Week 5 CVS Heme Flashcards
1
Q
Afib
Definition of paroxysmal AF
A
Paroxysmal AF
-continuous AF lasting >30 seconds, terminate within 7 days of onset
2
Q
Afib
Definition of persistent AF
A
Persistent AF
-continuous AF lasting > 7 days, < 1 year
3
Q
Afib
Definition of “longstanding” persistent AF
A
“longstanding” persistent AF
- continuous AF > 1 year
- rhythm control is being pursued
4
Q
Afib
Definition of Permanent AF
A
Permanent AF
- continuous AF
- therapeutic decision NOT to pursue sinus rhythm restoration
5
Q
Afib
Definition of valvular AF
A
Valvular AF
-AF in presence of mechanical heart valve
OR
-in presence of moderate to severe mitral stenosis
6
Q
Afib
HATCH represents higher occurrence of Afib and higher risk of stroke
What does HATCH stand for?
A
A higher HATCH score correlates with higher occurrence of AF and a higher risk for stroke.
Hypertension Age > 75 years TIA previously or Stroke COPD Heart Failure
7
Q
Afib
associated comorbidities?
A
Comorbidities:
- HTN
- DM2
- hx of MI
- valvular heart disease
- OSA
- obesity
- HF
- diastolic dysfunction
- CAD
- parenchymal lung disease
From weekly note: COPD is an independent predictor for major adverse cardiac events, and also for incidence of AFib
8
Q
Afib
counselling for modifiable risk factors?
Modifiable risk factors: ETOH: Smoking: Exercise: • moderate intensity aerobic exercise • Resistance exercise • Flexibility exercise Sleep Apnea: Weight: Diabetes: BP:
A
Modifiable risk factors:
ETOH: 0-1 drinks/day
Smoking: goal of abstinence
Exercise:
• moderate intensity aerobic exercise 30 min/day x 3-5 days/week (target >200 min/week)
• Resistance exercise 2-3 days/week
• Flexibility exercise 10 min per day 2 days/week if 65 and older
Sleep Apnea: CPAP if moderate OSA
Weight: weight loss >10% to keep BMI <27
Diabetes: target A1C 7.0% and under
BP: Target 130/80 or under at rest, 200/100 or under with peak exercise
9
Q
Afib
Describe opportunistic screening
A
In adults 65+ at every medical encounter
Pulse-based:
-check pulse and BP
OR
Rhythm-based:
-single lead ECG
if afib suspected –> 12 lead
10
Q
Afib
beta blockers
- side effects?
- contraindications?
A
Beta blockers
side effects: bradycardia, hypotension, fatigue, depression
CI: pre-excitation, bronchospasm
11
Q
Afib
ND-CCB
eg diltiazem, verapamil
A
side effects: bradycardia, hypotension
verapamil: constipation
diltiazem: edema
CI: pre-excitation, CHF, LV dysfunction
12
Q
Afib
CHADS
A
CHF +1 HTN +1 Age > 65 +1 DM +1 Stroke +2
if CHADS>1 or age 65 –> anticoagulate
13
Q
Afib
CHA2DS2-VASC
A
CHF (1) HTN (1) Age 75+ (2 points) DM (1) Stroke/TIA/TE (2 points) Vascular disease (prior MI, PAD) (1) Age 65-74 (1) Sex (1 if female)
14
Q
Afib
HASBLED
A
HTN Abnormal renal or liver function (1 point each) Stroke Bleeding Labile INR Elderly (65+) Drug or alcohol (1 point each)
HTN = SBP >160
Abnormal renal: Cr >200
Abnormal liver: 2-3xULN
Labile INR = <60% time in therapeutic range
Drug = concurrent use of antiplatelet/ASA/NSAID
15
Q
HF
presenting symptoms on history
in geriatrics?
A
dyspnea at rest or with exertion (decreased exercise tolerance) orthopnea PND palpitations lower extremity edema abdo distension fatigue weight gain
geriatrics:
- worsening fatigue
- decreased functional capacity
- delirium/confusion
- anorexia, nausea, abdo bloating
16
Q
HF
what is the best way to assess volume status?
A
elevated JVP = fluid overload
17
Q
Heart sounds in HF
extra heart sounds?
A
S3: L ventricular volume overload
- systolic dysfunction
- uncommon in HFpEF
S4: increased stiffness of L ventricle
*can be present with or without HF
18
Q
Lower extremity edema can be sign of HF
other DDx?
A
- meds (esp CCB)
- venous insufficiency
- kidney disease
19
Q
HF
what will CXR show?
A
CXR: enlarged heart, perivascular edema, pulmonary edema
20
Q
HF
initial workup if suspected on clinical history or physical exam?
A
CXR
ECG
Labs: CBC, ferritin, lytes, renal, U/A, glucose, TSH, troponin
21
Q
True or false
BNP, NT pro-BNP and troponin are renally excreted and can be elevated in renal disease without overt HF or acute ischemia
A
true
22
Q
Etiology of HF
FAILURES
A
F: Forget to take medications A: Arrhythmias, Anemia I: Infection, Ischemia, Infarction L: Lifestyle changes U: Upregulators (thyroid, pregnancy) R: Rheumatic heart disease and other valvular disease E: Embolism S: Stress (surgery)
23
Q
BNP can be elevated in what other non-cardiac causes?
A
Conditions associated with elevated BNP other than CHF are as follows:
Acute renal failure and chronic renal failure
Hypertension (HTN)
Pulmonary diseases such as pulmonary hypertension, severe chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary embolism, adult respiratory distress syndrome (ARDS)
Cardiac causes -Myocardial infarction, atrial fibrillation, acute coronary syndrome, cardioversion, valvular heart disease, myocarditis
Older age
Female sex
Liver cirrhosis
Hyperthyroidism
Sepsis
Chemotherapy
24
Q
common side effects with ACE-I?
A
- postural hypotension
- renal insufficiency
- HYPERkalemia
- dry cough (d/t bradykinin and substance P)
- angioedema
25
why is cough and angioedema less common in ARB compared with ACE-I?
no effect on bradykinin
26
what are some contraindications with Beta blockers?
bradycardia, hypotension, severe lung disease, and or bronchospasm, acute decompensated HF
27
Mineralocorticoid receptor antagonists (MRA)
eg spironolactone
MOA?
Side effects?
MOA: blocks action of aldosterone (which acts to retain Na and water)
-aldosterone is UPREGULATED in HF
S/E:
- hypotension
- HYPERkalemia
- worsening renal function
- gynecomastia
28
HFpEF
-first line?
uj
first line: diuresis to decrease pulmonary congestion and venous pressures
**avoid overdiuresis* HFpEF patients are pre-load dependent to maintain cardiac output
BP and afib need to be adequately controlled
29
HF
risk factors?
- HTN
- Heart disease (ischemic or valvular)
- DM
- ETOH or substance use
- Chemo or radiation
- Family hx cardiomyopathy
- Smoking
- Hyperlipidemia
30
HF patient teaching
-warning signs
warning signs:
- SOB with decreased tolerance, PND, orthopnea
- SOB at rest
- increased abdo swelling, pedal/leg edema
- weight gain (>2 kg/2 days)
- lightheaded/faint
- palpitations
- chest pain
- confusion
31
HF patient teaching
lifestyle and risk factor management
HTN and DM: control
Smoking: stop
Obesity
Immunizations: flu, pneumococcal
DIET: Na restrict 2-3g/day
Daily weight if fluid retention
32
SGLT2 inhibitor
MOA
SGLT2 is transporter that REABSORBS glucose in renal tubules
SGLT2-I:
- decrease reabsorption of glucose (increases excretion of glucose)
- decrease reabsorption of sodium (osmotic diuresis, reduces SBP)
33
Standard therapies for HFrEF: symptomatic with LVEF <40%
ACEi/ARB --> ARNI
Beta blocker
MRA (spironolactone)
SGLT2 inhibitor
34
What is the most common micronutrient deficiency in older adults?
what is the most common cause?
IDA secondary to GI bleeding: older adults more likely to be on antiplatelets and anticoagulants
Primary GI disease: older adults more likely to have cancer, diverticulitis, gastritis
35
What are two potential causes of B12 deficiency in older adults?
use of PPIs
| H pylori infection
36
anemia from chronic inflammation
most common causes?
advanced cancer
infection
autoimmune diseases
other implicated chronic conditions: DM, CHF, obesity
*severity of anemia does not correlate with severity or progression of chronic underlying condition
37
unexplained anemia of the elderly
etiology?
```
1/3 of anemia in older adults
• Not attributable to other causes
• Typically mild (Hb 100-120), normocytic, low reticulocyte
• Often multifactorial etiology
• Declining testosterone
• Decline in renal function and serum EPO
• Occult chronic inflammation
• Occult myelodysplasia
Monitor for progression to malignancy
```
38
multiple myeloma
CRAB
```
Calcium high (hypercalcemia)
Renal Failure (elevated creatinine and proteinuria)
Anemia
Bone Disease (bone pain)
```
39
Iron deficiency anemia
Characteristics seen on labwork
microcytic anemia
hypochromic
decreased ferritin
*may be normocytic in early stages
40
iron deficiency anemia
signs and symptoms:
- fatigue
- cold intolerance
- headaches
- restless legs
- irritability/depression
- nail changes (spoon nails)
- angular cheilitis
- pica
- decreased aerobic work performance
- hair loss
- impaired immune system
41
iron deficiency
cut off ranges
- normal healthy adult?
- chronic inflammatory condition
- elderly
ferritin <30
<70-100 in chronic inflammatory conditions
<50 in elderly
42
iron deficiency anemia
what to do if elevated ferritin?
ferritin is active phase reactant
-check CRP to see ferritin is elevated due to chronic disease, active inflammation or malignancy
43
iron deficiency anemia
history?
- diet
- GTPAL if female
- hx blood loss: GIB, hematuria, menorrhagia, blood donation
- GI symptoms: change in bowel habits, abdo pain, dyspepsia, unexplained weight loss
Fam hx colorectal cancer
44
what is the target ferritin for IDA?
target >100 ug/L
therapeutic range 100-200 mg elemental iron/day
45
if CBC comes back with microcytic anemia, what is the next step?
check ferritin
* do not treat with supplementation unless ferritin is confirmed to be low
* low MCV and normal ferritin is seen in hemoglobinopathies
46
Iron deficiency anemia
when to recheck CBC and ferritin?
check CBC in 2-4 weeks if moderate to severe anemia
Check CBC and ferritin in 3-6 months
47
duration of treatment for IDA?
continue iron for 4-6 months after correction to replenish Fe stores
*may take 6 months
48
PO iron supplement
patient counselling
Therapeutic dose range 100-200 mg elemental iron/day (consider lower dose for elderly)
Side effects: nausea, vomiting, dyspepsia, constipation, diarrhea, dark stools
Start at low dose, increase after 4-5 days
Take on empty stomach with vit C to increase absorption, but may have better tolerance if taken with food
Alternate day dosing
Avoid taking with multivit, calcium, antacid, tea, coffee, milk
49
B12 deficiency
Etiology / risk factors
Dietary deficiency rare unless long term vegans
Food-bound cobalamin malabsorption in 20-40% of adults 60+ years old
• Lack of gastric acid
• H pylori infection
Long term rx: H2 blocker, PPI, metformin
Gastric resection
Pernicious anemia (autoimmune destruction of parietal cells, no IF)
50
B12 deficiency is tied to long term use of which medications?
H2 receptor antagonists or PPI (12 months)
metformin (4 months)
51
Sequelae of B12 deficiency
Megaloblastic anemia
Neuro symptoms: paresthesia, numbness, motor, memory/cognitive/personality change
***neuro symptoms may be irreversible, early treatment is key****
52
what is amaurosis fugax?
transient monocular vision loss
* *Harbinger of stroke**red flag
* *result of occlusion/internal carotid artery
* *painless, unilateral
* transient - 2 to 30 minutes
* full or partial curtain/darkening
53
Risk factors for carotid stenosis?
**TIA, stroke or amaurosis fugax in last 3 months
```
HTN
smoking
DM
CVD
CAD
dsylipidemia
age
```
54
Medical management of carotid stenosis
```
management of comorbidities:
HTN
DM
lipids
**high potency statin regardless of cholesterol level
ASA/clopidogrel
```
Smoking
Diet
55
AAA
risk factors
```
RISK FACTORS:
• Smoking
• Advanced age
• CAD,
• Atherosclerosis
• High cholesterol
• HTN
• First-degree relative affected
• Male gender
RISK FACTORS FOR EXPANSION:
• Advanced age
• Severe cardiac disease
• Prior stroke
• Tobacco use
RISK FACTORS FOR RUPTURE:
• Female
• Large initial diameter
• Low FEV1
• Current smoking
• Elevated mean blood pressure
```
56
Peripheral artery disease
symptoms
- cramping/claudication in calves
- claudication distance: pain with ambulation within known distance (2-3 blocks)
- relieved within 5-10 min of rest
57
Peripheral artery disease
physical exam
arterial ischemia lesions:
- toes or distal foot
- tend to be painful
- loss of hair on toes and distal ankles
pedal pulses
58
peripheral artery disease
diagnostic test?
doppler ABI
| ankle brachial index
59
peripheral artery disease
red flags?
pain at rest or at night
gangrenous wounds
pain relieved by hanging foot from bed
*critical limb ischemia
60
peripheral artery disease
ABCDEs of medical treatment
```
A: antiplatelet (ASA, plavix)
anticoagulate (if indicated)
ACE/ARB
B: BP target SBP <140, Beta blocker
C: cholesterol (statin), LDL <2, Cessation of smoking
D: Diabetes A1C <7, Diet
E: Exercise 3x/week, 20-30 min
```
61
3 components of Virchow's triad of thrombosis
-endothelial damage (dysfunction from smoking, HTN)
(damage from surgery, PICC, trauma)
-Hypercoagulation
(hereditary - factor V leiden, protein C+S deficiency)
(acquired - cancer, chemo, OCP/HRT, pregnancy, obesity, HIT)
-Stasis
(immobility, polycythemia)
62
What two factors can influence BNP?
age
| obesity
63
Risk factors for CAD?
Elevated blood glucose
Smoking
HTN
Hyperlipidemia
Chronic renal disease
Family history CVD
Peripheral artery disease
64
symptoms of unstable angina?
chest pain at rest
chest pain despite decreasing level of exertion
chest pain increasing in severity or frequency
chest pain pain following myocardial infarction
dyspnea, nausea, fatigue, diaphoresis, syncope, and epigastric, shoulder, arm or neck pain
chest pain is less likely, particularly in the older adult with diabetes
65
medications recommended for asymptomatic stable ischemic heart disease?
ANTIPLATELET
ASA 81 mg daily for secondary prevention
Alternative: clopidogrel 75 mg daily
STATIN
Myopathy often dose dependent, try another statin if intolerant of one
Recommend LDL reduction proportional to estimated CV risk (eg aggressive if high CV risk)
66
medications recommended for symptomatic stable ischemic heart disease/
```
beta blocker (caution bradyarrhythmia, advanced AV block, sick sinus)
-may worsen fatigue
```
ACE-I or ARB for HTN
CCB
- if angina not controlled with BB
- smooth muscle relaxation
- side effect: edema, palpitations, constipation
long action nitrates
- in combo with BB and/or CCB
- if angina not controlled with BB and/or CCB
- side effect: headache, hypotension, reflex tachycardia
67
SPRINT trail
side effects from aggressive SBP treatment to target under SBP 120?
higher rate of syncope, AKI, hypotension (but not injury from falls)
68
symptoms of afib?
complications?
Fatigue
Palpitations
SOB
Lightheadedness
Older adults; falls, delirium, syncope
May also present with tachycardia, HF or stroke
COMPLICATIONS:
4-5x increased risk of stroke
69
anticoagulation in afib
indications for warfarin?
doac?
DOAC: non-valvular AF
-contraindicated in renal impairment (CrCl <30)
warfarin: valvular AF (if mechanical valves and/or moderate/severe mitral stenosis)
70
rate control for afib
- indications
- class of meds?
resting HR >100 bpm
beta blocker
CCB (diltiazem, verapamil)
cardioversion or ablation if poorly controlled
71
pill in pocket approach to afib
-indications?
- if symptomatic with sustained AF episodes (eg > 2 hours) less frequently than monthly
- absence of severe symptoms during AF episode (chest pain, fainting, breathlessness)
- ability to follow instructions
72
pill in pocket approach to afib
instructions?
when to go to ER?
- take AV node blocker (diltiazem 60 mg/verapamil 80 mg/metoprolol 25 mg) 30 min after onset
- take antiarrhythmic (flecainide or propafenone) 30 min later
- rest supine/seated x 4 hours or until resolved
- go to ER if
AF does not terminate within 6-8 hours
Worsening or severe symptoms
Another episode within 24 hours (can only take PIP once in 24 hours)
73
main cause of right heart failure?
left heart failure
if pulmonary cause: cor pulmonale
74
what are beta blockers not used in decompensated heart failure?
decreased HR
| decreased contractility
75
what two classes of diabetes medications improve CV outcomes?
SGLT2-i
GLP-1 RA
76
warfarin
initiation: when to recheck INR?
how long does it take for full anticoagulant effect?
check in 2 days after starting, adjust
check every 2-4 days until normal range for 2 values
once stable, check INR weekly
full effect 5-7 days
77
MGUS (monoclonal gammopathy of undetermined significance) is a precursor to…..
multiple myeloma
78
ferritin level is low/normal/high in anemia of chronic disease?
high (acute phase reactant)
decrease in serum iron and iron-binding capacity
79
etiology of microcytic anemia
TAILS
```
thalessemia
anemia of chronic disease
IDAD
lead poisoning
sideroblastic anemia
```
80
CLL
patho?
diagnostic hallmark?
symptoms?
malignant B lymphocytes
isolated lymphocytosis total WBC count> 20x 109/L, up to several hundred thousand.
**often asymptomatic
lymphadenopathy (cervical and supraclavicular most commonly), hepatosplenomegaly, and constitutional symptoms (fatigue, fevers, nights sweats, weight loss and early satiety).
81
CML
diagnostic hallmark?
symptoms?
triad?
leukocytosis with immature granulocytes, basophilia, eosinophilia
Symptoms are non-specific and include constitutional symptoms such as fatigue, weakness, anorexia, weight loss, night sweats, a sense of abdominal fullness particularly in LUQ, gouty arthritis
triad
tinnitus, stupor, and urticaria
82
risk factors for multiple myeloma?
```
age (60+)
race (black >> white)
sex (slight M>F)
hx of radiation
MGUS
```
83
MGUS (monocloanl gammopathy of undetermined significance) is diagnosed by...?
presence of M protein in blood or urine without evidence of MM
84
presence of Bence Jones protein in urine (or serum) indicates....?
multiple myeloma
85
unexplained anemia of the elderly
microcytic/normocytic/macrocytic?
normocytic
usually mild (Hb 100-120), low reticulocyte count
86
unexplained anemia of the elderly
how often should CBC be checked?
q6 months to monitor progression and underlying pathology
*watch for progression to MGUS or MM
87
when should investigation of anemia NOT be pursued in elderly?
if life expectancy if <1 year
