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Flashcards in CARDIAC Deck (210):
1

What valve connects the right atrium to the right ventricle

tricuspid valve

2

What valve connects the right ventricle to the pulmonary artery

pulmonic valve

3

what carries blood to the lungs

the pulmonary artery

4

what varies blood out of the lungs

the pulmonary veins

5

what valve connect the left atrium to the left ventricle

the mitral valve

6

what valve connects the left ventricle to the aorta

aortic valve

7

what carries blood form the heart to the body

aorta

8

where does deoxygenated blood enter the heart

the superior vena cava

9

what side of the heart get deoxygenated blood

the right side

10

what side of the heart has the oxygenated blood

the left side

11

what are the AV valves

tricuspid and mitral

12

what are the semilunar valves

pulmonic and aortic

13

What is the sound of S1

mitral/tricuspid (AV) valves closure (and the semilunar valves are open)

14

what is the sound of s2?

the aortic/pulmonic (semilunar) valves closure and the AV valves are open

15

what is the period between s1 and s2

systole

16

what is the period between s2 and s1

diastole

17

what does s3 sound like

ken-tuck-y

18

what is s3 associated with

increased fluid states (e.g. CHF, pregnancy)

19

what is the most common murmur heard with CHF

s3

20

what does s4 sound like?

ten-ne-ssee

21

what does s4 signify

stiff ventricular wall (MI, LVH, chronic HTN)

22

when is a systolic ejection click normal

in pregnancy along with a s3

23

What level is a barely audible murmur?

I/VI

24

what level is an audible but faint murmur?

II/VI

25

What level is a moderately loud; easily heard murmur

III/VI

26

what level is a loud murmur associated with a thrill?

VI/VI

27

what level is a very loud murmur, heard with one corner of stethoscope off the chest wall?

V/VI

28

What level is the loudest murmur?

VI/VI

29

mitral stenosis

loud S1 murmer, Low pitched, MID-DIASTOLIC; apical "crescendo" rumble

30

Mitral regurgitation

S3 with systolic murmur at 5th ICS MCL (apex); may radiate to base or left axilla; musical, blowing or high pitched. ALSO MITRAL VALVE PROLASPSE

31

Aortic stenosis

2ND RIGHT ICS, SYSTOLIC blowing, rough harsh murmur, usually radiating to the neck

32

Aortic regurgitation

2ND LEFT ICS, DIASTOLIC, "blowing" murmur

33

MSARD and MRASS

Mitral
Stenosis
Aortic
Regurgitation
DIASTOLIC

Mitral
Regurgitation
Aortic
Stenosis
Systolic

34

what valve is indicated if the sound is 5th ICS=apex

MITRAL

35

what does holo mean?

throughout

36

describe heart failure

a syndrome that results when cardiac output is insufficiency to meet the metabolic needs of the body

37

describe systolic HF

inability to contract results in decreased cardiac output

38

describe diastolic HF

inability to relax and fill results in decreased cardiac output

39

what happens in acute heart failure

usually the Left side into the LUNGS, abrupt onset follows acute MI or valve rupture

40

what happens in chronic HF

usually right side, as a result of inadequate compensatory mechanisms that have been employed over time to improve cardiac output

41

what kind of med does someone with diastolic HF need to be on

a dilator

42

what kind of med does someone with systolic HF need to be on

inotrope

43

what is the most common cause of right HF

left HF

44

describe NYHA class 1 HF

No limitations of physical activity (is normal activity causing no s/sx)

45

describe NYHA class II HF

SLIGHT LIMITATIONS OF PHYSICAL ACTIVITY but comfortable at rest (physical activity results in fatigue, palpitations, dyspnea, or angina)

46

describe NYHA class III HF

Marked limitations of physical activity but comfortable at rest

47

describe NYHA class IV HF

SEVERE, inability to carry out any physical activity without discomfort (s/sx while at rest)

48

s/sx of Left HF (ACUTE)

dyspnea at rest, coarse rales over all lung fields, wheezing frothy cough, appears generally health except for the acute event, S3 GALLOP, murmur of mitral regurgitation (systolic murmur loudest at apex)

49

s/sx of right HF (CHRONIC)

JVD
HEPATOMEGALY, SPLENOMEGALY
DEPENDENT EDEMA as a result of increased capillary hydrostatic pressure
paroxysmal nocturnal dyspnea (PND)
Appears chronically ill
Diffuse chest wall heave
Displaced PMI
abdominal fullness
fatigue on exertion
s3 and/ or s4

50

diagnostics of heart failure

echocardiogram: will show contractile/relaxation, valve function, ejection fraction
ECG may show deviation or underlying problem: acute MI or dysrythmia
hypoxia and hypocapnia on ABG
BMP normal unless chronic failure
chest XRAY: pulmonary edema, kerly B lines, effusions
PFTs for wheezing during exercise
urinalysis

51

what is the non-pharmacologic management of CHF

sodium restriction
rest/activity balance
weight reduction

52

pharmacologic management of CHF

ACE INHIBITORS (PRILS)
DIURETICS: thiazides, loop
Anticoagulation therapy for atrial fib

53

define HTN

a sustained elevation of SBP>140 or DBP>90

54

causes of secondary HTN

estrogen use, renal disease, pregnancy, endocrine disorders, renal artery stenosis (most common)

55

what are some exacerbating factors to HTN

smoking, obesity, excessive alcohol intake, use of NSAIDs and other

56

what are some symptoms of HTN

epistaxis, dizziness/ lightheadedness, S4 relate to left ventricular hypertrophy, with severe HTN: SUBOCCIPITAL PULSATING headache, occurring early in the morning and resolving though out the day

57

when are labs normal in HTN?

in uncomplicated HTN

58

what labs/ diagnostics for HTN

renovascular studies
CXR if cardiomegaly is suspected
plasma aldosterone level to rule out aldosteronism
AM/PM cortisol levels to rule out cushiness syndrome
UA, CBC, BMP, calcium, phosphorus, uric acid, cholesterol, triglycerides
ECG
PA and later CXR

59

what is the JNC 7 "prehypertension"

SBP120-139 or DBP80-89

60

what is the JNC 7 stage I HTN

SBP 140-159 OR DBP 90-99

61

What is the JNC 7 stage II HTN

SBP >160 OR DBP>100

62

what are the JNC 8 treatment recommendations for non-african americans

thiazide diuretics
CCB
ACEI
ARB

63

What are the JNC 8 treatment recommendations for African americans

thiazide diuretics, CCB,
ACEI or ARB if diabetes

64

what are the JNC 8 treatment recommendations for adults with CKD

ACEI or ARB regardless of race or other medical conditions

65

What are the general treatment time frames and follow ups for HTN

TREATMENT GOAL FOR INTIAL TREATMENT IS 1 MONTH
increase dose or add a second drug
continue to assess monthly unit goal is reached
do not use ACEI and ARB together
Refer to HTN specialist if 3 or more drugs are needed

66

what is the DASH diet

dietary approaches to stop hypertension- fruits, vegetables and low fat diary products with reduced saturated and total fat

67

Maintenance of adequate_________ for HTN

potassium, calcium and magnesium intake

68

what is the general goal of therapy for HTN

to prescribe the least number of medications possible at the lowest dosage to attain acceptable BP, thereby decreasing cardiovascular and renal morbidity and mortality

69

kind of thiazide diuretics

chlorothiazide (diuril), chlorthalidone (hygroton), HCTZ, indapamide (lozol), metolazone (zaroxolyn)

70

what are the first line of drugs for HTN

thiazides

71

what is the MOA of thiazdide diuretics

increases excretion of sodium and water

72

what kind of allergy should you screen for thiazide diuretics

sulfa

73

what may thiazide diuretics cause?

hypokalemia, hypomagnesmia, hyperglycemia, hyponatrmia, hypercalcemia

74

Examples of ACE inhibitors

benazpreil (lotensin), captopril (capoten), enalapril (vasotec), fosinopril (monopril), lisinopril (zestril), moeipril (univasc) perindopril (aceon), quinapril (accupril), ramipril (altace), trandolapril (Mavik)

75

what is the MOA for ACE inhibitors

cause vasodilation and block sodium and water retention

76

when would you not want to put someone on an ACEI

do not initiate if potassium is greater than 5.5
contraindicated in pregnancy

77

SE of ACEI

cough, rash, taste disturbances, hyperkalemia, renal impairment

78

examples of ARBS

candesartan (atacand), eprosartan mesylate (tevetan), irbesartan (avapro), losartan (cozaar) olmesartan (benicar), telmisartan (micardis) valsartan (diovan)

79

how to ARBs work?

cause vasodilation and block sodium and water retention

80

when should you not consider ARB

do not initiate if potassium is greater than 5.5
contraindicated in pregnancy

81

SE of ARB

cough, hyperkalemia, HA, taste disturbances, renal impairment

82

calcium channel blocking agents

verapamil IR, verapmil (calan SR), diltiazem IR, diltiazem (dilacor XR), amlodipine (norvasc), felodipine (plendil), isradipine (dynacirc), nicardipine (cardene SR), nifedipine (adalat CC), nisoldipine (sular)

83

what should you monitor with CCB?

HR, especially with verapamil and diltiazem

84

What are some good uses for CCB?

angina, arryhthmias, migraines

85

What may CCB cause?

HA, flushing, bradycardia

86

what are examples of beta blockers

acebutolol (sectral), atenolol (tenormin), betaxolol (kerlone), bisoprolol (zebeta), carvedilol (coreg), labetalol (normodyne), metoprolol (lopressor), nadolol (corgard), pndolol (visken), propranolol (inderal), timolol (blocadren)

87

what is the MOA of BB?

directly relaxes the heart

88

what may BB be also used for

angina and arrhythmias

89

what should you caution and monitor with BB?

monitor HR
avoid use in patients with asthma and COPD

90

what might BB cause?

dizziness, bradycardia, heart block, fatigue, insomnia, nausea, ect.

91

what is not used as first line tx for HTN?

beta blockers

92

what are examples of peripheral alpha-1 antagonists?

prazosin (minipress), terazosin (hytrin), doxazosin (cardura)

93

what is the MOA of alpha-1 antagonists?

cause vasodilation

94

when should you take the first dose of peripheral alpha-1 antagonist?

at bedtime

95

what is another use of peripheral alpha-1 antagonist?

BPH

96

what are some side effects of peripheral alpha-1 antagonists?

syncope, dry mouth, orthostasis, dizziness, headache, nausea, ect.

97

central alpha-2 agonists examples

clonidine (catapress), methyldopa (aldomet)

98

what is the MOA of central alpha-2 agonist?

prevents vasoconstriction, causes vasodilation, and slows heart rate

99

what central alpha-2 agonist is preferred in pregnancy

methyldopa (aldomet)

100

how should you discontinue central alpha-2 agonists?

do not d/c abruptly, as it may cause rebound hypertension

101

SE of central alpha-2 agonist

dry mouth, sedation, depression, HA, bradycardia

102

what are some examples of arterial vasodilators?

hydralazine (apresoline) and minoxidil (loniten)

103

what is the MOA of arterial vasodilators?

directly relax the vascular smooth muscle resulting in arterial vasodilation

104

what may arterial vasodilators cause?

reflex tachycardia, nausea, flushing, dizziness, orthostatic hypotension

105

example of direct renin inhibitor

aliskiren (Tekaturna)

106

what is the MOA of a direct renin inhibitor?

inhibits renin, which decreases the plasma renin activity (PRA) and inhibits the conversion of angiotensinogen I to angiotensin I

107

What is the downside of direct renin inhibitor

expensive, no advantages, avoid in pregnancy

108

what might direct renin inhibitors cause?

diarrhea, dizziness, headache, hyperkalemia

109

what is the goal in mind when using pharmacotherapy for HTN

to use as few medications at the lowest doses to maintain BP control

110

define hypertensive urgencies

characterized by severe elevations in BP >180/110 without progressive target organ dysfunction

111

define hypertensive emergency

rare, require immediate (within 1 hour) BP reduction to prevent or limit target organ damage. associated with severe elevations in BP >180/120 or higher but may occur at a lower level if complicated by evidence of impending or progressive target organ dysfunction

112

what oral therapies are used in hypertensive urgencies

clonidine (catapress), captopril (captopen), nifedipine (procardia), loops diuretics

113

what are some examples of hypertensive emergencies

funcoscopic changes, hypertensive encephalopathy, intracranial hemorrhage, unstable angina, acute MI, acute LV failure with pulmonary edema, dissecting aortic aneurysm, elampsia

114

what kind of fundscopic changes are seen in malignant hypertension

fundoscopic changes include FLAME-SHAPED RETINAL HEMORRHAGES, SOFT EXUDATES AND PAPILLEDEMA (SWELLING OF THE OPTIC DISK WITH BLURRED MARGINS)

115

management of hypertensive crisis

refer for IV agents

116

what shows on an EKG of angina

ST depression

117

what is occurring during angina

decreased blood flow through the vessel leading to ischemia

118

what is stable angina

classic or chronic: exertional (most common), goes away with rest or nitro

119

what is prinzmetals angina?

variant, occurs at various times, including at rest

120

what kind of medications are used in prinzmetals angina

CCB

121

what is unstable angina

pre-infarction, rest or crescendo, coronary syndromes

122

what is microvascular angina

metabolic syndrome

123

what are s/sx of angina

chest discomfort lasting several minutes, exertional is usually precipitated by physical activity; subsides with rest/ nitro, nitro shortens or prevents attacks

124

physical exam findings of angina

peripheral artery disease, Levine's sign= clenched fist sign, transient s4 not uncommon during angina

125

what will you see on a ECG for angina

down sloping of ST segment, or T-wave peak or inversion during an attack

126

what is the only definitive diagnostic procedure for angina?

coronary angiography, but not indicated solely got diagnosis

127

man agent of angina

reduction of risk factors
diet: decrease saturated fats, then decrease unsaturated fats, then consider plant sterols
LOW DOSE ENTERIC COATED ASA (81mg daily

128

common pharmacotherapy for angina

nitrates, beta blockers, calcium channel blockers

129

what is the ASCVD risk

Pooled cohort equations to estimate 10 year atherosclerotic cardiovascular disease risk, defined as the first occurrence of nonfatal and fatal MI and nonfatal and fatal stroke, to identify candidates for statin therapy

130

what is the 10 year ASVCD risk based on?

age, sex, race, total cholesterol, SBP, diabetes, smoking

131

identify the 4 groups that may benefit from statin therapy

1) individuals with clinical evidence of ASCVD
2) individuals with elevated LDL-C >190
3) diabetics 40-75 years of age with LDL between 70-189 but without clinical evidence of ASCVD
4) individuals without ASCVD or diabetes with LDL between 70-189 but with an estimated 10 year ASCVD risk of 7.5% or higher

132

HOw often should ASCVD be recalculated for individuals not receiving cholesterol-lowering drug therapy

every 4-6 years for those 40-75 without clinical ASCVD or DM and LDL 70-189

133

what is first line tx in women and men

high intensity statin is first line, moderate-intensity if high is contraindicated or if statin-associated adverse effects are present

134

tx for adults age>21 with primary LDL-C >190

high intensity statin tx unless contraindicated and intensity until at least 50% LDL reduction. After maximum intensity has been achieved, can add a non-statin drug

135

what is the tx for adults 40-75 with diabetes with diabetes mellitus

moderate intensity statin or high intensity statin if 10 year ASCVD risk >7.5%

136

what is the tx for adults 75 with diabetes

evaluate the potential for ASCVD benefits and drug interactions

137

when should the pooled cohort equations be used

to estimate 10 year ASCVD risk for individuals with LDL 70-189 without clinical ASCVD to guide initiation of statin therapy for the primary prevention of ASCVD

138

how do you treat a 40-75 yo with LDL 70-189 without clinical ASCVD or diabetes and estimated ASCVD risk >7.5%

moderate or high intensity statin

139

How do you treat adult age 40-75 with LDL 70-189 without clinical ASCVD or diabetes and an estimate 10 year risk 5%-7.5%

offer a moderate intensity statin

140

examples of high-intensity statin therapy

atorvastatin 40-80mg
rosuvastatin 20-40mg

141

examples of moderate intensity therapy

atorvastatin 10-20mg
rosuvastatin 5-10mg
simvastatin 20-40mg
pravastatin 40-80mg
lovastatin 40mg
fluvastatin 80mg
pitavastatin 2-4mg

142

low intensity statin

simvastatin 10mg
pravastatin 10-20mg
lovastatin 20mg
fluvastatin 20-40mg
pitavastatin 1mg

143

how much does high intensity lower LDL

on average 50%

144

how much does moderate intensity lower LDL

30-50%

145

how much does low intensity lower LDL

on average less than 30%

146

what is another term for statins

HMG-CoA reductase inhibitors

147

commonly used agents other than statins

bile sequestrates, fibrates, cholesterol absorption inhibitor, niacin

148

what do bile sequestrates do to LDL and triglycerides

lowers LDL, may increase triglycerides

149

examples of bile sequester ants

cholestyramine (questran)
colesevelam (welchol)
colestipol (colestid)

150

what do fibrates do to triglycerides, LDL, and HDL?

decrease triglycerides, slightly decreaseLDL and possibly increase HDL

151

examples of fibrates

gemifibrozil (lopid)
fenofibrate (tricor)
fenofibric acid (trilipix)

152

what does cholesterol absorption inhibitors do?

when used in combo with statin, decrease LDL

153

example of cholesterol absorption inhibitor

ezetimibe (zetia)

154

what does niacin do?

decreases LDL and triglycerides and increase HDL

155

s/sx of MI/ ACS

1/3 of patients give a history of alteration in typical anginal pain
MOST INFARCTIONS OCCUR AT REST; Pain similar to angina but more severe
NITROGLYCERIN HAS LITTLE EEFCT
cold sweat; weakness
impending doom
apprehension
light-headedness
syncope
dyspnea
cough
N/v

156

physical exam findings in MI/ACS

dysrhythmia common
S4 very common
wheezing
pulmonary crackles
low grade fever during the first 48 hours
tachycardia

157

how many people have no initial ECG changes in MI/ACS

30%

158

what kind of ECG changes might you see

peaked T waves, ST elevations, q wave development (q waves do not develop in 30-50% of MIs)

159

what leads will show MI

1. I, aVL
2. II, III, aVF
3. V leads (precordial leads) or V3 and V4

160

when will cardiac enzymes rise after MI

above normal within 4-6 hours of MI and remain high for several days (3 days to 3 weeks)

161

what will happen to white count in a n MI

leukocytosis 10-20 on the second day

162

Management of MI

activate EMS
ASA 325mg tablet to chew
NTG SL every 5 minutes x 3
begin 02
12 lead ECG and cardiac monitor
hospital transport

163

Normal INR

0.8-1.2 seconds

164

therapeutic INR

MI: 2.5 to 3.5x normal
coumadin 2-3

165

activated coagulation time normal

70-120

166

therapeutic activated coagulation times

150-190 or >300 post-stent

167

activated partial thromboplastin time APTT normal

28-38 seconds

168

therapeutic value to APTT

1.5-2.5x normal

169

Prothrombin time normals

11-16 seconds

170

prothrombin times therapeutic

1.5-2.5x normals

171

partial thromboplastin time (PTT) normals

60-90 seconds

172

PTT therapeutic

1.5-2.5x normal

173

what are the indications for pharmacologic revascularization

UNRELIEVED CHEST PAIN (>30min and 0.1 mV in 2 or more contiguous leads

174

define venous thrombosis

a partial or complete occlusion of a vein by thrombus with secondary inflammation to the wall of the vessel; may be superficial or deep

175

sign of superficial thrombosis

sudden onset of pain

176

sign of deep thrombosis

sudden onset of pain, pain or tenderness especially while walking, pain may present as dull ache or tight feeling

177

physical exam findings for superficial thrombosis

localized heat and erythema, low grade temp

178

physical exam findings for deep thrombosis

edema distal to occlusion, low grade temp, skin may be cool to touch

179

diagnostics of superficial thrombosis

none

180

diagnostics of deep thrombosis

consider need for deep thrombosis tests
US
d-dimer
venography

181

management of superficial thrombosis

elevation of extremity
warm compresses
NSAIDs
D/C oral contraceptives

182

Management of deep thrombosis

bed rest with leg elevated until local tenderness subsides 7-14 days
walking gradually re-introduced
Lovenox 1mg/kg every 12 hours (1.5mg/kg)OR
heparin infusion for 7-10days
coumadin therapy for 12 weeks
consult with anticoagulant therapy instituted

183

pathology of peripheral vascular disease (PVD)

arteriosclerotic narrowing of the lumen arteries resulting in decreased blood supply to the extremities

184

causes/ incidence of venous thrombosis

immobility
female
post-operative period
prolonged bed rest
use of oral contraceptives (especially with smokers)
hypercoagulability

185

causes/ incidence of peripheral vascular disease

atherosclerosis causes
similar risk factors for CAD
peak incidence 40-70
hyperlipidemia
smoking
DM

186

s/sx of PVD

usually first symptom: ℅ calf pain, claudication
cold/numbness to extremities
progresses to pain at rest

187

physical findings of PVD

shiny, hairless skin
dependent rubor
pallor
cyanosis
ulcerations
reduced pulses

188

labs/ diagnostics of PVD

doppler U/S to evaluate flow
ankle/brachial index
X-rays may show calcification
arteriography: most definitive test

189

Management of PVD

stop smoking
exercise walking 1 hour/day: stopping during pain and resuming when pain subsides to DEVELOP COLLATERAL CIRCULATION
Pentoxifylline (trental)
Cilostazol (pletal)
weight reduction as needed
manage diabetes and hyperlipidemia
angioplasty
bypass surgery
amputation

190

pathology of chronic venous insufficiency

impaired venous return due to either destruction of valves, changes due to deep thrombophlebitis, leg trauma, or sustained elevation of venous pressure (CHF)

191

causes/ incidences of CVI

more common in women than men
may be genetic predisposition
history of leg trauma may be associated with varicose veins

192

s/sx of CVI

aching of the lower extremities relieved by elevation
edema after prolonged standing
night cramps of the lower extremities

193

physical findings of CVI

trophic changes with brownish discoloration
stasis leg ulcers
edema of lower extremities
dermatitis is common
cool to touch

194

diagnostics of CVI

nonspecifically
RO edema due to CHF or other causes

195

management of CVI

bed rest with legs elevated to diminish chronic edema
use of heavy duty elastic support stocking
weight reduction in the obese
treat dermatitis or ulcerations as indicated
acute weeping dermatitis

196

management of CVI acute weeping dermatitis

wet compresses
0.5% hydrocortisone cream after compresses
systemic antibiotics only indicated if active bacterial infection

197

what happens to baroreceptors in aging

baroreceptors that monitor BP become less sensitive

198

what happens to the anatomy of the heart in aging

arterial walls thicken and stiffen- decreased compliance
heart stiffens and may increase in size related to left ventricular and arterial hypertrophy

199

what happens with pacemaker cells and AV conduction time as we age

loss of pacemaker cells with increased AV conduction time

200

what happens with aging to cardiac reserve

decreased, may lead to orthostatic hypotension or syncope

201

what is the jnc normal BP

202

what is the JNC 8 goal for BP for people over 60yo

SBP

203

What is the JNC 8 goal BP for people less than 60yo

SBP

204

what is the JNC BP goal for people >18 with CKD

SBP

205

What is the JNC BP goal for people >18 with DM

SBP

206

what is desirable total cholesterol

207

What is normal VLDL (triglycerides)

normal

208

What is optimal LDL?

209

What is the HDL range

Low=60

210

What is the LDL, HDL, and TG goal levels for diabetes

LDL40
TG