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Flashcards in Geriatric Medical Potpourri Deck (64):
1

1. HTN is defined as what?

2. Isolated systolic hypertension (ISH) a common form of HTN in the elderly, is defined as what?

3. For most elderly pts can this be reversed?

4. Most common presentation?

1. Defined as systolic BP >140 or diastolic BP > 90

2. sys BP >140 and diastolic BP less than 90

3. For most elderly patients, hypertension does not have a reversible cause

4. is asymptomatic

2

1. Evaluation should include detection of what? 3

2. Treatment with lifestyle modifications and drugs, often starting with a what?

1.
-cardiovascular risk factors and
-end-organ damage and a
-search for secondary causes when appropriate

2. thiazide diuretic

3

The volume of blood pumped into the arterial tree is detemined by what?
3

1. Volume of blood within the heart

2. Vigor of the hearts contraction

3. Kidneys

4

Stiffness of the arteries is determined by what?
3

1. Vascular Smooth muscle cell contracile tone
2. Endothelial Cell function
3. Matrix that embeds the vascular smooth muscle

5

Associated Conditions with HTN?
5

1. MI
2. CVA
3. PVD
4. CHF
5. Renal failure

6

If this is ideal…115/75:
Each ______ mmHg rise doubles risk of CVD?


KH
84 year old W F
OA, osteoporosis, urinary incontinence
-Urogyn clinic: BP=190/100
Asymptomatic
BP history: 130/80 – 160/90, no consistency
No meds
What should you do?

20/10



Send em in

7

Name the SBP/DBP associated with the following BP Classification:
1. Normal?
2. Prehypertension?
3. Stage 1 HTN?
4. Stage 2 HTN?

1. less than 120 and less than 80
2. 120-139, 80-89
3. 140-159, 90-99
4. equal to or greater than 160, equal to or greater than 100

8

Benefits of Lowering BP
Describe the average paercent reduction in the following:
1. Stroke incidence?
2. Myocardial infarction?
3. Heart Failure?

1. 35-40%
2. 20-25%
3. 50%

9

Reduced progression of what mental problem occurs with effective antihypertensive therapy?

dementia
-Cognitive impairment more common w/ HTN

10

Accurately Measuring BP
depends on what? 4

1. Cuff size

2. Correct inflation

3. Appropriate interval

4. Several readings

11

Secondary Hypertension Causes?
10

1. Sleep apnea
2. Drug-induced
3. Chronic kidney disease
4. Primary aldosteronism
5. Renovascular disease
6. Chronic steroid therapy or
7. Cushing’s syndrome
8. Pheochromocytoma
9. Coarctation of the aorta
10. Thyroid or parathyroid disease

12

CVD risk factors?
9 (what are the top 4)

1. Hypertension*
2. Obesity* (BMI >30 kg/m2)
3. Dyslipidemia*
4. Diabetes mellitus*

5. Cigarette smoking
6. Physical inactivity
7. Microalbuminuria or estimated GFR less than 60 ml/min
8. Age ( 55+ for men, 65+ for women)
9. Family history of premature CVD(men less than 55 or women less than 65)

13

Target Organ Damage
1. Of the heart specifically? 4

2. Of other organ systems? 4

1. Heart
- LVH
- Angina or prior MI
- Prior coronary revascularization
- CHF

2.
-Cerebrovascular disease (CVA/TIA)
-Renal disease
-Peripheral arterial disease
-Retinopathy

14

1. LVH = __________ risk factor for CVD.



2. Regression of LVH occurs with aggressive BP management: Such as? 3

3. What should you get to dx this?

1. independent

2.
-weight loss,
-sodium restriction, and
-treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.

3. LVH

15

Laboratory Tests
For HTN?
1. Always? 6

2. Optional? 1

1. Always
-EKG!!
-UA
-Chem
-Fasting lipid panel
-H/H,
-TSH

2. Optional tests
-Microalbumin

16

Match the modification with the Approximate SBP reduction range:
1. Weight reduction?
2. Adopt DASH eating plan?
3. Dietary sodium reduction?
4. Physical activity?
5. Moderation of ETOH?

1. 5–20 mmHg/10 kg weight loss

2. 8-14 mmHg

3. 2-8 mmHg

4. 4-9 mmHg

5. 2-4mmHg

17

Tx of HTN
1. Stage 1 HTN without compelling indications?

2. Stage 2 HTN without compelling indications?

3. With compelling indications?

1. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

2. Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

3. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

18

1. Ambulatory BP values are usually ______ than clinic readings.

2. Hypertensive individuals:
-average awake BP > _____?
-average sleep BP >_____ mmHg?

3. Lack of BP drop of 10 to 20% during night could mean what?

4. Home measurement of >______ mmHg is generally considered hypertensive

1. lower

2.
-135/85
-120/75

3. possible increased risk for cardiovascular events.

4. 135/85

19

JNC 7: Key Messages
1. Is BP >20/10 mmHg above goal?
2

2. Most will require how many drugs to achieve goal BP?

1.
-start with two agents
one usually should be a thiazide-
-type diuretic.

2. >1

20

Describe the initial therapies for the following drugs:
1. Heart failure? 5
2. S/P MI? 3
3. High CAD risk? 4

1.
-THIAZ,
-BB,
-ACEI,
-ARB,
-ALDO ANT

2.
-BB,
-ACEI,
-ALDO ANT

3.
-THIAZ,
-BB,
-ACE,
-CCB

21

Describe the initial therapies for the following drugs:
1. Diabetes?5
2. Chronic renal Dz? 2
3. Recurrent stroke prevention? 2

1.
-THIAZ,
-BB,
-ACE,
-ARB,
-CCB

2.
-ACEI
-ARB

3.
-THIAZ,
-ACEI

22

Drugs: Other Considerations
1. Thiazides? 1
2. BBs? 5
3. CCBs? 1
4. Alpha-blockers? 1

1. Thiazides: good for osteopenia/osteoporosis.

2. BBs:
-atrial tachycardias,
-migraine,
-thyrotoxicosis,
-essential tremor,
-perioperative period

3. CCBs: useful in Raynaud’s syndrome

4. Alpha-blockers: useful in BPH

23

Relative Contraindications for the following:
1. Thiazides? 2
2. BBs? 2
3. ACEI/ARBs?
4. Aldosterone antags / K-sparing diuretics?

1.
-gout,
-hx hyponatremia

2.
- RAD or
-2nd/3rd degree heart block

3. risk of pregnancy

4. hyperkalemia

24

Postural Hypotension
1. What is it?
2. Always check what when adjusting meds?
3. Avoid what? 2

1. Drop in standing SBP >10 mmHg ; associated with dizziness/fainting


2. Always check orthostatics when adjusting meds


3. Avoid
-volume depletion and
-excessively rapid titration

25

Hypertensive emergencies:
1. Definition? 2
2. Examples? 7
3. Requires what treatment? 2

1. Emergency:
-marked BP elevations AND
-acute TOD

2.
-encephalopathy,
-TIA/CVA,
-papilledema,
-MI or unstable angina,
-pulmonary edema,
-life-threatening arterial bleeding or aortic dissection,
-renal failure

3.
-requires hospitalization and
-parenteral drug therapy.

26

Hypertensive Urgencies
1. Definition?
2. Tx?

1. Urgency:
-marked BP elevation but
-NO acute TOD

2. does require immediate combination oral antihypertensive therapy.
-usually does not require hospitalization

27

Hypertension-Geriatric Essentials
1. Most people >65 have hypertension. What kind accounts for > 2/3 of cases?

2. ISH is caused primarily by what? (an increase in what? Due to what? 5)

3. All elderly people should be screened for _________ at every health care visit and at least annually?

1. Isolated systolic hypertension (sys BP >140 with diastolic BP less than 90)

2. an increase in arterial stiffness due to increased
-collagen deposition and
-cross linking,
-degeneration of elastin fibers,
-atherosclerotic changes, and
-age-related endothelial dysfunction

3. hypertension

28

What is pseudohypertension?

BP readings may be falsely elevated in some elderly patients with very stiff, calcified arteries.

29

1. Treatment of hypertension other than ISH reduces incidence of what? 3

2. Treatment of ISH when systolic BP is >= _____ reduces incidence of MI, stroke and heart failure.

Benefits with treatment of ISH when systolic BP is 140-160 are presumed but not proven

1.
-MI,
-stroke, and
-heart failure in the elderly

2. 160

30

1. Most elderly patients ultimately require 2 or more antihypertensive drugs to control BP. What are especially safe in the elderly?

2. In the elderly, all-cause mortality rates increase when diastolic BP is > ___ and

1. Thiazide type Diuretic

2. 80, 60

31

Elderly benefit from aggressive BP control!!!!
1. Goal?

2. Evaluate for? 2

1. Goal: less than 140/90


2.
-Target organ damage
-Other cardiovascular risk factors

32

Complications of stroke may be more devastating than the stroke itself. Such as?
3

Strokes activate the body’s clotting system, potentially leading to
1. venous thromboembolism and
2. MI during the acute period or during convalescence
3. Sometimes it is hard to determine whether the myocardial ischemia or the brain ishemia came first

33

Major risk factors for stroke?13

1. Hypertension ( Systolic or diastolic)
2. Smoking
3. Atrial Fibrillation
4. Myocardial Infarction
5. Hyperlipidemia
6. Diabetes
7. Congestive Heart Failure
8. Acute Alcohol abuse
9. TIA with>70% occlusion of the carotid arteries
10. Oral contraceptives when combined with smoking in women
11. Hypercoagulopathy
12. High RBC count and Hemoglobinopathy
13. Age, Gender, Race, Prior Stroke, and Heredity

34

Classification of Stroke 2

1. Ischemic (75% of strokes…due to embolus or thrombosis)

2. Hemorrhagic

35

Definitions of Stroke 2

1. Transient Ischemic Attack
2. Completed Stroke

36

What is a TIA?

Brief episodes of focal neurological deficits lasting 2-3 minutes to at most a few hours but no longer than 24 hours leaving no residual deficits with complete functional recovery.

37

> 75% of TIAs last less than how long?

5 minutes

38

1. What is the definition of a completed stroke?

2. There is what in in at least a part of area supplied by the affected artery? 2

1. Acute, sustained functional neurological deficit lasting from days to permanent.

2. There is neuronal necrosis or infarction

39

What does the presentation of the stroke depend on?
2

Presentation depends on the
1. affected vessel and
2. whether or not there are any further complicating factors.

40

Stroke Syndromes
7



1. ICA occlusion
2. ACA occlusion
3. MCA occlusion (MC)
4. PCA occlusion
5. Vertebrobasilar occlusion
6. Lacunar Infarct
7. Spinal stroke

41

Anterior Circulation TIA’s and stroke
1. Involvment of what vessels? 2
2. What is Amaurosis fugax?
3. What paresis will present?
4. What two other symptoms?

1. Anterior or Middle Cerebral artery involvement

2. Amaurosis fugax (monocular blindness). If it doesnt clear then its CRAO

3. Face-hand-arm-leg contralateral hemiparesis

4.
-Aphasia
-dysarthria

42

MCA occlusion
Symptoms? 1

Dominant Hemisphere? 1

Nondominant Hemi? 4

1. Contralateral hemiplegia in face-arm-hand

2. Dominant hemisphere = aphasia

3. Nondominant Right hemisphere =
-confusion,
-spatial disorientation,
-sensory and
-emotional neglect

43

ACA occlusion
Symptoms? 2

3. What rarely affects ACA distribution?

1. Sensorimotor deficit in contralateral foot and leg

2. Brocas or anterior conduction aphasia in dominant hemisphere is possible (deep frontal lobe nuclei)

3. TIA’s

44

Posterior Circulation TIA and Stroke
Symptoms?
8

1. Vertigo
2. Diplopia/ dysconjugate gaze,
3. ocular palsy homonymous
4. hemianopsia

Sensorimotor deficits -
5. Ipsilateral face and contralateral limbs,
6. drop attack (rarely TIA)
7. Dysarthria
8. Ataxia

45

Vertebro-Basilar posterior circulation occlusion
1. Emboli less frequent in the posterior circulation but more common ________?

2. Various syndromes depending on what?

3. VA-PICA syndrome – What characterizes this? 6

1. anterior

2. the site of occlusion

3.
-HA,
-ataxia,
-nausea/vomiting,
-paralysis in tongue and swallowing all ipsilateral,
-Ipsilateral face and contralateral body.
-Horner's Syndrome.

46

Vertebro-Basilar posterior circulation occlusion
1. V-B junction symptoms? 5

2. Basilar apex symptoms? 4

3. PCA (distal branches)?

4. PCA (proximal branches)? 2

1.
-lower extremity paraplegia or tetraplegia,
-conjugate or dysconjugate gaze paralysis,
-constricted pupils,
-respiratory depression,
-coma.

2.
-PCA junction results in hemiplegia-diplegia,
-pupillary and occulomotor paralysis,
-visual field defects,
-stupor and coma.

3. quadrantic or homonymous hemianopsia

4. Thalamus involvement hence
-memory loss and
-sensorimotor hemiplegias.

47

Spinal Stroke
1. How common?
2. Which vessel?
3. Associated with what? 2

1. Rare
2. Anterior spinal artery
3. Associated with
-prolonged hypotension and
-intraspinal mass lesions

48

Lacunar Infarct
What are they?

Small, deep infarcts caused by occlusion of the small arteries that penetrate deeper brain structures (internal capsule, thalamus, pons)

49

1. What are the two kinds of hemorrhagic stroke?

2. In general how do pts present? 4

1.
-Subarachnoid Hemorrhage
-Intracerebral Hemorrhage

2. In general patients with hemorrhagic stroke present seriously ill.
-Deteriorate more rapidly
-have HA,
-N/V, and
-decreased consciousness as prominent signs

50

1. What is a subarachnoid hemorrhage?

2. Most common causes? 2

1. Rupture of an artery with bleeding onto the surface of the brain

2.
-aneurysm,
-AVM

51

Subarachnoid hemorrhage: Presents how?
4

1. “Worst headache ever” in the patients life
2. radiates to face and neck.

3. Progresses to maximal intensity immediately after onset

4.
-Phonophobia or
-photophobia

52

Subarachnoid Hemorrhage
Physical Signs? 4

Poor Sign if what? 1

1. Nuchal rigidity
2. Altered mental status
3. Papilledema
4. May not have a neurological deficit

Poor sign if associated with
1. transient loss of consciousness,
may represent a complicating factor such as seizure or cardiac dysrythmia

53

Intracerebral hemorrhage
1. What is it?
2. Main causes? 2
3. These patients can present with any of the signs and symptoms of what?

4. Hypertensive atherosclerotic hemorrhage usually involves what? 4

5. Often large and catastrophic, found in __________ 60% of time. Degenerative-atherosclerotic vascular injury.

6. Which are smaller hemorrhages?

1. Rupture of an artery with bleeding into the brain parenchyma
2.
-Hypertension,
-amyloid angiopathy
3. ischemic stroke

4.
-basal ganglia
-thalamus
-cerebellum
-pons

5. hypertensives

6. Lobar hemorrhages smaller (frontal-temporal-parietal-occipital)

54

Stroke Dx?
9

1. ABC’s
2. History and Physical exam
3. A thorough neurological exam.
3. EKG, monitor,
4. pulse oximetry
5. Labs
6. CT or MR head scan
7. Echocardiography, EEG
8. Carotid Duplex Ultrasonography
9. MRA or Angiography

55

Stroke: Which labs?
7

1. CBC,
2. electrolyte,
3. glucose,
4. ABG,
5. PT/PTT,
6. Urine drug screen,
7. LP

56

Management of Acute Stroke
Medical Management?
5

1. Prevention and Lifestyle Modification
2. Early Recognition with Rapid Transport/Pre-arrival Notification
3. ABC’s, IV
4. O2
5. Rapid Evaluation for Fibrinolytic therapy (TPA)

57

Anticoagulants-Indicated in the acute setting?

Recent studies have shown no net short or long term benefit of administering heparin for acute ischemic stroke

58

Thrombolytics
1. Only TPA approved for ischemic stroke if given within when?

2. 30 % more likely to have what at 3 months?

3. 3% vs. 0.3% increase in frequency of what?

4. 6.4% vs. 0.6% increase in the frequency of what?

1. 3 hours of onset of signs and symptoms Class I AHA recommendation

2. minimal or no disability at 3 months ( NINDS trial)

3. intracranial hemorrhages

4. all symptomatic hemorrhage

59

Thrombolytic contraindications
11

1. Contraindicated in BP > 185/110,
2. AMI,
3. Seizure,
4. Hemorrhage,
5. LP within 7 days,
6. arterial puncture at incompressible site,
7. surgery within 14 days,
8. bleeding diathesis,
9. within 3 months of head trauma,
10. history of intracranial hemorrhage,
11. minor or rapidly improving stroke symptoms

60

Acute or Chronic Prophylactic Anti-platelet therapy? 2

1. Role of ASA 81mg vs 325mg
2. Role of Plavix or Ticlodipine

61

Chronic prophylactic anticoagulation
Indicated when? 2

1. Indicated in acute ant. wall MI with mural thrombus formation. ( continue Heparin/Warfarin until thrombus dissolves.) INR

2. Chronic atrial fibrillation with any or all of the following risk factors,


Same contraindications

62

Chronic atrial fibrillation with any or all of the following risk factors? 5


A-fib without any of the following risk factors may be treated with what?

1. CHF within 3 months,
2. HTN,
3. previous thromboembolism,
4. LV dysfunction and/or enlarged left atrium,
5. Chronic valvular disease.


chronic ASA therapy.

63

Chronic management of Stroke
7

1. Multidisciplinary approach
2. Psychiatric Services
3. PT/OT/Speech-Language
4. VNS/Home health attendant
5. Skilled nursing facility
6. Social Services
7. Family support groups

64

Carotid Endarterectomy
1. Indications in symptomatic carotid stenosis? 5

2. Contraindications in asymptomatic carotid stenosis? 5

3. Worse outcome with what?

1.
-Good general Health
-Hypertension controlled
-Internal carotid stenosis 70-99%
-Ipsilateral stroke or TIA within 3-6 months
-Surgeon with morbidity/mortality less than 2%

2.
-Multiple coexisting comorbid conditions
-Hypertension poorly controlled
-Internal carotid artery either completely or less than 70% occluded
-No history of ipsilateral TIA or stroke
-Inexperienced surgeon



3. -Worse outcome if used to treat evolving stroke