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Cardiology

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Blood pressure diagnosis cutoffs
Pre: > 120/80
Stage 1: > 140/90
Stage 2: > 160/100
Hypertensive urgency vs emergency
Urgency: BP > 200 / 110 (either)
Emergency: BP > 200 / 110 with evidence of end organ damage
1st line drug - hypertension with no comorbidities
Thiazides (HCTZ)
1st line drug - hypertension with diabetes
ACE inhibitors (-pril)
ARBs (-artan)
1st line drug - hypertension with CHF
ACE inhibitors (-pril)
ARBs (-artan)
B blockers (-lol)
K sparing diuretics (triamterene, amiloride, eplerenone, spiranolactone)
1st line drug - hypertension with MI
B blocker (-lol) AND ACE inhibitor (-pril)
1st line drug - hypertension with osteoporosis
Thiazides (HCTZ)
1st line drug - hypertension with prostate
A blockers
1st line drug - hypertension with pregnancy
Methyldopa
1st line drug - prinzmetal angina
Dihydropyridine calcium blocker (amlodipone)
1st line drug - rate control in atrial fibrillation or flutter
Diltiazem / verapamil
Or B blocker
When to use hydralazine
Combined with isordil
2nd line for CHF after ACE inhibitors
When to use minoxidil
Combined with B blocker
B blockers contraindicated in
COPD -bronchospasm
ACE inhibitors contraindicated in
Pregnancy - teratogenicity
Renal artery stenosis - acute renal failure
Renal failure (Cr > 1.5) - hyperkalemia
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Family history of premature CAD is defined as
1st degree relative
Male < 55 YOA
Female < 65 YOA
Increased risk for CAD occurs at age
Male > 45 YOA
Female > 55 YOA
Greatest risk factor for CAD
Most common risk factor for CAD
Greatest risk: diabetes
Most common risk: hypertension
Takotsubo cardiomyopathy
Person who is usually calm has an emotional event
MI with normal angiogram and absence of vasospasm
EKG shows STEMI; increased troponins
Echocardiogram shows apical LV "ballooning"
D/t massive catecholamine discharge
Correcting which risk factor for CAD has the most immediate benefit?
Quitting smoking
Characteristics of ischemic pain
2-10 minutes (stable angina)
10-30 minutes (ACS)
Substernal (NOT left-sided) squeezing, tightness, heaviness, pressure, or aching
Alleviated by rest, provoked by physical activity, cold, emotional stress
Radiates to neck, lower jaw / teeth, arms, shoulders
A/W SOB, nausea, diaphoresis, dizziness, fatigue (nonspecific)
Chest wall tenderness is likely to be
costochondritis
Chest pain with radiation to back; unequal blood pressure between arms is likely to be
aortic dissection
CXR shows widened mediastinum. CTA, MRA, or TEE to confirm
Chest pain worse with lying flat, better when sitting up is likely to be
pericarditis
EKG shows diffuse ST elevation with PR depression
Sharp, pleuritic pain with tracheal deviation is likely to be
pneumothorax
CXR
When to order cardiac enzymes
Acute chest pain in the emergency department
do NOT order for acute chest pain in outpatient setting!
When to order stress testing
Etiology of chest pain is unclear or EKG is nondiagnostic / nonspecific
Nuclear stress test looks for
myocardium is alive & perfused
Stress echo looks for
abnormalities that cause decreases in wall motion
Avoid use of dipyridamole in
asthmatics
Indications for CABG
> 70% occlusion in at least 3 vessels
> 70% occlusion in at least 2 vessels + diabetes
> 70% occlusion of left main artery
Which medications decrease mortality in chronic angina?
Aspirin
Beta blockers
NOT nitroglycerin - symptomatic relief only
Clopidogrel: indications and adverse effects
Indications: acute MI (with/without aspirin), recent angioplasty with stenting

Adverse effect: rarely causes TTP
Prasugrel: indications and adverse effects
Indications: acute MI (with/without aspirin), recent angioplasty with stenting

Adverse effect: increased hemorrhagic stroke in patients > 75 YOA
Ticlopidine: adverse effect
Neutropenia
ACE inhibitors are most likely to decrease mortality in patients with
low EF / systolic dysfunction (dilated cardiomyopathy)
ACE inhibitors: adverse effect
Cough
Hyperkalemia (inhibits aldosterone)
Statins are most likely to decrease mortality in patients with
CAD and LDL > 100 mg/dL
CAD with diabetes - give statins when LDL >
70 mg/dL
Give statins if LDL > 100 and:
Peripheral artery disease
Carotid disease
Aortic artery disease
Diabetes mellitus

Coronary artery disease NOT required. These are CAD equivalents
Most common adverse effect of statins
liver dysfunction

Rhabdomyolysis can occur, but is rare
Niacin adverse effects
Glucose intolerance (avoid in diabetics)
Uric acid elevation (avoid in gout)
Pruritis from histamine release
Niacin's major effect on lipid profile is
Raising HDL
Gemfibrozil adverse effect
fibrates + statin = increased myositis
Gemfibrozil's major effect on lipid profile is
Decreasing triglycerides
Cholestyramine adverse effects
Interactions with medications in GI - may reduce absorption
GI complaints
Ezetimibe's major effect on lipid profile is
Lowering LDL, but does not decrease mortality or morbidity
Calcium channel blocker adverse effects
Reflex tachycardia --> increased myocardial oxygen consumption --> increased mortality with CAD
Edema
Constipation
Heart block (if OD)

Verapamil and diltiazem do not cause reflex tachycardia
No evidence of decreased mortality with Ca Channel blockers