WelcometoCardiologyBootCamp!BoardReviewSession#1SteveMadhavan,MDBrendaFortunate,DOHypertensionPearlsStartwithdiureticorbetablockerIfnoresponse,trydrugfromdifferentclassorasecondagentfromadifferentclass(adddiureticifnotalreadyused)Diureticsreducemortality&strokeriskinelderlywithisolatedsystolichypertensionACEinhibitorsreducemortalityinCAD,prolongsurvivalinCHF&postMILVdysfunction,preserverenalfunctioninDMInitialtreatmentofhypertensiondependsonriskgroupdeterminantsTargetorgandamage(TOD):

Stroke,TIA,

nephropathy,peripheralarterialdisease,hypertensiveretinopathyClinicalCardiovascularDisease(CCD):

LVH,angina,priorMI,priorCABG,CHFBloodPressureStagesCategory Systolic Diastolic

(mmHg)(mmHg)Optimal <120 and <80Normal <130 and <85HighNormal 130-139 or 85-89Stage1HTN 140-159 or 90-99Stage2HTN 160-179 or100-109Stage3HTN 180+ or 110+ HTNTreatmentRecommendationsNomajorriskfactors,TOD,CCD:treatstage1withlifestylemodificationupto12months,stages2&3:adddrugsOnemajorriskfactorbutnoDM,TOD,CCD:treatstage1withlifestylemodificationupto6monthsbeforeaddingdrugs.(adddrugsearlierifmultipleriskfactors.Begindrugtherapyimmediatelyforhigh-normalpressureifDM,TOD,CCDHypertensionPearls(Again)StartwithdiureticorbetablockerIfnoresponse,trydrugfromdifferentclassorasecondagentfromadifferentclass(adddiureticifnotalreadyused)Diureticsreducemortality&strokeriskinelderlywithisolatedsystolichypertensionACEinhibitorsreducemortalityinCAD,prolongsurvivalinCHF&postMILVdysfunction,preserverenalfunctioninDMWhichofthefollowingstatementismostaccurateregardinghypertensiveencephalopathy?FunduscopicexamwillbenormalItisusuallysecondarytoanadrenaltumorImmediateuseofhypotensivedrugsisindicatedlumbarpuncturemaybenecessaryWhichofthefollowingstatementismostaccurateregardinghypertensiveencephalopathy?FunduscopicexamwillbenormalItisusuallysecondarytoanadrenaltumorImmediateuseofhypotensivedrugsisindicatedlumbarpuncturemaybenecessaryHypertensiveencephalopathy:

severehypertensioncharacterizedbyheadache,nausea,vomiting,convulsions,&confusionprogressingtostupororcoma.

Bythetimeneurologicmanifestationsoccur,hypertensionhasreached

malignantstage.FundoscopicExamRetinalhemorrhagesExudatesPapilledemaCausesofhypertensiveencephalopathyEssentialhypertensionchronicrenaldiseaseacuteglomerulonephritisacutetoxemiaofpregnancyPheochromocytomaACTHtoxicity(soldassupplementorfromadrenaltumor)Cushingsyndromenon-compliancewithmedicationincludingabruptcessationofalphablockersHypertensiveEncephalopathy

(cont)LoweringBPwithdrugsmayreversepicturein1-2days.IfBPnotcontrolled,thismaybefatal.LumbarpunctureiscontraindicatedandmaycausedeathduetoincreasedICP.Reference:Harrison’s,ed14,pp.1392-94Whichismostlikelytocauseseriousmalfunctionofatransvenouspacemaker?CervicalMRIscan(theoreticallypace3000beatsperminute)MicrowaveovensElectrosurgeryforremovalofskinlesionExtracorporealshock-wavelithotripsyAirportmetaldetectorsWhichismostlikelytocauseseriousmalfunctionofatransvenouspacemaker?CervicalMRIscan(theoreticallypace3000beatsperminute)MicrowaveovensElectrosurgeryforremovalofskinlesionExtracorporealshock-wavelithotripsyAirportmetaldetectorsPacemakersElectrocautery

cancausetemporarysensingproblemsorreprogramming.Checktoconfirmproperfunctionaftercompletionofprocedure.Lithotripsymaycauseproblemswithdualchamberpacing.Monitorpatient.Reprogrammingmaybeneeded.Reference:AnnalsInternalMedicine1993;828-835andCecils,ed21.P.204WhichstatementregardingtreatmentofAMIiscorrect?Reference:Hennekensetal,NEJM1996;335(22):1660-7BetaBlockersreduceinfarctsizeandchestpainwhengivenforAMI.CCB’sreducemortalityfromAMI.ACEinhibitorscauseCHFifgivenduringAMI.(TheypreventCHF.)NeitherlidocaineormagnesiumareroutinelyindicatedafterAMI.Theydonotreducemortality.BetaBlockersreduceinfarctsizeandchestpainwhengivenforAMI.CCB’sreducemortalityfromAMI.ACEinhibitorscauseCHFifgivenduringAMI.(TheypreventCHF.)NeitherlidocaineormagnesiumareroutinelyindicatedafterAMI.Theydonotreducemortality.AcuteCoronarySyndromeDefinedasunstableangina,non-ST-segmentelevationMI&ST-segmentelevationMIInitialtreatmentincludes325mgASAchewednoadvantageoft-PAinpatientswithoutSTsegmentelevationTroponinIremainselevatedupto2weeks;checkCPKforsuspectedre-infarctReference:2003FamilyPracticeBoardReviewCourseAcuteCoronarySyndrome

adjunctivetreatmentstPAwithIVheparinisfibrinolyticofchoiceStreptokinasewithoutIVheparinif75+SublingualnitroIVnitroforrefractorypain;keepSBP>105-110mmHgIVmorphineisanalgesicofchoiceOxygenonlyifhypoxemicWhichoneofthefollowing

statementsistrue

regardingthedeterminationof

bloodpressure?Reference:JAmericanBoardofFamilyPractice1998,11(4):252-8Measurebloodpressureinseatedpositionwithpatient’sbacksupported.Whenindoubtaboutcuffsize,itisbettertousealargecuff.(Alargecuffcausesnegligibledifference;asmallcuffmayoverestimatepressureby4-9.5mmHg.)Allowatleast30seconds(not5minutes)betweenmeasurements.Measurepressureinbotharms;repeatinarmwithhigherpressure.Donotaverage.Measurebloodpressureinseatedpositionwithpatient’sbacksupported.Whenindoubtaboutcuffsize,itisbetterto

usealargecuff.(Alargecuffcausesnegligibledifference;asmallcuffmayoverestimatepressureby4-9.5mmHg.)Allowatleast30seconds(not5minutes)betweenmeasurements.Measurepressureinbotharms;repeatinarmwithhigherpressure.Donotaverage.Whichisassociatedwithhighserumcholesterol?Diabetesinsipidus(correct=diabetesmellitus)AmyloidosisMultipleSclerosisNephroticsyndrome(alongwithhypertension,proteinuria&edema)hyperthyroidism(correct=hypothyroidismwhichshouldbecorrectedbeforeinitiatingtx)Whichisassociatedwithhighserumcholesterol?Diabetesinsipidus(correct=diabetesmellitus)AmyloidosisMultipleSclerosisNephroticsyndrome(alongwithhypertension,proteinuria&edema)hyperthyroidism(correct=hypothyroidismwhichshouldbecorrectedbeforeinitiatingtx)A72yearoldsmokerwithseveredegenerativearthritis,

diabetes,&cardiovasculardiseasecomplainsofbilateral

legpainthatoccursafterwalking200yards.Restimproveshissymptoms.Whichisthemostappropriatetest?

AnklebrachialindexMRIoflumbarspineUltrasoundofthelowerextremitiesElectromyelogramofthelowerextremitiesArteriogramofthelowerextremitiesWhichisthemostappropriatetest?

AnklebrachialindexMRIoflumbarspineUltrasoundofthelowerextremitiesElectromyelogramofthelowerextremitiesArteriogramofthelowerextremitiesRef:Fauci,Braunwald,etal.Harrisons,16thed.2005:1486>1.3Calcifiednoncompressible artery1.0-1.3Normal0.4-0.9Usualrangeclaudication<0.4AdvancedischemiaAnkleBrachialIndexWhichismostappropriateforinitialtreatmentofclaudication?Warfarin(coumadin)VasodilatingagentsChelationRegularexerciseWhichismostappropriateforinitialtreatmentofclaudication?Warfarin(coumadin)VasodilatingagentsChelationRegularexerciseRef:Santillietal,AmerFamilyPhysician1996;53(4):1245-53Duringahealthmaintenanceexam,a54yearoldsmokerstatesheistakingbetacarotenebecauseitwasrecommendedbyalocalhealthfoodstorespecializinginnaturalsupplements.

Heaskswhatyourecommendwithregardtothissupplement.

Heshouldnottakethebetacarotene.

Althoughbetacarotenehasnotbeenprovenbeneficial,thereisnoharmintakingit.Betacarotenesupplementationhasbeenshowntoprevent

lungcancer.Betacarotenesupplementationhasbeenshowntodecreasecoronaryarterydisease.

Heshouldnottakethebetacarotene.

Althoughbetacarotenehasnotbeenprovenbeneficial,thereisnoharmintakingit.Betacarotenesupplementationhasbeenshowntoprevent

lungcancer.Betacarotenesupplementationhasbeenshowntodecreasecoronaryarterydisease.TheBeta-Carotene&Retinol

EfficacyTrialwasterminated

prematurelybecauseofasignificantincreaseinlungcancermortality&insignificantincreaseinCAD.Ref:Adams&McBride:AmerFamPhysician1999;60(3):895-904Youarechiefofstaffofasmall

communityhospital.TheheadofyourEDwantstodevelopaprotocolforuseoftissueplasminogenactivator(tPA)forstrokevictims.

Whichisthe#1reasonaspecificstroketeamprogramwouldhavelittleimpactoncommunityhealth?TheuseoftPAincreasesshort-termmortality.TheusesotPAdoesnotreducelong-termdisability.MRIscanningwouldnotbeavailablewithin3hours.VeryfewpatientswouldbeeligiblefortPAevenifastroketeamandprotocolwereinplace.ItisoftendifficulttoobtaintPAwithin3hours.TheuseoftPAincreasesshort-termmortality.TheusesotPAdoesnotreducelong-termdisability.MRIscanningwouldnotbeavailablewithin3hours.VeryfewpatientswouldbeeligiblefortPAevenif

astroketeamandprotocolwereinplace.ItisoftendifficulttoobtaintPAwithin3hours.Ref:Luisi&Hume:JAmBoardFamPract1998;11(2):145-51Discussion Fewpatientseligibleeitherbecausetheypresentmorethan3hoursaftersymptomonsetorhavecontrastotPAMRIscannotneeded.(24hourCTscanwithexpertinterpretationneeded.)rt-PAmayincreaseearlymorbidity&mortalitybutdecreaseslongtermdisability.CentersinNINDSstudyhadonly2-5eligiblepatients.Aninspiratoryincreaseinjugularvenouspressure(Kussmaul’ssign)isassociatedwithCirrhosisoftheliverChronicconstrictivepericarditiscorpulmonalepatentductusarteriosusarteriovenousfistulaAninspiratoryincreaseinjugularvenouspressure(Kussmaul’ssign)isassociatedwithCirrhosisoftheliverChronicconstrictivepericarditiscorpulmonalepatentductusarteriosusarteriovenousfistulaRef:Goldman&Bennett(eds):CecilTextofIM,ed21,pp252-3DiscussionLarge-moderatepatentductuscauseswidepulsepressure&boundingpulses.Incorpulmonaleadvancedpulmonarydiseaseisusuallypresent&venouspressurefallswithinspiration.Congestivehepatomegaly&

ascitesmayoccurwithconstrictivepericarditis.Distendedneckveinsshouldpromptsearchforcardiacdisease.DissectionofthedescendingaortaismostlikelytoproduceUnequalbloodpressureinthearmsdecreasedrightcarotidpulseparadoxicalpulseof25mmHgearlydiastolicmurmuralongleftsternalborderseverepainasthepresentingsymptomDissectionofthedescendingaortaismostlikelytoproduceUnequalbloodpressureinthearmsdecreasedrightcarotidpulseparadoxicalpulseof25mmHgearlydiastolicmurmuralongleftsternalborderseverepainasthepresentingsymptomRef:Goldman&Bennett(eds):Cecils,ed21,2000,pp354-6Dissectionofthedescendingaortaordinarilybeginsjustbeyondtheoriginofthesubclavianarteryandproceedsdistally.

Hemopericardium&aorticregurgitationoftenfoundinascendingaorticdissectionsdonotoccur.Patientstakingticlopidine(Ticlid)asforstrokeprophymustinitiallybemonitoredq2weekswith:CBC(asneutropeniawithanabsolutecount<450/mm3mayoccurbetween1st&3rdmonthoftherapy)LipidPanelUrinalysisSerumCreatininePatientstakingticlopidine(Ticlid)asforstrokeprophymustinitiallybemonitoredq2weekswithCBC(asneutropeniawithanabsolutecount<450/mm3mayoccurbetween1st&3rdmonthoftherapy)LipidPanelUrinalysisSerumCreatinineDCifneutropenicRef:MolonyB:arisk-benefitanalysisofticlopidineinstrokeprophy.Stroke1992;34(874):30Whichisnotconsideredariskfactorf