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Cardiology > Hypertension, cardiomyopathy, and congestive heart failure > Flashcards

Hypertension, cardiomyopathy, and congestive heart failure Flashcards

1
Q

hypertension

A

-Elevation of BP at 2 or more office visits after an initial screening (3 total)
-With 2 or more readings at each office visit
-If there is a disparity in category between the systolic and diastolic pressures, thehigher value*determines the stage
-normal- <120/<80
-prehypertension- 120-129/<80
-hypertension (stage 1)- 130-139/80-89
-hypertension (stage 2)- >140/>90

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2
Q

primary hypertension- essential

A

-90-95% of cases, no identifiable cause
-no treatable cause
-Hypothesized factors:
-SNS hyperactivity, abnormal renal development
-Exacerbating factors:
-Alcohol, tobacco, sedentary lifestyle
-NSAIDs
-Polycythemia vera
-Males, African American
-Diet
-Obesity

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3
Q

secondary hypertension

A

-5-10% of cases
-Causes:
-Parenchymal renal disease- Angiotensin cascade
-Renal artery stenosis- Angiotensin cascade
-Coarctation of the aorta- (hypertensive on the left)- congential abnormality
-Pheochomocytoma
-Cushing’s Syndrome
-Hypothyroidism
-Hormone use
-Obstructive sleep apnea

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4
Q

reasons to screen for secondary HTN

A

-recommendation for screening- new onset of uncontrolled hypertension- screen 2ndary HTN
-presence of drug resistant or drug induced HTN
-abrupt onset of HTN
-onset of HTN in young person <30
-exacerbation of previously controlled HTN
-disproportionate target organ damage for the degree of HTN
-accelerated or malignant HTN
-onset of diastolic HTN in older adults >65
-unprovoked or excessive hypokalemia

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5
Q

hypertension complications

A

-Cardiovascular:
-Coronary artery disease
-heart failure
-valvular disease
-left ventricular hypertrophy
-aortic aneurysm/dissection
-peripheral vascular disease

-Nephro- Renal sclerosis

-Neuro:
-TIA
-CVA- for every 10mmgh of mercury lower stroke risk by 25%
-encephalopathy
-aneurysms

-Optic:
-Retinopathy
-retinal hemorrhage
-blindness

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6
Q

hypertension initial testing

A

-12 lead EKG: Left ventricular hypertension (LVH)

-Labs: Rule out secondary causes:
-Potassium, blood glucose (diabetes), creatinine, BUN, aldactone, etc.:
-Pheochromocytoma- 24 hour urinary metanepharine and normetanephrine
-Thyroid and parathyroid disease- TSH, T3/T4, serum PTH
-Primary aldosteronism- 24 hour urinary aldosterone level

-Lipid profile- Atherosclerosis risk

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7
Q

echocardiogram

A

-2-D echocardiogram (Transthoracic):
-Ultrasound technology allowing to view cardiac structures including atria, ventricles, and valves
-Ejection fraction = percentage of blood ejected from left ventricle
-Normal: 55%
-Low normal: 50-55%
-Low: 45% and less

-Transesophageal echocardiogram (TEE):
-Ultrasound technology through esophagus allowing better visualization of the mitral valve and left atrium
-Left atrial appendage thrombus*
-Mitral regurgitation
-best way to see aortic and mitral valve

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8
Q

hypertension tx

A

-Goal BP:
-DM or CKD < 130/80
-All others <140/90

-Lifestyle management:
-2. Dietary Approach to Stopping Hypertension (DASH diet)- Low salt, low saturated fat, increasing fruits and vegetables
-3. Aerobic exercise- 30 mins or more, 5 days or more
-1. Weight loss- BMI 18.5-24.9
-Smoking cessation**
-4. Limitation of alcohol consumption- 2 or less drinks daily for men, 1 or less drinks daily for women
-<2000mg salt for low salt diet

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9
Q

hypertension: pharm modifications

A

-DM, CKD, and patient without comorbidities who have failed non-pharmacologic modifications
-Diuretics are first-line for all pt w/o comorbidities (hydrochlorothiazide) ****
-diabetes mellitus- ACE inhibitors (-prils) or ARB
-chronic kidney disease- ACE inhibitors or ARB
-coronary artery disease (post-MI)- beta blocker, ACE inhibitors or ARB
-cerebral vascular disease- ACE inhibitors or ARB
-heart failure- beta-blockers, ACE inhibitors or ARV, diuretics

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10
Q

Angiotensin 2 receptor (ARB)

A

-sartan
-vasodilation by inhibiting activation of angiotensin 2 receptor
-decrease preload/afterload
-ADR- hyperkalemia, cough (less common), angioedema, renal impairment

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11
Q

ACE inhibitors

A

-prils
-vasodilation by inhibiting angiotensin-converting enzyme
-decrease preload/afterload
-category X in preg
-ADR- hyperkalemia**, cough, angioedema (mouth and lips), renal impairment

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12
Q

beta blockers

A

-olol
-antagonists
-block receptor sites of epinephrine and norepinephrine on adrenergic beta receptors
-ADR- bronchospasm**, hypotension, fatigue (normal for 2 weeks), bradycardia -> if bronchospams try a selective

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13
Q

calcium channel blockers

A

-decrease smooth muscle contraction and cardiac monocyte contraction by blocking calcium entry
-non-dihydropyridine have less vasodilation, selective to myocardium
-can cause dizziness when you stand - ask
-ADR- peripheral edema**, fatigue, hypotension, muscle cramps (K shift)

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14
Q

diuretics

A

-increase sodium excretion
-increasing water extrication
-HCTZ- thiazide
-flurosemide- loop
-ADR- hypokalemia, hypochloremia, hypotension, pancreatitis, renal failure

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15
Q

alpha blockers

A

-block alpha receptors in smooth muscle causing vasodilation
-only use when they are on meds and cant get BP down
-ADR- orthostatic hypotension**, dizziness, somnolence, headache

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16
Q

meds to avoid with comorbities

A

-chronic kidney disease (stage 3, 4)- ACE inhibitors or ARB
-hyperkalemia- ACE inhibitors or ARB, aldosterone antagonist
-hyponatremia- thiazide diuretics
-asthma- beta blockers
-gout- thiazide and loop diuretics (first toe pain)
-angioedema- ACE inhibitors
-2nd/3rd degree heart blocks, bradycardia- beta blockers, non-dihydropyridine calcium channel blockers

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17
Q

hypertensive urgency

A

-Blood pressure reading of systolic BP>180 mmHg and/or diastolic BP >120 mmHg WITHOUT evidence of end organ damage
-Management:
-Gradual reduction of mean arterial pressure- Reduction should be no more than 25% over 24-48 hour period
-Use of oral medications for treatment goal of less of equal to 160/100 mmHg:
-Beta-blocker – Labetolol
-Nicardipine – Calcium cannel blocker
-Captopril – ACE inhibitor

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18
Q

hypertensive emergency

A

-Blood pressure reading of systolic BP >220/or diastolic BP >120 with end-organ damage
-Required immediate reduction of BP**
-End-organ damage:
-Papilledema
-Intracranial hemorrhage
-Encephalopathy
-Renal failure
-Unstable angina (w/o exertion), myocardial infarction, -CHF, aortic dissection
-Pulmonary edema

-End-organ damage may not be reversible

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19
Q

causes of hypertensive emergency

A

-Noncompliance
-Renal artery stenosis
-Hyperaldosteronism
-Cushing’s syndrome
-Eclampsia
-Vasculitis
-Polycystic kidney disease
-Illicit drug use
-Alcohol withdrawal

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20
Q

hypertensive emergency tx

A

-Reduce mean arterial pressure (MAP) by 25% in 1-2hrs
-MAP = average blood pressure during a single cardiac cycle:
-Cardiac output
-systemic vascular resistance
-central venous pressure “preload”
-Quick reduction of BP can lead to ischemic CVA**
-IV agents:
-Esmolol, Labetolol
-Hydralazine
-Nitroglycerine
-Nitroprusside

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21
Q

white coat hypertension

A

-consistently elevated office blood pressure readings with out of office readings that do not meet criteria for hypertension
-Difficult to differentiate
-Increased risk of developing hypertension
-Ambulatory and home blood pressure monitoring

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22
Q

hypotension

A

-Systolic BP < 90 mm Hg and/or diastolic BP < 60 mm Hg
-Significant if symptoms are present

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23
Q

causes of hypotension

A

-Medications:
-Beta-blockers
-Alpha-blockers
-Calcium channel blockers
-Nitrates

-Hypovolemia:
-Blood loss
-Excessive diuretic use
-Dehydration
-Anemia

-Low CO:
-Myocardial infarction
-Bradycardia
-Heart failure

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24
Q

hypotension symptoms

A

-Dizziness/lightheadedness
-if they are getting up fast or bending down and getting lightheaded -> not vasoconstricting enough to compensate when they move quick -> are they on a vasodilator?
-Fatigue
-Weakness
-Syncope
-Shortness of breath
-Exertion dyspnea
-Chest pain
-Palpitations
-Headache
-Cough- compensation to increase preload
-Seizures- no blood flow to brain

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25
Q

orthostatic hypotension

A

-Decrease in BP >20 mm Hg systolic or >10 mm Hg diastolic from supine and sitting/standing

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26
Q

causes of orthostatic hypotension

A

-Cardiac Arrhythmias
-Dehydration*
-vasovagal- no adjustment
-Medications:
-Alpha-blockers: Terazosin, tamsulosin, doxazosin -> vasodilators!
-Diuretics: Flurosemide, hydrochlorathiazide
-Nacrotics: Morphine
-MAOIs: Rasagiline
-TIAs: amitriptyline

-Neurogenic
-Parkinson’s
-Diabetes

-Endocrine disorders
-Hypoaldosterosterism
-Hypothyroidism

-Anemia

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27
Q

orthostatic hypotension dx and tx

A

-dx- blood pressure measurements -> lying, sitting, standing
-tx:
-you need to change management/meds -> falls are just as bad as HTN
-Conservative management
-Increase oral hydration
-Increase salt intake
-Slow positional changes- pump legs before you stand -> muscular pump
-Compression stockings
-Exercise
-Treat underlying cause

-Medications:
-Fludrocortisone- glucocorticosteroid
-Midodrine- alpha agonist (dont give to HTN pt)
-Droxidopa (dont need to know)

28
Q

cardiogenic shock - bp

A

-Cardiovascular failure due to lack of or loss of tissue perfusion
-End-organ tissue perfusion
-Hypotension refractory to volume resuscitation
-Systolic BP < 90 mm Hg with urine output < 20mL/hr

29
Q

cardiogenic shock causes

A

-Acute MI - MC cause**
-Cardiac tamponade
-Pneumothorax
-Arrhythmias
-PE
-Cardiomyopathies
-Heart failure
-Cardiac contusion
-Valvular and septal abnormalities

30
Q

features of cardiogenic shock

A

-Hypotension!
-Tachycardia!
-Cool extremities- organs not perfused
-Altered mental status!
-Oliguria/anuria!
-Decreased capillary refill
-Weak peripheral pulses
-Jugular venous distension- volume overload or right HF
-Pulmonary congestion

31
Q

cardiogenic shock tx

A

-First step for all patient with shock = ABCs
-Airway, breathing, circulation- 2 large bore needles, central line arterial line

-Vasopressors: positive ionotropic agents
-Dopamine
-Dobutamine
-Norepinephrine*

-Intra-aortic balloon pump
-ecmo
-Identify and treat underlying cause

-Acute MI:
-Aspirin, heparin, nitrates, etc
-Emergent revascularization – coronary angiogram
-bypass, stent

-Cardiac tamponade- Pericardiocentisis, pericardial window

-Arrhythmias: ACLS protocol

32
Q

heart failure

A

-chronic and progress disease in which the heart is unable to meet the body circulatory demand
-Resulting in abnormal retention of fluid causing venous congestion due to a pathologic change

33
Q

heart failure classification

A

-High output vs. low output
-Diastolic vs. systolic
-Right sided vs. left sided

34
Q

high output CHF causes

A

-High-output: Increase in cardiac output
-this is not usually problem with heart -> more compensation for something else
-Anemia (anemic pts compensate -> increase HR, hypertrophy)
-Thyrotoxicosis
-Hemachromatosis
-Pregnancy
-Wet beriberi (dont need to know)
-Paget’s disease of the bone
-AV fistulas

35
Q

low output CHF causes

A

-Low-output: decrease in cardiac output
-Decrease in myocardial contractility
-Cardiomyopathies
-Valvular disease- stenosis -> back flow -> improper filling
-Diastolic dysfunction
-Most common cause of HF**

36
Q

systolic heart failure

A

-Reduced left ventricular ejection fraction (LVEF)
-45% or less* -> dx with HF
-<35% -> defib
-Difficulty with myocardial contractility -> Failure to contract

-Causes:
-MC- Coronary artery disease -> Post MI
-HTN
-Valvular disease
-Myocarditis
-Alcohol abuse
-Radiation treatment

37
Q

diastolic heart failure

A

-Preserve LVEF with impaired ventricular filling
-Difficulty with relaxation myocardium
-Failure to relax

-Causes:
-chronic HTN - Left ventricular hypertrophy- MC cause of diastolic dysfunction
-Valvular disease
-Restrictive cardiomyopathy:
-Amyloidosis- fat deposits in heart tissue
-Sarcoidosis- inflammatory
-Hemachromatosis

38
Q

left sided heart failure

A

-Pulmonary vascular congestion
-Dyspnea
-Orthopnea
-Paroxysmal nocturnal dyspnea
-Cough- frothy clear fluid
-Confusion
-Fatigue

-Rales, decreased breath sounds at bases -> sometimes nothing
-Tachypnea
-S3 heart sound – ventricular gallop

-tx- lower volume

39
Q

right sided heart failure

A

-Systemic vascular congestion
-Anorexia- volume compressing stomach
-Nausea/Vomiting
-Jugular venous distention -> JVD reflex
-Hepatomegaly
-Ascities
-Peripheral pitting edema
-ABSENCE OF LUNG FLUID IF ONLY RIGHT SIDED

-Left heart failure is the most common cause of right*

40
Q

congestive heart failure

A

-CLINICAL DIAGNOSIS!
-Labs:
-CBC, CMP, TFTs,
-B-type natriuretic peptide- Released from the ventricles with volume overload or expansion

-Chest radiography
-Cardiomegaly
-Kerley B lines – interstitial edema- Horizontal lines at periphery of lungs
-Pulmonary dilations
-Pleural effusions- Blunting of costophrenic angles
-EKG – nonspecific

-Echocardiogram:
-LVEF
-Valvular abnormalities
-Pericardial effusion

-Stress test – identification of ischemia
-Cardiac angiogram

41
Q

IVC US

A

-pleuthoric - no IVC movement -> volume overload
-hypotensive pt -> check IVC sniff test -> HF pt with overload will have no IVC collapse
-pt with dehydration the IVC will completely collapse
-normal- 50% collapse
-if you assume the pt with hypotension needs volume and they are really in HF -> you make it worse

42
Q

common triggers of elevated BNP and NT - proBNP

A
43
Q

classification of HF

A

-<45% EF -> classify
-classification is based of symptoms -> tx is based on EF
-EF and classification can have no correlation -> low EF and athletic
-Class 1- no limitations, ordinary activity does not cause symptoms
-Class 2- slight limitation with physical activity, ordinary physical activity results in symptoms
-Class 3- marked limitation of physical activity, comfortable at rest -> less than ordinary activity causes symptoms (walking)
-Class 4- unable to engage in physical activity without discomfort, symptoms at rest

44
Q

heart failure lifestyle tx

A

-Treat any underlying cause
-Lifestyle modifications
-Low sodium diet- <1800 mg
-Fluid restriction- volume overload
-Weight loss
-Alcohol reduction
-Smoking cessation
-Exercise programs
-Monitor daily weights
-Require annual influenza and pneumococcal vaccines**

45
Q

heart failure diuretic tx

A

-1. Diuretics- most effective with symptomatic relief
-Loop diuretics: Furosemide (Lasix)- MOST POTENT
-Thiazide diuretics: Hydrochlorothiazide (not really HF, just keep volume a little lower)

-Aldosterone antagonist: Spironolactone, eplerenone
-Potassium sparing
-Effective in more advanced stages

46
Q

heart failure ACE inhibitor tx

A

-2. ACE inhibitors – REDUCE MORTALITY
-if you have HF YOU NEED TO BE ON THIS
-Decrease LV stress – decrease preload and afterload
-Slow remodeling- All patient with systolic heart failure should be on ACE inhibitor
-monitor K
-Causes atrial and venous dilation
-Angiotensin II receptors blockers (ARBs) can be used if a pt is intolerant of ACE inhibitors

-Side effects: Hyperkalermia, angioedema, cough*
-Cough due to bradykinin production*

47
Q

tracking water weight

A

-tell pt to check weight every morning and night
-tell pt to check weight when they are having symptoms
-tell them to take an extra diuretic if symptomatic and weight increased by about 3 lbs -> shows that symptoms are due to volume overload

48
Q

heart failure tx: beta blockers

A

-3. Beta-blockers – proven to decrease mortality with post-MI HF
-Decreases remodeling
-Slows heart rate decreasing the rate of O2 consumption
-Antiarrhythmic and anti-ischemic properties
-Types: metoprolol (Toprolol), carvediolol (Coreg)
-COMET TRIAL showed significant improvement in survival with carvedilol -> especially prior MI
-Caution in patient with pulmonary disease -> Bronchial spams

49
Q

heart failure tx digoxin

A

-useful with patients with reduced EF or severe Afib
-Positive inotropic affects- Increase cardiac contractility
-Has not been shown to decrease mortality -> last resort
-Second-line treatment
-Check digoxin levels
-Narrow therapeutic range

-Signs of digoxin toxicity:
-Green halos around lights* (board question)
-Nausea, vomiting, anorexia
-AV blocks, ventricular arrhythmias
-Disorientation, memory impairment

-5. Other Inotropes: mildirone, dobutamine, etc.

50
Q

heart failure sacubitril-vasartan tx

A

-Neprilysin inhibitor which increases levels of natriuretic peptide
-increases BNP -> encourages to reduce volume status
-Increasing vasodilation and decreases volume through sodium excretion
-For systolic heart failure patients - With class II-IV heart failure
-Decreases mortality and hospitalizations

51
Q

heart failure implantable cardioverter-defibrillation (ICDs)

A

-Prevention of sudden death
-Most common cause of death in CHF patients
-LVEF <35%
-PPM-AICD options

52
Q

heart failure left ventricular assist device (LVADs)

A

-pt who require frequent hospitalization
-bridge to transplant* or destination therapy
-need anticoagulation therapy
-very last resort

-> cardiac transplantation

53
Q

heart failure cardioMEMs tx

A

-monitor pulmonary artery pressures for titration of diuretics

54
Q

dilated cardiomyopathy

A

-Dilation of the ventricles/atria causing a reduction in strength and contraction
-Most common cardiomyopathy (95%)
-Men > females

55
Q

dilated cardiomyopathy causes

A

-Idiopathic
-Genetic
-Alcohol*
-Ischemia - Coronary artery disease*
-Chemotherapy toxicity
-Post-partum state
-Myocarditis
-Thyroid disease
-Lyme disease
-Diabetes
-Arrythmias
-Cocaine

56
Q

dilated cardiomyopathy symptoms and dx

A

-Symptoms/Signs:
-Heart failure signs and symptoms
-S3 and S4
-Cardiomegaly
-Sudden death

-Dx:
-Chest x-ray
-Echocardiogram – diagnostic test of choice
-Genetic testing

57
Q

hypertrophic cardiomyopathy (HCM)

A

-Hypertrophy of the left ventricular septum
-Blockage of blood flow for the left ventricle = hypertrophic obstructive cardiomyopathy (HOCM)
-Men = women
-Common cause of sudden death in people younger than 30 years*

58
Q

hypertrophic cardiomyopathy S&S

A

-Dyspnea
-Chest pain
-Palpitations
-Syncope
-Sudden death
-Arrhythmias

-Systolic ejection murmur at Lower left Sternal Border:
-Decreases squatting, lying down
-Increases with Valsalva and standing

-Increased carotid pulse (bisferious pulse/ biphasic)

59
Q

hypertrophic cardiomyopathy dx

A

-EKG
-echocardiogram- dx of choice
-genetic testing

60
Q

restrictive cardiomyopathy

A

-Collagen defect infiltrating the ventricular wall causing reduced relaxation
-“stiffening” of the ventricle
-Impedes ventricular filling

61
Q

restrictive cardiomyopathy causes

A

-Amyloidosis
-Sarcoidosis
-Hemochromatosis
-Scleroderma
-Carcinoid Syndrome
-Radiation/chemotherapy
-Idiopathic

62
Q

restrictive cardiomyopathy symptoms and dx

A

-dyspnea
-exercise intolerance
-right sided heart failure S&S
-dx:
-EKG- low voltage (low amplitude)
-echocardiogram
-endomyocardial bx

63
Q

cardiomyopathy tx

A

-Dilated and restrictive:
-Treat underlying cause
-Supportive treatment of congestive heart failure
-defibrillator

-Hypertrophic:
-Avoid strenuous activity
-Beta-blockers or calcium channel blockers
-Septal myomectomy
-Alcohol septal ablation

-All cardiomyopathies:
-AICD
-Cardiac transplantation

64
Q

picture of cardiomyopathies

A
65
Q

ejection fraction

A

-Ejection fraction = percentage of blood ejected from left ventricle
-Normal: 55%
-Low normal: 50-55%
-Low: 45% and less

Cardiology (11 decks)

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