ANP Review-Cardiac

Raynaud's

A. Sudden color changes of extremity, numbness, and tingling, burning pain. B. Medical Management: Avoid stimuli the cold and tobacco. Treated with calcium channel blockers. Sympathectomy interrupting the sympathetic nerves by removing the sympathetic ganglia or dividing branches. Nurse Management: Teach stress management, Minimize exposure to cold, Smoking cessation program, and Safety pre

The recommended LDL goal for a 64 male with diabetes who had MI 2 years ago should be less than:

70mg/dl

BMI

<18.5 = underweight 18.5-25 = healthy 25-30 = overweight 30-35 = obese class I 35-40 = obese class II >40 = morbidly obese

What type of meds would be good for chronic renal disease

ACEI & ARB

JNC-7 Lifestyle Modification Recommendations-Dietary sodium reduction

dietary sodium should be reduced to no more than 100 mmol per day (2.4 grams of sodium); SBP reduc. 2-8mm HG

Blood Pressure

BP=HR X SV (stroke volume) X PR (peripheral resistance)

etiology of DVT

Became known as Vichow's triad, trauma (intinal wall)-endothelial damage, Venous stais-immobility, MI, CHF, COPD, obesity, pregnancy, previous DVT, extrinsic compression, surgery. Hypercpagulability-pregnancy, cancer, hormones, ie, estrogen intake

Split S2-pathologic

Fixed split, no change with inspiration; paradoxical split-narrow or closes with inspiration. Fixed split often found in uncorrected septal defect, also conditions that delay aortic closure such as LBBB

MR PASS

Systolic murmurs (benign or pathologic) Mitral Regurgitation (holosystolic) Physiologic (innocent, functional) Aortic Stenosis (descrendo) Systolic

Which changes on the 12-lead EKG would you expect to find in a patient with a MI?

T Wave inversion

Pre-hypertension

120-139/80-89

Alpha adrenergic antagonist

(block stimulation of alpha receptors). Ex: (alfuzosin, doxazosin, tamsulosin, terazosin) Use: Vasodilator Tx: refractory CHF, hypertension, Raynaud vasopasm, prostatic obstruction Adverse Effects: (most serious) 'first dose syncope', lightheadedness, dizziness, headache, drowsiness, weakness, lethargy, nausea, papitations Maximizing Therapeutic Effects: refrain from administering any OTC drug in combination with prazosin Not as solo 1st agent=higher rate of stroke, heart failure (ALLHAT)

Angiotension Receptor Blockers (ARBS)

- prevent the release of aldosterone; block angiotension II from receptors in tissues - cause vasodilation & decreased PVR -losartan (Cozaar) Valsartan (diovan) -maybe used as first line Tx for HTN SE: dizziness, insomnia, diarrhea

Direct Renin Inhibitor

-Aliskiren (Tekturna) -Binds tightly with renin and inhibits the cleavage of angioteninogen into angiotensin 1 -decreased PVR -Adverse effects: angioedema, cough, GI effects, hyperkalemia, fetal injury and death -Expensive, hasn't proven to be better or worse than ACE inhibitors or ARBS. More GI effects than ACE and ARBS

Aldosterone antagonist (K+ sparing diuretic)

-Block aldosterone in the collecting duct -Drugs: spironolactone and eplerenone -Both agents decrease mortality in HF -Spironolactone useful in treating resistant HTN -Eplerenone contraindicated in high risk patients (DM, CrCl < 50 mL/min, SCr > 1.8 women; > 2.0 men) -Side effects: hyperkalemia (both), gynecomastia, & impotence with spironolactone -caution with renal impairment

LDL Goals

0-1 Risk Factor: <160 mg/dL 2+ Risk Factors: <130 mg/dL Existing CHD or CHD Risk Equivalents (DM, 10-year risk >20%): <100 mg/dL (optional goal <70: -Multiple major risk factors (CHD or CHD risk equivalent) -Severe and poorly controlled risk factors (heavy cigarette smoking, poorly controlled HTN, -strong family history of premature CHD, very low HDL) -Multiple risk factors of metabolic syndrome -Acute coronary syndrome)

screening for hyperlipemia

1) Complete lipid profile (fasting) every 5 years starting at age 20. 2) Over age 40 years, screen every 2 to 3 years. 3) Preexisting hyperlipidemia, screen annually or more frequently.

Risk Factors: Heart Disease

1) Hypertension 2) Family history of premature heart disease (women with MI before age <65 years or men with MI age <55 years) 3) Diabetes mellitus (considered a CHD risk equivalent even if patient has no history of preexisting heart disease) 4) Dyslipidemia 5) Low HDL cholesterol: <40mg/dL 6) Age (men older than 45 or women older than 55) 7) Cigarette smoker 8) Obesity (BMI ≥30 kg/m2) 9) Microalbuminuria *Adapted from JNC 7 (May 2003)

treatment of DVT

1. Anticoagulation a. Prevents further propagation of thrombus b. IV heparin at constant to maintain PTT of 1.5-2 times aPTT c. Start warfarin once aPTT theraptuc and continue 3-6 mo. INR 2-3 2. Thrombolytic therapy (streptoK; uroK; tPA (alteplase)) 3. IVC filter placement (Greenfield filter in patients) if other prophylaxis isnt working. PE prevention, NOT DVT prevention

Therapeutic Lifestyle Changes

1. Dietary options to ∇LDL: ^ inake of plant sterols & stanols to 2g/day (Take Control, Benecol); vicous or soluble fiber to 10-25g/day (oatmeal, oat bran). 2. Reduce intake of saturated fat <7% & cholesterol, 200mg/d & dietary fat to 25-35% of total daily caloric intake 3. Increase intake of omega-3 fatty acids 4. Weight management-balance energy intake & expenditure to maintain desirable body weight & avoid weight gain 5. Regular physical activity-daily for at least 30 min/day most days of week (150 total minutes/week)

Stage 1 Hypertension

140-159/90-99

diagnosis of DVT

1. doppler=> high sensitivity and specificity for proximal thrombi >>> distal 2. venography=> most accurate !!!! 3. impedance plethysmography=> same as doppler, less activator dependant 4.D dimer => high sensitivity, low specificity. evaluation of Dx: 1. intermediate/ high clinical probability -> doppler (+)-> anticoagulate. doppler non diagnostic -> repeat US every 2-3 days until two weeks. 2. low/intermediate clinical probability-> doppler (-) -> no need for medication, repeat US in two weeks.

Thrombolytic therapy is indicated in patients with chest pain & ECG changes such as:

3-mm ST segment elevation in leads V1 to V4

Omega-3 FAs

AT 4gm p/d dose: ∧ HDL (1-5%), ^ TGs (20-30%) MOA: Reduce hepatic triglyceride production and increase triglyceride clearance Modestly increases plasma levels of LDL cholesterol and increase HDL cholesterol levels Ex: Lovaza SE: fishy taste, rash, eructation, dyspepsia, taste perversion, allergic reaction CI: drugs that enhance bleeding

What are the characteristics of a S4 heart sound?

After it is initially noted, it is a permanent finding It is hear best in early diastole It is a high pitched sound best heard with the diaphragm of the stethoscope

Grade 6 Murmur

Audible without stethoscope

What type of meds would be good for after an MI?

BB, ACEI, and aldosterone antagonist

Centrally acting agents

Agents:-Clonidine, -Methyldopa -used in combination with a diuretic to treat all stages of HTN Adverse Effects: -sedation, dry mouth, bradycardia, constipation, sexual dysfunction, fluid retention, postural hypotension, mental depression -sympathetic crisis with sudden withdrawal -Methyldopa: decreased liver function, mental lassitude, impaired concentration

Spironolactone is what type of med?

Aldosterone antagonist

What is the most common cause of a systolic ejection murmur in the elderly?

Aortic Sclerosis

What is the most common cause of a systolic ejection murmur in the elderly?

Aortic stenosis

S4 heart sound

Caused by the increased resistance due to a stiff left ventricle usually indicates left ventricular hypertrophy. Considered as normal finding in some elderly (slight thickening of left ventricle). Occurs during late diastole (atrial gallop or atrial kick). Best heard at the apex (mitral area) using the bell.

What is the definition of unstable angina?

Chest pressure that occurs at rest

S2 (diastole) heart sound

Closure of the aortic and pulmonic valves

S1 (systole) heart sound

Closure of the mitral and tricuspid valves. AV valves

ACE Inhibitors

Decr AII -> decr aldost -> decr Na+/H2O retention, Vasodil, incr bradykinin -> incr PG -> vasodil; Tx: CHF in kidney dz/diabetes, HT; ADE: hyperK+, dry cough, acute renal failure, angioedema; CI: pregnancy Ex: -pril, lisinopril, enalapril

Which changes on the 12-lead EKG would you expect to find in a patient with a history of acute transmural MI 6 months ago?

Deep Q waves

MS ARD

Diastolic murmurs (always pathologic) Mitral Stenosis Aortic Regurgitation Diastolic

Calcium Channel Blocker

Dihydropyridine (DHP) Ex: Amolodipine, felodipine NonDHP: diltiazem, verapamil MOA: causes vasodilation (decrease PVR) -SE : ankle edema (DHP), NonDHP: caution with BB=1 degree HB -avoid w/heart failure, renal or hepatic impairment

What is the MOA of alsikiren?

Direct renin inhibitor

Which classification of drugs are most effective for treating HTN in black clients?

Diuretics

HDL (high-density lipoprotein

HDL: >40 mg/dL If <40 mg/dL, associated with increased risk of CAD even if normal LDL or cholesterol

What are the characteristics of a S3 heart sound?

Heard in early diastole noted in the presence of ventricular overload heard best with the bell of the stethoscope

What type of medication is doxazosin?

It is a alpha-adrenergic antagonist

What type of med is carvedilol?

It is a alpha/beta adrenergic antagonist

What type of medication is amlodipine?

It is a dihydropyridine calcium channel blocker

What type of medication is diltiazam?

It is a nondihydropyridine calcium channel blocker

What type of medication is trandolapril?

It is an ACEI

What type of medication is telmisartan?

It is an angiotensin receptor antagonist

LDL (low-density lipoprotein)

LDL: <130 mg/dL for low-risk patients with fewer than 2 risk factors

Grade 4 Murmur

Loud with thrill

Beta adrenergic antagonists

MOA: block adrenergic B1 receptor sites, blunt catecholamine response, non-cardioselective (propanolol, nadolol, other) also block B2 receptor sites (decrease HR & SV); use with caution with COPD, asthma, untreated heart block. Ex: atenolol, metoprolol, etc

Alpha-Beta adrenergic antagonists

MOA: block adrenergic B1, B2, Alpha 1 receptor sites, blunt catecholamine response (decrease HR, SV, & PVR) use with caution with COPD, asthma, untreated heart block. Ex: carvedilol, labetalol

Diuretic (thiazide)

MOA: low volume sodium depletion that leads to PVR reduction; Ex: HCTZ

What type of murmur is a mid to late systolic?

MVP

MR PASS wins the Most Valuable Player Award

Mitral Valve Prolapse

Which condition is associated with the finding of a third heart sound?

Mitral Valve Prolapse

Which condition is associated with finding of a 3rd heart sound (S3)?

Mitral valve regurgitation

Grade 3 Murmur

Mod. loud w/o thrill

What are some of the characteristics of retinopathy?

Narrowing of the terminal arterioles, sharp optic disc borders, and absence of retinal hemorrhage.

Triglycerides

Normal: <150 mg/dL High risk of acute pancreatitis: >500 mg/dL

total cholesterol

Normal: <199 mg/dL Borderline: between 200 and 239 mg/dL High: >240 mg

S3 heart sound

Pathognomic for CHF, occurs during early diastole, always consider abnormal if it occurs after the age of 40. Best hear with bell

Grade 2 Murmur

Quiet but immediately heard

The cardiac finding most commonly associated with unstable angina is:

S4

Variant angina (Prinzmetal's) is characterized by:

ST elevation

Which changes on the 12-lead EKG would you expect to find in a patient with ACS?

ST segment deviation

Normal blood flow

SVC & IVC>Right atrium>tricuspid valve>right ventricle>pulmonic valve>pulmonary artery>lungs>pulmonary veins>left atrium>mitral valve>left ventricle>aortic valve>aorta>general circulation

When a heart valve fails to open to its normal orifice size, it is said to be:

Stenotic

Treatment guidelines for hypertension Stage 2

Stage 2: 2 drug therapy:Thiazide-type diuretics & another drug class anti-hypertensive agent

What type of meds would be good for recurrent stroke?

Thiazide and ACEI

Treatment guidelines for hypertension Stage 1

Thiazide-type diuretics for most pts

What type of meds would be good for diabetes?

Thiazides, BB, ACEI, ARB, and CCB

What type of meds would be good for heart failure?

Thiazides, BB, ACEI, ARB, and aldosterone antagonist

What type of meds would be good for high risk CAD?

Thiazides, BB, ACEI, and CCB

Niacin

Use: ∇ LDL (5-25%), ∧ HDL (15-35%), ∇ TGs (20-50%) Ex. Niacin, Niaspan MAO: Inhibits lipolysis in adipose tissue; reduces hepatic VLDL secretion into circulation SE: Red, flushed face (∇ by ASA), Hyperglycemia, Hyperuricemia CI: active liver disease, severe gout, peptic ulcer

What are the causes of unstable angina?

Vasoconstriction, nonocclusive thrombus, inflammation or infection

Grade 5 Murmur

Very Loud with thrill

Grade 1 Murmur

Very faint

risk factors for high cholesterol

age, family history of chd, hypertension, smoking

Aortic stenosis in a 15 year old is most likely:

a result of a congenital defect

A grade 3 systolic heart murmur is usually

about as loud as the S1 heart sound

JNC-7 Lifestyle Modification Recommendations-DASH Eating Plan

adopt a diet rich in fruits, vegetables, and low fat dairy products with reduced content of saturated & total fat-SBP reduc. 8-14mm HG

JNC-7 Lifestyle Modification Recommendations-Moderate consumption of alcohol

alcohol intake should be limited to no more than two drinks (1 oz ethanol) per day in men and to no more than one (0.5 oz ethanol) per day in women and lighter-weight persons; SBP reduc. 2-4mm HG

Patients reporting symptoms of digoxin toxicity includes:

anorexia

You are examining an elderly woman & find a grade 3/6 crescendo-decrescendo systolic murmur with radiation to the neck. This is most likely cause by:

aortic stenosis

ECG findings in a patient with digoxin toxicity includes:

atrioventricular heart block

hyperlipidemia

condition of having too high level of lipids such as cholesterol in bloodstream; risk factor for developing atherosclerosis and coronary artery disease

What are some characteristics of Heart Failure?

elevated serum b-type natriuretic peptide, Kerly B Lines noted on chest x-ray, left ventricular hypertrophy on ECG

Stage 2 Hypertension

greater than or equal to 160/100

What is an absolute contraindication to the use of thrombolytic therapy?

history of hemorrhagic stroke

You are examining a 18 year old who is seeking sports clearance physical examination. You note a mid-systolic murmur that gets louder when he stands. This may represent:

hypertrophic cardiomyopathy

When a heart valve fails to close properly, it is said to be:

incompetent

What are the symptoms of a 65 male with dilated cardiomyopathy and HF?

jugular venous distention, tenderness on the right upper abdominal quadrant palpation, and peripheral edema.

In evaluating the person with aortic stenosis, the NP anticipates finding 12-lead ECG changes consistent with:

left ventricular hypertrophy

You are evaluating a person who has rheumatic hear disease. When assessing her for mitral stenosis, you auscultate the heart, anticipating finding the following murmur:

localized diastolic with little radiation

JNC-7 Lifestyle Modification Recommendations-Weight reduction

maintain normal body weight (BMI 18.5-24.9)-average SBP reduc. 5-20mm Hg per 10kg weight loss

MOTIVATED APPLES

mnemonic for the names of valves and type of valve: MOTIVATED APPLES M (mitral ) A (aortic) T (tricuspid) P (pulmonic) AV (atrioventricular) S (semilunar)

When assessing a woman with or at risk for acute coronary syndrome, the NP considers that the patient will likely present:

more commonly with angina & less commonly with acute MI

What is least likely to be reported in ACS?

pain reproduced with palpation

Goal of Hypertension Treatment

prevent complications and death by achieving and maintaining the arterial blood pressure at 140/90 to avoid target organ damage (per JNC-7)

potassium containing foods

raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery (fruits &vegs)

What are the goals of HF therapy?

reduction of preload reduction of systemic vascular resistance (afterload reduction) inhibition of the renin & sympathetic nervous system

JNC-7 Lifestyle Modification Recommendations-Aerobic physical activity

regular aerobic physical activity at least 30 minutes per day most days of the week has been found to lower SBP by 4 to 9 mm Hg

What is the definition of MI?

restrosternal diffuse pain for 30 minutes accompanied by diaphoresis

purine containing foods

salmon, liver, sardines

An ECG finding in a patient who is taking digoxin in a therapeutic dose typically includes:

slightly depressed, cupped ST segments

In evaluating mitral valve incompetency, you expect to find the following murmur

systolic with radiation to the axilla

Best diagnostic technique for DVTs?

two Doppler examinations, a week apart

Diabetics and HTN Meds

unless contraindicated, all diabetics should be on a ACE inhibitor or ARB because of their renal protective properties

Split S2-physiologic

widening of normal interval between aortic and pulmonic components of the second hear sound. Caused by the delay in the pulmonic component. Heard best in the pulmonic region. Split increases on patient inspiration.

Bile acid resins (sequestrants)

∇ LDL (15-30%), ∧ HDL (3-30%), ^ TGs (20-50%) Ex. Cholestyramine Colestipol Colesevelam MOA: Exchange chloride ions for bile acids in the intestine, thus inhibiting reabsorption of bile acids in terminal gut; Disrupt the normal enterohepatic re-circulation of bile acids from the intestinal lumen to the liver; Convert hepatocellular cholesterol into bile acids ***should be taken with food SE: Constipation, nausea, cramping, bloating, flatulence, taste intolerability, hypertriglyceridemia CI: Relative: TG>300 mg/dL; Absolute: TG>500 mg/dL; Absolute: Bowel or biliary obstruction, hypertriglyceridemia-induced pancreatitis, dysbetalipoproteinemia

Fibrates-Fibric Acid derivates

∇ LDL (5-20%), ∧ HDL (10-20%), ∇ TGs (20-50%) Ex. Gemfibrozil, clofibrate, bezafibrate, fenofibrate MOA: upregulate LPL, increases TG clearance SE: myositis, hepatotoxicity (increase LFTs), cholesterol gallstones, dyspepsia CI: severe renal or hepatic disease

Statins (HMG CoA Reductase Inhibitors)

∇LDL 18-55%, ∧ HDL (5-15%), ∇ TGs (7-30%) ∇cholesterol in the blood &reduce its production in the liver by blocking the enzyme that produces it; ∇cholesterol when combined with a cholesterol absorption inhibitor reduces its production in the liver, but also decreases absorption of dietary cholesterol from the intestine; (ex: lipitor, zocor, vytorin)