Cardio/Hema Flashcards
Initial investigations for HTN
- Urinalysis +/- ACR (urinary albumin for DM)
- Lytes (Na, K), Cr
- FBS/A1C
- cholesterol
- ECG
Optional
- Echo for suspected LV dysfunction or CAD
- beta-HCG (ACEi/ARB contraindicated in preg)
- carotid dopplers for bruits, ABI for PAOD
What are the causes of induced HTN?
Rx:
- NSAIDs
- steroids
- OCP/hormones
- decongestants
- calcineurin inhibitors (cyclosporine, tacrolimus)
- erythropoietin
- antidepressants (MAOI, SSRI, SNRI)
Exogenous substances
- cocaine
- salt
- EtOH OR EtOH withdrawal
- caffeine
- licorice root
- gingko biloba
- St. John’s wort
- sympathomimetics
Conditions
- renal insufficiency
- renovascular
- primary hyperaldosteronism
- hyperthyroidism
- Cushing disease
- pheochromocytoma
- OSA
- coarctation of aorta
Etiology of Secondary HTN
PRESSURE
P - pheochromocytoma, polycythemia, pre-eclampsia/eclampsia
R - renovascular (7%)
E - endocrine: thyroid, Cushing, hyperaldosteronism, hyperparathyroidism
S - substances: estrogen, cocaine, caffeine, EtOH withdrawal, sympathomimetics
S - coarctation, arteriosclerosis (fibromuscular dysplasia)
U - upper motor neuron problem: IICP
R - renoparenchymal: glomerulonephritis, DM
nephropathy
E - essential (90%), error in cuff size
What are the symptoms and the diagnosis of pheochromocytoma?
Sx:
- paroxysmal/severe BP > 180/110 and refractory to typical meds
- symptoms of catecholamine excess: H/A, palpitation, sweating, panic attacks, pallor
- HTN trigger by beta-blocker, MAO inhibitor
- incidentally discovered adrenal mass
Dx:
24-hour urine total metanephrine AND urinary metanephrine : Cr ratio
MRI
What are the Sx and Dx of hyperaldosteronism?
Sx:
- if K < 3.5 (if on a diuretic <3.0)
- resistance to >= 3 meds
- incidental adrenal adenoma
Dx:
- plasma aldosterone + plasma rennin activity
Sx and Dx, and management of renovascular HTN
Meets > or = 2 of the following
- sudden onset/worsening HTN < 30 y/o OR > 55 y/o
- abdominal bruit
- resistance to >= 3 meds
- elevated Cr > 30% on ACEI or ARB
- atherosclerotic disease (smoker, increased chol)
- pulmonary edema with elevated BP
Dx:
- captopril-enhanced radioisotope renal scan (eGFR >60)
- doppler
- CT-angio
- MRA (eGFR >3)
Management: Stent / angioplasty if
- uncontrolled HTN
- acute pulmonary edema
- sig decreased Cr
Sx and investigations of suspected Fibromuscular dysplasia in pt with HTN
Sx:
- resistant to >= 3 meds
- significant (> 1.5cm) unexplained renal asymmetry
- abdominal bruits w/out atherosclerosis
- FMD in another vascular territory
- Family history
Dx:
- MRA + CTA => if positive, screen cervico-cephalic/intracranial aneurysms
What are the Sx of Cushing syndrome and the Dx?
Sx:
- skin thinning, purple striae
- weight gain/fatty tissue deposits: moon facies, facial plethora, supraclavicular fat pads, buffalo hump, truncal obesity
- proximal muscle weakness
- easy bruising
- hirsutism
Dx of Cushing syndrome (one of the 4)
- Midnight serum or salivary cortisol
- 24-hour urine free cortisol (needs 24hr urine Cr to confirm adequacy)
- Low dose dexamethasone suppression test
Heart failure precipitating factors
[FAILURES]
F - forgot meds, or meds that worsen (CCB, BB, NSAIDs, TZD, chemo toxin)
A - arrhythmia/anemia: Afib, anemia
I - ischemia/ infection: worsening/new CAD, pneumonia, endocarditis
L - lifestyle: increased salt or fluid intake, alcohol
U - upregulation: pregnancy, hyperthyroidism, steroid
R - renal failure: increased preload, acute/progressing CKD
E - embolism: increased Right side afterload, PE
S - stenosis: worsening AS, RAS (renal artery stenosis)
Screening test for heart failure
BNP (natriuretic peptide) (BP> 50 pg/ml or NT-proBNP>125 pg/ml prompt referral + echo)
risk factors of HF?
demographic: older age, male, family hx of cardiomyopathy
exposure: EtOH, smoking, substances (cocaine, amphetamines), chemotherapy/radiation
medical hx: HT, obesity, dyslipidemia, IHD/CAD, DM, valvular dz
triple therapy for heart failure with reduced EF?
- ACEI/ARB
- BB
- MRA (do not add/increase if Cr>200 or K+> 5.0
How to assess PE
1) Check vitals
- if SBP<90 and stable: CTPA
- if SBP<90 and unstable: cardiac echo
2) if SBP >90: check Well’s score
- if Well’s score > 4.5: CTPA or V/Q scan
- if Well’s score < 4.5: check PERC
3) PERC negative: < 2% risk, no investigation
PERC positive: order D-dimer
4) If D-dimer negative (age adjusted): exclude PE
If D-dimer positive (age adjusted): CTPA or V/Q
What is included in PERC? (PE rule-out criteria)
Used when Well’s score =/<4
- Age < 50 y/o
- Pulse < 100
- O2 > 94%
- No unilateral leg swelling
- No hemoptysis
- No surgery or trauma in 4 weeks
- No previous VTE
- No estrogen use
How to rule out PE during pregnancy
YEAR’S RULE
1) clinical signs of DVT
- If YES, ultrasound (abnormal = anti-coagulate)
2) Hemoptysis?
3) PE most likely diagnosis?
If YES to 0 of above:
Exclude PE w/ D-dimer < 1000ng/mL
If YES to 1, 2, or 3 of above
Exclude PE with D-dimer < 500 ng/mL
