Cps Exam 1 2012

Front 1

Lab monitoring of renal function for ACEI for htn:

Back 1

Before start treatment, then 1wk after starting tx and at any subsequent dose increase.
4-10d after start tx or incr dose IF patients at high risk of hyperkalemia or deteriorating renal fxn: PVD, Diabetes, existing renal impairment, or increasing age

Front 2

Lab monitoring of electrolytes and renal fxn for Thiazide:

Back 2

Within 4-6wk of starting tx
Thereafter q6-12mo
Whenever clinical condition changes or potentially interacting drug added

Front 3

HTN Lifestyle (listed in order)

Back 3

Weight reduction to normal BMI
DASH: fruit/veggie/low fat dairy
Sodium restriction to <2.4g NA or 6g NaCl.
Aerobic 30min/day most days
Moderate alcohol (1drink=12oz beer, 5oz wine, 1.5oz 80-proof)

Front 4

Pain during MI: persists thru NG dose
May see painless in diabetes and elderly!

Back 4

May be severe
Deep and visceral
Heavy, squeezing, crushing (may be stabbing or burning)
Similar to anginal pain but more severe and lasts longer
Centrl portion of chest and epigastrium
Occasionally radiates to arms (abd, back, lower jaw, neck less common)
If started during period of exertion does not usually subside upon cessation

Front 5

MI sxs other than characteristic pains

Back 5

Anxiety/restlessness
Pallor
Diaphoresis
Cool extremities
Tachycardia/htn (25% of pt's w/ anterior MI)
Bradycardia/hypotn (50% of pt's w/ posterior MI)

Front 6

Interpret lab tests and ECG changes in acute MI

Back 6

ECG: ST change
Lab: CK, troponin (take a while to become positive)

Front 7

Recommend drugs to start in pt w/ acute MI unless contraindicated

Back 7

Thrombolytic (6hr)/PCI (90min)
Antiplatelet: GP2b/3a inhibitor (effient) only if PTCA. ASA 160-320. Clopidogrel added particularly in those w/ PCI.
UFH/LMWH if: anterior wall mi with high embolic risk, undergoing surgical/percutaneous revasc, thrombolytic administered
BB (not if hypotension, bradycardia, heart block, cardiogenic shock or bronchospastic disease)
ACEI w/in 24h after BP stabilized
Nitrates at beginning
Statin indefinitely

Front 8

3 drugs after acute MI that should be prescribed when discharged unless CI'd

Back 8

BB, low dose ASA, ACEI, Statin
Indefinite!!!

Front 9

Screening for HTN

Back 9

q2yr if normal BP
q1yr if prehypertensive

Front 10

Compelling indications for thiazide

Back 10

HF, high CVD risk, diabetes, prevention of recurrent stroke

Front 11

Compelling indications for BB

Back 11

HF, High CVD risk, diabetes, post MI

Front 12

Compelling indications for ACEIs

Back 12

HF, post MI, high CVD risk, diabetes, CKD, stroke prevention!! All!!

Front 13

Compelling indications for CCBs:

Back 13

High CVD risk, diabetes

Front 14

HF
Post MI:
High CVD risk:
Diabetes:
CKD:
Recurrent stroke:

Back 14

thiazide, bb, acei
bb, acei
thiazide, bb, acei, ccb
thiazide, bb, acei, ccb
acei
thiazide, acei

Front 15

NYHA CLASSIFICATION: based on symptoms!!! 1-4

Back 15

No limitations
limitation with high physical activ
limitation with mild exertion
limitations at rest!

Front 16

ACC/AHA STAGES: adds in structural disease!! a-d

Back 16

A) RFs only: HTN, CAD, DM, cardiotoxic dr, rheumatic fvr
B) Structural disease w/o s/s (post MI, LV dysfxn, a-sxatic valvular di)
C) Past/current HF sx ass'd w/ structural di (SOB, fatigue, reduced exercise tolerance)
D) adv structural di; marked sx despite MAX therapy; recurrent hosp

Front 17

Drugs that may precipitate/exacerbate CHF:

Back 17

TZD: Na/fl retention
NSAID: same
Salicylate: same
CCB (nonDHP only?)

Front 18

Nonpharmacologic measures for pt with CHF:

Back 18

Na restriction <2.4g/d
Restrict st'd fats (red meat, high fat dairy)
Incr physical activity: 30min/d 5+ days/wk
wt loss
Fl restriction <2L/d esp in hyponatremic pt's experiencing fl retention
Reduce alcohol
Stop smoking
Reduce stress/anxiety

Front 19

Initiate lisinopril and suggest a schedule for lab monitoring in a patient with CHF.

Back 19

Initial: 2.5-5mg QD, increasing by no more than 10mg increments at intervals no less than 2wks to max of 40mg as tolerated.
Monitor w/in 7-10days after start:
K+, BUN, SCr
BP, renal fxn
WBC

Front 20

Target CHF dose of Enalapril
Lisinopril

Back 20

ENALAPRIL is BID
Enal target 10-20 BID
Lisin target 20-40 QD

Front 21

Role of diuretics in CHF:

Back 21

restore/maintain volume status in those evident of fl overload (orthopnea, edema, SOB OR JVD, periferal edema, pulsatile hepatomeg, rales)--usually loops with option of further adding chlorothiazides or metolazone temporarily (QOD, weekly)

Front 22

ID pt with CHF that would be candidate for BB

Back 22

LVEF<40%
Prior MI, HTN, Afib if preserved LVEF
NOT If active bronchospasm
AFTER optimization of volume status and DC of iv diuretics and vasoactive agents including inotropes
Continue UNLESS shock, refrac vol overload, or sxatic bradycardia

Front 23

Initiate therapy and recognize target doses for pt with CHF treated w/ coreg

Back 23

Start at 3.125mg BID after other HF meds stabilized
Target: 25mg BID (50 BID if >85kg)
Dbl dose q2-4wks to highest tolerated

Front 24

Define role of digoxin in CHF

Back 24

Also have Afib: controls ventricular response rate
Sx reduction and effects on clinical outcomes in mild to severe HF w/ reduced systolic fxn
Used with diuretics, ACEIs and BBs in sxatic HF to reduce hospitalizations!

Front 25

Appropriate starting dose of digoxin in geriatric pt

Back 25

If >70, has impaired renal fxn, or has low BMI: 0.125mg QD

Front 26

ID pts with HF that may be candidates for use of spironolactone and recommend starting dose

Back 26

NYHA Class IV or III from reduced LVEF<35% while receiving std therapy incl diuretics
Consider in pts following acute MI, w/ clinical s/s or hx of DM and LVEF <40%
NOT pt w/ cr>2.5 or crcl<30 or K+>5 or w/ other k-sparings
Starting dose: 12.5-25mgQD

Front 27

Diagnostic characteristics of HF w/ normal EF (myocardial relaxation and filling impaired and incomplete; V unable to accept adequate vol of blood...EF 50%+)

Back 27

Sxs consistent w/ effort intolerance and dyspnea, esp in presence of venous congestion and edema. Modest: dyspnea/fatigue only when stressed or activity
Ventricular chamber not enlarged
Reduced exercise tolerance when have elevated LV diastolic pressures.
Elevated BNP, S4 gallop, rales, exaggerated BP and HR rise after exercise
DIAGNOSTICS: 2D echo will show EF, CO, and LVH and/or remodeling...Doppler echo will show elevated pulm venous pressures...Chest radiography will show pulm congestion...EKG may reflect LVH.

Front 28

Recommend agents to manage HF w/ normal EF

Back 28

1) Diuretics titrated if vol overload.
Want BP <130/80
2) BB if HR >70
3) ACEI/ARB
4) CCB
Aldosterone antagonists
Nitrates
Digoxin: limited role if normal rhythm

Front 29

RFs for T2DM

Back 29

Over 45yo
BMI 25+ (overweight)
FH (parent/sibling)
Habitual physical activity
AA, Hispanic-American, Native American, Asian-American, Pacific Islander
Previous IFG or IGT
Hx of GDM/baby >9lb
HTN>140/90
HDL<35 and/or TG>250
PCOS
Hx of vascular disease

Front 30

Criteria for diagnosis of DM

Back 30

A1C>6.5%
FPG>126mg/dL (8h+ of no calories)
2h glc>200 during OGTT (75g glc)
If sx: random glc>200

Front 31

Goal levels of LDL in patient with diabetes. Also HDL, TGs

Back 31

LDL: <100mg/dl
HDL: >40
TG: <150

Front 32

Therapeutic plan to meet lipid goals must be devised

Back 32

Titrate statin. If TG>1000, consider gemfibrozil.

Front 33

ID Diabetic patients that would benefit from ASA as primary of secondary prevention strategy based on their RFs. (75-162mg/d)

Back 33

Primary: Type 1 or 2 and increased CV risk (10-yr >10%). This includes most men >50 and most women >60 who have at least 1 RF (FH, HTN, smoking, dyslipidemia, albuminuria). If <50/60 and no mj RF don't tx...multiple RFs needs clinical judgement.
Secondary: diabetes w/ hx of CVD (Plavix if asa allergy)
Combo ASA/Plavix reasonable up to yr after acute coronary syndrome.

Front 34

Therapeutic goals for glc and A1C in patient receiving diabetes tx:

Back 34

A1c <7% (individualized)
Preprandial: 70-130mg/dL
Peak postprandial: <180mg/dL

Front 35

Sx experienced in Afib:

Back 35

Palpitations, irregular HB, SOB, chest discomfort, dizzy, weak, anxiety

Front 36

Prioritize goals of tx in Afib patient

Back 36

Control ventricular response rate to get resting HR<80 (<90-100, exercise)-->rhythm control if achievable-->prevent clots

Front 37

Select appropriate agent for pharmacologic HR control in patient with Afib

Back 37

Chronic rate ctrl: metoprolol 50-100mg BID, diltiazem/verapamil, digoxin 0.125-0.25mcg QD if low activity level--slow acting too.
Avoid CCB in HF
Avoid BB if hypotensive, heart block, severe bradycardia.

Front 38

RFs for development of DVT

Back 38

Venous stasis (mj surgery w/ anesthesia>30min, immobilization, paralysis, obesity, hospitalization due to stroke/MI/HF, varicose veins, age >65
Endothelial injury: surgery, trauma, central venous access catheters, pacemaker wires, previous thromboembolic event
Hypercoagulable state: malignant disease, estrogen, pregnancy
Hematologic disorders incl polycythemia, leukocytosis, thrombocytosis, inflammatory bowel disease, DVT/leg clot, others

Front 39

Non-pharmacologic measures to prevent DVT

Back 39

Ambulation
Leg elevation (heels above heart to increase venous return)
Elastic compression stockings
(these all decrease venous stasis)

Front 40

Management plan for patient diagnosed with DVT incl initial doses of UFH, enoxaparin, warfarin

Back 40

mOBRI (up to 4 points for bleed risk):
Age 65+
Hx of stroke
GI bleed past 2wk
Recent MI, Hct<30%, SCr>1.5, OR Diabetes
Heparin 80U/kg IV bolus then 18U/kg/hr infusion
Heparin 333U/kg SQ then 250U/kg BID if unmonitored. If monitored, 17,500U or 250/kg BID adjusted to maintain hep level 0.3-0.7U/ml
Enox (if can do outpatient and low risk of bleed): 1mg/kg SQ q12h oR 1.5mg/kg q24h.
Stay on one of these at least 5d, until INR >2 for 2+ days.

Front 41

Monitoring of UFH, LMWH, warfarin

Back 41

Day 1: Baseline PT/INR< SCr, CBC w/ platelets (for UFH/HIT). aPTT at baseline and 6h after start or adjust dose: Heparin
Day 2: Evaluate PE (SOB, chest pain, cough), clot extension, &/or bleeding
Day 3: INR, same things as Day 2
Day 4: same
Day 5: same + CBC/platelets

Front 42

Weird things that can be s/s of hemorrhagic complications

Back 42

Loose/runny stools
Fever/illness that worsens
Pain/swelling
Headache

Front 43

Appropriate duration of anticoag in patient who had DVT

Back 43

Proximal, provoked by surgery: 3mo
1st event, reversible RF: 3mo
Isolated distal: 3mo
1st/2nd unprovoked: AT LEAST 3mo/extended
Upper extremity DVT: 3mo
Continuing RFs (CA, FVL, ATIII, protein C or S): 6mo/indefinite
APS: Indefinite!

Front 44

Manage warfarin outside of range; monitor

Back 44

Monitor: twice wkly @ initiation until 2 therapeutic INRs; wkly x1mo; monthly once stable. If change wkly dose/give bolus/hold dose, INR drawn in 1wk/possibly 2wk. See algorithm for remaining answer.

Front 45

Meds on Beers list that are highly anticholinergic or may be used in management of CV conditions or diabetes

Back 45

1st gen AH
Antiarrhythmics, digoxin >0.125
Insulin, sulfonylureas glyburide and chlorpropamide