______ angina is precipitated by exertion and relieved by rest or no more than one Nitro tab and generally lasts 1-3minutes
Chronic Stable Angina
______ ______ _______ occurs when there is objective evidence of ischemia in the absence of symptoms.
Silent Myocardial Infarction
______ ______ is described as coronary spams, HX of spontaneous or unprovoked episodes of typical angina.
Variant Angina
A 50y/o F patient comes in complaining of chest pain. What is the number one test that should be completed first?
EKG
When should a provider recommend a male patient start ASA therapy?
Age 45-79 years
When should a provider recommend a female patient start ASA therapy?
55-79 years
What are major considered major risk factors of CHD?
Smoking, HTN, elevated LDL, premature CHD family HX (esp. first degree), low HDL
What are considered CHD risk equivalents?
DM, Symptomatic coronary artery disease, PAD, AAA
Which patients are considered sodium sensitive?
African American and elderly
Which blood pressure medication causes activity intolerance?
beta-blockers
Which electrolyte abnormality can occur with the use of ACEI's in a healthy kidney patient?
hyperkalemia
If a patient had a severe sloughing of skin reaction with a sulfa medication, which BP medication would you want to avoid?
HCTZ
What medication is best for long term prognosis of CHF?
ACEI's
If a patient is DX with dyslipidemia, which other disorders should be ruled out?
DM, renal disease and hypothyroidism
What is the most powerful predictor of CHF?
long-term HTN
_____ refers to the load that stretches the cardiac muscle before contraction. The volume of blood in the right ventricle at the end of diastole.
Preload
Vascular resistance in known as?
Afterload
Which valves are closed during diastole?
aortic and pulmonic valve
Which valves are closed during systole?
Mitral and tricuspid valve
______ ________ is the ability of cardiac muscle to shorten.
Muscle Contractility
What is the drug of choice for angina?
rapid acting organic nitrates
A patient presents to clinic for heart palpitations. After further interview her only HX was migraines which she took an unknown BP medication for but she just quit taking it about 2 weeks ago, What medication are you suspecting she was taking?
beta blocker (propranolol): abruptly stopping can cause rebound tachycardia
At what age should lipid screening be started in men?
35 years or older
At what age should statins not be prescribed?
<10 years old
When is a beta blocker most effective?
recent MI use
Diastolic heart failure is caused by what?
ventricle loses its ability to relax normally, decreasing filling during rest periods
Systolic heart failure is caused by...
ventricle loses its ability to contract normally
According to NYHA classification of heart failure, how would you describe stage II?
slight limitations of physical activity
A patient presents to clinic with a history of heart failure but today he says he hasn't even been able to get up and go to the bathroom without discomfort and extreme SOB. How would you classify the stage?
Stage VI - NYHA
Which medications should be avoided in heart failure?
CCB and NSAIDs
The medication decreases pulmonary and systemic vascular resistance by preventing the release of aldosterone and norepinephrine while elevating the levels of vasodilator hormone bradykinin.
ACEI's
When first starting a patient on an ACEI's what labs should be drawn after the first week?
serum potassium, renal function and the BP should be checked.
Why should you use precaution with beta blockers in a patient with DM?
Mask hypoglycemia
What are the 6B's in the use of beta blockers?
beta 1 heart, beta 2 lungs, bradycardia, bronchoconstriction, blood pressure, blood glucose
Can beta blockers cause a decrease libido?
yes
Hypokalemia caused by HCTZ may increase _____
toxicity?
digoxin
When should digoxin be considered in a patient with CHF?
Atrial Fibrillation in conjunction with heart failure, dyspnea at rest (hx of), those who remain symptomatic on diuretics, ACEI's and beta blockers.
How often should digoxin levels be monitored?
once a month until stabilized then every 6 months
Should digoxin be used in diastolic heart failure?
NO, are sensitive to fluids depletion, can cause decrease preload and stroke volume
When should Pharm therapy be started in those < 60 years old for hypertension?
>=140/90
When should pharm therapy be started in those >60 years old for hypertension?
>=150/90
What medications would an African American patient without CKD benefit from?
Thiazides and CCB
What is the goal BP in patient with DM, CKD who are < 60y/o?
<140/90
Isolated systolic hypertension is commonly seen in what population?
elderly
When should you as a provider suspect secondary hypertension?
- resistant HTN if on 3 or more meds
- onset of HTN before puberty
- not obese, no family history, non-black
What is the main purpose of diuretics in CHF?
reduce symptoms
A blood pressure of 140-159/ 90-99 us considered what stage of hypertension?
Stage 1
A blood pressure of >160/ >100 is what stage of hypertension?
Stage 2
A patient comes in for an annual exam, when performing a funduscopic exam you notice AV knicking and copper wiring. What does this suggest?
uncontrolled hypertension
If a patient presents to clinic with >180 SBP or a DBP > 120 and you notice papilledema, what would you do?
this is considered a hypertensive emergency - TARGET organ damage is TRU HTN emergency
If an African American CKD patient presents to clinic with HTN what should the regimen include?
ACEI or ARB: regardless of race in CKD patients
Can you DX HTN with one blood pressure?
No - must be at 2 or more visits.
Which class of anti-HTN medication should be avoided in athletes?
beta blocker
What is the drug of choice in ISH (Isolated systolic HTN)?
CCB
A 60 year old patient presents to clinic complaining of edema to lower extremities but she has no other symptoms. She reports she recently started a new blood pressure medication. Which class are you suspecting?
CCB - cause "puffy feet" when there is not other cause.
What medications can cause hyperlipidemia?
Diuretic, B Blockers, anabolic steroids estrogens and androgens, protease inhibitors, retinoids, glucocorticosteriods
When should screening of an AAA begin?
USPSTF, recommends one-time screening for AAA in men 65-75 years old, who have ever smoked or had a first degree relative who required repair or died from rupture regardless of smoking HX.
When does this risk of AAA rupture increase?
when size is greater than 5.0cm
What is the quickest way to evaluate a AAA?
US
All are considered risk factors for AAA except?
a. women
b. Smoking
C. family HX
d. HTN
a. women - most affected are men over the age of 65 who have or currently smoke.
What must be ruled out before DX of Kawasaki disease?
Scarlet fever (the mimic each other)
A 3year old presents to clinic and mother c/o fever of 101-103 over the last 5 days and a rash on her abdomen. On PE you notice she has a strawberry looking tongue, palpable cervical lymph nodes, conjunctivitis and peeling to hands and feet. Her Strep tes
Kawasaki disease
What are complications of Kawasaki disease?
Coronary artery aneurysm
regurgitation
decrease muscle contractility
Pericardial effusion (ruptures blood vessel)
Which anti-hypertensive medication can worsen claudication associated with PAD?
beta blockers
What is the major risk factor of PAD?
Smoking
Intermittent claudication is considered a late sign of PAD. T/F?
False (early manifestation)
Pain at rest and dependent rubor are considered severe PAD. T/F?
true
What is the ankle-brachial index used for?
to classify severity of PAD
What is the gold standard of management for extensive PAD?
Bypass
Which medications can be used to prevent claudication?
cilostazol (pletal) and pentoxifylline (trental)
What are the 5 P's have acute arterial disease?
Pain, Pallor, Paresthesia, Paralysis, pulselessness
A 55 year old patient presents to clinic complaining of sudden severe pain an hours ago with decrease sensation. On exam you notice mottling from the waist down. What is your next step?
Call 911, this is suggestive of aortic occlusion and needs immediate treatment
When should a patient with PAD be referred?
if exercise or medications have not helped after 3-6 months and for all non-healing ulcers
What is the drug of choice for a blood thinner for patients who are pregnant or have malignancy?
LMW heparin (Lovenox)
All of the following are risk factors of DVT except?
a. Immobility
b. oral contraceptive use
c. non-smokers
d. postoperative status
C. non-smokers (smoking is a risk)
A 35 week pregnant patient presents to clinic with pain to her r leg. She reports she has been on bedrest for 2 weeks. On exam she has calf pain with dorsiflexion of the foot. What test is this and how would you treat her?
Positive Homan's sign & consult her OB and Lovenox
These type of ulcers usually appear medially and sometimes over lateral malleolus?
Venous ulcers
This type of ulcer usually appears at the tips of the toes or heels?
Arterial Ulcers
Which murmurs are considered systolic?
MR,AS,MVP
Which murmurs are considered diastolic?
AR, MS
Which valve is associated with rheumatic hearts disease?
Mitral
Which murmur is described s occasional honking, or clicking at the left sternal border?
MVP
This murmur is described as a harsh, crescendo-decrescendo located at the right sternal border with radiation to the neck?
AS
How is symptomatic aortic stenosis managed?
surgical
In mitral valve prolapse that is asymptomatic what is the management?
evaluation every 3-5 years
T/F? More men the women are DX with MVP.
False: women
Which valvular disorders may cause atrial fibrillation?
Mitral stenosis & Mitral Regurgitation
Which valvular disorders are common in the elderly?
AS & MR
Which patients would need prophylaxis antibiotics to prevent infective endocarditis?
those with prosthetic heart valves,
prior HX of IE,
unrepaired congenital defects,
repaired congenital defects with residual defects,
valve regurgitation d/t an abnormal valve in a transplanted heart
Which procedures require prophylaxis antibiotics?
Incision or biopsy of respiratory mucosa (T&A, bronchoscopy)
dental work
undergoing procedure for infected skin, skin or muscle structure
What is the expected therapeutic range for mechanical valves on warfarin?
2.5-3.5
What is the therapeutic range while on warfarin?
2.0-3.0
What is the antidote for warfarin?
Vitamin K
If there is ischemia suspected what changes would you suspect on EKG?
T wave inversion
What is a possible consequence of antiarrhythmic drugs?
potential to increase ectopy or induce or aggravate monomorphic VT, torsades de pointes, VF or bradycardia
What is the electrical activity pathway in the heart?
SA node - AV node- bundle of his - Purkinjie fibers
How often should an US or CT be completed in a patient with a AAA of <4.0cm?
2-3 years
How often should an US or CT be completed in a patient with AAA of 4.0 -5.4cm?
6-12 months
How long would you prescribe anticoagulants in a patient with a provoked DVT?
3 months
These anticoagulants inactivate both circulating and clot bound activated coagulation factors and do not induce antiplatelet antibodies?
Direct Thrombin inhibitors & direct factor Xa inhibitors
Renal Stenosis, Phenochromocytoma, Cushing's disease and Obstructive sleep apnea are things to be consider when DX primary or secondary HTN?
Secondary
Would a patient that is 25 with already DX CHD benefit from a statin?
Yes, Age 21-75 years old with clinical atherosclerotic CV disease in a "STATIN" benefit group
A 60 y/o African American patient with an LDL level of 195 would not benefit from a statin. T/F?
False: Age >= 21 years LDL >= 190
A 70 y/o patient with DM and an LDL level of 67 would benefit from a statin. T/F?
False: Age 40-75 y/o with DM and LDL 70-189
Would you start a patient who is 78 y/o on a statin?
depends, one would have to evaluate risk benefits, considering adverse drug effects and patient preference
Would is a s/e of Niacin?
Flushing
What interventions would you tell a patient to take if they experience flushing with Niacin administration?
taking ASA 1 tab 30mins prior to and avoid taking with warm fluids
If a patient had an elevated ALT prior to considering statin therapy would you still prescribe it?
No, measure ALT for baseline then again for hepatoxicity symptoms occur
What is a major complication with use of statins which may cause a patient to be statin intolerant?
myopathy, Rhabdomyolysis
A patient who currently takes a CCB everyday has started feeling dizzy every morning for the last 6 days. When asked if he has been doing anything different he reports, "I drink 2-3 glasses of grapefruit a day." Would this cause him to be feeling dizzy?
Yes, grapefruit enhance bioavailability with CCB and can increase affect making the patient at risk for hypotension.
A 10 year old patient comes into the clinic today and the BP is 135/90. This has been the patients normal BP for the last 3 visits. On exam there are no signs of target organ damage. Would you start this patient on medication?
No, Stage 1 HTN with no evidence of target organ damage should remain on non-pharm therapy for 4-6 months for a target goal below the 95%
Which medications TX both HTN and BPH?
alpha -blockers such as tamsulosin, doxazosin, prazosin
Which anti-hypertensive medication should be avoided in a patient with gout?
HCTZ
What are some examples of ARB's?
cozaar (losartan) & Diovan (Valsartan)
If murmur is heard in conjunction with carotid pulse is it systolic or diastolic?
Systolic
If you hear a murmur at left sternal border is typically associated with which valve?
aortic murmur
A 30 year old female presents to clinic with chest pain and palpitations. On exam you hear a clicking at the apex. What murmur do you suspect?
MVP
What is the goal BP for any age patient with DM?
<140/90
What stage of HF according to AHA would you place a patient who is SOB on exertion, has 3+ pitting edema who has underlying structural abnormalities?
Stage C
A patient with structural heart disease that is strongly associated with the development of heart failure but without symptoms is what stage of HF?
Stage B
Those who are at high risk for heart failure without no identified structural or functional abnormality are placed at what stage of HF?
Stage A
Why should NSAIDS be avoided in heart failure?
retain sodium
How long should you as a provider should a patient with a first time DVT be placed on anticoagulant?
at least 3 months
Arterial or Venous: cool, absent pulses to lower extremity, and no hair noted.
Arterial
Arterial or venous ulcer: Ulcers form typically at medial area of ankle.
Venous
When should a pedi patient with a murmur be referred?
any murmur associated with thrill or > grade 3/4
The pharmacological TX for MVP is?
beta blockers
Systolic or Diastolic: These murmurs are always considered bad and should be referred.
Diastolic
What should you do as a provider if someone's BP does not improve after the first month of new DX with medication?
increase dose of initial drug or and a second or third drug
Which statins are considered high dose statins?
Rosuvastatin and Atorvastatin
Which type of angina are beta blockers contraindicated?
Variant
A 32 y/o female who is healthy with no PMH would benefit from an ECG and/or exercise stress test. T/F?
False: The USPTF recommends screening against a resting ECG or exercise stress test in adult patients with low risk
Who would benefit from a pre-screening for CHD?
Competitive athlete, High risk occupation, Public safety occupation
Symptomatic heart failure with structural abnormalities should be treated with which medication and what stage?
Stage C - ACEI's/ARB's, beta blocker, diuretics
According to the USPTF, adults 18 or older and a BP of 120-139/ 80-89 should be re-evaluated how often?
annually - if less than 120/80 would be every 2 hours
Which percentile should a child be below if they are DX with stage 1 HTN?
95th
What are 3 classes of potassium sparing diuretics?
ACE, ARB, Aldosterone antagonist