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CAM II > Cardiac Part I- Intro > Flashcards

Cardiac Part I- Intro Flashcards

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1
Q

Classic cardiac sx

A 
CP or discomfort
Palpitations
Arrhythmias
Dyspnea
Syncope
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2
Q

Other cardiac sx

A 
Fatigue (rule out the following:)
-Anemia, hypothyroid, depression
-Vit D deficiency, dehydration, DI
-Addison's, fibromyalgia
Swelling in hands or feet
Tooth pain
Reflux
Asymptomatic
Shoulder pain
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3
Q

Major independent risk factors

A 
HTN
Tobacco use
DM
Elevated serum total (and LDL) cholesterol
Low serum HDL cholesterol
Advancing age
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4
Q

Major risk factors

A

Obesity/abdominal obesity

Physical inactivity

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5
Q

Gender for risk factors

A

Men > pre-menopausal women

Once past menopause, risk is similar

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6
Q

Risk factors- FHx

A

First-degree blood relative with coronary heart disease or stroke before 55 yo (male) or 65 yo (females)

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7
Q

6 vital signs

A
  1. Temperature and location
  2. Pulse and regular or irregular
  3. BP and location
  4. Respirations and labored or unlabored
  5. Pulse ox and on how much oxygen
  6. Pain (out of 10) and when last took pain medication
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8
Q

BP

A 
After pt rests for at least 5 min with both feet on the ground
No recent stimulants
Auscultatory
-Sphygmomanometer (Korotkoff sound)
Palpation
-Systolic number only
-70/80/90 rule
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9
Q

What does central cyanosis indicate?

A

Significant right-to-left shunting

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10
Q

What does peripheral cyanosis indicate?

A

Small vessel constriction (heart failure, shock, PVD)

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11
Q

What does jaundice indicate?

A

Advanced right heart failure (cardiac cirrhosis)

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12
Q

What do subcutaneous xanthomas (tendon sheaths) indicate?

A

Various lipid disorders

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13
Q

What does a high-arched palate indicate?

A

Marfan’s syndrome

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14
Q

What do blue sclerae indicate?

A

Osteogenesis imperfecta

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15
Q

In head and neck, what does dusky and slightly cyanotic with elevated venous pressure indicate?

A

SVC syndrome

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16
Q

What can be found in advanced obstructive lung disease?

A

PMI may be in the epigastrium

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17
Q

What does liver enlargement indicate?

A

Chronic heart failure

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18
Q

Marfan syndrome

A

Arachnodactyly

Positive “wrist” or “thumb” sign

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19
Q

Endocarditis

A

Osler’s nodes
Janeway lesions
Splinter hemorrhages

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20
Q

What can lower extremity edema indicate?

A

Chronic heart failure or constrictive pericarditis

Lymphatic or venous obstruction (insufficiency)

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21
Q

What is nl JVP?

A

<4 cms elevation above the sternal angle

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22
Q

What is HTN a major contributing factor to?

A 
CAD
CVA
CHF
Chronic renal failure
Atherosclerosis
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23
Q

When should one suspect secondary HTN?

A

Onset <30 or >50
Sudden onset of HTN
Sudden change in chronic HTN
Multi-drug resistance

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24
Q

Primary vs secondary HTN

A

Primary- 95%
-Genetic and/or idiopathic
Secondary- 5%

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25
Renal causes of secondary HTN
Renal artery stenosis (atherosclerosis > fibromuscular dysplasia) Renal parenchymal diseases (most common), DM
26
Adrenal causes of secondary HTN
Cushing's syndrome Pheochromocytoma (intermittent sx) Hyperaldosteronism
27
Medications/drugs causing secondary HTN
``` OCPs Ephedrine MAOIs Cocaine Adderall EPO ```
28
Other causes of secondary HTN
``` Pregnancy Coarctation of aorta OSA (obstructive sleep apnea) Thyroid disease Hypercalcemia Increased ICP ```
29
Physical exam of HtN
``` Evaluate for signs of end-organ damage -Claudication -Bruits -LVH -Angina -MI -HF -CVA -PAD -Retinopathy -Renal disease Evidence of potential causes of secondary HTN ```
30
Labs for HTN
``` Electrolytes (sodium) and serum creatinine Fasting glucose or A1C UA CBC (Hgb) and lipid profile Uric acid ```
31
HTN meds for general nonblack population (including diabetics)
Thiazide diuretic Calcium channel blocker ACE-inhibitor Angiotensin receptor blocker
32
HTN meds for general black population (including diabetics)
Thiazide diuretic | Calcium channel blocker
33
Thiazide diuretics MOA
Inhibits sodium reabsorption in distal renal tubules, resulting in increased excretion of water and of Na, K, and H ions
34
Main indications for thiazide diuretics
HTN and edema
35
Caution in thiazide diuretics
``` Fluid or electrolyte balance Hypercholesterolemia Hyperuricemia or gout Hypercalcemia Hypotension SLE Liver or renal disease Hypokalemia Parathyroid disease ```
36
Calcium channel blockers MOA
Inhibits transmembrane influx of extracellular calcium that inhibits cardiac and vascular smooth muscle contraction
37
Main indications for calcium channel blockers
HTN Chronic stable angina and CAD (not 1st line therapy) Vasospastic angina
38
Adverse effects of calcium channel blockers
Edema HA Heart block Constipation
39
Cautions for calcium channel blockers
CHF Symptomatic hypotension possible, particularly with severe aortic stenosis Worsening of angina and acute MI, particularly with severe obstructive CAD
40
Considerations for HTN in elderly
Poorest rates of control, usually require multi-drug therapy | Start low and slow
41
HTN considerations in children/adolescents
Consider secondary causes (renal diseases, coarctation)
42
Secondary prevention of hyperlipidemia
In pts with known CVD or at similar risk who can tolerate statin therapy, treat with an intensive dose of a statin (e.g, atorvastatin 40-80 mg; rosuvastatin 20-40 mg) independent of the baseline LDL-C
43
Therapeutic lifestyle changes for hyperlipidemia
``` Reduce saturated and trans-fats Restrict dietary cholesterol to <200 mg/d Increase soluble fiber Fish oil supplements Weight reduction Increase physical activity Increase fruits/vegetables ```
44
Non-cholesterol drug therapy for hyperlipidemia
ASA prophylaxis 81 mg daily Antihypertensives Smoking meds
45
Pectus carinatum
Pigeon chest
46
Pectus excavatum
Funnel chest
47
What does a barrel chest indicate?
Obstructive lung disease
48
What can ankylosing spondylitis indicate?
Aortic regurgitation
49
What does straight back syndrome indicate?
Mitral valve prolapse
50
What can hepatomegaly indicate?
Chronic heart failure
51
What can liver systolic pulsations indicate?
Severe tricuspid regurg
52
What can splenomegaly indicate?
Infective endocarditis
53
What can ascites indicate?
Atherosclerotic disease
54
What can muscular atrophy or absence of hair indicate?
Severe arterial insufficiency
55
What is JVP a reflection of?
Right atrial pressure
56
What should the order be when auscultating carotid arteries
Auscultate first for bruits before ever palpating the neck
57
What should you look for when evaluating extremities?
``` Pulses, cap refill, pallor Shiny skin, absence of hair Edema -Pitting vs nonpitting Warm, erythema, tenderness Wounds-healing or nonhealing Ankle-branchial index (ABI) Allen test ```
58
What should one look for in cardiac inspection and palpation?
Chest deformities (pectus carinatum or excavatum) Apical impulse or point of maximal impulse (PMI) -Left ventricular hypertrophy- tangential light -May require left lateral decubitus position Central precordial heave (lift)- palpable lifting sensation that suggest severe RV hypertrophy Thrills- felt murmurs in your MCP joint
59
What sound occurs with close of AV valves and carotid pulse with the onset of ventricular contraction?
Lub sound (S1)
60
What causes the S2 sound?
Closing of semilunar valves
61
S3
Low-pitched sound occurring in mid-diastole | Usually associated with heart failure or cardiomyopathy (rarely heard in >40 healthy individuals)
62
S4
Occurs late in diastole and is generated by forceful atrial contraction It indicates an abnormally increased resistance to ventricular filling
63
HR
Normally 60-100 bpm | Max HR is 220 - age
64
Stroke volume
Volume of blood pumped from one ventricle of the heart with each beat Nl SV for a 70-kg person is approximately 70 mL
65
Cardiac output (CO)
``` Volume of blood being pumped by the heart in one minute CO= HR x SV Nl value: Males 5.6 L/min Females 4.9 L/min ```
66
Cardiac index (CI)
Parameter that relates cardiac output to body surface area CI= CO/BSA Nl range is 2.2-4.2 L/min per square meter Cardiogenic shock can occur if the pt has a low CI
67
Central venous pressure (CVP)
AKA Right atrial pressure (RAP) | Nl is 2-8 mmHg
68
Right ventricular pressure
Systolic: 15-30 mmHg Diastolic: 3-8 mmHg
69
Pulmonary artery pressure (PAP)
Systolic: 15-30 mmHg Diastolic: 4-12 mmHg
70
Pulmonary capillary wedge pressure (PCWP)
Nl: 2-15 mmHg
71
Left ventricular pressure
Systolic: 100-140 mmHg Diastolic: 3-12 mmHg
72
Mean Arterial Pressure (MAP)
Average BP over a cardiac cycle | MAP= DBP + 1/3 (SBP - DBP)
73
Vascular resistance
Resistance to flow that must be overcome to push blood through the circulatory system
74
Systemic vascular resistance (SVR)
Nl: 700-1600 Vasoconstriction increases SVR Vasodilation decreases SVR
75
HTN risk factors
``` Increasing age Obesity Physical inactivity Ethnicity EtOH Smoking DM ```
76
Optimal BP
<120/80
77
Prehypertension
120-139/80-89
78
Stage 1 HTN
140-159/90-99
79
Stage 2 HTN
Greater than or equal to 160/100
80
How to take an accurate BP
Pt seated for 5 mins, feet flat on the floor, arm supported at heart level Appropriate-sized cuff At least 2 readings...both arms 1/2 hour after eating, drinking, or smoking
81
Complications of HTN
``` Coronary heart disease Heart failure Ischemic and hemorrhagic stroke Chronic kidney disease End-stage renal disease Acute hypertensive emergencies ```
82
HTN tx goals
General <60 yrs, DM, and CKD = <140/90 60+ years = <150/90 Long-term reduction in cardiovascular morbidity and mortality, renal disease, cerebrovascular disease
83
HTN meds in pts greater than or equal to 18 with CKD
ACE-inhibitors or ARBs
84
When should the initial HTN med dose increase or add a second drug?
One month after BP goal is not reached
85
What are the main classes of HTN meds
Thiazide diuretics Calcium channel blockers Angiotensinogen-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs)
86
ACE-inhibitors (ARBs) MOA
Prevents the conversion of angiotensin I to angiotensin II (potent vasoconstrictor) through competitive inhibition of angiotensin-converting enzyme and in part by decreasing renin activity, and decreased aldosterone secretion Also increases renal blood flow
87
Adverse effects of ACE-inhibitors (ARBs)
Dizziness | Cough
88
Monitoring for ACE-inhibitors (ARBs)
Evaluate creatinine and potassium within 7-10 days of starting ACE-inhibitors
89
Black box warning for ACE-inhibitors (ARBs)
Contraindicated in pregnancy
90
Beta blocker MOA
Blocks response to beta-adrenergic stimulation; cardioselective (beta1 receptors) or noncardioselective (beta2 receptors)
91
Main indications for beta blockers
HTN Myocardial ischemia and infarction CHF
92
Black box warning for beta blockers
When long-term beta blocker therapy is d/c-ed, dosage should be gradually reduced over 1-2 weeks with careful monitoring
93
Side effects of thiazide diuretics
Hypokalemia Hyperglycemia Gout
94
Side effects of ACE-inhibitors
Angioedema Cough Hyperkalemia
95
Side effects of ARBs
Hyperkalemia
96
Side effects of calcium channel blockers
Constipation Edema Heart block
97
Side effects of beta blockers
Fatigue Bradycardia Reactive airway disease/COPD (beta-2), heart block
98
Side effect of methyldopa
Liver disease
99
Contraindications for thiazide diuretics
None
100
Contraindications for ACE-inhibitors or ARBs
Pregnancy
101
Contraindications for calcium channel blockers
``` Bradycardia Hypotension 2nd or 3rd degree heart block Wolff-Parkinson-White syndrome Ventricular tachycardia ```
102
Contraindications for beta blockers
Bradycardia Hypotension 2nd or 3rd degree heart block
103
Contraindications for methyldopa
Active hepatic disease | MAOI use
104
HTN considerations for left ventricular hypertrophy
Independent risk factor for CVD | Regression may occur with aggressive therapy leads to BP control, weight loss, Na+ reduction, Rx therapy
105
HTN considerations with racial disparity
Native and Mexican Americans= lower rates of control African Americans -Increased prevalence, increased severity, increased morbidity and mortality -Reduced effectiveness of ACEI and BB. First line is generally CCB or thiazide-type diuretic -Increased angioedema
106
HTN considerations in women
Increased risk with OCPs | Worse with longer duration, must consider non-hormonal alternative. Not with post-menopausal HRT
107
HTN considerations in pregnancy
No ACEI/ARB | Methyldopa, BB, or hydralazine
108
Possible causes of resistant HTN
``` Improper BP measurement Excess sodium intake Inadequate diuretic therapy Drug nonadherence Drug inadequate doses Cocaine Amphetamines Oral contraceptives Licorice Obesity Excess alcohol intake ```
109
Hypertensive urgency
``` Severe HTN without severe end organ damage Systolic >180 mmHg Diastolic >110 mmHg Generally treat as an outpatient Goal: reduce BP within a few hours ```
110
Hypertensive emergency
Acute, severe elevation of BP with evidence of end organ damage (usually DBP >130)
111
CNS end organ damage
``` ICH, stroke- presenting disease HA Focal neuro deficits Seizures AMS Visual disturbances ```
112
CVS end organ damage
``` Diseases: -Angina -MI -Dissection -CHF Sx: pulmonary edema, chest/back pain ```
113
Renal end organ damage
Acute renal failure | Sx: hematuria, oliguria, proteinuria
114
Eyes end organ damage
Hypertensive encephalopathy | Sx: Papilledema, retinal hemorrhage
115
Tx of hypertensive emergency
``` Hospital admission Decrease MAP by 25% over 1-4 hrs (24 hrs in stroke) IV meds -Labetalol -Sodium nitroprusside -Nicardipine -Esmolol ```
116
LDL ranges
``` <100 optimal 100-129: above optimal 130-159: borderline high 160-189: high >190: very high ```
117
HDL ranges
<40: low | >60: high
118
Total cholesterol ranges
<200: desirable 200-239: borderline high >240: high
119
Triglycerides
<150: nl 150-199: borderline high 200-499: high >500: high
120
Major drug classes- hyperlipidemia
``` Statins Niacin Fibrates Bile acid sequestrants Cholesterol absoprtion inhibitor: Ezetimib Fish oil: OTC, Lovaza, Vascepa ```
121
Effects of statin
``` Lipid-lowering activity Improves endothelial function Modulate inflammatory responses Maintains plaque stability Prevents thrombus formation ```
122
Statin contraindications
Pregnancy | Liver disease
123
Side effects of statins
``` Heptatotoxicity Myalgia Myopathy Myositis Decrease dose iwth Amiodarone ```
124
F/u with statins
Monitor LFTs at 3 mos, 6 mos, then every year | Check CPK if myalgias
125
Contraindications of Niacin
Active liver disease
126
Side effects of Niacin
Flushing (minimize with ASA/NSAIDs and titrate slowly) Peptid Ulcer Disease Gout Hyperglycemia Hepatotoxicity
127
F/u with Niacin
LFTs +/- CPKs
128
Severe Vit B3 deficiency
``` Pellagra Diarrhea Dermatitis Dementia Digestive disturbances Delirium Depression Death ```
129
Fibrates examples
Gemfibrozil
130
Contraindications of fibrates
Hepatic or severe renal dysfunction Primary biliary cirrhosis Use with simvastatin
131
Major effects of statins
Increase HDL Decrease LDL Decrease triglycerides
132
Major effects of niacin
Increase HDL Decrease triglycerides Decrease LDL
133
Major effect of fibrates
Major class used if triglycerides >400
134
Side effects of fibrates
Cholelithiasis Myositis Hepatotoxicity
135
Bile acid sequestrants examples
Cholestyramine Colesevelam Colestipol
136
Contraindications for bile acid sequestrants
Bowel obstruction and hypertriglyceridemia
137
Side effects of bile acid sequestrants
GI sx Flatulence and constipation Decreased absorption of other drugs Safest lipid class to use in pregnancy
138
Major side effects of Ezetimibe
Back pain/arthralgias Abdominal pain Diarrhea
139
F/u for Ezetimibe
CK for myalgias (esp with statins) | LFTs (esp with statins)

CAM II (3 decks)

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