Cardiology Exam 1

what is the most common cause of sudden cardiac death?

hypertrophic cardiomyopathy

cardiovascular screening is recommended for what athletes?

all middle school-aged and older

according to the AHA, what are the 4 physical exam findings that warrant CV screening in athletes?

heart murmur

diminished femoral pulse

marfan syndrome phenotype

brachial artery BP

what is the #1 cause of uncontrolled HTN

noncompliance

SBP high; DBP normal =

SBP normal; DBP high =

isolated systolic HTN

isolated diastolic HTN

hypertensive crisis is defined as systolic greater than ____ and diastolic greater than ____

180

120

ABSENCE of acute target organ damage

hypertensive urgency

PRESENCE of acute target organ damage

hypertensive emergency

in what population is hypertension the highest?

black men & women

what are the causes of secondary HTN?

"MEDS & OCRAP3"

meds

obstructive sleep apnea

cushing syndrome

renal causes

aorta coarctation

pheochromocytoma

hyperaldosteronism, hyperparathyroidism, hyper/hypothyroid

what meds can cause secondary hypertension?

aaaabcdhi

alc

amphetamines

antidepressants

antipsychotics

birth control

caffeine

decongestants

herbals

immunosuppressants

which cause of secondary HTN is suspected?

- resistant HTN, overweight/obese, snoring, breathing pauses during sleep, daytime sleepiness, morning confusion, fatigue

obstructive sleep apnea

which cause of secondary HTN is suspected?

- moon facies, central obesity, purple striae/stress marks, dorsal fat pad, hirsutism, gynecomastia, menstrual changes, decreased libido

cushing syndrome

which cause of secondary HTN is suspected?

- atherosclerosis in other arteries, abrupt increase in Cr after starting ACEi, epigastric/renal artery bruit, episodes of flash pulmonary edema

renal causes

what are the renal artery stenosis associated w/ secondary HTN is caused by?

atherosclerosis

what is the most common renal cause of secondary HTN?

- suspected with DM, autoimmune disease, collagen vascular disease, high Cr, low eGFR, protein/albumin in urine

CKD

which cause of secondary HTN is suspected?

- younger pt's, continuous murmur over back/chest, BP and HR differences between UE & LE, radial-femoral delay in younger pt's

aorta coarctation

narrowing of aortic arch distal to origin of LT subclavian artery

aorta coarctation

which cause of secondary HTN is suspected?

- triad of headache, palpitations, and sweating

pheochromocytoma

adrenal gland tumor that secretes catecholamines

paroxysmal elevation in BP

pheochromocytoma

what is the most common cause of resistant HTN?

hyperaldosteronism (aka conn syndrome)

which cause of secondary HTN is suspected?

- HYPOkalemia, metabolic alkalosis, resistant HTN, adrenal adenoma

hyperaldosteronism

which cause of secondary HTN is suspected?

serum calcium elevated (hypercalcemia)

primary hyperparathyroidism

which cause of secondary HTN is suspected?

fatigue, weight gain, cold intolerance, hair thinning, constipation

hypothyroidism

which cause of secondary HTN is suspected?

fatigue, palpitations, heat intolerance, sweating, weight loss

hyperthyroidism

to diagnose HTN, what is needed?

2 BP's taken on 2 different occasions

after determining target BP goal, what is the 1st line tx for HTN?

lifestyle modifications

what are the 4 1st line meds for primary HTN?

ACEi / ARB

BBs

CCBs

thiazide Diuretics

ACE inhibitors are preferred for pt's with what? (2)

CKD

DM with evidence of ckd/albuminuria

what are the side effects of ACEi?

chronic cough**

angioedema

rash

HYPERkalemia (stop if > 5.6)

chronic cough, angioedema, and rash are side effects in ACE inhibitors that are due to what?

bradykinin effects

what med is good for diabetics due to its renal protection?

ARBs

how can the side effect of peripheral edema with CCBs be minimized?

by combining with ACE/ARB

which med is most active in peripheral vascular system and is preferred over its counterpart for HTN?

DHP (dihydropyridine) CCB

which HTN med has SA and AV node depressant effects

non-DHP CCB

combining CCBs with ____ could cause SA/AV node depression

BBs

what should be checked 1-2 weeks after starting thiazide diuretics? (2)

Cr and electrolytes

side effects of which HTN med?

- electrolyte disturbances, gout/hyperuricemia, dyslipidemia, dysglycemia(insulin resistance), ED, rash

thiazide diuretics

with thiazide diuretics, how can dysglycemia/insulin resistance be minimized?

by adding MRAs

MRAs have a risk of causing ____ when combined with ACE/ARB

hyperkalemia

what meds are beneficial for pts with a previous MI? (2)

ACEi / ARB

BBs

what are the 2 types of beta blockers?

cardioselective (beta-1 only)

non-selective (blocks beta-2 also)

stepped care approach for HTN:

step 4 =

ACE/ARB

+

CCB

+

Thiazide

+

MRA (spironolactone)

in black americans with HTN, what is recommended?

if they have HF or kidney disease?

CCB or diuretics

ACEi / ARB

in non-black pt's > 55 yro, what is the 1st line HTN tx?

CCB or diuretics

in non-black pt's < 55 yro, what is the 1st line HTN tx?

ACEi/ARB or CCB or diuretics

if pt has angina what HTN med should you use? (2)

BB

CCB

if pt has A-Fib, you should control the rate with _____ and then use what med?

BB

Non-DHP CCB

in a pt w/ suspected secondary HTN, what would be the likely cause given normal kidney function and hypokalemia?

a. renal artery stenosis

b. cushing syndrome

c. primary aldosteronism

d. coarctation of aorta

c. primary aldosteronism

which med would be safe to use in a pt w/ known hyperkalemia?

a. loop diuretic

b. spironolactone

c. ACEi

d. ARB

a. loop diuretic

which drug class would be the best choice to treat HTN in a pt with diabetes and microalbuminuria?

a. ACEi

b. CCB

c. BB

d. diuretic

ACEi

injury to which of the following systems is NOT considered end organ damage due to HTN?

a. hepatic/liver

b. neuro/brain

c. cardiac/heart

d. renal/kidney

hepatic/liver

acute marked elevation in BP =

what are the levels

hypertensive crisis

SBP >=180

DBP >= 120

when treating hypertensive urgency what is the goal BP with meds that reduce over hours?

clonidine, captopril, labetalol

160/100

when treating hypertensive urgency over the course of days, if the pt is treatment naive, what should be added?

2 long acting meds

(ACE/ARB, CBC, or diuretic)

for most hypertensive emergencies, BP should be lowered by how much in the 1st hour?

should be lowered by NO MORE THAN how much in the 1st 1-2 hours?

10-20%

20-25%

what condition will cause impaired baroreflex?

orthostatic hypo

what is the 1st line tx (non-pharm) for orthostatic hypotension (4)

stop causative meds

increase salt/water

compressive stockings

stand slowly

what is the 2nd line (pharmacologic) tx for orthostatic hypotension

fludrocortisone

midodrine

what orthostatic hypotension med should be avoided after 4pm? why?

midodrine

prevent supine HTN

non-pharm tx's should be initiated to treat HTN and then a med should be added if....

- CV risk is not increased and their BP is:

- CV risk is increased and their BP is:

- CV risk is present due to > 65 yro and their BP is:

> 140/90

> 130/80

> 130/80

ACC/AHA defines elevated BP as what?

what is the tx?

S 120-129 and D < 80

non-pharm therapy

ACC/AHA defines stage 1 HTN as what?

what is the tx?

S 130-139 and D 80-89

non-pharm + pharm

ACC/AHA defines stage 2 HTN as what?

what is the tx?

S > 140 and D > 90

non-pharm + pharm

JNC8 defines pre-HTN as what?

S 120-139 and D 80-89

JNC8 defines stage 1 HTN as what?

stage 2?

S 140-150 and D 90-99

S > 160 and D > 100

deposits cholesterol INTO blood vessels

LDL

takes cholesterol AWAY from blood vessels to liver

HDL

subfraction of LDL; casual factor in atherosclerosis

Lp(a)

what is used as a one time measurement in pts with strong FHx of early CVD or familial hypercholesterolemia?

Lp(a)

what is the normal value for Lp(a)

(levels are largely genetically determined)

< 30

FLPs are often obtained with the pt fasting for how long?

8-12 hours

on FLP, what is the optimal TG level?

optimal HDL level?

optimal non-HDL?

< 150

> 60

< 130

on FLP, what is the optimal LDL level?

optimal VLDL level?

< 100

< 32

how is VLDL estimated?

when is this estimate least accurate?

by dividing TG by 5

when TGs are high

do fasting states or non-fasting states affect TGs that most?

non-fasting

type of HLD in which the LDL and Total are both elevated

hypercholesterolemia

what are secondary causes of hyperlipidemia? (5)

obesity

sedentary

DM

alcohol use

CKD

what are the typical exam findings of a pt with markedly elevated cholesterol levels? (2)

xanthomas

pancreatitis

extremely high TGs that usually presents in childhood with recurrent pancreatitis, hepatosplenomegaly, or eruptive xanthomas

familial chylomicronemia syndrome

high LDL with early ASCVD

familial hypercholesterolemia (FH)

most common genetic lipid disorder thought to be due to overproduction of VLDL by the liver

obesity, pre-CHD, xanthelasmas

familial combined hyperlipidemia

high Total and high TGs from accumulation of IDL (defective ApoE)

palmar xanthomas, tuberous xanthomas, tuboeruptive xanthoma

familial dysbetalipoproteinemia

what is likely the secondary cause?

high TG and low HDL

obesity

what is likely the secondary cause?

high TGs and high total

diabetes

what is likely the secondary cause?

high TGs and high HDL

alcohol use

what is the ACC/AHA screening recommendation for hyperlipidemia?

what is the USPSTF screening recommendation for hyperlipidemia?

all adults 20+ yro

begin at 35 for men // no rec for women

according to NCEP, how often should an FLP be done for adults 20+ yro?

every 5 years

when assessing 10-year CVD risk for tx of pts with hyperlipidemia, at what percentage is statin therapy recommended?

7.5% or higher

non-contrast, cardiac-gated CT scan that shows calcium containing plaques inside the coronary arteries

best test for additional risk stratification

CAC

CAC is used to help eval those who are 40-79 yro with ______ ASCVD risk OR those who are reluctant to _____

borderline - intermediate

start statins

what CAC score has neg predictability?

no statin at this time unless what?

repeat CAC when?

0

diabetic or LDL >190

in 3-5 years

what CAC score shoud begin moderate intensity statin?

1-99 or 75th percentile

what CAC score should consider mod to high-intensity statin?

> 100 or > 75th percentile

what CAC score should consider high intensity statin?

> 1000

what is the non-pharm 1st line tx for hyperlipidemia?

lifestyle measures

(exercise, stop smoking, weight loss, BP and DM control, diet)

what is the 1st line pharmacologic tx for hyperlipidemia

statins

what is the statin rec if pt has clinical ASCVD?

if > 75 yro?

high intensity

mod intensity

what is the statin rec if pt has a primary LDL > 190?

high intensity

what is the statin rec if pt has LDL > 70, diabetes, or is 40-75 yro?

if diabetes AND 10 yr risk > 7.5%?

mod intensity

high intensity