HTN, Dyslipidemia, Heart Failure Flashcards

1
Q

Hypertensive retinopathy

A
  • retinal vascular damage cused by poorly-controlled HTN

Grade1
* common in longstanding poorly controlled htn, reversible when treated
* narrowing of terminal arteriolar branches. No vision change or permanent findings

Grade2
* common in longstanding poorly controlled htn, reversible when treated
* narrowing of arterioles with severe local constriction
* no vision change or permanent findings

Grade 3
* Usually with DBP >110, implies HTN emergency
* preceding signs with flame-shapped hemorrhages
* potential for visual change and permannet retinal findings
* Complaints of dark spots in vision

Grade 4
* Usually DBP > 130, HTN emergency
* papilledema with preceding signs
* potential for visual change and permanent retinal findings (scar tissue develops)

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2
Q

1st line HTN treatment

A

JNC8 goal 140/90 for most pts (150/90 if >65)
AHA goal 130/80 for all
* Thiazide diuretic (HTZ, chlorthalidone)
* Calcium Channel Blocker (Amlodipine/diltiazem)
* ACE inhibitor or ARB (linsinopril/ losartan)
* If African american (thiazide and CCB, ACE/ARB not as effective)
* If CKD ACE/ARB

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3
Q

HTN testing with new Dx

A
  • to facilitate CVD risk profile, establish a baseline for medication use and screen for secondary causes of HTN
  • Fasting blood glucose/A1C
  • CBC
  • lipid profile
  • serum creatinine with eGFR
  • Serum sodium, potassium, calcium
  • TSH
  • urinalysis (looking for proteinuria)
  • Electrocardiogram/Echo - evaluate heart, rhythm, and chamber size
  • Urine albumin:creatinine ratio
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4
Q

Priority medications for HTN

A

Diuretic
* reduces vascualr resistance
* HCTZ, chlorthalidone (preferred)
* Na, K, Mg depleating, Ca sparing
* lower observed rate of fractures in womenwho are long-term thiazide diuretic users

ACEI (-pril suffix)
* Lisinopril, enalapril
ARB (-sartan suffix)
* Losartan, telmasartan
* reduces vascualr resistance
* K sparing, hyperkalemia risk
* ACEI - induced cough, use ARB as alternative
* ACEI <1% risk of angioedema, increased risk african, latino, hx of NSAID allergy
* priority med with DM
* Do not use with pregnancy

CCB
* decreases vascular resistance
* dihydropyridine (-ipine suffix): Amlodipine(Norvasc)
* non dihydropyridine: Diltiezem (cardizem)
* ankle edema with -ipines, usually dose dependednt
* avoid use/use with caution in presence of HF, renal or hepatic impairment

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5
Q

Secondary HTN medications

A

Beta Blocker (-lol suffix)
* Atenolol (tenoretic), metoprolol (toprol, lopressor), propranolol (inderal)
* decreases heart rate, and stroke volume
* not a 1st line med - decressed efect in select populations
* avoid non-cardioselective BB in lowe airway disease (propranolol). Lower dose cardioselective BB (metoprolol) usually acceptable if otherwise indicated (HF, difficult to control HTN)

Aldosterone antagonist
* Spironalactone (aldactone), eplerenone (Inspira)
* decresed vascular resistance
* potassium sparing diuretic
* hyperkalemia risk, particularly with ACEI/ARB use or volume depletion
* gynecomastia with prolonged use
* not a first line med

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6
Q

Hypertinsive Urgency Vs. Emergency

A

Urgency
* severe elevation in BP >180/>120
* stable without acute or impending change in HTN target organ dysfunction
* Ex. longstanding HTN who stopped or is non-adherant with HTN therapy, no lab or clinical evidence of rapidly progressing HTN TOD
* Intervention: No indication for in offce BP reduction with short acting hypertensive meds. No indication for referral to ED/hospitalization. Restart prior or intentensify standard HTN therapy

Emergency
* Severe elevation in BP >180/>120
* Evidence of impending or progressive HTN target organ dysfunction
* Ex: longstanding HTN, stopped/non-adherent to therapy, with evidence of rapidly progressing HTN TOD such as HF, pulmonary edema, high-grade HTN retinopathy, intracerebral hemorrhage
* Intervention: No indication for in offce BP reduction with short acting hypertensive meds. Immediate transfer to ED, usally with admission to ICU for parenteral antihypertensive tx.

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7
Q

Lipid Protein Profile

A
  • used for dyslipidemia screening in detection particularly in the person with CV risk (DM, HTN, family Hx, obesity)
  • TC - total cholesterol: NL <200
  • LDL-c low density lipoprotien cholesterol: NL <100
  • HDL-c High density lipoprotien cholesterol: NL > 40, >60 preferred
  • TG triglycerides: NL <150 - can be performed fasting or not, If >400 repeat fasting
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8
Q

Statin therapy reccomendations

A

absolute indications for use
* LDL-c >190: high intesity statin
* DM and age 40-75: moderate intensity or add ASCVD risk assessment for high intesity therapy
* ASCVD score >20%

other indication for use based on ASCVD score
* <5% : low risk
* >5% - <7.5%: borderline risk - if risk enhancers present may start med-intensity statin
* >7.5 - <20%: if risk enhancers present start med-intensity statin

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9
Q

Statin Therapy

A

HMG-CoA reductase inhibitor: Statin used for LDL lowering

High intensity statin
* avoid with higher risk for statin ADE such as rabdo, age>75, impaired renal function, fraility, multiple comorbids, fibrate use
* LDL-C reduction of >50%
* atorvostatin, rosuvastatin

Medium intensity statin
* preferred in high risk for ADE
* LDL-C reduction of 33%
* Atorvastatin, rosuvistatin, simvastatin, pravastatin, lovastatin

  • chek hepatic enzymes prior to initiation to establish baseline
  • caution with grapefruit juice (CYP450 3A4 inhibitor)
  • ADE: rhabdo, myositis, rare but most noted with higher dose
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10
Q

other LDL- lowering medications

A

Selective cholesterol absorption inhibitor
* Ezetimibe (Zetia)
* Lowers LDL-C up to 20%
* few adverse effects due to limited systemic absorption
* can be combined with simvastain

Protien convertase subtilisin/kexine type 9 inhibitor (PCSK9)
* Evolocumab, alirocumab
* monoclonal antibody
* lowers LDL-C >60%
* Injection only
* add on to satin for familial hypercholesterolemia and/or clinical athlerosclerosis when goal LDL cannot be met

ACL (adenosine triphosphate-citrate layse) inhibitor
* non-statin
* bempedoic acid (new drug)
* lowers LDL-C up to 33%
* adjunct to maximally-tolerated statin or ezetimbe therapy
* also used in statin intollerant

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11
Q

Triglyceride lowering agents

A

Omega 3 fatty acid by prescription
* 4g/d dose
* decrease in TG up to 30%
* adverse effect: increased risk of bleeding due to antiplatelet effect

Fibric acid dirivative (Fibrate)
* fenofibrate
* HDL increase of 20%
* TG decrease up to 50%
* Adverse effects: myopathy, including rhabdomyolysis, esp if taken with statin (do not give with satin)

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12
Q

Hypertriglyceridemia

A

TG <150
* mild 150-199
* mod 200-999
* severe 1000-1999
* mod/severe = risk for CVD
* Very severe <2000 - risk factor for CVD, acute pancreatitis

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13
Q

common causes of 2ndary hypertriglyceridemia

A
  • DM with poor glycemic ctrl
  • Untreated hypothyroidism
  • Select medication use
    1. 2nd gen atipsychotics
    2. systemic corticosteroids
    3. systemic estrogen supplements
    4. systemic retinoid

lifestyle risk factors
* High carb diet
* excessive alcohol use
* sedentary lifestyle
* obesity

condition reverable with treatmetn of underlying cause

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14
Q

Pharmacologic tx of triglyceridemia

A

TG 199-499
* treat secondary cause
* statin therapy

TG >500
* treat secondary cause
* stain therapy
* Consider TG loering therapy with Omega 3 fatty acid or fibrate therapy

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15
Q

Heart failure etiology

A
  • systolic left ventricular dysfuction (most frequent cause)
  • Diastolic LV dysfunction
  • Valvular disease
  • congenitial HD
  • pericardial disease
  • endocardial disease
  • rhythm/conduction disturbance
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16
Q

Heart failure Dx

A

Suspected
* dyspnea, fatigue, edema

Clincal Hx
* previous MI/ACE
* angina
* hypertension
* Valvualr disease/rhumatic fever
* palpitations

Clincial exam
* tachycardia
* increased JVP
* displaced apex beat
* S3 heart sound
* Murmur
* pulmonary crackles
* dependednt edema

Investigation directed by clinical presentation
* ECG
* CXR
* Echo
* Hemoglobin
* Blood chem
* Thyroid function

17
Q

Stage A
at risk for HF

A
  • at risk - get Bnp and use validated HF risk score

Conditions that increase risk
* HTN - control BP
* T2DM and CVD or high risk of CVD - SGLT2-I treatmetn (-gliflozin suffix) - dapagliflozin
* CVD - optimixe management
* Cardiotoxic exposure - multidiciplanary management
* 1st degree relative with genetic cardiomyopathy - genetic screen

18
Q

Pre-Heart Failure
Stage B

A
  • cardiology consult
  • LVEF <40% with or without HX of MI/ACS - ACEI and Beta-blocker
  • Recent MI or ACS - statin therapy
  • LVEF <30% - implantable cardiodefibrilator
  • nonischemic cardiomyopathy - genetic testing
19
Q

Pysiologic Murmur

A
  • GR1-3/6 early to mid systoloc murmur
  • heard best at LSB but usualy audible over pericordium
  • No radiation beyond pericordium
  • softens or diapperas with standing
  • increases with activity, fever, anemia
  • S1, S2 intact, normal PMI
  • Asymptomatic
  • possibly heard in 80% of thin healthy adults
20
Q

Aortic stenosis

A

*difficulty opening valve
* G1-4/6 harsh systolic murmur
* cresendo-decrescendo pattern
* heard best at 2nd RICS, apex, softens with standing
* radiates to coarotid, may have deminshed S2, slow filling carotid pulse, narrow pulse pressure
* Loud S4, heaving PMI
* in younger adults: congenital bicuspid valve
* In older: calcific rheumatic in nature
* Dizziness, syncope, ominous signs, pointing to severly decreased CO

21
Q

Aortic sclerosis

A
  • Gr 1-4/6 harsh sytolic ejection murmur
  • heard best at 2nd RICS
  • No S4, absence of symtoms
  • Benign thickeneing and/or clacification of aortic valve leaflets
  • no change in valve pressure
  • “50 over 50” - found in 50% of people over 50
22
Q

Aortic Regurgitation

A

*problem with valve closing
* G1-3/4 high pitched blowing diastolic murmur
* heard best at 3rd LICS
* may be enhanced by forced expiration, leaninf forward
* Usually with S3, wide pulse pressure, sustained thrusing apical impulse
* more common in men - rheumatic heart disease, tertiary syphilis

23
Q

Mitral stenosis

A
  • Left AV valve
  • Grade 1-3/4 low pitched late diastolic murmur, heard best at apex, localized
  • short crescendo-decrescendo rumble, like a bowling ball rolling
  • often with opening snap, accentuated S1 in mitral area
  • enhanced by left lateral decubutis position, squat cough, immediately post valsalva
  • nearly all rhumatic in origin
  • protracted latency period then gradual decrease in exercise tolerance leading to rapid downhill course due to low CO
  • Afib common
24
Q

Uncorrected Atrial septal defect

A
  • G1-3/6 systoloc ejection murmur at pulmonic area
  • widely split s2, right vericular heave
  • typically without symptoms until middle age, then presenting with HF
25
Q

Pulmonary HTN

A
  • Narrow splitting S2, murmur of tricuspid regurgitation (right AV valve)
  • report of SOB nearly universal
  • Seen with RVH, RAH as identified by ECG, echo
26
Q

Mitral regurgitation

A
  • left AV valve
  • Grade 1-4/6 high pitched blowing systolic murmur, often extending beyon S2
  • sounds like long “haa”, “Hoo”
  • heard best at RLSB
  • radiates to axilla, often with laterally displaced PMI
  • decreased with valsalva manuver
  • increased by squat, hand grip
  • found in ischemic HD, endocarditis, RHD, often with other valve abnormalities
27
Q

Mitral Valve prolapse

A
  • Grade 1-3/6 late systoloc crescendo murmur with honking quality
  • heard best at apex
  • murmur follow mid systolic click
  • with valsalva or standing, click moves forward into earlier systole, resulting in longer sounding murmur
  • with hand grasp, squat, click moves back resulting in shourter murmur
  • often seen with minor thoracic deformities
28
Q

Conditions for dental procedure ABX endocarditis prophylaxis

A
  • prosthetic cardiac valve replacement with. prosthetic material
  • Previous endocarditis
  • Unrepaired cyanotic congenital heard disease, including paliative shunts nd conduits
  • Completely repaired congenital heard defect with prosthetic material/device during the 1st 6 months after surgery
  • repaired congenital heart disease with residual defects at the site or adjacent to the site repaired with prosthetic material
  • cardiac transplant where cariac valvulopathy has developed.
29
Q

ABx for prevention of endocarditis with dental, oral, respritory or esopogeal procedures

A
  • give once 30-60 min prior to procedure
  • Amoxiicillin 2 g po

unable to take orals
* ampicillin 2g IM/IV
* cefazolin/ceftriaxone IM/IV

if pen allergy
* cephalexin
* doxycycline
* azthromycin/clarithromycin

if pen allergry and can’t take po
cefazolin/ceftriaxone IM/IV