Cardiology Master Deck

Blood pressure (BP) equation

$$Cardiac\text{ }output \times systemic\text{ }vascular\text{ }resistance$$

First-line hypertension medications

Thiazides, ACE inhibitors, ARBs, and calcium channel blockers.

ACE inhibitor mechanism of action

Blocks the conversion of angiotensin $I \rightarrow II$.

Thiazide adverse effects.

Hypokalemia, hyperglycemia, hyperuricemia.

Amlodipine common side effect

Peripheral edema.

Resistant hypertension definition.

Blood pressure that remains uncontrolled despite $3$ drugs including a diuretic. Most commonly due to medication non-adherence.

The most common cause of secondary hypertension.

Renal parenchymal disease (CKD, glomerulonephritis).

A hormone that is increased in patients with renal artery stenosis.

Renin.

A clinical clue suggesting renal artery stenosis after starting an ACE inhibitor.

Increased creatinine.

Pheochromocytoma classic triad

Headache, sweating, and palpitations. (catecholamine secreting tumor)

The diagnostic test used for pheochromocytoma.

Plasma metanephrines or 24 hour urine metanephrines.

Pheochromocytoma treatment order

The correct sequence is alpha blockade followed by beta blockade. Never treat with beta blockade first.

A condition associated with resistant hypertension.

Obstructive Sleep Apnea (OSA).

Hypertensive emergency

A condition defined by hypertension accompanied by acute end-organ damage.

Hypertensive urgency treatment

Managed through gradual adjustment of oral medications, asymptomatic can be outpatient follow up.

IV medications for hypertensive emergencies.

Nicardipine, labetalol, nitroprusside, nitroglycerin.

Rapid blood pressure lowering in hypertensive emergency.

An action that should be avoided because it can cause ischemia.

A cardiac complication resulting from chronic hypertension.

Left Ventricular Hypertrophy (LVH).

A retinal finding that suggests the presence of severe hypertension.

Papilledema.

Safe pregnancy hypertension medications

Labetalol, nifedipine, and methyldopa.

Primary hyperaldosteronism treatment.

Spironolactone.

Preferred hypertension treatments when the patient also has CAD, HF, or arrhythmia.

Beta blockers.

When combined with hypertension, this suggests renal involvement.

Proteinuria.

A potential toxicity resulting from the use of nitroprusside.

Cyanide toxicity.

The screening test used for Cushing syndrome.

Dexamethasone suppression test.

Hyperthyroidism blood pressure pattern

Characterized by an increase in systolic pressure (widened pulse pressure).

Hypothyroidism blood pressure pattern

Characterized by an increase in diastolic pressure.

A physical exam finding that suggests renal artery stenosis.

Abdominal bruit.

A hypertensive emergency typically presenting with tearing chest/ back pain.

Aortic dissection.

A hypertension complication caused by long-standing pressure overload.

Heart failure.

The lifestyle diet specifically recommended for the management of hypertension.

DASH diet.

Normal blood pressure value.

<120 / <80 mmHg

Stage 1 hypertension.

130-139 systolic or 80-89 diastolic (mmHg)

Stage 2 hypertension.

>140 systolic or >90 diastolic (mmHg)

Hypertensive crisis values.

≥180 systolic and/or ≥120 diastolic (mmHg)

Difference between hypertensive urgency and hypertensive emergency.

Presence of end organ damage.

Presentation of essential/ primary hypertension.

Usually gradual onset asymptomatic, “silent killer”.

Proper blood pressure measurement protocol.

Patient seated for 5 minutes, feet flat on floor, back flat against chair, arms heart level, correct cuff size, no exercise/ smoking/ caffeine beforehand.

Hypertensive retinopathy findings.

Arteriolar narrowing, AV nicking, cotton wool spots, flame hemorrhages, papilledema (malignant HTN).

AV nicking.

Visual narrowing of a retinal vein where a thickened artery crosses over it. Caused by chronic hypertension.

Cotton wool spots.

Fluffy white/ gray retinal lesions with feathery borders. Represent nerve fiber layer micro-infarcts caused by local ischemia.

Flame hemorrhages.

High blood pressure weakens and damages the walls of superficial capillaries, leak into the retinal nerve fiber layer.

Thiazide diuretics adverse effects.

Hypokalemia, hyponatremia, hyperglycemia, hyperuricemia, hypercalcemia.

Specific condition in which to avoid thiazide diuretics.

Gout, due to risk of hyperuricemia.

MOA of ACE inhibitors.

↓ Angiotensin II, ↓ Aldosterone, ↑ Bradykinin

ACEi are first line for hypertension in patients with which comorbidities.

CKD, heart failure, diabetes with albuminuria.

Contraindications to ACE inhibitors.

Pregnancy, bilateral renal artery stenosis.

Dihydropyridine calcium channel blockers.

Amlodipine, nifedipine. MOA vasodilation. Adverse effects flushing, headache, peripheral edema.

Non-dihyropyridine calcium channel blockers.

Diltiazem, verapamil. MOA reduces heart rate and contractility. Adverse effects constipation, bradycardia, heart block.

Beta blocker use in hypertension.

Patients with concurrent CAD, heart failure, arrythmia.

Beta blockers adverse effects.

Bradycardia, fatigue, sexual dysfunction.

MRA use in hypertension.

Resistant HTN, primary aldosteronism.

Common secondary causes of resistant hypertension.

OSA, renal artery stenosis, CKD, primary aldosteronism.

When to suspect secondary hypertension.

Young patient, sudden onset, severe, resistant, abnormal labs.

Renal artery stenosis as a secondary cause of HTN.

Decreased renal perfusion activates RAAS. Clues may be abdominal bruit, rise in creatinine after ACEi.

Primary hyperaldosteronism is also called

Conn syndrome.

Primary hyperaldosteronism classic triad.

Hypertension, hypokalemia, metabolic alkalosis.

Screening for primary hyperaldosteronism.

Aldosterone to renin ratio (increased aldosterone, decreased renin).

Cushing syndrome as a cause of secondary hypertension.

Cortisol excess. Clues: moon facies, purple striae, central adiposity, proximal muscle weakness.

Approach to hypertensive urgency vs emergency.

Oral medication adjustment and follow up vs intravenous medication and hospitalization.

Hypertensive emergency stabilization timeline.

Reduce MAP by 10-20% in first hour, then reduce by another 5-15% over the next 23 hours.

Biggest clue to cyanide toxicity from nitroprusside.

Cellular hypoxia → confusion & lactic acidosis.

Nitroprusside cyanide toxicity antidote.

Hydroxycobalamin.

Preeclampsia.

Hypertension after 20 weeks pregnancy with proteinuria or end organ dysfunction.

Preeclampsia treatment.

Delivery is definitive. Magnesium sulfate to prevent seizures. Labetalol/ nifedipine for blood pressure control.

In adults with resistant hypertension, you should always screen for what

Primary aldosteronism, regardless of whether hypokalemia is present.

Initial workup in pediatric hypertension.

BMP, UA, lipid panel. Then add on tests as needed.

Is spironolactone safe in pregnancy

No. Anti-androgenic effects of special concern in male fetus.

Gestational hypertension versus preeclampsia.

Only difference is the presence of proteinuria or end organ damage.

What condition is the exception that warrants rapid BP lowering in hypertensive emergency.

Aortic dissection, goal is systolic 100-120 mmHg within 20 minutes.

Genetic condition most strongly associated with aortic dissection.

Marfan syndrome.

Diagnostic of choice in aortic dissection.

CT contrast.

What should always be assessed in physical exam for primary HTN.

Ocular fundus.

First line medication for uncomplicated hypertension.

Thiazide diuretic.

USPTF hypertension screening.

All patients >18 years old.

Which medication class should be started first for BP control in patient with aortic dissection.

Beta blocker.

ACC/AHA hypertension guidelines blood pressure target.

<130/80 mmHg.

Potassium and hypertension relationship.

Increase in dietary potassium can decrease blood pressure.

ACEi and ARB relationship.

Should never be used together.

Most common cause of HFrEF

Ischemic heart disease.

Most common cause of HFpEF

Hypertension.

HFrEF Ejection Fraction cutoff

A measurement of $\le 40\%$.

BNP (Brain Natriuretic Peptide)

A hormone released due to ventricular stretch.

The first-line medication used for fluid overload in heart failure.

Loop diuretic

Four pillars of HFrEF therapy

ARNI (/ACE/ARB), beta blocker, MRA, and SGLT2 inhibitor.

ACE Inhibitor Adverse Effects

Cough, hyperkalemia, and angioedema.

Spironolactone Adverse Effects

Hyperkalemia and gynecomastia.

Beta blockers proven to reduce mortality in Heart Failure

Carvedilol, metoprolol succinate, and bisoprolol.

When should beta blockers be avoided in heart failure

Acute decompensated Heart Failure

SGLT2 inhibitors provide benefits for which type of heart failure

Both HFrEF and HFpEF

Digoxin toxicity symptoms and treatment

Visual disturbance, nausea, arrhythmias; activated charcoal

HF medications contraindicated in pregnancy

ACE inhibitors, ARBs, and ARNI.

Classic CXR finding in Heart Failure

Pulmonary vascular congestion (kerley B lines, etc), cardiomegaly, pleural effusion

Acute decompensated HF pulmonary edema treatment

A combination of diuretics, oxygen, and nitrates (if the patient is hypertensive).

A condition in which BNP levels may be falsely low.

Obesity

Conditions in which BNP levels may be elevated (other than HF)

Renal failure, atrial fibrillation, COPD, ARDS, sepsis, liver cirrhosis, hyperthyroidism, chemotherapy.

Most common cause of Right Heart Failure

Left heart failure.

RAAS activation effect on Heart Failure

Promotes sodium retention and cardiac remodeling.

ARNI for Heart Failure

Sacubitril/ valsartan.

MOA and use of Ivabradine

Reduces rate of SA node; use in HFrEF sinus rhythm with HR still >70 bpm on maximum tolerated beta blocker