Cardiology - HTN, ACS, HF, Hyperlipid Flashcards
HTN, ACS, HF (138 cards)
1
Q
normal home blood pressure
A
<135/85
2
Q
technique
A
non-dom arm, quiet, rest, arm raised to heart level, back supported, feet flat
no caffeine within 30 mins
no tobacco
no full bladder
no immediate exercise
2 readings before meds in AM, 2 readings 2 hrs after dinner
3
Q
masked HTN
A
normal BP in office, elevated at home
4
Q
CVD risk factors
A
> 55yo
male
family history
LVH, PAD, CVA/TIA
DM, obesity, sedentary
smoker
lipids
poor diet and stress
5
Q
HTN complications (head to toe)
A
stroke, vasc dementia, brain atrophy
retinopathy
LVH, HF, ACS, stable angina
renal CKD, albuminuria
PAD
6
Q
when you start screening for HTN?
A
> 40yo or if there’s risk factors (annually)
adults 18-39 q3yrs
7
Q
what percentage is essential hypertension
A
90%
8
Q
meds that can cause HTN
A
steroids
NSAIDs
hormones (estrogen)
anti-depressants
decongestants
EPO
calcineurin inhibitors (cycle/tacrolimus)
natural: St. John’s wort, licorice root, gingko biloba
9
Q
PRESSURE mnemonic (secondary causes of HTN)
A
P: phaeo, polycythemia, pre-eclampsia
R: renovascular
E: endocrine (hyperthyroid, Cushing, aldosterone)
S: substances (estrogen, cocaine, caffeine, alcohol, sympathomimetics)
S: structural (coarctation, arteriosclerosis, OSA)
U: UMN Problem (elevated intracranial pressure)
R: renal (glomerulonephritis & DM nephropathy)
E: essential and error in cuff size
10
Q
Complications to ask about in HTN history
RRCC (retinal, renal, cardio, CVR)
A
retinopathy, visual disturbances
stroke symptoms
HF sx (orthopnea, PND, edema)
chest pain & arrhythmias
CKD sx (hematuria, nocturne, edema)
PAD sx (claudication)
11
Q
initial HTN investigations
A
creatinine and electrolytes
Urinalysis
FBG and A1c
lipids
ECG
consider coronary calcium scan (CAC score), B-HCG some meds c/I
can consider echo, carotid dopplers, ABI, abdominal us, CAC, BNP
12
Q
What are secondary causes of HTN
A
PRESSURE MNEMONIC
pre-eclampsia
phaeo, aldosterone, cushings, hyperthyroid
OSA, coarctation of aorta
substances & meds
renal
13
Q
what do you need to check after starting HTN meds?
A
Cr and electrolytes 2-4 weeks after
14
Q
what is target BP
A
usually <130/80
unless 85+yo than <140/90
15
Q
how often are you monitoring once starting HTN meds?
A
every 1-2 months until 2 readings are in target, then every 3-6mo
16
Q
common HTN meds
A
ACEi/ARB
BB
CCB
Thiazide diuretic
17
Q
ace arb contraindicated in?
side effects?
A
bilateral RAS, pregnancy, angioedema
s/e: chronic cough, angioedema, acute renal failure
18
Q
BB contraindicated in?
A
asthma
2nd/3rd degree heart block
uncompensated HF
severe PAD
s/e: ED, low HR, bronchospasm, insomnia, reduced ex tolerance
19
Q
CCB c/I and s/e
A
recent MI with palm edema
heart block
s/e: edema, flushing, dyspnea/pulmonary edema in patients with LVD
20
Q
thiazide contraindications
A
gout and can precipitate renal failure and hypokalemia
21
Q
go to HTN med for DB
A
ace/arb +/- CCB
22
Q
HTN meds for HFrEF
A
ace/arb + BB + MRA + SGLT2
- add loop for volume control
- add thiazide for BP control
23
Q
hypertensive emergency definition
A
decompensation of vital organ function due to high BP (no cutoff)
high BP + either:
- MI
- encephalopathy
- LVF
- aortic dissection
AND AKI, papilloedema
24
Q
which conditions define hypertensive emergency?
A
high BP + either:
- MI
- encephalopathy
- LVF
- aortic dissection
**impacting brain or heart function
25
ICD used for?
prevent SCD in patients with life threatening rhythm (VT, VF) and can pace
26
Pacemaker used for
slow or irregular rhythm
- can either pace on demand as needed to maintain min HR
- full control
27
differentials for chest pain
cardiac:
- MI/ACS
- aortic dissection
- stable angina
- pericarditis/myocarditis
- HF
- anemia
- aortic stenosis (SAD)
- cardiac tamponade
resp:
- PE
- TPTX
- malignancy
- pneumonia
- bronchitis
- asthma
GI:
- gerd
- esophageal spasm/esophagitis
- PUD, pancreatitis, cholecystitis
- IBD
- hiatal hernia
MSK pain
- rib
- chostochondritis
- rheum
- arthritis
- fibromyalgia
Psych:
- anxiety or panic attack
- somatoform
- cocaine use
Neuro:
- herpes zoster
- radiculopathy
- slipped disk
28
investigations for suspected ACS
ECG
bloods:
- serial troponin and CKMB (good for re-infarction rises for 1-2 days)
- BUN, Cr, electrolytes (renal function for contrast)
- CBC - WCC (ix), plts for thrombolysis, Hb for anemia
- RFs: A1c, fasting glucose, fasting lipids
- d-dimer - negative reduces risk of PE & AD
- CRP - elevated in carditis
chest xray - resp path
echo - cardiac valvular function, size, complications (HF & valvular)
29
major complications of ACS
CRASH PAD
- HF (pulm edema)
- Valvular (ex: MR)
- Arrhythmia (broad complex tachycardia) = VTACH --> VFIB = deadly
- heart blocks
- Cardiac arrest (pump failure)
- ventricular aneurysm/septal defect
- Dresslers (pericarditis)
Cardiac Rupture
Arrhythmia
Shock
Heart failure/HTN
Pericarditis/pulmonary rales
Aneurysm
DVT
30
STEMI time is muscle - what are the time windows?
within 90-120mins of contact, within 12hours of symptom onset (check the 12hours)
31
STEMI management
ECG
Defib pads and 2 large bore cannulas
- DAPT --> aspirin 325mg chewable + 180 ticagralor or 600mg clopidogrel
- if not right sided infarct, give nitro sublingual or IV if SBP > 90mmHg
- if ongoing pain, 2mg morphine IV
- beta blocker
- statin
- heparin or LMWH
- urgent cardio consult for PCI or thrombolysis if >120min since contact
before discharge - start ace-i (has mortality benefit - prevents remodelling)
32
NSTEMI Mx
ECG
Defib pads and 2 large bore cannulas
- DAPT --> aspirin 325mg chewable + 180 ticagralor or 600mg clopidogrel
- if not right sided infarct, give nitro sublingual
- if ongoing pain, 2mg morphine IV
- beta blocker
- statin
- heparin or LMWH
- urgent cardio consult - may need angio to assess for PCI need
- monitor with ongoing ECG
33
which type of ACS do you avoid nitrates in?
inferior MI infracting right ventricle -- avoid nitrates & give IV fluid support, can develop heart block or Brady arrhythmia because impacting sinus node
34
what should you order if ACS patient is desaturating?
chest x-ray - pulm edema
need to administer IV diuretics if SBP > 100mmHg
35
serial troponins taken at what times and what is cutoff?
0 (baseline) and 3 hours
delta refers to the change in troponin
>10ng/L strongly suggests MI (needs to be above 99% ULM which is usually 14ng/L for hs-troponin
36
discharge planning for ACS
MDT approach to cardio rehab (physio, OT, social work, dietitian, specialized cardiac nurses to teach sx)
meds:
- ace-i (prevents remodelling and HTN)
- bb (rhythm control)
- statin (stabilize plaque)
- anti platelet for 12 months post PCI (check this)
- tighten DM control
- diuretic if HF
37
CRASH PAD mnemonic for ACS complications
Cardiac Rupture
Arrhythmia
Shock
Heart failure/HTN
Pericarditis/pulmonary rales
Aneurysm
DVT
38
cardiac & resp differentials for chest pain
cardiac:
- MI/ACS
- aortic dissection
- stable angina
- pericarditis/myocarditis
- HF
- anemia
- aortic stenosis (SAD)
- cardiac tamponade
resp:
- PE
- TPTX
- malignancy
- pneumonia
- bronchitis
- asthma
39
non-cardiac/resp differentials for chest pain
GI:
- gerd
- esophageal spasm/esophagitis
- PUD, pancreatitis, cholecystitis
- IBD
- hiatal hernia
MSK pain
- rib
- chostochondritis
- rheum
- arthritis
- fibromyalgia
Psych:
- anxiety or panic attack
- somatoform
- cocaine use
Neuro:
- herpes zoster
- radiculopathy
- slipped disk
40
Type 1 vs. 2 MI
Type 1: atherothrombotic (clot)
Type 2: demand ischemia
41
Angina 3 criteria:
1. retrosternal pain
2. provoked by exertion or emotion
3. relieved with rest 5 min or nitro
42
ACS pain is exacerbated and relieved by?
classic sx exacerbated by lying down, meals, emotional stress and exertion
relieved by sitting up, rest, nitro
43
typical ACS pain should not be reproducible by what?
palpation
pleuritic (breathing)
position (pericarditis)
44
atypical ACS pain sx and population
women, DM, elderly
GI sx: N/V, belching, indigestion, hiccups, epigastric pain,
Dizzy
Diaphoretic/clammy
Pleuritic chest pain
SOB
Pain in both arms, neck, jaw
Pain at rest
**SOB and dizzy on exertion as opposed to pain
45
GI sx: N/V, belching, indigestion, hiccups, epigastric pain,
Dizzy
Diaphoretic/clammy
Pleuritic chest pain
SOB
Pain in both arms, neck, jaw
Pain at rest
What should you be thinking of?
ACS atypical symptoms
46
What are you looking at on physical exam for ACS?
- Vitals (hypotension - unstable, BP both arms r/o AD)
- Neck - JVP (RHF)
- CVR - MR, gallops (S3 a/w HF)
- Resp - lung bases (pulmonary edema)
- Legs - edema
47
What is costochondritis
inflammation of the cartilage that connects ribs to sternum
- happen with heavy working out/lifting, direct injury, RA/fibromyalgia, repetitive coughing
- worse with movement, breathing, palpation
*differentiate from cardiac via labs, reproducible on palpation and not improved with nitroglycerin
Improves with NSAIDs, heat/ice, stretching, PT
48
What is pleurisy
Pain caused by inflammation to the pleural lining in the lungs
- most commonly viral, can be bacterial/fungal
- caused by PE, lung cancer, collapsed lung (anything that causes ix in lungs)
Treat with NSAIDS and tx underlying condition
48
How to differentiate costochondritis from cardiac pain?
labs (normal)
palpate = pain
NTG spray = do nothing
49
Investigations for stable chest pain
ECG
Bloods - CBC, INR, BUN, CR, lytes, LFTs, FBG/A1c, lipids
CXR - HF, cardiomeg, pneumonia
Risk stratify with CAC, exercise ECG, echo, CCTA, SPECT, cardiac MRA, angio
50
which cardiac imaging would you order for low pretest risk?
High risk?
CAC score
CCTA
Mod - high risk: SPECT, MRA, stress echo
HIGH RISK: angiography
51
what are the BP, cholesterol and DM targets for ACS
SBP 120-130
A1c < 7%
LDL < 1.8mmol/L
52
lifestyle mods to counsel on
exercise (consider cardiac rehab)
diet (<2300mg salt, no trans fats, reduce refined carbs & sat fats)
alcohol (<1/d for W, <2 for M)
sleep & stress
weight (loss + semiglutide + bariatric)
smoking cessation
environment
immunizations - pneumo, COVID, flu
53
Acute mx of ACS
ABCs, O2 if needed, IVF
Aspirin 325mg, clopidogrel 300mg
nitroglycerin 0.4mg 1-2 sprays q5 mins x 3
Morphine 3-5mg for severe pain
Anticoagulate per cardio pref
ECG
Hs-trop q3-6 hours, CBC, INR, FBG/A1c, fasting lipids, LFTs, renal, BNP
CXR
Consider echo, SPECT, CCTA as needed
Start BB and Ace-i within 24 hours if no c/I, start statin
54
Discharge planning for ACS
nitroglycerin
DAPT
BB
ace-i (consider)
statin
no driving for 2-4 weeks
manage AFib
cardiac rehab
**tight glycemic control, BP, lipids, Afib, TSH and anemia
55
What are other causes of elevated troponin?
SAH & stroke
myocarditis, pericarditis, HF
PE
malignancy & sepsis
renal failure
56
Contraindications of beta blockers
asthma
reactive airway disease
second or third degree heart block
bradycardia
prolonged PR interval
risk of cariogenic shock
low output
57
contraindications of ace-inhibitors
angioedema
???
58
what blood work to order in acute ACS
hs-troponin serial
INR
CBC
FBG/A1c
lipids
renal function & lytes
LFTs
BNP
59
what should you order for patient following conservative management of NSTEMI before discharge?
echo
stress test
60
treatment options for NSTEMI
1. conservative management with meds
2. PCI with stent
3. CABG
61
what med needs to be discontinued prior to CABG?
P2Y12 inhibitors
62
treatment options for STEMI
1. PCI
2. Fibrinolytics
3. CABG
4. Conservative
63
absolute contra for fibrinolytics
- intracranial hemorrhage
- ischemic stroke <3 months
- head neck trauma in 3 months
- intracranial/spinal surgery in 2 months
- cerebral lesion
- malignancy
- active bleed
- aortic dissection
- severe uncontrolled HTN
64
which 6 conditions do you want to ensure tight control of at discharge of ACS patient?
Glycemic control
HTN
Lipids
Afib
TSH
Anemia
65
For chronic angina, which meds will you start?
Nitroglycerin
Aspirin
Beta blocker
Statin
Ace-i
*consider SGLT2 if HF or DM
*consider GLP1 if DM or BMI > 27
*consider DAPT
66
If patient has ACS symptoms but angio comes back showing stenosis < 50%, what conditions are you thinking of?
Mimickers - myocarditis, supply demand ischemia
spasm, plaque disruption, embolism, microvascular dysfunction
67
*vasospasm what do you give
CCB and nitrates
68
Stage 1 and 2 Hypertension
Stage 1 <140/90
Stage 2 >140/90
69
Hypertensive urgency number
180/120 without organ damage
emergency is with organ damage
70
secondary hypertension mnemonic from ninja nerds
RENALSS
Renovascular - RAS or CKD
Endocrine - thyroid & adrenal gland
Neuro - increased ICP (Cushing triad)
Aortic - coarctation
Little people - preeclampsia
Sleep apnea
Substances - increase SNS
71
cardiac complications of HTN
1. LVH --> diastolic HF (HFpEF)
2. Flash pulmonary edema
3. Atherosclerosis --> MI
4. Atherosclerosis--> PAD
5. Aortic aneurysm
6. Aortic dissection
72
neuro complications of HTN
rupture or plaque up the vessels
1. ICH or SAH - rupture
2. carotid stenosis - TIA
3. CVA
73
renal complications of HTN
HTN causes high GFR, kidney doesn't like that so causes sclerosis of afferent arteriole --> ischemia and renal injury --> AKI or CKD
HTN and DM 2 major causes of CKD
74
retinal complication of HTN
cotton wool spots, microedema haemorrhages
look out for blurring of optic disc - papilloedema
75
what do you start for stage 1 hypertension? For stage 2?
lifestyle mods
if ASCVD risk > 10%, start meds (ACE/ARB, Thiazide, CCB)
Stage 2 start meds right away
76
In African patients, what BP med to start?
Avoid ace/arb
Try CCB or Thiazide
77
which antihypertensive do you start post-MI?
HF?
CAD?
Post-MI: BB & ACE/ARB
HF: BB, ACE/ARB, Spironolactone
CAD: we want to dilate --> nitrates, BB, CCB
78
Which ANTI-HTN for DM and CKD?
ACE/ARB
79
Which ANTI-HTN for AFIB?
BB or non-DHP CCB
80
Anti HTN for pregnancy
Healthy moms like nifedipine
Hydralazine, Methyl dopa, Labetalol, Nifedipine
81
when do you avoid ACE/ARB/AA?
if AKI, if hyperkalemia, if African American ethnicity
82
Hypertensive emergency conditions (head to toe)
CVA
Encephalopathy
ACS or HF (pulm edema)
Aortic Dissection
AKI
83
How to manage hypertensive emergency
drop MAP by 25% in 1-2 hours using IV agents, drop BP to <160/100 in 2-6 hours
normalize BP in 1-2 days
84
HF symptoms
HF signs
symptoms:
- SOB, fatigue, orthopnea, PND
- chest pain
- cough with pink frothy sputum
- leg swelling and weight gain (central)
precipitants:
- chest pain
- palpitations
- viral symptoms
- nocturia
signs:
- JVD, hepatojug reflex
- rales at lung bases & pulm crackles
- displaced apex and left parasternal heave
- S3 gallop
- peripheral edema
- peripheral cyanosis
85
HF signs
signs:
- orientation, confused (encephalopathy)
- JVD, hepatojug reflex
- rales at lung bases & pulm crackles
- displaced apex and left parasternal heave
- S3 gallop
- peripheral edema & ascites
- peripheral cyanosis, cold and clammy
*vitals - hypotensive, tachycardia, tachypnea, hypoxia
86
HFrEF vs. HFpEF
HFrEF < 40%
HFpEF > 50% plus either LVH/LA dilation or diastolic dysfunction
87
three main causes of heart failure
damage to myocardium
- ischemic heart disease
- toxicology (hypothyroid, cocaine, amphetamines, steroids, alcohol, thiamine def)
- infiltrative diseases
- genetic - HOCM, dilated cardiomyopathy, hemochromatosis
abnormal load
- hypertension/LVH
- fluid overload state (renal failure, iatrogenic)
- constrictive pericarditis
- valvular abnormalities (aortic stenosis)
arrhythmias
nutritional (thiamine, selenium, malnutrition, obesity)
pregnancy (PET and GDM)
infections (pneumonia, myocarditis, influenza)
DM, thyroid, cushings (METABOLIC)
88
NYHA classifications
1 - no limitation
2 - comfort @ rest, mild sx with normal activity
3 - comfort @ rest, moderate sx with normal activity & significant limitation
4 - uncomfortable at rest, severe limitation
89
SOB differentials
HF
MI
LRTI
COPDE
PE
PTX
Asthma Exacerbation
Severe anemia
Aortic stenosis
A fib
Other causes of fluid retention:
- meds (CCB, NSAIDS)
- renal
- liver (cirrhosis)
90
Pt presents with acute onset SOB, pleuritic CP and tachycardia. What are you thinking of immediately?
PE & PTX & MI
91
Precipitating factors for HF
FAILURES
1) forgetting meds
2) arrhythmia
3) ischemia/ACS
4) lifestyle factors - salt, alcohol, fluid
5) upregulated states - preg, thyroid, steroids, anemia
6) renal
7) upregulated states - preg, thyroid, steroids, anemia
8) Embolism
9) Stenosis (AS and RAS)
92
what can be used to screen for HF?
BNP --> if elevated order echo & refer
93
what initial investigations will you order for HF?
labs:
- hs-troponin
- BNP
- CBC + ferritin (anemia, WCC)
- CRP/ESR
- Cr, BUN, electrolytes
- LFTs
- FBG & lipids
- TSH
ECG (ischemia, LVH, afib)
chest x-ray (r/o differentials & expect to see certain things)
THEN order echo
Consider graded exercise stress test to see functional limit
94
what should you be monitoring after starting ace/arb or diuretics?
creatinine and electrolytes
95
when do you repeat echo in HF patients?
meds should be titrated to goal dose by 3 months (titrate every 2-4 weeks) - do echo after 3 months of target therapy and then every 1-3 years if stable
96
how to counsel HF patient on home care
contact MD if:
- SOB at rest, with less activity, worsening PND or orthopnea
- edema
- weight gain (2kg in 2 days, 3kg in 7 days)
- dizzy, confused
- reduced appetite
- impaired sleep
- chest pain or palpitations
97
lifestyle modifications for HF
1) daily weights
2) sleep upright if PND or orthopnea
3) limit salt to 2-3g/day = <1 tsp
4) fluid restriction 1.5-2L/day
4) regular physical activity that does not produce symptoms (cardiac rehab)
5) flu shot yearly and pneumonoccal
98
management of HFrEF
BB + ACE/ARB/ARNI + MRA + SGLT2 - titrate every 2-4 weeks until at goal (plus omega 3 1g daily)
*acute management - LMNOP
- lasix, nitrate infusion, oxygen, position upright and CPAP
*start BB when DRY and ARNI when WET (better outcome this way)
*re-do echo at 3 months once meds at target
*HR goal is 50-60 -- if >70, try ivabradine
*if Afib suboptimal, try digoxin
*if black - do not give ace/arb/arni - try hydralazine/nitrates
99
what to do if LVEF <35% at 3 month echo check?
consider CRT or ICD to prevent SCD
if >35%, continue medical management
100
what to monitor at regular visits with HF patient
- vitals: HR (BB therapy), BP, O2, weight
- new symptoms
- orthostatic vitals
- JVP, edema, CVR & RESP exams
101
office based management of acute decompensated HF
mild to moderate can be managed in office
- any signs of resp distress (tachypneic, tachycardia, hypoxic, AMS, SBP < 90) need to go to ER
- sit upright & administer oxygen
- determine trigger
- 1.5 - 2x furosemide dose
- consider halving or holding beta blocker if hypotensive
- check renal function before deciding ace/arb dosage
- consider spironolactone if pulm congestion severe
- if hypertensive consider GTN spray
discuss sodium and water restriction, check renal function and electrolytes within 24-48 hours
102
SBP < 90mmHG in heart failure patient indicates what?
cardiac shock and low perfusion
103
for preserved EF, do you follow GDMT or symptom based?
symptom based (diuretics, BP control, SGLT2i)
104
how to start HF meds as a family doc
1) confirm diagnosis - need an echo
2) week 1-2 - start ARNI & BB
3) week 2-4 - start spironolactone (if K < 5 & eGFR > 30)
4) week 4+ - start SGLT2i
*titrate every 2 weeks and monitor HR, BP, renal function, side effects (dizzy, fatigue, hyperkalemia)
*furosemide 20-40mg qd PRN for volume overload
105
what are the four pillars of goal directed medical therapy (GDMT) for HF:
ARNI (or ace / arb)
BB
MRA
SGLT2i
106
what do you prescribe for PRN volume overload in HF patients
*furosemide 20-40mg qd PRN for volume overload
107
what do you expect to see on chest x-ray for HF patient
A - alveolar edema (bat wing opacities)
B- Kerly B lines
C - cardiomegaly
D - diversion of upper lobe vessels
E - pleural effusion
108
atherosclerosis mnemonic
SAD CHF
Smoking
age
diabetes
Cholesterol
HTN
FH
109
complications of hyperlipidemia
atherosclerosis of heart, brain, legs
steatosis --> steatohepatitis --> cirrhosis
pancreatitis (a/w HIGH TGs)
xanthomas and xanthalasma
110
Framingham risk score (FRS) for hyperlipidemia
risk of CVD (MI/stroke/PAD) in 10 years time
<10% low risk - diet only
10-19% - intermediate risk - consider mod statin
>20% high risk - high intensity statin
111
what level of LDL do you treat with statin always
LDL >5 mmol/L
112
when do you screen for hyperlipidemia
40-75yo unless risk factors present (ex SAD CHF, CKD, FH)
113
risk factors to screen for early hyperlipidemia
smoking
premature CVD FH
DM
obesity
HTN (+ preeclampsia)
ED
CKD
HIV
COPD
evidence of atherosclerosis
AAA
clinical - xanthomas, xanthelasmas, corneal arcus
acanthuses nigricans
south asian or indigenous
114
clinical signs of hyperlipidemia
clinical - xanthomas, xanthelasmas, corneal arcus
acanthuses nigricans
115
which common drugs can increase LDL and TGs
beta blockers
steroids
oral estrogen
thiazides
antipsychotics
retinoids
amiodarone
116
four common conditions associated with acquired HLD
DM
hypothyroid
nephrotic syndrome
pregnancy
117
what will you order if you suspect FH
lipid panel (fasting if TG > 4.5)
genetic testing
carotid ultrasound
echo
stress test
118
combined health behaviours can reduce CVD risk and mortality by 75%!!!!
diet, alcohol (<1-2 drinks per day), >150min mod exercise per week, smoking cessation, lose 5-10% of body weight, sleep
119
what meds would you give a patient on a statin with high triglycerides
high dose EPA (icosapent ethinyl 2000g BID) - modified EPA it's not a fish oil
120
LDL > 5.0, what do you do?
treat with statin
121
FRS risk 14%, LDL 4.2, what do you do?
intermediate risk FRS
LDL > 3.5
consider treatment with moderate statin
122
FRS risk 22%, DM patient, what do you do
treat with statin - DM is high risk, FRS score is high risk
LDL goal is <2.0
123
Patient with ASCVD history (MI last year), should they be on a statin?
Yes, for secondary prevention high intensity statin
124
Who should be on high intensity statin?
DM > 40 (or 15 years since diagnosis)
CKD Stage 3+
FH
Secondary prevention
125
what is ApoB and non-HDL?
Lp(a)?
126
what are the high intensity statins
atorvastatin 40-80mg
rosuvastatin 20-40mg
127
if maxed out statin and cannot get LDL to target, what do you do?
consider ezetimibe or PCSK9i
128
Patient's TG is 11.1, what do you do?
consider fenofibrate (but risk of hepatitis and rhabdo if on a statin), or icosapent ethinyl
to prevent pancreatitis
129
what is LDL target for FH
target for ASCVD?
DM?
FH - <2.5
ASCVD - <1.8
DM/CKD - < 2.0
130
what can you use for lipids in pregnancy?
not a statin, cholestyramine (bile acid sequestrant)
131
how much will high intensity vs. mod intensity drop LDL?
high will drop by 50%, mod should drop by 30%
132
if patient develops statin induced myopathy, what do you do?
evaluate muscle ache PRIOR to statin
discontinue statin, order CK & LFTs, renal function
follow CK to normal
restart at a lower dose, consider different statin or alternative agent
133
types of lipid lowering meds
LDL lowering
- statins
- bile acid sequestrates (inhibit bile abs - diarrhea)
- ezetimibe (inhibit chol abs - diarrhea)
- PCSK-9i (really reduce LDL, $$$)
TG lowering
- fibrates (can increase gallstones, LFTs, rhabdo)
- icosapent ethinyl
- niacin (flushing and gout)
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complications of an MI
arrhythmias (first 24 hours)
- RCA knocks out AV node - HB bradyy
- LAD re-entrant circuits --> VT --> VF
HF (first 24 hours)
- heart not pumping as effectively, low LVEF
- back up into lungs = pulm edema
- can lead to severe hypotension = cardio shock
Pericarditis:
- pleuritic chest pain, relieved leaning forward
- friction rub on exam
- can happen within a few days or a few weeks
Rupture syndromes:
- papillary muscle = MR
- ventral septal rupture = VSD
- left wall rupture = cardiac tamponade
- pseudo- aneurysm
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How to decide between PCI and CABG?
PCI
- <3 vessel disease
- not main left vessel
- normal LVEF
CABG is opposite
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what will patients be on after a stent
DAPT for a year
ace, bb, statin
nitroglycerin pen
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