Term
| What is the principle transporter of ENDOGENOUS triglycerides? Exogenous? |
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Definition
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Term
| What is the most severe familial hypercholesterolemia? What are physical indications of familial hypercholesterolemia? |
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Definition
Null defect - complete lack of receptors.
Look for thick and nodular Achilles' tendon, plantar xanthomas (yellowish discoloration) |
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Term
| What are some of the causes of polygenic hypercholesterolemia? |
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Definition
| ApoB100 defects, increased cholesterol absorption, decreased metabolism. |
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Term
| What are the biochemical consequences of high free fatty acids? |
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Definition
| Increased VLDL and TG production; CETP transfers TG to HDL and LDL. When hepatic lipases remove TG, HDLs with increased density are excreted in kidney and LDLs become sdLDLs. sdLDLs are easily oxidized. |
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Term
| What is the benefit of sitosterol? |
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Definition
| Plant cholesterol that competitively inhibits absorption of cholesterol without itself being absorbed. |
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Term
| What is the action of cholestyramine and colesevelam? |
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Definition
Bile sequestrates; bind bile acids to form non-absorbable complex. Reduces intrahepatic cholesterol, upregulating LDL receptors.
Increases uptake of TG. Prevents uptake of digoxin, warfarin, diuretics and thyroxine, so avoid taking medications together. |
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Term
| What is the mechanism of action for gemfibrozil and fenofibrate? |
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Definition
Fibric acid derivatives, which stimulate transfer of cholesterol to HDL and lypolysis. Reduce LDL 8-10%, increase HDL 8-10%, decrease TG 30%.
Can create gallstones. Drug interactions with statins and warfarin |
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Term
| What is the effect of niacin/nicotinic acid? |
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Definition
Increases HDL and lower TG (moderate effect on LDL).
Side effects prevent usage (flushing, hepatotoxicity). Contraindicated in diabetics and hyperuricemics. Since side effects are mediated by prostaglandin, can be taken with aspirin. |
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Term
| Which are the most potent statins? The CYP450 3A4 metabolized? The CYP450 2C9 metabolized? Which statin is not metabolized by any cytochrome?What are some pertinent side effects? What should be avoided in the diet? |
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Definition
- Atorvastatin and rosuvastatin
- Atorvastatin, simvastatin and lovastatin (avoid macrolides and itraconazole)
- Fluvastatin and rosuvastin
- Provostatin
- Rhabdomyolysis, muscle toxicity, kidney failure
- Grapefruit juice
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Term
| When would you use fenofibrate? When would it be contraindicated? |
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Definition
| When combining with statins (gemofibrozil contraindicated); contraindicated with renal disease |
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Term
| What is the mechanism of action of ezetimibe? |
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Definition
| Acts on brush border of intestine and prevents cholesterol absorption. Excellent when used in conjunction with statins. |
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Term
| What are some preconditions for NBTE? |
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Definition
- Pressure gradients across the heart valves (especially aortic valves)
- Valvular anatomy
- SLE (Libman Sack's)
- Mechanical damage from catheters and cannulas
- Particulate matter in IV drugs (RIGHT side only)
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Term
| What is the only gram negative bacteria commonly associated with endocarditis? |
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Definition
Pseudomonas
HACEK (small G- rods found in gingival crest) -
Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella |
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Term
| What are the distinguishing factors between acute and subacute endocarditis? |
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Definition
- Bacterial type
- Acute - Staph aureus
- Subacute - Strep and coagulase negative Staph
- Duration (acute = immediate, subacute = 2-3 months)
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Term
| Where do non-IV drug related endocarditis typically occur? |
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Definition
| Left side (site of mitral prolapse, most common site of congenital defect, site of high pressure gradients) |
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Term
| Which bacteria is a common cause of endocarditis in colon cancer patients? Patients receiving dental care? How does treatment differ? |
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Definition
- Streptococcus bovis
- Strep. viridans or HACEK
- Enterococci resistant to pencillin
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Term
| What are the major consequences of endocarditis? |
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Definition
- Emboli (note: lung protective in left-sided endocarditis)
- Heart block (if conducting system destroyed)
- Valve destruction
- Glumerulonephritis
- Microcytic aneurysms
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Term
| What are the peripheral signs of endocarditis? |
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Definition
FROM JANE
Fever, Roth's spots, Osler's nodes, murmur, Janeway lesion (dusky macula), anemia, nail-bed hemorrhage (splinter hemorrhages), emboli |
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Term
| What are the typical causative agents for pericarditis? |
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Definition
- Virus - typically echo or coxsackievirus. HIV, hepatitis and influenza also possible
- Bacteria - TB, pneumococcus and staph (purulent)
- Post-MI (ST elevated) - potentially auto-immune, occurs 2 weeks
- Radiation and neoplastics
- Drugs- hydralazine, procainamide
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Term
| What are the physical symptoms of pericarditis? |
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Definition
Sharp, prolonged retrosternal pain, radiating to back. Shortness of breath, with LOW-grade fever.
Frictional rub early, although loss of rub if pericarditis escalates to effusion |
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Term
| What are some of the major lab signs of pericarditis? |
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Definition
PR depression is very specific sign. Also, ST segment elevation, slightly concave upward.
No response to nitroglycerine. |
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Term
| What treatment for pericarditis in contraindicated post-MI? |
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Definition
| NSAIDs (may impair healing of myocardium). Use colchicine and steroid instead. |
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Term
| What hormone should you test for in case of pericardial effusion? |
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Definition
TSH - thyroid function test to rule out hypothyroidism.
Also note that cirrhosis can be cause (ascites, lymphatic obstruction, low colloid oncotic pressure) |
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Term
| Under what instances is tamponade most likely to occur? |
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Definition
| RAPID filling of the pericardium which does not allow time for compensation (proximal aortic dissection) |
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Term
| What are some peripheral signs for pericardial effusions? |
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Definition
May be asymptomatic
Dysphagia (pressing against esophagus), SOB, hiccups (pressing against recurrent laryngeal nerve).
Ewart's sign = dullness at left lung base at scapula due to atelectasis |
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Term
| What is electrical alternans and when would you see it? |
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Definition
| Shifting heart causes changes in height of ECG. Can be seen in effusion. |
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Term
| What complications can ensue with insidious pericardial effusion? |
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Definition
Right-sided heart failure due to pressure on IVC and SVC.
Pulsus paradoxus (>10 mmHg decrease in systolic pressure on inspiration due to pressure imposed by RV upon LV across septum) |
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Term
| What can be learned from pericardiocentesis? |
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Definition
Etiology of effusion
Exudate = infection
Transudate = viral / autoimmune problem
Adenosine deaminase = TB |
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Term
| What is the common cause of constrictive pericarditis? What lab is diagnostic for it? Physical signs? |
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Definition
- Recurrent viral pericarditis
- On diastolic filling wave, there is exaggerated Y descent with sudden upswing. Tamponade will plateau.
- Diastolic knock from sudden cessation of ventricular filling
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Term
| What degree of coronary artery occlusion qualifies as "high-grade"? What is the average grade that generates an MI? |
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Definition
| 70%; 50% due to minimal correlation between grade and MI |
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Term
| In order of time, which diagnostic tests are best for acute MI? |
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Definition
- Within first 6 hrs, ECG is gold standard
- Cardiac troponin I is most specific and is present from 4th hour --> 7 days
- CK-MB percentage is non-specific, but readily available after first day
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Term
| What are some non-genetic causes of dilated cardiomyopathy? |
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Definition
- Alcohol abuse
- Beriberi
- Coxsackie B virus
- Cocaine use
- Doxrubicin
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Term
| Who are at lower risk for CHF? Higher risk? |
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Definition
Premenopausal women are protected (although protection is attenuated by smoking)
African Americans develop HF a decade earlier than general population (may be due to HTN) |
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Term
| What is the Tetralogy of Fallot? |
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Definition
- Pulmonary stenosis
- RVH
- Overriding aorta (overrides the VSD)
- Ventricular septal deficit
Patient will squat to improve symptoms. Boot shaped heart will appear on X-ray. Caused by anterosuperior displacement of infundibular septum
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Term
| What is Eisenmenger's syndrome? |
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Definition
| Ventricular septal deficit leads to L --> R shunt. As pulmonary resistance increases, shunt shifts, leading to cyanosis. |
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Term
| Young athlete comes in complaining of syncopal episodes. On inspection, you observe a normal-sized heart with an S4 sound and systolic murmur. What is the most likely diagnosis? How would you treat? |
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Definition
Hypertrophic cardiomyopathy, most likely genetic, autosomal dominant. Concentric hypertrophy causing mitral leaflet obstruction of outflow (systolic murmur) and diastolic dysfunction
Treat with ß-blocker or calcium channel blocker (verapamil). |
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