1
Q
S1 is associated with which heart valves?
A
S1 - Mitral and Tricuspid (AV) CLOSE
2
Q
S2 is associated with which heart valves?
A
S2 - Aortic and Pulmonic (SL) CLOSE
3
Q
Define systole.
A
The period between S1 and S2
1: MV) —–squeeze—– (2: AP
4
Q
Define diastole.
A
Period between S2 and S1
2: AP) —– rest —– (1: MV
5
Q
Which heart sound is associated with CHF?
A
S3 - atrial gallop - kentucky (bourbon sloshy)
passive blood flow hits dilated, non-compliant walls
- think: hypervolemia - CHF, pregnancy, etc
6
Q
Which heart sound is associated with LVH?
A
S4 - ventricular gallop - tennessee (tenneseeze-squeeze - kick/thick)
atrial KICK kicks blood + it bounces off extra THICK wall like a soccer ball
- think: stiff ventricular wall - LVH, htn, MI
- LA squeezes harder to overcome thick LV
7
Q
Describe a grade IV/VI heart murmur.
A
loud + thrill
IV has what III does not (III is just loud)
8
Q
Patient presents with history of multiple syncopal episodes. Physical exam remarkable for loud diamond shaped systolic murmur at 2nd R ICS that radiates to neck. What do you suspect and what are your actions?
A
Aortic Stenosis - syncope r/t decreased cardiac output
Consult cardiology
9
Q
Which murmur is associated with S3 systolic murmur at 5th ICS MCL that radiates to L axilla?
A
Mitral Regurgitation
10
Q
what is heart failure?
A
syndrome where CO is insufficient to meet body’s metabolic needs
11
Q
what is diastolic heart failure?
A
HFpEF: inability to relax and FILL = ↓ CO
WWJD: “the heart doesn’t FILL well!”
12
Q
what is systolic heart failure?
A
HFrEF: inability to contract = ↓ CO
13
Q
what is acute heart failure?
A
LEFT-sided failure r/t acute MI, valve rupture
also LVH, htn
14
Q
what is chronic heart failure?
A
RIGHT-sided failure d/t inadequate compensatory mechanisms to improve ↓ CO
15
Q
acute heart failure: s/s x5
A
LEFT heart failure; L = LUNGS
- dyspnea @ rest
- crackles/rales: all lung fields
- wheezy, frothy cough
- S3 gallop (hypervolemia!)
- mitral regurg: systolic @ apex
16
Q
What heart murmur is associated with acute heart failure? What heart sound?
A
murmur: mitral regurg (systolic @ apex)
sound: S3 gallop (hypervolemia!)
acute heart failure is LEFT-sided heart failure!
17
Q
chronic heart failure: s/s x9
A
RIGHT heart failure. chRonic = RIGHT
- JVD, dependent edema, abd fullness
- hepatomegaly, splenomegaly
- fatigue on exertion
- paroxysmal nocturnal dyspnea (PND)
- displaced PMI
- S3 and/or S4
18
Q
Which NYHA stage of heart failure could be described as “ordinary activity causes symptoms but comfortable at rest”?
A
Class III
19
Q
What signifies a NYHA Class IV Heart Failure score?
A
inability to carry out ANY physical activity without discomfort
- s/s @ REST
20
Q
heart failure: diagnostics x7
A
ABG: hypoxemia, hypocapnia
BMP: normal unless chronic failure
UA
CXR: pulm edema, Kerley B lines, effusions
Echo
EKG: deviation or underlying problem (acute MI, dysrhythmia)
PFT: for wheeze during exercise
21
Q
heart failure: non-pharma mgmt x3
A
Na restriction
rest/activity balance
weight reduction
22
Q
heart failure: pharm interventions x3
A
ACE inhibitors **
diuretics: furosemide (Lasix), thiazide
anticoagulation: for a fib
23
Q
what is flash pulmonary edema?
A
aka acute pulmonary edema!
- fluid moves into lung interstitium (space w/in alveolar septum btw alveolus + capillary)
- d/t pulmonary capillary hydrostatic pressure
- fluid flow out of capillaries exceeds lymph system ability to remove it
- most common cause: LEFT-sided (acute) heart failure; also: acute MI, ↑ LV pressure
24
Q
pulmonary edema: mgmt x7
A
- O2 1 - 2 L/min + ABG
- semi-Fowlers
- morphine 2-4 mg IVP q20 - 30 mins PRN (stop if hypercapnic)
- furosemide (Lasix) 40 mg IVP (repeat in 10 min if no response)
- if severe: nitroprusside or hydralazine (reduce preload & afterload)
- if CO/CI stays low: dobutamine 2.5 - 20 ug/kg/min (if SBP under 100 mmHg - dopamine 5 - 20 ug/kg/min)
- if severe bronchospasm: albuterol (Proventil)
25
What are 2 meds used to reduce preload + afterload in the setting of pulmonary edema?
nitroprusside or hydralazine
26
What 2 meds are indicated for persistently low CO in the setting of pulmonary edema?
dobutamine 2.5-20 ug/kg/min
| dopamine 5 - 20 ug/kg/min (SBP lt 100)
27
55 yo M w PMH significant for left-sided heart failure develops flash pulmonary edema. He has persistently low CO and is hypotensive at 88/46. What pharm intervention is indicated?
dopamine 5 - 20 ug/kg/min
| dopamine ↑ SVR + SBP (∴ BP)
28
what is hypertension?
sustained SBP 140+
OR
DBP 90+
29
What is secondary hypertension? What is its most common cause?
hypertension secondary to other known causes
#1 = renal artery stenosis
others: renal disease, pregnancy, estrogen use, endocrine disorders
30
What kind of headache occurs in severe hypertension?
sub-occipital (back of head) pulsating HA in early AM, resolves throughout the day
31
Your patient has hypertension. Name 3 labs you would order and your rationale (what causes are you ruling out?)
- AM/PM cortisol levels: r/o Cushings
- CXR: if cardiomegaly suspected
- renovascular disease studies
32
JNC8 goal BP for patients under 60?
less than SBP 140
| less than DBP 90
33
JNC8 goal BP for patients 60+?
less than SBP 150
| less than DBP 90
34
What are the JNC 8 treatment recommendations for a non-black hypertension patient?
thiazide diuretic, CCB, ACE-inhibitor, ARB
35
What are the JNC 8 treatment recommendations for a black hypertension patient?
thiazide diuretic
| CCB
36
What are the JNC 8 treatment recommendations for hypertension in adults 18+ with CKD?
ACE inhibitor OR ARB
REGARDLESS OF RACE/MEDICAL CONDITION
37
What are the JNC 8 treatment goals for hypertension? x5
initial treatment goal: 1 month; if not reached
- first: increase dose
- second: add second drug
- refer to hypertensive specialist if 3+ drugs needed
assess monthly until goal reached
do not use ACE-i + ARB together
38
Per JNC 8 guidelines, how often do you assess BP until hypertension goal is reached?
MONTHLY
39
#1 therapeutic lifestyle change necessary in HTN management?
Restrict sodium intake
40
67 yo. F presents to the clinic with no significant PMH. Initial BP read 168/92 with no other significant findings on physical exam. Before leaving - second BP read 158/88. You should?
Teach the patient about lifestyle changes - diet/exercise
41
What is a hypertensive urgency?
BP greater than 180/110 WITHOUT target end organ damage
42
hypertensive urgency: mgmt options x4
```
PO!
clonidine (Catapres)
captopril (Capoten)
nifedipine (Procardia)
furosemide (Lasix)
```
43
what is a hypertensive emergency?
BP greater than 180/120 WITH end target organ damage
| requires IMMEDIATE intervention - in less than 1 hour
44
What are examples of end target organ damage associated with hypertensive emergency? x8
```
malignant hypertension
hypertensive encephalopathy
intracranial hemorrhage
acute MI
unstable angina
acute LV failure with pulmonary edema
dissecting AA
eclampsia
```
45
hypertensive emergency: mgmt x5
IMMEDIATE - less than 1 hour + ICU admit (art line + IV meds)
lower BP to SBP 160 - 180 OR under 105 DBP
- lower BP no more than 25% within 1 - 2 hrs then gradually over several days w PO tx
options:
- nicardipine (Cardene) ** gold standard
- nitroprusside (Nipride)
46
What are the parameters for lowering BP during a hypertensive emergency?
goal BP: SBP 160-180 / DBP under 105
do NOT lower more than 25% within 1 - 2 hrs
then lower gradually over several days with PO
47
What is the gold standard pharm intervention for hypertensive emergency?
IV nicardipine (Cardene)
48
angina: expected EKG findings
ST depression ** (most common)
T-wave peak or inversion
(DURING ATTACK)
49
What is angina? What is its pathophysiology?
characteristic chest discomfort lasting several minutes
↓ blood flow through vessel → TISSUE ISCHEMIA
50
What is stable angina?
- aka classic aka chronic
- predictable: pattern, onset, duration
(4E: eating, exercise, exposure to cold, emotions)
- exertional: most common
- relieved by rest + nitroglycerin
51
What is Prinzmetal's angina?
- aka variant
- intermittent, including at rest
- patho: VASOSPASM d/t ↑ intracellular Ca, NOT r/t CAD
52
What is Levine's Sign?
clenched first over precordium
| 90% diagnostic for angina
53
lipid panel goals: DM or CAD pts
LDL less than 70
HDL 40+
trigs less than 150
54
ideal total cholesterol
less than 200 mg/dL
55
What is the definitive diagnostic procedure for angina?
coronary angiography - but not indicated solely for diagnosis
56
Your obese 38 yo. patient has the following lipid panel:
Total Cholesterol 270
HDL 28
LDL 168
What is the most appropriate intervention at this time?
Start a statin
57
Which of the following lipid panels has 3 of the 4 values abnormal, warranting attention from the AG-ACNP?
a. cholesterol 170 LDL 80 TG 240 HDL 20
b. cholesterol 180 LDL 136 TG 160 HDL 29
c. cholesterol 210 LDL 182 TG 160 HDL 34
B. Cholesterol 180 LDL 136 TG 160 HDL 29
58
normal triglycerides
less than 150 mg/dL
59
optimal LDL
less than 100 mg/dL
60
ideal HDL
40 to 60
low = under 40
high = 60+
61
angina: non-pharm mgmt
- reduction of risk factors
- manage diet
↓ saturated fats
then, ↓ unsaturated
then, consider ↓ plant sterols (nuts, veg oils, etc)
62
angina: pharm mgmt
ASA 81 mg QD (enteric coated)
nitrates
beta blockers
calcium channel blockers
63
What is the leading cause of death in adults in the United States?
myocardial infarction
64
acute myocardial infarction: pathophys
↓ perfusion to myocardial tissue → infarction
| - result: irreversible myocardial necrosis
65
When do most AMI occur?
@ rest
66
What three groups present with non-classic acute MI symptoms and how do they present?
women: fatigue; epigastric pain
elderly + diabetic: no pain
- in DM r/t neuropathy
67
acute MI: classic s/s x7
substernal chest pain: radiates to L arm + jaw
dyspnea
n/v
impending doom, syncope
68
Which heart sound is common in acute MI?
S4 r/t ventricular wall stiffness
69
acute MI: EKG findings
~ 30% have no initial changes
ST elevation gt 1 mm from baseline
peaked T waves
significant Q wave (gt25% height of R wave)
70
What two cardiac enzymes are cardioselective?
Troponin I
| CK-MB
71
After acute MI, when do cardiac enzymes elevate and how long do they remain elevated?
elevate above normal w/n 4 - 6 hrs
| remain elevated for days - 3 wks
72
ST change: I + aVL - indicative of what kind of MI?
LATERAL
73
ST changes: Leads II, III, + aVF - indicative of what kind of MI?
INFERIOR
74
ST changes: V leads/V3-V4 - indicative of what kind of MI?
ANTERIOR
75
anterior MI: EKG findings
ST elevation in V leads/V3-V4
76
acute MI: mgmt
MONA
- O2
- Morphine 2-4 mg IVP q30 min PRN
- NTG SL q 5min x3
- ASA 325 mg chewed
- IVF @ KVO: large-bore PIV x3
- 12 lead + cardiac monitor
- if pulm edema: furosemide 40 mg IVP
- metoprolol 5mg IV q2 min x 3 /THEN/ 15 min after last IV dose, 50mg PO q6 hrs
- heparin vs Lovenox 1 mg/kg q12hrs + monitor coag
- ACE Inhibitor: to prevent remodeling if HF or lg infarction
- - otherwise, only after fibrinolytics, ASA
77
acute MI: beta blocker of choice + dosage
metoprolol 5 mg IV q2min x 3
| - then, 15 minutes after last IV dose: 50 mg PO q6hrs
78
What is the reversal agent for coumadin?
Vitamin K
79
indications for pharmacological revascularization in the setting of an AMI?
unrelieved chest pain 30 min - 6 hrs
/with/
ST elevation over 1mm in 2+ CONTIGUOUS leads
pharm revasc: fibrinolytics - tPA
80
acute STEMI: door to needle time? door to cath time?
door to needle - 30 minutes
| door to cath - 90 minutes
81
Absolute contraindication for tPA.
Active bleeding or risk thereof including abn coags
82
acute MI: Lovenox doseage
SQ 1 mg/kg q12hrs
83
What is venous thrombosis?
partial or complete occlusion of vein by a thrombus with secondary inflammation to vessel wall
- superficial OR deep
84
venous thrombus: causes x5
```
immobility
hypercoagulable state
endothelial damage
recent surgery
PO contraceptives: esp if smoker
```
85
superficial thrombosis: s/s + exam findings x3
sudden onset pain
localized heat/erythema
low grade temp
86
DVT: s/s + exam findings x4
sudden onset pain, esp while walking
- may be dull ache or "tight" feeling
edema distal to occlusion
skin cool to touch
low grade temp
87
superficial venous thrombosis: mgmt
elevate extremity
warm compress
NSAID
d/c PO contraceptives
88
What is peripheral vascular disease?
arteriosclerotic narrowing of arterial lumen → ↓ blood supply extremities
similar risk factors for CAD (hld, tobacco, DM)
89
What is usually the first symptom of PVD?
calf pain (claudication)
90
PVD: s/s x3
claudication
cool/numb extremity
progresses to pain at rest
91
PVD: exam findings x6
```
SHINY/HAIRLESS
dependent rubor
pallor, cyanosis
ulcerations
reduced pulses
```
92
PVD: diagnostics
Arteriography: most definitive
Doppler US: eval flow
Ankle-Brachial Index (ABI)
XRays: may show calcification
93
What is the most definitive diagnostic for PVD?
arteriography
94
What is the priority intervention in the management of PVD?
Walking 1 hr/day to develop collateral circulation
95
Your patient has a history of coagulapathy and is scheduled to go to the OR. What is the most appropriate intervention for this patient?
Pneumatic stockings. NOT Heparin; coumadin; or lovenox.
96
A patient's coags read: PT 29 INR 4.4. What would you do to the patient's Coumadin dose?
Lower the coumadin. Goal INR 2.5-3.5
97
Which of the following patients are most likely to develop a DVT:
a. 45 yo. liver failure pt
b. 30 yo. s/p ORIF R tib/fib
c. 59 yo. parapalegic, bedridden
d. 24 yo. F PO contraceptives
a. 45 yo. liver failure pt r/t high risk for bleeding
98
Patient is admitted to telemetry floor with a history of atrial fibrillation and preserved LV function. What is the drug class of choice?
Beta Blocker
99
Dependent rubor is a physical finding associated with what cardiovascular disease?
Peripheral Vascular Disease (arteriosclerotic occlusive disease)
100
What is chronic venous insufficiency?
impaired VENOUS return d/t valve destruction, DVT, leg trauma, or sustained elevation of venous pressure (CHF)
more common in women
101
Varicose veins are associated with what vascular disease?
Chronic venous insufficiency
102
chronic venous insufficiency: s/s x3
LE aching relieved by elevation
Dependent edema
Night cramps in LE
103
chronic venous insufficiency: PE findings
trophic (soft tissue) Δ + BROWNISH discoloration
edema, stasis leg ulcers, dermatitis
cool to touch
104
What is the mainstay of chronic venous insufficiency management?
Heavy-duty elastic support stockings to increase venous return
105
Acute weeping dermatitis is associated with what vascular disease?
Chronic venous insufficency
106
acute weeping dermatitis: mgmt
wet compresses + 0.5% hydrocortisone
| if bacterial infection is present: systemic abx
107
Cardiac rehabilitation is an example of what type of prevention?
Tertiary prevention.
108
What are appropriate medications for post-op a fib rate control?
digoxin
verapamil
metoprolol (Lopressor)
109
What artery is associated with an Inferior MI?
right coronary artery (RCA)
110
What class of medication should be used cautiously in a patient complaining of angina with reduced LV function?
Calcium Channel Blockers: may reduce LV fxn further
111
What is the leading cause of new onset at fib?
Hyperthyroidism.
112
Your patient is a 45 yo. F with new onset a fib. PMH is unremarkable. What medication would you start this patient on?
ASA
113
What medication regimen would you initiate for a patient s/p AMI with reduced LV function of EF 10%?
Coumadin: indicated EF under 30%
ACE Inhibitor - prevent remodeling
Beta Blocker - prevent remodeling
114
What routine lab is important to monitor with use of statins?
LFT: 3 - 6 mo
| r/t risk for hepatic toxicity with statins
115
What is pericarditis?
inflammation of the pericardium
116
What is the most common cause of pericarditis?
Viral infection
117
43 yo. M presents to ED with complaints of substernal chest pain that increases with inspiration; coughing and swallowing and decreases when he leans forward. He recently had fever; chills and loss of appetite. What is your primary differential?
Pericarditis
118
pericarditis: s/s
very LOCALIZED, PLEURITIC retrosternal/precordial chest pain
- worsens: deep inspiration, coughing, swallowing, recumbent position
- decreases: leaning forward
SOB s/t inspiration pain
119
What is the classic physical finding suggestive of pericarditis?
pericardial friction rub
120
What two EKG findings are highly suggestive of pericarditis?*
ST segment elevation in ALL leads
| PR depression: highly indicative
121
What test do you order to confirm pericarditis?
Echocardiogram: will show pericardial fluid/inflammation
122
What is the mainstay treatment for pericarditis?*
NSAIDS!!
- ibuprofen (Advil) 400-600 mg PO q6-8 hrs
- indomethacin (Indocin) 25 - 50 mg q8hrs x2 wks
123
What major physiological complication is associated with pericarditis?
Cardiac tamponade.
Beck's Triad:
- distant heart sounds
- distended jugular veins
- decreased arterial pressure
124
What is endocarditis?
infection: endothelial surface of the heart
- usually affects valves
- usually bacterial
- assoc w known valvular heart disease: rheumatic, AV/MV prolapse with significant regurg
125
Endocarditis must be considered a differential for patients presenting with what 2 primary physical findings?
heart murmur
| FUO
126
What are Osler's Nodes?
Endocarditis finding. Painful red nodules in distal phalanges.
127
What are Janeway Lesions?
Endocarditis finding. RARE. Small, non-painful macules on palms + soles.
128
What are Roth Spots?
Endocarditis finding. Small, white, retinal infarcts encircled by hemorrhage.
129
What are splinter hemorrhages and what cardiac disease are they associated with?
Endocarditis finding. Linear, subunugal (finger/toe nail), splinter-appearance.
130
What is the mainstay of diagnoses for endocarditis?
Blood culture x 3 at 3 different sites
131
Bandemia is always present in what type of cardiovascular disorder?
Endocarditis. WBC always elevated with left shift.
132
What is the treatment for endocarditis?
PCN G IV q4hrs in combination with gent
133
What is the pharmacological intervention for PCN-resistant streptococci and MRSA endocarditis?
Vancomycin 12-15 mg/kg q12hrs via PICC line x6 weeks
134
first time a fib in young vs older patients
young: ASA
older: coumadin
135
Describe blood flow through the heart.
→ superior/inferior vena cava, R atrium, (tricuspid valve), R ventricle, (pulmonic valve), pulmonary artery, lungs, pulmonary veins, L atrium, (mitral valve), L ventricle, (aortic valve), aorta →
136
Kentucky gallop is
S3
kentucky bourbon slushy
137
Tennessee gallop is
S4
tenneseez-squeeze the kick against thick
138
Describe grade I - VI heart murmurs.
```
I: barely audible
II: faint
III: loud
IV: loud + thrill
V: very loud (one side of stethoscope off)
VI: loudest: no stethoscope needed
```
139
How do you remember New York Heart Association (NYHA) Class III heart failure?
III = sleep with 3 pillows
140
Describe mitral stenosis + where to auscultate it.
MS ARD: mid-diastolic murmur
- auscultate apex
S1 murmur, crescendo rumble
141
Describe aortic stenosis + where to auscultate it.
MR ASS: systolic murmur
- auscultate 2nd R ICS
harsh "blowing" - radiates to NECK
142
Describe mitral regurg + where to auscultate it.
MR ASS: systolic murmur
- auscultate apex
musical "blowing" - radiates to BASE or L AXILLA
143
Describe aortic stenosis + where to auscultate it.
MS ARD: diastolic murmur
- auscultate 2nd L ICS
"blowing"
144
which murmur radiates to base or L axilla during systole?
mitral regurg
145
which murmur radiates to neck during systole?
aortic stenosis
146
which murmurs radiate?
systolic (MR ASS)
147
which murmur is a mid-diastolic rumble?
mitral stenosis
148
Your patient with chronic atrial fibrillation now has an audible extra heart sound. What is it? What is your rationale?
S3/Kentucky. There is no atrial kick in a fib. (That kick is what creates S4.)
149
What are Kerley B lines on CXR indicative of?
pulmonary edema
150
What are 3 key pieces of information observed with an echocardiogram?
- contractility
- valve function
- ejection fraction
151
what is the physiologic basis of dependent pulmonary edema?
↑ capillary hydrostatic pressure
152
nitroprusside class + MOA
class: vasodilator
↓ preload & afterload: via relaxation of vascular smooth muscle (d/t NO)
- immediate reduction of BP
dilation of coronary arteries
153
hydralazine class + MOA
class: vasodilator
direct vasodilator: dilates arterioles + little effect on veins
- ↓ SVR = ↓ BP
154
What heart sound is associated with hypertension? Rationale?
S4 - d/t LVH: myocardium is enlarged d/t the heart having to pump against ↑ SVR
155
what lab findings do you expect with uncomplicated hypertension?
they are usually normal.
156
hypertension: non-pharm mgmt
- restrict dietary Na
- weight loss
- DASH diet
- exercise
- stress mgmt
- reduce/eliminate EtOH
- smoking cessation
- adequate K, Ca, Mg intake !
157
hypertension: general goal of pharmacologic mgmt
prescribe least # meds @ lowest dosage to attain acceptable BP
- decreases CV + renal morbidity/mortality
158
first-line drug of choice for hypertension?
thiazide diuretics
159
what allergy should you screen for before thiazide diuretic admin?
sulfa
160
do not initiate an ACE-inhibitor or ARB with what K value?
greater than 5.5 mEq/L
161
ACE-inhibitor or ARB use is contraindicated in what condition?
pregnancy
162
What should you monitor with CCB admin?
HR, esp with verapamil or diltiazem
163
In which population should you avoid beta blocker use?
asthma/COPD
164
key administration consideration for alpha-1 antagonists
may cause first-dose syncope, take first dose at bedtime
165
key administration consideration for alpha-2 agonists
do not discontinue use abruptly, as this may cause withdrawals and rebound hypertension
166
How do age and gender impact response to anti-hypertensives?
They don't.
167
fundoscopic changes observed in malignant hypertension? x3
flame shaped retinal hemorrhages
soft exudates
papilledema (swelling of optic disk with blurred margins)
168
What is unstable angina?
- unrelieved by rest or nitro
| - PRE-INFARCTION
169
What is microvascular angina?
r/t metabolic syndrome
170
What is exertional angina?
- most common form of stable angina
- precipitated by physical activity
- subsides with rest
171
What is the purpose of nitroglycerin in angina management?
shortens or prevents attacks
172
What heart sound is associated with angina?
transient S4
173
triglycerides are aka
VLDL
174
ASCVD
atherosclerotic cardiovascular disease
175
individuals who may benefit from statin therapy x4
- clinical evidence of ASCVD
- LDL-C 190+
- DM 40 - 75 + LDL-C 70 - 189 + no clinical ASCVD
- no ASCVD or DM + LDL-C 70 - 189 + est 10-yr risk ASCVD 7.5%+
176
high-intensity statin therapy: indication
first-line in women + men under 75 who have clinical ASCVD (unless contraindicated)
LDL-C 190+ in 21+ (unless contraindicated)
DM + 7.5%+ est 10 yr ASCVD risk in 40 - 75
use moderate-intensity when high contraindicated or statin-associated AE
177
statin therapy for ASCVD 75+
moderate or high-intensity, but eval potential for
- risk-reduction benefits
- AE
- drug interactions
- patient preferents
178
what is a reasonable LDL-C reduction goal when intensifying statin therapy?
at least 50% LDL-C reduction
179
high-intensity statin therapy: 2 examples + what is the effect?
daily dose lowers LDL-C on average by greater than 50%
atorvastatin (Lipitor) 40 - 80mg
rosuvastatin (Creator) 20 - 40mg
180
mod-intensity statin therapy: 5 examples + what is the effect?
daily dose lowers LDL-C on average by 30 - 50%
```
atorvastatin (Lipitor) 10 - 20mg
rosuvastatin (Crestor) 5 - 10mg
simvastatin (Zocor) 20 - 40mg
pravastatin 40 - 80mg
lovastatin 40 mg
```
181
low-intensity statin therapy: 3 examples + what is the effect?
daily dose lowers LDL-C on average by less than 30%
simvastatin (Zocor) 10mg
pravastatin 10 - 20mg
lovastatin 20 mg
182
atorvastatin (Lipitor): high, mod, + low intensity therapy doses
40 - 80
10 - 20
10
183
rosuvastatin (Crestor): high, mod, + low intensity therapy doses
20 - 40
5 - 10
none
184
simvastatin: high, mod, + low intensity therapy doses
none
20 - 40
10
185
statins are aka
HMG-CoA reductase inhibitors
186
bile acid sequestrants x3 examples + effects
mostly ↓ LDL + may ↑ trigs
cholestyramine (Questran)
colesevelam (Welchol)
colestipol (Colestid)
lipid mgmt for angina tx
187
fibrates: indication x2 examples
lipid mgmt for angina tx
gemfibrozil (Lopid)
fenofibrate (Tricor)
188
cholesterol absorption inhibitor: indication + effects + name one
lipid mgmt for angina tx
use in combo + statin to ↓ LDL
ex: ezetimibe (Zetia)
189
niacin: indication + effects
lipid mgmt for angina tx
↓ LDL + trigs
↑ HDL
190
angina: 5 classes of drugs used for lipid mgmt
```
HMG-CoA reductase inhibitors (statins)
bile acid sequestrants
fibrates
cholesterol absorption inhibitors
niacin
```
191
acute MI: diagnostics to order
EKG
cardiac enzymes (Trop-T, Trop-I, CK-MB)
echo
CBC (leukocytosis 10 - 20 on day #2)
192
INR: normal
0.8 - 1.2 seconds
193
activated coagulation time (ACT): normal
70 - 120 seconds
194
aPTT: normal
28 - 38 seconds
195
PT: normal
11 - 16 seconds
196
PTT: normal
60 - 90 seconds
197
Virchow's Triad
3 factors thought to contribute to thrombosis
- venous stasis
- endothelial damage
- hypercoagulable state
198
superficial thrombosis: diagnostics
none
199
superficial thrombosis: diagnostics x3
US
D Dimer
venography
200
DVT: mgmt x5
- bed rest + elevated leg until local tenderness subsides (7 - 14 days)
- reintroduce walking gradually
- lovenox 1mg/kg q12 --OR-- heparin infusion 7 - 10 days
- coumadin therapy 12 wks
- consult when anticoag therapy initiated
201
PVD: mgmt x9
- tobacco cessation
- exercise: walk 1 hr/day to develop collaterals
- vasodilators: pentoxifylline (Trental), cilostazol (Pletal)
- weight reduction
- manage DM, hld
- angioplasty
- bypass surgery
- amputation
202
In patients with chronic venous insufficiency: intervention to diminish chronic edema
bed rest with legs elevated
203
chronic venous insufficiency: diagnostics
non-specifically diagnostic of CVI
| r/o edema d/t HF + others
204
pericarditis: mgmt x5
- NSAIDS: mainstay (ibuprofen or indomethacin)
- corticosteroids ONLY when total FAILURE of high-dose NSAIDs over weeks + relapsing pericarditis (dexamethasone, prednisone)
- abx if bacterial infection
- codeine 15 - 60mg PO QID: for pain
- monitor for tamponade
205
When are corticosteroids indicated for use in the mgmt of pericarditis? Which 2?
Only after total failure of high-dose NSAIDs (tx mainstay) over several weeks and relapsing pericarditis. (They can increase viral replication.)
- dexamethasone 4 mg IV: can relieve pain in a few hours
- prednisone 60 mg daily, then taper
206
endocarditis: causes x11
USUALLY BACTERIAL
- known valvular heart disease: rheumatic, AV/MV prolapse with significant regurg
- congenital heart disease
- recent dental/oropharyngeal surgery
- GU instrumentation
- resp tract surgery
- prolonged use of IV or TPN
- burns
- HD
207
endocarditis: s/s
very vague
| fever, malaise, night sweats, weight loss, general "sick" feeling IS THAT NOT MALAISE GEEZ
208
endocarditis: PE findings
- murmur: absent in 30%, esp with R sided endocarditis
- fever: med - high
- Osler's Nodes
- Splinter hemorrhages
- Janeway Lesions
- Roth Spots
- petechiae, purpura, pallor
209
endocarditis: diagnostics x4
- WBC: normal or elevated + ALWAYS left shift + bands
- echo
- blood culture: determine causative organism (3 cx @ 3 diff sites in 1 hour)
- ESR: always elevated
210
How do you order blood cultures for an endocarditis patient?
get 3 cultures @ 3 different sites in 1 hour
211
endocarditis: mgmt
- hold abx until blood cx available: only if not acutely ill, no s/s HF or major embolic events
all other pts: start EMPIRIC ABX, options:
- pcn G 2 million units IV q4 hrs + gentamicin
- nafcillin (Unipen) 2g IV q 4 hrs
- vanc: if pcn resistant strep + MRSA
212
You have a patient who presents suspected endocarditis, a history of significant mitral valve prolapse who has developed flash pulmonary edema. In regards to endocarditis mgmt, what is your plan for antibiotic therapy?
3 options
- pcn G 2 million units IV q4 hrs + gentamicin
- nafcillin (Unipen) 2g IV q 4 hrs
- vanc: if pcn resistant strep + MRSA
213
What happens to heart size in older adults?
Increase is possible, r/t LV and LA hypertrophy.
214
What happens to HR in older adults?
Intrinsic and max decrease, resting and CO unaffected
215
What is one normal physiologic change that can lead to the development of orthostatic hypotension in older adults?
diminished cardiac reserve
