Module 4 (b)

Question 1

CAD

-Differentials and DX

Answer 1

1. CAD is a dx that has to be made w/ OBJECTIVE Testing
   - Positive stress test w/ follow up LHC to show obstructive vs non-obstructive dz
   - Hx of CABG
   - Hx of coronary stents

Question 2

Chest pain

-Diagnostic Testing

Answer 2

1. ECG
   - Refer to cardiology or ER
2. Cardiology Dx Testing:
   - Exercise stress test
   - Echocardiogram w/ suspicion of CHF
   - Coronary angiogram (Cardiac catheterization); Left Heart Catheterization

Question 3

CAD Treatment

Answer 3

1. Risk factor reduction
2. Lifestyle modification
3. Exercise
4. Cardiac rehab
5. Cardiology input

Question 4

CAD: Medical Management

Answer 4

1. ASA
2. Plavix, Effient vs Brillenta (MUST BE ON blood thinner post stent placement
3. Tight BG control w/ DM
4. BB
5. ACE-I or ARB
6. CCB
7. Follow up
8. Need a statin

Question 5

CAD: Medical Management

-Stent Management

Answer 5

1. Bare metal stent recommended for 3 months
2. Drug eluding stent recommended for 1 year
   - Surgery needs to be done in a facility with cath lab with drug eluding stent d/t risk of clotting

Question 6

CAD

-When to Refer

Answer 6

1. New Pt w/ hx of cardiac intervention seen by Cardiologist once a year
2. Condition is complicated w/ multiple co-morbidities
3. Change in angina
4. Hx of coronary ischemic syndrome
5. Symptoms and comorbidities dz should determine frequency of visits to specialist

Question 7

Heart Failure

-Definition

Answer 7

A complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to FILL with blood or EJECT blood.

Question 8

Heart Failure

-Patho

Answer 8

1. Myocardial insult
2. Myocardial dysfunction
3. Reduced Organ perfusion
4. Renin-Angiotensin-Aldosterone activation
5. Remodeling

Question 9

Heart Failure

-Treatment Goal***

Answer 9

ALL oral therapy to reduce morbidity and mortality is aimed at:
1. SLOWING or STOPPING the sympathetic activation in the renin-angiotensin-aldosterone system **

Question 10

Heart Failure

-LVEF

Answer 10

Normal is >55%

1. Measures how well heart is pumping

Question 11

Heart Failure

-LVEF = 40-45%?

Answer 11

1. Heart failure w/ reduced EF is HF with EF = 40-45%

- Mid range of 45-50% you treat as HFrEF

Question 12

Heart Failure

-Risk Factor for HFpEF

Answer 12

1. HTN (with prevalence of 60-89%)
2. Obesity
3. DM
4. A fib
5. Hyperlipidemia
6. Older age

HFpEF= preserved EF greater than 50%

Question 13

Heart Failure

-Risk factors for HFrEF

Answer 13

1. HTN
2. Diabetes
3. Metabolic syndrome
4. Atherosclerotic dz
5. Valve dz
6. Dilated cardiomyopathy

Question 14

Heart Failure

-Precipitating Event

Answer 14

1. CAD is cause of HF in 2/3 of patients w/ systolic dysfunction
2. Most patients w/ HF (70%) have systolic dysfunction HFrEF

Question 15

Heart Failure

-ACC/AHA HF Stages

Answer 15

1. A
   - High Risk w/ No structural disease
2. B
   - Structural heart DZ w/ no HF symptoms
3. C
   - Structural heart DZ w/ Prior or current HF symptoms
4. D
   - Refractory end-stage HF requiring special interventions

Question 16

Heart Failure

-NYHA Functional Class (Talks about Symptoms)

Answer 16

1. Class 1
   - Asymptomatic
2. Class 2
   - Symptomatic w/ moderate exertion
3. Class 3
   - Symptomatic w/ minimal exertion
4. Class 4
   - Symptomatic at rest

Question 17

Heart Failure

-Common Symptoms

Answer 17

1. Orthopedic
2. Dyspnea at rest and on exertion
3. Reduced exercise capacity
4. Ascites
5. Scrotal Edema (Nephrotic syndrome or HF)
6. Paroxysmal Nocturnal Dyspnea PND — wake up SOB

Question 18

Heart Failure

-Uncommon Symptoms

Answer 18

1. Wheezing or cough
2. Confusion/delirium
3. Depression/weakness (especially elderly)
4. Unexplained fatigue
5. GI symptoms
   - RUQ abdominal pain can be HF

Question 19

Heart Failure

-Differential Dx

Answer 19

1. MI
2. Pulmonary dz
3. Sleep disordered breathing
4. Obesity
5. Malnutrition/ anemia

Question 20

Treatment of HFrEF

-Guideline Directed Medical Therapy (reduced mortality)

Answer 20

1. ACE-I or ARB or ARNI
2. Beta Blocker
3. Aldosterone antagonist
4. Hydralazine/isosorbide (For African Americans and those who cannot tolerate ACE-I/ARB)
   - Add hydralazine/isosorbide to all the above w/ AA for significant benefit
5. SGLT2i**

Question 21

Treatment of HFrEF

-Guideline Directed Medical Therapy (reduced symptoms**)

Answer 21

1. Loop Diuretics
2. Potassium supplements if needed for loop diuretics
3. DIgoxin to reduce hospitalization
4. Thiazide diuretics can be added to boost loop diuretics

These meds are for SYMPTOMS NOT MORTALITY

Question 22

AFIB

-Anticoagulation w/ cardioversion

Answer 22

1. When the rhythm has been sustained for longer than 48 hrs, anticoagulation therapy should be uninterrupted for 4 weeks before and for at least 4 wks after elective cardioversion
2. TEE used to evaluate thrombosis before cardioversion

Question 23

Afib

-CHA2D2-VASc Score?

Answer 23

1. CHA2D2-VASc Score of 2 or greater in men and 3 or greater in women
   - Oral anticoagulants are recommended

Question 24

Afib

-Anti-coagulants (NOACs)

Answer 24

1. Pradaxa
2. Eliquis
3. Xarelto
4. Savaysa

No INR needed

Question 25

Afib

Answer 25

1. Refer a pacemaker to a specialist. DO not manage in clinic

Question 26

PVD | -Smoking

Answer 26

Smokers are twice as likely to develop PVD than non-smokers

Question 27

PVD Limb Pain | -Venous Pain

Answer 27

1. Decreased w/ elevation 2. Better with walking 3. Pain localized at sight of vein

Question 28

PVD Limb Pain | -Arterial Pain

Answer 28

1. Relieved with rest 2. Increased with elevation 3. Worse with walking 4. Pain in regional areas of arterial flow

Question 29

PVD | -Buerger’s Dz

Answer 29

1. Specific to young male smokers - Can lose digits & limbs - Resolves when smoking is stopped

Question 30

PVD | -When to refer

Answer 30

1. No pulse | 2. Ankle brachial index

Question 31

PVD | -AnkleBrachial Index ** Exam

Answer 31

1. Noncompressible >1.30 2. Normal = 0.91-1.30 3. Mild to Moderate PAD = 0.41-0.90 4. Severe PAD = 0.00-0.40 **TEST**

Question 32

Valve Disease | -Key Diagnostics

Answer 32

1. Cardiac Murmur | 2. Symptoms (SOB, dizziness, syncope)

Question 33

Valve Disease | -Aortic Stenosis

Answer 33

1. Elderly patients can develop aortic stenosis - Can progress to symptoms 2. Aortic Stenosis murmur is heard best at the Right sternal border 2nd intercostal space - Radiate to the neck as a brui REFER

Question 34

Valve Disease | -Medical MgMt

Answer 34

1. Manage other risk factors such as DM, HTN, Hyperlipidemia 2. DO NOT start a new exercise program - See cardiology prior to starting a new exercise program **