FNP CARDIO

HCTZ AND MUSCLE ACHES

HYPOK+ HCTZ IS K+ WASTING

Older adults have a unique blood pressure pattern. Which blood pressure reading below reflects this pattern? 100/50 140/100 160/60 160/100

160/60 ISH Nearly 2/3 of all older adults who are hypertensive have isolated systolic hypertension, i.e., the systolic blood pressure is elevated, the diastolic is normal. This probably occurs because vessels stiffen as people age and a higher systolic is required to move blood through stiffened vessels. Elevated systolic blood pressure is an important risk factor for cardiovascular disease and stroke in the elderly

Which patient could be expected to have the highest systolic blood pressure? A 21 year-old male A 50 year-old perimenopausal female A 35 year-old patient with Type 2 diabetes A 75 year-old male

75 Y/O MALE Nearly 25% of the US population has hypertension. The greatest incidence is in elderly patients because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African American adults have the highest incidence in the general population. Among adolescents, African Americans and Hispanics have the highest rates. Hypertension affects about 5-10% of pregnancies.

MOST COMMON ARRYTHMIA WITH MITRAL REGURGITATION AND WHAT MED WILL HELP

A FIB START ANTICOAGULATION= COUMADIN The most common arrhythmia associated with mitral regurgitation (MR) is atrial fibrillation. Anti-coagulation with warfarin will help prevent arterial embolism that can result in stroke or myocardial infarction. Atrial fibrillation occurs because the fibers in the atrium are stretched as the atrium dilates. The stretch results in conduction defects, notably, atrial fibrillation.

Which test below is most cost-effective to screen for abdominal aortic aneurysm? CT of the abdomen MRI of the abdomen Abdominal ultrasound Two hand palpation test

ABDOMINAL U/S While an abdominal aortic aneurysm (AAA) might be detected by multiple modalities, including a plain film of the abdomen, it is most cost effectively and efficiently identified using ultrasound (US). The sensitivity and specificity for AAA identification with US is nearly 100%. Both CT and MRI are very accurate in identifying AAA, but, they are both more expensive than US

An 87 year old has history of symptomatic heart failure. He presents today with lower extremity edema and mild shortness of breath with exertion. In addition to a diuretic for volume overload, what other medication should he receive today? ACE inhibitor Beta-blocker Calcium channel blocker Oxygen

ACE INHIBITOR A beta-blocker should be added when the patient is no longer symptomatic.' A calcium channel blocker will worsen systolic dysfunction because it will decrease the force of contractions.

Which class of medication is frequently used to improve long-term outcomes in patients with systolic dysfunction? Loop diuretics Calcium channel blockers ACE inhibitors Thiazide diuretics

ACE INHIBITORS ACE inhibitors are commonly used in patients with systolic dysfunction because they reduce morbidity and mortality, i.e. these medications alter prognosis. They also improve symptoms of fatigue, shortness of breath, and exercise intolerance. Loop and thiazide diuretics improve symptoms, but do not alter long-term prognosis with heart failure. Beta blockers should be used in conjunction with ACE inhibitors and diuretics, but not as solo agents. Beta blockers can potentially worsen heart failure, so their use in patients with heart failure should be monitored carefully. Despite this fact, beta blockers decrease morbidity and mortality associated with heart failure.

WHAT MEDS AFTER AN MI

ACE, ASA, BB, STATIN After a myocardial event, an aspirin, ACE inhibitor, beta-blocker, and statin should be taken daily. The goal for statin dose is LDL measurement of less than 70-100 mg/dL. The aspirin will provide anticoagulation, and the ACE inhibitor and beta-blocker are associated with reduced morbidity and mortality if given soon after ACS.

Which choice below would be the best choice for an 80 year-old patient whose blood pressure is 172/72 mm Hg? Chlorthalidone Amlodipine Monopril Acebutolol

AMLODIPINE THINK ISH According to JNC VIII and other learned authorities, this is best treated with a long-acting calcium channel blocker, particularly the ones that end in "pine". These belong to the class of calcium channel blockers termed dihydropyridines. Thiazide diuretics are not potent enough to decrease this patient's blood pressure into normal range and its effect is not additive when combined with calcium channel blockers

three most common symptoms associated with aortic stenosis

ANGINA, SYNCOPE AND HF evidenced by dyspnea. Syncope is usually exertional. Angina may be due to aortic stenosis, but, underlying coronary artery disease accounts for half of anginal symptoms in these patients. There is usually a prolonged asymptomatic phase, but the presence of symptoms usually indicates a need for valve replacement. Without replacement, there is a rapid decline in the patient's status and death will ensue.

How often should lipids be screened in patients who are 65 years and older if they have lipid disorders or cardiovascular risk factors? Annually Every other year Every 3 years Every 5 years

ANNUALLY IF HIGH RISK LOW RISK = Q 5 YEARS Explanation: Screening should take place annually for patients who have coronary artery disease and other risk factors like diabetes, peripheral artery disease, or prior stroke. These patients are at very high risk and annual screening is economically justified. In a setting of a low risk patient who does have any of the above mentioned risk factors, United States Preventive Services Task Force recommends screening every 5 years.

A decrease in blood pressure can occur in men who take sildenafil and: amlodipine. tamsulosin. metoprolol. any antihypertensive medication.

ANY B/P MED Any antihypertensive medication could have an additive effect with sildenafil (or another medication in this class). Caution is advised and should only be used if the male has stable blood pressure. A specific drug-drug interaction to be aware of is the one that can occur with sildenafil and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This combination of medications may increase the risk of symptomatic hypotension because the effect of these two drugs is additive. IE ALPHA BLOCKERS ARE COREG AND LABETALOL ARE BOTH ALPHA AND BETA BLOCKERS

Pharmacologic treatment for very elderly adults with hypertension should be initiated: only if there is a life expectancy of 10 years or more. for any type of hypertension. without regard to lifestyle modifications. only for those who are symptomatic.

ANY TYPE OF HTN Hypertension management has been found to be beneficial in preventing stroke and cardiac events in all ages. Treatment should begin without regard to age. Elderly patients are more likely to exhibit isolated systolic hypertension. This has been found to be a strong predictor of cardiac and cerebral events if not managed appropriately.

PAD

An absence of hair growth likely indicates peripheral artery disease in this patient. It is part of normal changes of aging that hair growth will diminish, but not become absent. His lower extremity pulses should be assessed, his cardiac risk factors should be assessed (he smoked for years), and he should be questioned about leg pain when he walks. An ankle-brachial index could be measured. If < 0.9, further assessment should be done. A normal ankle-brachial index should be greater than 0.9. Less than 0.4 is considered critical.

Significance of sildenafil and any blood pressure meds

Any antihypertensive medication ... could have an additive effect with sildenafil (or another medication in this A specific drug-drug interaction to be aware of is the one that can occur with sildenafil and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This combination of medications may increase the risk of symptomatic hypotension because the effect of these two drugs is additive

A patient with mitral valve prolapse (MVP) reports chest pain and frequent arrhythmias. In the absence of other underlying cardiac anomalies, the drug of choice to treat her symptoms is a(n): ACE inhibitor. beta blocker. calcium channel blocker. diuretic.

BETA BLOCKER Beta blockers are recommended to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse

An elderly patient with hypertension and angina takes multiple medications. Which one of the following decreases the likelihood of his having angina? ACE inhibitor Beta-blocker Diuretic Angiotensin receptor blocker

BETA BLOCKER The beta-blocker slows down heart rate, depresses myocardial contractility, and decreases sympathetic stimulation. These decrease myocardial oxygen demand and improve angina symptoms. It is an excellent drug class to use to prevent symptoms of angina in patients with underlying coronary artery disease. Calcium channel blockers are another class of medications that could be used to improve symptoms of angina.

A patient with shortness of breath has suspected heart failure. What diagnostic test would best help determine this? Echocardiogram B type natriuretic peptide (BNP) EKG Chest x-ray

BNP CHEAPER BNP is a hormone involved in regulation of blood pressure and fluid volume. When the BNP level is 80 pg/mL or greater, the sensitivity and specificity is 98% and 92%, favoring a diagnosis of heart failure. Alternatively, BNP levels less than 80 pg/mL strongly suggest that heart failure is not present (Some US institutions use 100 pg/mL). Other conditions may cause elevated BNP levels: thoracic and abdominal surgery, renal failure, and subarachnoid hemorrhage. Consequently, careful assessment of the patient is prudent. Echocardiograms mechanically evaluate the heart and establish an ejection fraction. If <35-40%, then HF can usually be diagnosed. Ejection fractions do not always correlate with patient symptoms. EKG evaluates the electrical activity of the heart. Chest x-ray can indicate heart failure but a BNP is a more sensitive measure.

WHAT LABS TO CHECK IN ONE WEEK AFTER STARTING ACE AND AFTER INCREASING A DOSE IN THOSE WHO HAVE HEART FAILURE

BUN/ CREATINGE, K+

An 80 year-old female who is otherwise well, has a blood pressure of 176/80. How should she be managed pharmacologically?

CCB This patient has isolated systolic hypertension (ISH). This is common in older adults and is associated with tragic cardiac and cerebrovascular events. The drug class of choice to treat these patients is a long-acting calcium channel blocker. The class of calcium channel blockers recommended for ISH has the suffix "pine" (amlodipine, felodipine, etc). Remember ISH = PINE

77 year-old patient has had an increase in blood pressure since the last exam. The blood pressure has risen to 168/88 with 2 readings. The last exam's reading was 144/90. If medication is to be started on this patient, what would be a good first choice?

CCB This patient is 77 years old and should have a goal blood pressure of < 150/90. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by 25 points to get him to goal. A long acting calcium channel blocker is appropriate for patients with isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta-blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Elderly patients tend to produce lower amounts of renin.

A 77 year-old patient has had an increase in blood pressure since the last exam. The blood pressure has risen to 168/88 with 2 readings. The last exam's reading was 144/90. If medication is to be started on this patient, what would be a good first choice? ACE inhibitor Beta blocker Calcium channel blocker Thiazide diuretic

CCB This patient is 77 years old and should have a goal blood pressure of < 150/90. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by 25 points to get him to goal. A long acting calcium channel blocker is appropriate for patients with isolated systolic hypertension, ISH and will be more likely to get this patient to goal pressure than HCTZ. Beta-blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Elderly patients tend to produce lower amounts of renin.

Which antibiotic should be used with caution if an elderly patient has cardiac conduction issues? Amoxicillin-clavulanate Trimethoprim-sulfamethoxazole Ciprofloxacin Macrodantin

CIPRO QUINOLONES =>QT Quinolones such as ciprofloxacin and levofloxacin are often used to treat urinary tract infections, especially in older adults. All of the quinolones have been implicated in possible QT prolongation. Knowing this should cause prescribers to use care especially when using these or other quinolones in adults with underlying conduction defects. This is especially the case if a patient is on other drugs concurrently that can prolong the QT interval.

A nurse practitioner has not increased the dosage of an antihypertensive medication even though the patient's blood pressure has remained >140/90. This might be described as: clinical inertia. malpractice. resistant hypertension. lackadaisical attitude

CLINICAL INERTIA Clinical inertia is the term used to describe healthcare providers who fail to intensify therapy despite patients not reaching goal. There are many reasons given as to why this takes place, but healthcare providers can potentially modify these

A patient taking atorvastatin for newly diagnosed dyslipidemia complains of muscle aches in his upper and lower legs for the past three weeks. It has not improved with rest. How should this be evaluated? Stop the atorvastatin immediately. Check liver enzymes first. Order a CPK level. Ask about nighttime muscle cramps.

CPK FIRST NOT LFT R/O RHABDOMYOLYSIS Explanation: This patient has a complaint of myalgias that could be associated with statin use. This patient should be assessed for rhabdomyolysis. This is done by measuring a CPK level. If this value is elevated, atorvastatin should be stopped immediately. Liver enzymes would not assess for the etiology of myalgias. They assess tolerance of statins in the liver. Nighttime muscle cramps are not usually associated with statin use. Myalgias are common but are typically not associated with an elevated CPK.

According to the National Heart, Lung and Blood Institute, which characteristic listed below is a coronary heart disease (CHD) risk equivalent; that is, which risk factor places the patient at similar risk for CHD as a history of CHD? Hypertension Cigarette smoking' Male age > 45 years Diabetes mellitus

DIABETES In determining whether a patient should be treated for hyperlipidemia, a patient's risk factors must be determined. After assessing fasting lipids, specifically LDLs, CHD equivalents must be identified. These are diabetes, symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, and multiple risk factors that confer a 10 year risk of CHD > 20 percent. Major CHD risk factors are elevated LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD [in male first degree relatives (FDR) < 55 years; female FDR, 65 years], and age (men > 45 years, women > 55 years). Patients with 2 or more risk factors should have a 10 risk assessment performed and treated accordingly.

Drugs that target the renin-angiotensin-aldosterone system are particularly beneficial in patients who have: hypertension. chronic heart failure. kidney stones. diabetic nephropathy.

DIABETIC NEUROPATHY Examples of drugs that target the renin-angiotensin-aldosterone system are angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs are particularly beneficial to patients who have diabetic nephropathy because they both prevent and treat diabetic nephropathy. Additionally, these agents also lower blood pressure which has been shown to be renoprotective. Management of glucose levels and hypertension is especially important in preventing diabetic nephropathy, but so is aggressive management of hyperlipidemia.

HOW TO MEASURE PULSE PRESSURE

DIASTOLIC - SYTOLIC IF greater than 60-70 points indicate "stiffening" of the vessels. Stiffening commonly occurs as aging occurs

The correlation between blood pressure and age greater than 60 years is: as age increases, diastolic blood pressure increases. as age increases, systolic blood pressure decreases. as age increases, blood pressure remains about the same. as age increases, diastolic blood pressure decreases.

DIASTOLIC DECREASES AND SYSTOLIC INCREASE SECONDARYN TO WIDEN PULSE PRESSURE Explanation: As age (beyond 60 years) increases, systolic blood pressure tends to increase, but diastolic blood pressure tends to decrease. This is evidenced by the observation of isolated systolic hypertension, seen almost exclusively in the elderly population. This results in a widening pulse pressure, a predictor of cardiovascular events in the elderly.

BEST TEST FOR MVP

ECHO The best means to identify mitral valve prolapse (MVP) is with 2D echocardiography. It will identify bulging of either, or both, of the leaflets (anterior or posterior) into the left atrium. Approximately 1-2% of the US population is identified to have MVP. A chest x-ray will not enable visualization of the mitral leaflets. Electrocardiography identifies the heart's rhythm. A physical exam may provide great clues to MVP, but in the absence of definitive mid to late systolic clicks, a diagnosis cannot be confirmed

WHAT TWO GROUPS OF PATIENTS HAVE ADVERSE B/P EFFECTS FROM CONSUMPTION OF SODIUM > 2000GM DAY

ELDERLY AND AFRICAN AMERICIANS

A common side effect of thiazide diuretics is: prostatitis. erectile dysfunction. fatigue. hyperkalemia

ERECTILE DYSFX Several studies have demonstrated that erectile dysfunction (ED) was associated with use of thiazide diuretics, specifically chlorthalidone. When ED was evaluated in patients taking chlorthalidone, acebutolol, amlodipine, enalapril, and doxazosin (the major antihypertensive drug classes), the thiazide diuretic, chlorthalidone had the greatest incidence of ED. The other drugs in the study were no more likely to cause ED than a placebo. However, a common complaint of men on antihypertensive medications is ED. This should always be evaluated as a side effect of antihypertensive treatment.

The carotid arteries are auscultated for bruits because: a bruit is indicative of an impending stroke. a bruit is indicative of significant carotid stenosis. this is indicative of generalized atherosclerosis. this is reflective of stroke risk.

GENERALIZED ATHEROSCHLEROSIS Asymptomatic bruits in the carotid area are more indicative of atherosclerotic disease than increased stroke risk. A symptomatic bruit requires attention immediately. Patients with carotid artery disease are more likely to die of cardiovascular disease than cerebrovascular disease. The Framingham Heart Study found that patients with an asymptomatic carotid bruit were at increased risk of stroke, but, the majority of strokes occurred in an area away from the carotid artery. The overall risk of stroke was insignificant when an asymptomatic carotid bruit was identified.

WHICH B/P MED IS CONTRAINDICTED WITH SOMEONE WHO HAS A SULFA ALLERGY

HCTZ This patient's allergy to "sulfa" sounds like Stevens Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide ring in its chemical structure, generally referred to as "sulfa". This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient's allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component.

In older adults, the three most common ailments are: hearing loss, vision loss, hypertension. hearing loss, hypertension, arthritis Depression, vision loss, hypertension. arthritis, hearing loss, depression.

HEARING LOSS, HTN, OA Explanation: Hypertension and arthritis are the two most common ailments that are seen in older adults. Hearing loss occurs in half to almost 2/3 of older adults. The most common form is known as presbycusis. There is no consensus for the frequency of screening for hearing loss, but minimally, it should be grossly evaluated at each visit and screened more thoroughly if deficits are observed. Blood pressure should be screened annually, but is usually screened at each visit. Arthritis is not routinely screened

A 75 year-old patient with longstanding hypertension takes a combination ACE inhibitor/ thiazide diuretic and amlodipine daily. Today his diastolic blood pressure and heart rate are elevated. He has developed dyspnea on exertion and peripheral edema over the past several days. These symptoms likely demonstrate: primary renal dysfunction. development of heart failure. failure of HCTZ dietary indiscretions.

HEART FAILURE The symptoms of increased heart rate in the presence of dyspnea on exertion and peripheral edema are symptoms of heart failure. Longstanding hypertension is a major risk factor for development of heart failure. Dietary indiscretion, like sodium/ fluid excess may produce peripheral edema, but should not produce dyspnea and peripheral edema in the absence of heart failure.

An overweight 76 year-old female with a recent onset of diabetes has longstanding hypertension and hyperlipidemia. She has developed atrial fibrillation. The nurse practitioner knows that now she will be at risk for: an S3 gallop. HF. peripheral edema. hypothyroidism.

HEART FAILURE This patient has longstanding hypertension that will increase her risk of HF. Once she develops atrial fibrillation (a-fib) she will lose about 30% of her cardiac output, the amount contributed by her atria when she is not in a-fib. Shortness of breath, peripheral edema or an S3 gallop may develop but are secondary to a consequence of HF or an embolism for which she is also at risk. Hypothyroidism can increase her risk of HF but the risk of hypothyroidism does not increase once a-fib develops. The most obvious risk of a-fib is stroke but this was not a choice

Tables are used for determination of maximum blood pressure values for adolescents. How are blood pressure values established for adolescents? Height percentile, body mass index, and gender Gender and age Height percentile, gender, and age Body mass index and gender

HT, GENDER AND AGE NOT BMI Body size is an important determinant in blood pressure in adolescents. Blood pressure tables are NOT based on body mass index. The tables include 50th, 90th, 95th, and 99th percentiles based on age, height, and gender. The age includes 17 years old. After this age, all blood pressures are based on adult values. Usually, 3 separate elevated blood pressure readings are required for diagnosis.

An ACE inhibitor is specifically indicated in patients who have: hypertension, diabetes with proteinuria, heart failure. diabetes, hypertension, hyperlipidemia. asthma, hypertension, diabetes renal nephropathy, heart failure, hyperlipidemia.

HTN, DM WITH PROTEINURIA AND HF Explanation: ACE inhibitors have numerous indications. Three are indicated in the first choice. ACE inhibitors are also indicated in patients who have renal insufficiency. However, ACE inhibitors can worsen renal insufficiency, so the patients must be monitored closely with lab tests for BUN, Cr, and potassium. Diabetes without proteinuria is not a specific indication for ACE inhibitors though, they are used by some healthcare providers in this way. This is an off-label use.

An ACE inhibitor is specifically indicated in patients who have: hypertension, diabetes with proteinuria, heart failure. diabetes, hypertension, hyperlipidemia. asthma, hypertension, diabetes. renal nephropathy, heart failure, hyperlipidemia.

HTN, DM WITH PROTEINURIA ANDD HEART FAILURE ACE inhibitors have numerous indications. Three are indicated in the first choice. ACE inhibitors are also indicated in patients who have renal insufficiency. However, ACE inhibitors can worsen renal insufficiency, so the patients must be monitored closely with lab tests for BUN, Cr, and potassium.

A common, early finding in patients who have chronic aortic regurgitation (AR) is: an hypertrophied left ventricle. atrial fibrillation. pulmonary congestion. low systolic blood pressure.

HYPERTROPHIED LV The left ventricle enlarges as blood regurgitates from the aorta. Atrial fibrillation is not typical or usual in aortic regurgitation (AR) since neither atrium is affected. Pulmonary congestion is seen later in the pathogenesis of AR. The blood pressure in patients with AR is characterized by an elevated systolic and decreased diastolic pressure. This is termed a wide pulse pressure.

Which of the following medications may have an unfavorable effect on a hypertensive patient's blood pressure? Lovastatin Ibuprofen Fluticasone Amoxicillin

IBPROFEN WATER RETENTION SECONDARY TO SODIUM RETENTION. This produces many systemic effects such as an increase in blood pressure, lower extremity edema, increased workload of the heart, and inhibition of prostaglandin synthesis. Patients with hypertension and heart failure should use NSAIDs cautiously. Neither lovastatin nor fluticasone would be expected to increase or decrease blood pressure. Amoxicillin is an antibiotic. This does not increase blood pressure.

Niacin can: decrease total cholesterol and triglycerides. decrease serum glucose and LDLs. cause flushing and hypertension. increase liver enzymes

INCREASE LFT Niacin can be used to decrease total cholesterol, LDLs, and increase HDLs. However its cardiovascular benefit is questionable although it improves lipid profiles. Liver function studies should be monitored prior to, with dosage increases, and periodically during consumption of niacin because elevations can occur. Glucose levels should be monitored as well because glucose levels can increase slightly in some patients who take niacin. Monitor for myalgias and rhabdomyolysis as with the statins. Niacin commonly causes flushing in patients, but, not hypertension NIACIN= DECREASE TC AND LDL INCREASE HDL-- PLUS GLUCOSE ALITTLE INCREASE LFT, MONITOR MYALGIA AND RHABDOMYOLYSIS WITH STATIN

Which infant has feeding behavior is least likely related to congenital heart disease? Feedings associated with persistent cough Feedings that take "a long time" to complete Feedings that are interrupted by choking Infants that burp frequently when feeding

INFANTS THAT BURP WITH FEEDING Infants who burp frequently probably are swallowing too much air with feeding. This is likely not related to congenital heart disease. Some red flags associated with feeding that should prompt the examiner to assess for congenital heart disease include feedings that are interrupted by choking, gagging, or vomiting. Some infants have rapid breathing with feeding or a persistent cough or wheeze. These should be assessed and CHD should be considered.

You are managing the warfarin dose for an older adult with a prosthetic heart valve. Which situation listed requires that warfarin be discontinued now? INR of 3, no bleeding INR of 4, no bleeding INR of 6, no significant bleeding INR of 2 with no significant bleeding

INR 6 INR is a good measure of the clotting status in an outpatient who takes an oral anticoagulant like warfarin. When warfarin is overdosed and INR climbs, or when warfarin is overdosed because of food or medication that produces deleterious side effects, warfarin doses may be omitted or discontinued until the INR is in a more acceptable range. Generally, one or 2 doses may be omitted before rechecking INR and resuming warfarin.

What should you do? Pt on Monopril and HCTZ for hypertension. His blood pressure is 160-170/92-98 on several blood pressure checks ? Would you add an ARB?

If these are at maximum doses, consideration should be given to adding a medication from a different class. CALCIUM CHANNEL BLOCKER NOT ARB - Adding an ARB may result in a precipitous decrease in his blood pressure because he takes an ACE inhibitor and both of these medications work in the renin-angiotensin-aldosterone system.

A common lab findings with ACE Inhibitors

Increase K+ ACE inhibitor = retention of potassium. Measure potassium one month after starting and one month after changing a dose

A 40 year-old African American patient has blood pressure readings of 175/100 and 170/102. What is a reasonable plan of care for this patient today? Start low dose thiazide diuretic. Start an ACE inhibitor twice daily. Initiate low dose HCTZ and candesartan. Initiate amlodipine, beta blocker, or ACE inhibitor. Explanation: This patient's blood pressure goal is < 140/90 according to JNC VIII. Since he is more than 20 points above systolic goal (or greater than 10 points above diastolic goal) it is reasonable to consider two medications today. Choice c offers this option.

Initiate low dose HCTZ and candesartan. START TWO MEDS IF OVER 20 POINTS This patient's blood pressure goal is < 140/90 according to JNC VIII. Since he is more than 20 points above systolic goal (or greater than 10 points above diastolic goal) it is reasonable to consider two medications today. Choice c offers this option.

Ramipril has been initiated at a low dose in a patient with heart failure. What is most important to monitor in about one week? Heart rate Blood pressure EKG Potassium level

K+ LEVEL ACE inhibitors work in the kidney in the renin angiotensin aldosterone system and can impair renal excretion of potassium in patients with normal kidney function. In patients with impaired renal blood flow and/or function, the risk of hyperkalemia is increased. Common practice is to monitor potassium, BUN, and Cr at about one week after initiation of an ACE inhibitor and with each increase in dosage in a patient who has heart failure and who receives an ACE inhibitor.

A patient taking an angiotensin receptor blocker inhibitor should avoid: strenuous exercise. potassium supplements. protein rich meals grapefruit juice.

K+ SUPPLEMENTS An ARB potentially can produce hyperkalemia because its mechanism of action is in the renin-angiotensin-aldosterone system where potassium is spared. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great

A 55 year-old male is obese, does not exercise, and has hyperlipidemia. His average blood pressure is 150/90. How should he be managed? He should be given low dose thiazide diuretic. An ACE inhibitor is appropriate. Lifestyle modifications are appropriate. He should receive an ACE inhibitor and thiazide diuretic.

LIFESTYLE MODIFICATIONS According to JNC VIII, a patient who is diagnosed with hypertension should have lifestyle modifications initiated today. He has several modifiable risk factors. Management of these can be expected to decrease blood pressure. If his blood pressure is not within normal range (< 140/90) after 3 months, it is reasonable to consider a medication like an ACE, ARB, thiazide diuretic, or calcium channel blocker.

Which choice below characterizes a patient with aortic regurgitation? Long asymptomatic period followed by exercise intolerance, then dyspnea at rest An acute onset of shortness of breath in the fifth or sixth decade Dyspnea on exertion for a long period of time before sudden cardiac death A long asymptomatic period with sudden death usually during exercise

LONG ASYMPTOMATIC PERIOD FOLLOWED BY EXERCISE INTOLERANCE THEN DYSPNEA AT REST. The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Then, shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aorta is replaced.

Mrs. Brandy is having contrast dye next week for a heart catheterization. What drug does NOT need to be stopped prior to her catheterization? Naproxen Furosemide Metformin Losartan

LOSARTAN Naproxen and furosemide should be stopped for 24 hours prior to the catheterization. Metformin should be stopped 48 hours prior to the catheterization. Furosemide is stopped because it contributes to volume depletion. NSAIDs like naproxen are withheld because of the impact on renal prostaglandin production. Metformin has been implicated in lactic acidosis when combined with contrast dye in an impaired kidney.

A patient is diagnosed with mild heart failure (HF). What drug listed below would be a good choice for reducing morbidity and mortality long-term? Verapamil Digoxin Furosemide Metoprolol

METOPROLOL Metoprolol is a beta blocker. Beta blockers are known to reduce morbidity and mortality associated with HF. Verapamil is a calcium channel blocker. These are contraindicated because they decrease contractility of the heart. Furosemide and digoxin will improve symptoms but not long-term outcomes. Their main benefit is in treating symptomatic patients.

A medication which may produce exercise intolerance in a patient with hypertension is: hydrochlorothiazide. amlodipine. metoprolol. fosinopril.

METOPROLOL Metoprolol is a cardioselective beta blocker. It can produce bradycardia that is responsible for exercise intolerance. As a patient exercises, a concomitant increase in heart rate allows for an increase in cardiac output. If the heart rate is not able to increase because of beta blocker influence, neither can the cardiac output. The patient will necessarily slow down his physical activity. Choices a and d have no direct effect on heart rate. Amlodipine is a calcium channel blocker that does not decrease heart rate.

The valve most commonly involved in chronic rheumatic heart disease is the: aortic. mitral. pulmonic. tricuspid.

MITRAL The mitral valve has a propensity for disorders secondary to rheumatic heart disease. Rarely is the pulmonic valve involved, but the aortic and tricuspid valves follow in descending order of involvement. Following an episode of rheumatic fever, which occurs infrequently in the US today but is common in developing countries, the valves can become stenotic or regurgitant. This is a major cause of valvular disease in the US seen primarily in immigrants

A patient has an audible diastolic murmur best heard in the mitral listening point. There is no audible click. His status has been monitored for the past 2 years. This murmur is probably: mitral valve prolapse. acute mitral regurgitation. chronic mitral regurgitation. mitral stenosis.

MITRAL STENOSIS Mitral valve prolapse (MVP) is an unlikely etiology since MVP is a systolic murmur. Additionally, the question states there is no audible click, and a mid to late systolic click is characteristic of MVP. Acute mitral regurgitation (MR) develops usually after rupture of the chordae tendineae, ruptured papillary muscle after myocardial infarction, or secondary to bacterial endocarditis. Symptoms of failure appear with abrupt clinical deterioration in the patient. There would not be a 2-year course for this patient as described in this patient. Dilation of the left atrium and ventricle is typical in chronic MR since both chambers are affected from regurgitant blood flow across the diseased valve, but, MR is a systolic murmur, not diastolic. This is mitral stenosis (MS) because MS produces the only diastolic murmur listed in the question

ORTHOSTATIC

MORE THAN 20 PTS SYSTOLIC WHEN RISING AFTER 3 MINUTES Orthostatic hypotension, also called postural hypotension, is diagnosed in older adults when the systolic blood pressure drops 20 mm Hg or more within 3 minutes of moving to a more upright position. This can be from lying to sitting or sitting to standing. Additionally, if the systolic blood pressure does not meet these criteria, but the diastolic drops by 10 mm Hg or more with a position change, postural hypotension can be diagnosed. Patients become symptomatic when this occurs and often report lightheadedness, weakness, dizziness, blurred vision, or decreased hearing

Which mitral disorder results from redundancy of the mitral valve's leaflets? Acute mitral regurgitation Chronic mitral regurgitation Mitral valve prolapse Mitral stenosis

MVP Mitral valve prolapse (MVP) is the most common adult murmur. It is a result of redundancy of the mitral valve leaflets and subsequent degeneration of the mitral tissue. The posterior leaflet is more commonly affected than the anterior leaflet. The valve's annulus becomes enlarged in conjunction with elongation of the chordae tendineae

MVP

Mitral valve prolapse (MVP) is most commonly diagnosed in women aged 14-30 years of age. However, it can be found in children (though not usually) or in older adults. The symptoms most commonly associated with MVP are arrhythmias, both atrial and ventricular, and chest pain. However, most patients with MVP are asymptomatic.

Which medication listed below could potentially exacerbate HF in a susceptible individual? Naproxen HCTZ Lovastatin Loratadine

NAPROXEN Naproxen is an NSAID. NSAIDs cause sodium retention and thus, water retention. A single dose of naproxen is unlikely to produce HF symptoms, but, repeated subsequent doses are very likely to produce water retention sufficient to cause edema and possible shortness of breath in susceptible individuals. The other medications listed are unlikely to have any direct effect on cardiac output in a patient with HF

An older adult has renal insufficiency, hypertension, osteoarthritis, hypothyroidism, and varicose veins. Which medication should be avoided? Acetaminophen Beta blockers NSAIDs Low dose aspirin

NSAID NSAIDs are contraindicated in patients who have renal insufficiency. They may produce a transient decrease in renal function and likely produce sodium retention and thus, water retention. For the same reason, this may worsen hypertension. Acetaminophen, mild narcotics, and/or topical agents could be used to treat her osteoarthritis. NSAIDs will have no effect on her varicose veins or hypothyroidism.

A patient taking an ACE inhibitor should avoid:

No K supplements ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is in the renin-angiotensin-aldosterone system where potassium is spared. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great.

A 63 year-old male has been your patient for several years. He is a former smoker who takes simvastatin, ramipril, and an aspirin daily. His blood pressure and lipids are well controlled. He presents to your clinic with complaints of fatigue and "just not feeling well" for the last few days. His vital signs and exam are normal. What should be done next? Order a CBC and consider waiting a few days if normal. Inquire about feelings of depression and hopelessness. Order a CBC, metabolic panel, TSH, and urine analysis. Order a B12 level, TSH, CBC, and chest x-ray

Order CBC, BMP, TSH, u/a Fatigue is a difficult complaint to assess and diagnose. This patient's exam and vital signs are normal. There is no reason to think that he is infected or is bleeding, so a lone CBC, offers little diagnostic help. However, in addition to a CBC, adding a metabolic panel, TSH, and urine (to screen for blood in this former smoker) is a more thorough laboratory assessment of his fatigue.

Benazepril should be discontinued immediately if: dry cough develops. pregnancy occurs. potassium levels decrease. gout develops.

PREGNANCY Benazepril is an ACE inhibitor = contraindicated during pregnancy because of the teratogenic effects to the renal system of the developing fetus. Dry cough is an aggravating side effect that occurs in some patients who take ACE inhibitors, but, discontinuation is elective. ACE inhibitor use is associated with increased potassium levels, not decreased levels. Gout is not exacerbated by ACE inhibitor use.

WHEN TO START MEDS FOR CHILDREN WITH HTN

Pharmacologic treatment should be initiated for children who have both hypertension and diabetes, symptomatic hypertension, hypertension > 95% tile, when end-organ damage is present. Obesity is a risk factor, but is not a sole indicator of treatment.

A patient with aortic stenosis has been asymptomatic for decades. On routine exam he states that he has had some dizziness associated with activity but no chest pain or shortness of breath. The best course of action for the nurse practitioner is to: monitor closely for worsening of his status. refer to cardiology. consider a non-cardiac etiology for dizziness. assess his carotid arteries for bruits.

REFER TO CARDIOLOGY In a patient with known aortic stenosis (AS) who has been asymptomatic for decades, one should be alert for symptoms that will precede angina, heart failure, and syncope. Dizziness precedes syncope in these patients and so this is an early indication that the patient is becoming symptomatic from his AS. Once symptoms develop, there is a rapid downhill course. Therefore, being alert for dizziness, chest discomfort, or exercise intolerance are very important symptoms to assess in previously asymptomatic patients who have aortic stenosis

An immune response to Group A Streptococcal infections involving the heart is: Kawasaki syndrome. rheumatic fever. hemolytic disease. pericarditis

RHEUMATIC FEVER Rheumatic fever is the correct answer. The immune response involves not just the heart, but can affect the joints, skin, and central nervous system. 0.1- 0.3% of untreated or under treated infections involving Group A beta hemolytic Strept can result in rheumatic fever. More often than not, this involves an infection in the upper airways. The most common age group affected is 5-15 years. However, the residual effect of rheumatic fever is realized into the later decades of life.

Most hypertension in pre-adolescents and children is: related to elevated BMI. primary hypertension. secondary hypertension. endocrine related

SECONDARY HTN Most hypertension in children and pre- adolescents is secondary hypertension. 60-70% is due to renal parenchymal disease. Rarely does primary hypertension exist in this age group. However, 85-90% of adolescents have primary hypertension.

RISK FACTORS FOR AAA

SMOKING AND HTN Smoking clearly increases the risk for abdominal aortic aneurysm (AAA). The prevalence in women is far lower than in men; and the benefits associated with screening women for AAA do not justify the costs.

Classic symptoms of a deep vein thrombosis include: swelling, pain, redness. calf complaints, pain with walking, history of exercise. swelling, pain, and discoloration in lower extremity. warmth, edema, and relief of pain with walking.

SWELLING, PAIN AND DISCOLORATION Swelling, pain, and discoloration from impaired blood flow are the classic symptoms. Choice A could describe infection, like cellulitis, and is not classic for DVT. A history of exercise actually decreases the risk of DVT. Pain secondary to DVT is not relieved by walking. The lower extremities are the most likely location of DVT, but symptoms don't always correlate with location of the thrombosis. Patients must be asked about history, family history of DVT, and precipitating conditions

Risk assessment for dyslipidemia- what age to start assessment

Start at age 2 Dyslipidemia assessment does not necessarily mean a Dyslipidemia assessment refers to assessing family history of dyslipidemia, premature cardiovascular disease, or diabetes, body mass index > 85% for age and sex, or history of other systemic diseases like Kawasaki Disease or treatment, or renal disease.

A patient who has hyperlipidemia should have: a statin daily. a thyroid stimulating hormone (TSH) level. second lipid measurement to confirm diagnosis. ] stress test done.

TSH If a patient's lipids are elevated, a TSH should be performed. If the TSH is elevated, it may be the secondary cause of the elevated lipids. It is considered safe practice to NOT treat elevated lipid levels until the TSH level has decreased to at least 10 mU/L. If the lipids are still elevated, they should be treated at that time.

Which test listed below may be used to exclude a secondary cause of hyperlipidemia in a patient with elevated lipids? CBC TSH U/A AND CULTURE SED RATE

TSH Patients who have dyslipidemia should be screened for diabetes, renal disease, and hypothyroidism. Nephrotic syndrome can produce remarkably elevated cholesterol levels. Therefore, measurements of glucose, creatinine, and thyroid stimulating hormone should be performed when evaluating dyslipidemia. Sedimentation rate is a measure of non-specific inflammation and so is not helpful in this situation. Specifically, hypothyroidism can produce marked lipid abnormalities.

ACE COUGH

USUALLY BEGINS WITHIN A WEEK AND IS DRY AND NON-PRODUCTIVE It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin converting enzyme). When degradation is impaired, bradykinin can accumulate and cough can ensue.

WHEN TO SCREEN FOR AAA

United States Preventive Services Task Force and American Heart Association recommend one-time screening for males aged 65 to 75 who have ever smoked. Other learned authorities recommend screening between 65 and 75 if they have a first degree relative who required repair of a AAA.

In order to reduce lipid levels, statins are most beneficial when taken: once daily in the AM. always with food. with an aspirin in the evening. in conjunction with diet and exercise.

WITH DIET AND EXERCISE Explanation: Statins are used to reduce elevated levels of lipids in conjunction with modifications in diet and exercise. The timing of statin dosing and indication with food (or not) is different for each statin. Most patients who take statins are also candidates for aspirin as primary or secondary prevention, but aspirin does not improve statin tolerance. Statins are correctly taken once daily but not necessarily in the AM.

An 80 year-old patient with long standing hypertension takes Monopril and HCTZ for hypertension. His blood pressure is 160-170/92-98 on several blood pressure checks. What should be done about his blood pressure? Add an angiotensin receptor blocker (ARB) Add another diuretic Add a calcium channel blocker Stop the HCTZ and add a beta blocker

add CCB This patient takes medications from 2 different classes of antihypertensives. If these are at maximum doses, consideration should be given to adding a medication from a different class. Adding an ARB may result in a precipitous decrease in his blood pressure because he takes an ACE inhibitor and both of these medications work in the renin-angiotensin-aldosterone system. Adding another diuretic will likely produce hypokalemia with a small decrease in blood pressure. The calcium channel blocker is a good choice because it will have an additive effect with the other medications he is taking. A beta blocker will slow the heart rate, not a preferred outcome in an elderly patient unless he has underlying angina or a heart rate problem.

ACE inhibitor is specifically indicated in patients who have ...

hypertension, diabetes with proteinuria, heart failure.

A patient who has diabetes presents with pain in his lower legs when he walks and pain resolution with rest. When specifically asked about the pain in his lower leg, he likely will report pain: in and around the ankle joint. in the calf muscle. radiating down his leg from the thigh. pain in his lower leg which waxes and wanes.

in the calf muscle This patient's symptoms are typical of arteriosclerosis. The term for this symptom is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common complaint is reproducible pain in a specific group of muscles. The pain occurs because there is an incongruence between blood supply and demand. This produces pain that causes a patient to stop exercising in order to obtain relief of pain.

An independent 82 year-old male patient is very active but retired last year. His total cholesterol and LDLs are moderately elevated. How should the NP approach his lipid elevation? He has reached an age where treatment holds little benefit. Treatment is not age dependent; he should receive niacin today. Treatment is based on expected length of life. He should receive a statin today until he is 85 years

older adults have higher rates of coronary events than younger adults do. Treatment of elevated lipids in older adults has been shown to decrease overall mortality, decrease major coronary events, and is associated with relative risk reduction for subsequent coronary events. United States Preventive Services Task Force and American Heart Association recommend lipid-lowering therapy because it clearly benefits older adults. This patient should have a statin started if lifestyle modifications do not allow him to reach goal lipid values. Niacin is poorly tolerated and wouldn't be a first choice in older adults because of hypotension and flushing.

When to start lipid profiles

recommended between 18 and 21 years of age.