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Cardiovascular Module Flashcards

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1
Q

Hypertension Risk Factors

A 
Age/Gender - Men: Middle age; Women: Post Menopause
Race - African Americans
Family History
Obesity
Sedentary Lifestyle
Low potassium diet
High salt diet
Tobacco Use
Alcohol
Stress
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2
Q

What race is correlated with higher blood pressure?

A

African American

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3
Q

When do women have a higher risk for HPTN?

A

Post menopause

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4
Q

When do men have a higher risk of HPTN?

A

Middle Age

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5
Q

How is a sedentary lifestyle correlated with HPTN?

A

Indirectly affects BP due to direct effect on weight.

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6
Q

What chronic conditions are HPTN risk factors?

A

Sleep Apnea - correlated with obesity
Endocrine diseases
Kidney disease- change in response to ADH and Aldosterone

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7
Q

How does the brain affect blood pressure?

A

The brain controls the adrenergic system.

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8
Q

What hormones affect blood pressure?

A

Adrenaline
Aldosterone
Angiotensin II
ADH

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9
Q

What are the symptoms of HPTN?

A

Headache
Fatigue
Dizziness
End Organ Damage

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10
Q

What is the most common way HPTN is discovered?

A

Screening

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11
Q

How do most patients with HPTN present?

A

Asympomatic

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12
Q

What are the signs of HPTN?

A

Usually related to other contributing conditions and/or end organ damage.

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13
Q

Why should we treat HPTN?

A

Reduce the risk of cardiovascular events.

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14
Q

What cardiovascular events can occur due to HPTN?

A 
Stroke -  ischemic or hemorrhagic
Myocardial Infarction
Peripheral Arterial Disease
Congestive Heart Failure
Left Ventricular Hypertrophy
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15
Q

What is the effect on the heart with left ventricular hypertrophy?

A

Heart becomes weaker and the ventricle becomes smaller.

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16
Q

How do you choose a medication?

A 
Co-morbidity
Contraindications
Compliance
Limitation
Price
Side effects
Interactions
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17
Q

At what blood pressure would a patient sees benefits from medication?

A

> 140/90

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18
Q

According to the seventh national committee (JNC7) what is HPTN?

A

Elevated blood pressure in 2 or more visits.

Normal <80

Pre-hypertension: Systolic 120-139; Diastolic 80-89

Hypertension: systolic greater than or equal to 140; diastolic greater than or equal to 90

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19
Q

What is stage 1 HPTN?

A

SBP: 140-159
and/or
DBP: 90-99

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20
Q

What is stage 2 HPTN?

A

SBP >160
and/or
DBP >100

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21
Q

What is isolated systolic HPTN?

A

SBP > or equal to 140

DBP less than 90

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22
Q

What is isolated diastolic HPTN?

A

SBP less than 140

DBP > or equal to 90

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23
Q

What is optimal blood pressure?

A

SBP < 80

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24
Q

What is normal blood pressure?

A

SBP 120-129

DBP 80-84

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25
What is high normal blood pressure?
SBP 130-139 | DBP 85-89
26
What should be considered in a hypertensive patient with kidney disease?
More aggressive therapy and goals. Ideally keep BP below 130/80
27
When should you consider starting a second medication for HPTN?
If BP is 20S/10D points higher from the target.
28
What are some calcium channel blockers?
Verapamil Diltiazem Amlodipine
29
What are side effects of calcium channel blockers?
Leg Edema- Dose dependent | Cancer?
30
What is long-acting Amlodipine used for?
Angina in COPD
31
What effect does Amlodipine have?
Vasodilator
32
What do Verapamil and Diltiazem do?
Effect heart rate
33
What negative impact can Verapamil and Diltiazem have?
Can worsen CHF
34
Is it beneficial to treat low risk patients?
Results unclear
35
What is the target BP for the elderly?
Variable
36
What work up should be done in those with HPTN?
``` EKG UA Renal Function Electrolytes Glucose CBC Lipid Panel ECHO ```
37
What drugs are superior in CAD?
Beta Blockers
38
What are some non-pharmacological approaches to HPTN?
Low sodium diet Weight loss Decrease alcohol intake Aerobic exercise
39
What should be looked for in a UA with HPTN?
Protein in the urine
40
What are the top 4 medications for treating HPTN?
Diuretics (Thiazides) Calcium channel blockers Beta blockers ACE Inhibitors/ Angiotensin Receptor Blockers
41
What medication is often used as an "add-on" for HPTN?
alpha blockers
42
What medication is inferior in protecting against stroke?
Beta blockers
43
What medication is often used in atrial fibrillation or CHF?
Beta blockers
44
What effect do beta-blockers have on migraines?
None
45
What are side effects of beta blockers?
Impaired glucose Fatigue Worsening COPD Younger males - sexual dysfunction
46
What medication for HPTN is better after a heart attack?
Beta blockers
47
What are the types of beta blockers?
Selective | Non Selective
48
What are the thiazide medications?
``` Hydrochlorthiazide Chlorthalidone (longer hours 24-72) ```
49
What are common side effects of thiazides?
Hypokalemia Glucose Intolerance Hyperuricemia Lipid disorder
50
What medications do not work in renal failure?
Thiazides
51
What is the most common dose for thiazides?
25 mg | Dose ranges from 6.5-50 mg
52
What are alpha 1 blockers used for?
Enlarged prostate symptoms
53
What are alpha 2 blockers used for?
Used in VERY high blood pressure
54
What are the side effects of alpha-1 blockers?
Dizziness | Orthostatic changes
55
What are the side effects of alpha 2 blockers?
Sedation Fatigue Depression *Hypertensive rebound effect when medication is stopped
56
What are ACE inhibitors/ ARBs used for?
CHF MI Proteinuria DM
57
What drug is highly contraindicated in pregnancy?
ACE I / ARB
58
What drugs for HPTN are #1 used in diabetics?
ACE I / ARB
59
What are the side effects of ACE I/ ARB?
*Dry cough Hyperkalemia Renal Failure
60
Where to ACE I's work?
Stop conversion of Angiotensin I to Angiotensin II to stop binding with the AT1 receptor preventing vasoconstriction.
61
Where to ARBs work?
Block AT1 receptor which prevents vasoconstriction
62
What are the components of arterial pressure?
Cardiac Output and Peripheral Resistance
63
What are determines cardiac output?
Stroke Volume and Heart Rate
64
What determines stroke volume?
Myocardial contractility and Size of the vascular compartment
65
What determines peripheral resistance?
Vascular structure and function
66
What happens to the elasticity of blood vessels with age?
Elasticity decreases
67
What is the effect on blood pressure of increased myocardial contractility?
Increased Blood Pressure
68
What is the effect on blood pressure of decreased myocardial contractility?
Decreased blood pressure
69
What medications are used sparingly in hypertensive patients?
Hydralazine A-Methyl Dopa Minoxidil
70
What HPTN medications work on the CNS?
Beta Blockers | Alpha 2 Agonists
71
What HPTN medications work on the blood vessels?
``` Alpha 1 Receptor Blockers Calcium Channel Blockers Vasodilators AT1 Receptor Antagonists ACE Inhibitors ```
72
What HPTN medications work on the kidneys?
Diuretics Beta Blockers ACE Inhibitors
73
What HPTN medications do African Americans respond well to?
Diuretics and Calcium Channel Blockers
74
What HPTN medications do African Americans respond poorly to
ACE I and ARBs
75
What HPTN medications have dose-dependent side effects?
Beta Blockers | Calcium Channel Blockers
76
Should you look for a reason for secondary HPTN?
In general- looking for a reason has little value and is not cost effective unless there are clues suggestive for secondary causes.
77
When do you treat secondary HPTN?
Severe or resistant to treat. Acute Rise. Age <30, non-obese, no family history, no other risk factors. Malignant or accelerated with end organ damage.
78
What work up should be performed for secondary hypertension?
``` Renal Imaging Plasma rennin activity Plasma and Urine Catecholamines MRA, duplex US CTA ```
79
What is the most common cause of secondary HPTN?
Renal Artery Stenosis
80
What is the most underestimated cause of secondary HPTN?
Sleep Apnea
81
What are the causes of secondary HPTN?
``` Genetics Abdominal bruits Primary Hyperaldosteronism Phenochromocytoma Cushing's Syndrome Sleep Apnea Coaractation of the Aorta (evidenced by radial-femoral delay; check pulse in lower limbs) Medications ```
82
What is hypertensive urgency?
SBP Greater than or Equal to 180 | DBP Greater than or Equal to 120
83
What symptoms are seen in hypertensive urgency?
No symptoms or just a headache
84
What are the common causes of hypertensive urgency?
Not taking medications | Too much salt
85
What is the goal in treating hypertensive urgency?
Gradual reduction to safer level - 160/100
86
How do you treat hypertensive urgency?
``` Rest Reduce anxiety Restart medications Add or increase dose Decrease salt Send home with follow up in a few days ```
87
What is a hypertensive emergency?
End Organ Damage SBP greater than or equal to 180 DBP greater than or equal to 120
88
What are signs of a hypertensive emergency?
``` Encephalopathy Retinal Hemorrhage Papiledema Acute Renal Failure Chest Pain EKG Changes ```
89
How do you treat a hypertensive emergency?
``` *Nitroprusside Nitroglycerine Labetalol Nicardipine Clevidipine Hydralazine Enalaprilat ```
90
Which medication is the most rapid and has the most potent duration of action?
Nitropusside 2-5 minutes Important in hypotension
91
What is a side effect of Nitroprusside?
Cyanide Toxicity >24 hours or with renal failure.
92
Why do you want to avoid over reduction of blood pressure in stroke?
You must avoid ischemia to the surrounding healthy areas.
93
What should be considered in management of acute pulmonary edema?
Consider nitroglycerine and diuretics; avoid Labetalol which could affect contractility.
94
What management considerations are necessary for aortic dissection?
Nitroprusside should only be used after controlling the heart rate with a beta blocker.
95
What should not be used in acute increases in sympathetic activity caused by pheochromocytoma or cocaine?
Beta Blocker alone- will have alpha adrenergic unopposed and this will raise BP.
96
What should be used in acute increases in sympathetic activity caused by pheochromocytoma or cocaine?
Nitroprusside | Phetolamine (alpha adrenergic blocker)
97
What causes orthostatic hypotension?
Autonomic reflexes are impaired or intravascular volume is depleted.
98
What are risk factors for orthostatic hypotension?
``` Elderly Medications Diabetic Neuropathy Autonomic Dysfunction Parkinsons Pareneoplastic Familial ```
99
What is orthostatic hypotension similar to?
Aortic Stenosis Arrhythmia Postural Tachycardia Syndrome Postprandial Hypotension
100
What are symptoms of orthostatic hypotension?
Dizziness Weakness Syncope
101
How is orthostatic hypotension diagnosed?
Fall of 20 systolic or 10 diastolic 2-5 minutes in supine position.
102
What does an increase in heart rate of greater than 30 BPM suggest?
Postural Tachycaridia Syndrome
103
What is the work up for orthostatic hypotension?
CBC Renal Function Glucose
104
What is the treatment for orthostatic hypotension?
``` Avoid/treat primary reason Fluids Arise slowly Avoid long standing Avoid coughing, hot weather, straining Wear elastic stocking extended to the waist Tense the legs ``` Increase salt and water consumption Avoid large meals
105
What medications are used to treat orthostatic hypotension?
Fludrocortisone Midodrine alpha1 adrenergic Caffeine
106
What are the risk factors of coronary artery disease?
``` Smoking Dyslipidemia Hypertension Diabetes Abdominal obesity Psychosocial factors Physical activity Family History Age Gender Collagen Vascular Disease Infections! Sleep apnea Homocystiene Cocaine Methamphetamine Takotsubo stress cardiomyopathy Anemia Arrhythmia Hypoxia ```
107
What are the symptoms of an MI?
``` Chest Pain SOB GI Diaphoresis Dizziness Fatigue Sudden Death ```
108
What are signs of an MI?
``` Sweating Increased heart rate Change in blood pressure New murmurs/ heart sounds Chest congestion Irregular heart beat ```
109
What diagnostics are performed on someone with CAD?
``` EKG Cardiac Enzymes CXR CBC Renal Function Electrolytes Transthoracic Echo Stress Test/ coronary angiogram ```
110
What are appropriate questions to ask about a patient's chest pain?
``` Location Radiation Quality Duration Response to medication Provoking factors Timing ```
111
What is the pathophysiology of an aortic dissection?
A tear in the aortic intema which could involve branch vessels, the aortic valve, or could enter the pericardial space.
112
What can aortic dissection cause?
Ischemia Aortic regurgitation Cardiac Tamponade
113
Who is most likely to get aortic dissection?
Mostly men aged 60-80.
114
What is the most predisposing factor for aortic dissection?
Hypertension
115
What are risk factors for aortic dissection?
``` Hypertension Inflammatory changes such as vasculitis, Giant Cell Arterities, Takayasu, Syphilitic Aortis, RA Marfan Syndrome Ehler-Danlos Syndrome Aortic coarctation Turner Syndrome CABG Cardiac catheterization High Intesnsity Weight Lifting ```
116
What are the signs and symptoms of aortic dissection?
``` Severe sharp or tearing chest pain Syncope CVA Myocardial Infarction Painless in cases like DM Patients are usually hypertensive but not always. ```
117
How is aortic dissection diagnosed?
``` CXR Ct scan MRI Aortogram TTE ```
118
How is a Type A aortic dissection treated?
Surgically
119
What is a Type A aortic dissection?
An aortic dissection which occurring in the ascending aorta.
120
What is a Type B aortic dissection?
An aortic dissection occurring in the descending aorta.
121
How is a Type B aortic dissection treated?
Medically
122
What is peripheral vascular disease?
Accumulation of lipid and fibers in the intimal and medial layers of the vessel.
123
What are the risk factors of PVD?
``` Age >50 DM Smoking Men Family History HTN Hyperlipidemia Homocysteinemia Metabolic Syndrome ```
124
What are the symptoms of PVD?
``` Claudication Diminished pulses Tissue loss Ulcer gangrene Limb threatening ischemia Erectile dysfunction (common iliac disease) Bruit, pale, ulcer, loss of hair Nerve involvement ```
125
What imaging should be ordered for PVD?
CTA MRA Angiogram
126
How is PVD managed?
Smoking Risk Factors Exercise Phosphodiesterase inhibitors
127
How is PVD treated?
Angioplasty Stent Bypass graft - Aorto-femoral or axillo-femoral
128
What is the ankle-brachial index?
The blood pressure difference between the ankle and the brachial artery.
129
What ankle-brachial difference may indicate PVD?
<0.9
130
What is a normal Ankle-Brachial Index?
1-1.2
131
What are the symptoms of acute PVD?
``` Embolus or Thrombosis Pain Low Pulse Numbness Pallor especially on elevation Cool limb Acidosis ```
132
How is acute PVD treated?
``` QUICKLY!! Irreversible damage occurs >3 hours Heparin TPA Catheter based ```
133
What causes chronic venous insufficiency?
Trauma DVT Obstruction
134
What are the symptoms of chronic venous insufficiency?
Edema Dull Pain Skin Changes Ulcers
135
What causes superficial thrombophlebitis?
Intravenous catheters Trauma Pregnancy
136
What are the symptoms of superficial thrombophlebitis?
Pain Redness Tenderness Tends to improve in 1-2 weeks
137
How is superficial thrombophlebitis treated?
Head NSAID Anticoagulation ABX with infection
138
What causes deep vein thrombosis?
``` Cancer Immobilization Coagulopathy Birth Control Major surgery ```
139
What are the symptoms of DVT?
Pain Swelling Redness Pulmonary Embolism
140
What is Virchow's Triad?
The three factors leading to thrombosis: venous stasis vessel wall injury altered blood coagulation
141
How is a thrombus formed where there is no inflammation?
through phlebothrombosis
142
What leads to a thrombus formation where inflammation is present?
The thrombus would cause inflammation of the vein walls or what we call thrombophlebitis. This will eventually lead to thrombus formation.
143
What is Virchow's Triad?
Stasis Hypercoagulability Intimal Change
144
What are venous thrombi?
Accumulation of platelets in response to inflammation which attach to the vein wall adn contain a tail-like attachment made of WBCs, RBCs, and fibrin.
145
How do you diagnose a DVT?
Duplex US D-Dimer Venogram Serial US
146
How is a DVT treated?
Anticoagulation Thrombolysis Greenfield Filter
147
When is a Greenfield Filter used?
when anticoagulation therapy is contraindicated

Clinical Medicine (4 decks)

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