponins
1) High serum CK is indicative of what?
2) What has highest concentration of CK?
3) CK is most commonly used to do what?
1) Release from damage to CK-rich tissue
2) Skeletal muscle
3) Diagnose and follow muscle disease/injury
Creatine Kinase (CK):
1) What can it be measured as?
2) List each
1) Can be measured as total CK or as one of its 3 isoenzyme forms:
2) CK-MM, CK-MB, CK-BB
1) CK-MB can be used to assess for myocardial injury/AMI, but now has generally been replaced by what?
2) When can it be released?
3) When does it begin to rise? When does it peak?
4) Duration?
1) Troponins (higher sensitivity/specificity)
2) AMI or skeletal muscle injury
3) Generally begins to rise 4-6 hours after onset of MI
Peak: 12-24 hours
4) Duration: 36-48 hours (returns to normal more quickly than troponin)
What may the duration of CK-MB tell you?
May help identify infarct extension/reinfarction if levels rise again after declining (although troponin levels also rise from even an abnormal baseline in this circumstance)
Myoglobin:
1) What is it?
2) What does it tell you? When?
3) Sensitivity and specificity? Describe when it’s elevated
1) Oxygen-binding protein in cardiac and skeletal muscle
Provides early index of cardiac muscle injury/necrosis
2) Rises within 3 hours; cleared rapidly – serum levels may return to normal within 6-8 hours after release from muscle
3) More sensitive than CK-MB but not as specific
-Also elevated in skeletal muscle injury/disease: Muscular dystrophy, skeletal muscle ischemia, trauma, rhabdomyolysis, myositis, hyperthermia
Myoglobin:
1) What color is it in urine?
2) What is myoglobinuria?
1) Turns the urine red/brown (excreted in urine, nephrotoxic)
2) Positive urine dipstick for “blood” (contains heme) but no RBCs on urine sediment microscopy (not hematuria)
Myoglobin:
1) What is it?
2) What does it provide?
3) When does it rise?
4) Compare its sensitivity and specificity to CK-MB
1) Oxygen-binding protein in cardiac and skeletal muscle
2) Early index of cardiac muscle injury/necrosis
3) Within 3 hours
4) More sensitive than CK-MB but not as specific
1) What are the 2 cardiac specific troponins (cTn)?
2) What are they used for?
3) What are they preferred for?
1) troponin T (TnT) and troponin I (TnI)
2) To assess myocardial injury
3) The preferred blood-based tests for evaluation of patients with suspected AMI
Troponins have several advantages over CK-MB in AMI diagnosis, list 3
1) Extremely specific (more than CK-MB) for myocardial cell injury
2) More sensitive
3) Becomes elevated sooner and lasts longer
-Increased window for diagnosis
List and describe the 2 common troponin tests
1) “Sensitive”/“contemporary” assays: Rise 2-3 hours after injury
2) “High sensitivity” (hs) TnT: Newer test with increased sensitivity for cardiac myocyte necrosis
-Detects infarct as early as 90 minutes after onset
-Duration: 7-14 days
1) BNP was discovered in brain tissue but more appropriate name is what?
2) What primarily releases it and when?
3) What are its effects? Explain
1) Ventricular natriuretic peptide
2) Released primarily by ventricular myocytes when stretch receptors are triggered
3) Effects include increased diuresis, natriuresis, and vascular smooth muscle relaxation (vasodilation)
-Negative feedback loop, decreases pressure in the ventricles
1) What are the 2 ways BNP may be measured?
2) What may cause it to be increased?
1) May be measured as plasma BNP or N-terminal (NT)-рrοΒΝΡ
2) Too much pressure in the ventricles (especially left)
B-Type Natriuretic Peptide (BNP) & NT-proBNP:
1) Useful as part of the evaluation of suspected_________________ when the diagnosis is uncertain
2) Can also provide ___________ information in pts with CHF/LV dysfunction
1) congestive heart failure (CHF)
2) prognostic
In a dyspneic (SOB) pt in whom you are trying to differentiate CHF from a respiratory cause, what can BNP tell you?
1) BNP <100 pg/mL: HF is very unlikely as the cause of dyspnea
2) Most dyspneic pt’s with HF have ΒΝΡ value >400 pg/mL
Can BNP be elevated without HF? If not, explain. If so, give an example.
Yes; can be elevated in some pts without heart failure
-ex: CKD (decreased clearance by the kidneys)
Sandra, a 25-year-old otherwise healthy female, presents to the Emergency Department complaining of severe pain diffuse to the muscles of her bilateral lower extremities that began shortly after running a marathon on a hot day.
You initiate pain medication, IV fluids, and collect some blood work and a urinalysis.
You note her urine sample is dark/tea-colored. You suspect rhabdomyolysis, which is a syndrome that causes muscle necrosis and release of contents from muscle cells into the bloodstream.
Which of the following lab tests is most likely to be elevated?
a) CK-MB
b) CK-BB
c) CK-MM
d) Troponin
e) NT-proBNP
c) CK-MM
Arthur, a 64-year-old male with history of hypertension and DM type 2 presents to the emergency department (ED) complaining of crushing chest pain radiating to his right shoulder that began 30 minutes prior to arrival while push-mowing the lawn. He reports associated shortness of breath and diaphoresis.
You are concerned for possible acute coronary syndrome/acute myocardial infarction (AMI).
Immediately upon arrival to the ED, a 12-lead ECG is performed, the patient is given aspirin, and a cardiac troponin test is sent to the lab.
The initial troponin level returns as within normal reference range. It is now 2 hours since the patient’s symptoms have started, and he is still having chest pain.
Which of the following options would be the best course of action regarding this patient’s initial troponin result?
a) Tell the patient everything is ok because the normal troponin test shows he cannot be having a heart attack (AMI), and he is safe to be discharged home.
b) Repeat the cardiac troponin test to see if the levels trend upward.
c) Order a CK-MB test to be drawn immediately as this elevates earlier than troponin in AMI.
d) Order a CK-MM as this is the most sensitive and specific lab test for AMI.
b) Repeat the cardiac troponin test to see if the levels trend upward.
A 60-year-old male with history of obesity, cigarette smoking (20 pack years), and methamphetamine abuse presents to the emergency department (ED) complaining of shortness of breath (SOB) worsening over the past several days with an associated cough and fatigue.
On exam, he is tachypneic with scattered wheezing and diffuse crackles to bilateral lung bases. Oxygen saturation is low on room air at 88%.
Which of the following lab findings would best support congestive heart failure (CHF) as the most likely cause of his acute dyspnea?
a) Cardiac Troponin I: 5.0 ng/mL
b) BNP: 50 pg/mL
c) BNP: 200 pg/mL
d) BNP: 1000 pg/mL
e) D-Dimer: 1000 ng/mL DDU
d) BNP: 1000 pg/mL
A 60-year-old male with history of obesity, cigarette smoking (20 pack years), and methamphetamine abuse presents to the emergency department (ED) complaining of shortness of breath (SOB) worsening over the past several days with an associated cough and fatigue.
On exam, he is tachypneic with scattered wheezing and diffuse crackles to bilateral lung bases. Oxygen saturation is low on room air at 88%. His lab values are:
a) Cardiac Troponin I: 5.0 ng/mL
b) BNP: 50 pg/mL
c) BNP: 200 pg/mL
d) BNP: 1000 pg/mL
e) D-Dimer: 1000 ng/mL DDU
Which of the above lab findings would best rule out congestive heart failure (CHF) as the cause of his acute dyspnea?
b) BNP: 50 pg/mL
1) What is a pleural effusion? Explain
2) What are the 2 main categories?
3) What can be used to extract pleural fluid?
1) Fluid accumulation in the pleural space
-Normally pleural fluid is continuously created and absorbed, but various fluids can accumulate (Blood, pus, serous fluid)
2) Transudative and exudative; determines DDx and subsequent evaluation
3) A thoracentesis (pleural tap)
For transudative pleural effusions, list the:
1) Physiology
2) Local Pleural Disease (i.e., underlying lung pathology)
3) Lung(s) affected
4) Most common causes
5) Typical pleural fluid analysis results
1) Due to increased hydrostatic or decreased oncotic pressures (with normal capillaries)
2) Usually absent
3) Usually bilateral (both lungs)
4) CHF, Cirrhosis (liver disease), Nephrotic syndrome (kidney disease), Hypoalbuminemia
5) Low cell/protein/LDH content, low specific gravity
For exudative pleural effusions, list the:
1) Physiology
2) Local Pleural Disease (i.e., underlying lung pathology)
3) Lung(s) affected
4) Most common causes
5) Typical pleural fluid analysis results
1) Due to increased capillary permeability (e.g., pneumonia, tumors) or impaired lymphatic drainage (e.g., sarcoidosis)
2) Usually present
3) Usually unilateral
4) Infection (e.g., bacterial pneumonia, TB), Inflammation, Cancer
5) High cell/protein/LDH content, high specific gravity
Pleural Fluid Analysis:
1) What should you note first?
2) What should you do next?
1) Gross appearance and odor of fluid for clues to etiology
2) Routine tests, differentiate transudate vs. exudate, +/- other tests targeted at specific etiologies (as suspected
1) List routine Pleural Fluid Tests for pts undergoing thoracentesis
2) List routine serum tests for pts undergoing thoracentesis
1) White and red cell count and differential, total protein, lactate dehydrogenase (LDН), glucose, cholesterol
+/- culture, Gram stain, and cуtоlοgу (esp. if suspecting pleural infection or malignancy)
2) Blood drawn for total protein and LDH if using Light’s criteria
Fluid is considered exudative if at least one of the Light’s criteria is present; what are they? (3)
1) Pleural fluid protein/serum protein ratio >0.5
2) Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio >0.6
3) Pleural fluid LDH level >2/3 the upper limit of the laboratory’s reference range of serum LDH
1) What is LDH?
2) Where can it be measured?
3) What is a common use?
1) LDH = lactic/lactate dehydrogenase; cytoplasmic enzyme present in tissues throughout body (highest concentration in heart, muscle, kidney, lung, and RBCs)
2) Can be measured in various body fluids (e.g., serum, urine, effusion)
3) One common serum use is in evaluation of suspected hemolysis (serum LDH elevated)
You are a PA in the emergency department, and you have performed a thoracentesis on Dave, a 65-year-old male, due to pleural effusion with associated dyspnea.
You are reviewing the pleural fluid analysis and serum lab results, shown here. Normal reference ranges are provided in parentheses.
Total Protein: 3.0 g/dL
LDH: 170 units/L
Serum (blood) tests:
Total Protein: 7.0 g/dL (6.4–8.3)
LDH: 210 units/L (80-225)
Based on Light’s Criteria, is this more likely a transudative or exudative pleural effusion? What is one common cause of this type of effusion?
a) Transudative: cirrhosis
b) Transudative: bacterial pneumonia
c) Exudative: congestive heart failure
d) Exudative: lung cancer
d) Exudative: lung cancer
