Sleep Apnea

Hypertension

Cushing disease

Kidney stenosis

Primary Aldosterone

Pheochromocytoma (rare)

Coarctation of aorta

Drugs

Stroke

Retinopathy

Peripheral Artery

Heart

Kidney proteinurea

b-Blockers

Non-DHP

CCBs

Diuretics

b-Blockers

ACE Inhibitors

AT1 Blockers

Direct renin inhibitors

a1-Blockers

a2-Agonists

All CCBs

Diuretics

Sympatholytics

Vasodilators

Hydrodiuril® (hydrochlorothiazide)

Zaroxolyn®

Diuril®

Lozol®

take potassium supplement

Block:

Lasix®

Bumex®

Demadex®

Edecrin®

 use for renal insufficiency (serum creatinine over 2, 1.8 women)

do not use in normokidney

Aldactone®/Spironolactone

Dyrenium®/ Triamtorene

Midamor/Amiloride

hyperkalemia

COST = $ à CHEAP

Preload, blocks aldosterone secretion

Afterload, blocks contriction

pril

Contraindications

  monitor: kidneys, CI Kiney (Interacts with Kidneys)

blocks AGII in periphery

Decrease tone, Dec. afterload

If they had a cough assoc. with Ace

If they had a sulf allergy

What is the only drug you can't give to a Heart failure pt?

Aldosterone antagonists

Spirolactone, Eplernone,

lower Na, hyper k

Gynecomastia

C/I If K >5.5

Scr, more than 2

Creatine below 50

K suppliments

NOT FOR DM OR PROTEINUREA

takes 4 weeks

Verapamil 

decrease HR and decrease contract force

decrease CO, decrease preload

works like a BB, $$

decrease vascular smooth (afterload)

Norvasc, amlodipine

heart block absolutely

Heart falure relative

Interacts with ETOH, Digoxin

Decrease Plasma Renin activity
prevent flight or fight response

Cardioselective Atenolol, Metoprolol (Lepressor)

not propranolol; No ISI

Bronchospasm: bad for asthma

Fatigue that goes away

Depression

BB

ACEi

ARBs

alpha 1 blockers

start with azosin (alpha)

orthostatic

sexual dysfx

Syncope after 1st dose (elderly)

Headache

alpha 1 blockers,

increase HDL, decrease TC and TG

clonidine

Reduce NE release

block alpha 2 receptors too

decreases systemic

symptoms are orthostatic, drowsy, dizzy

A2 agonists, but probably all BB

Aliskiren (Tekturna)

Renin Ali are Trekis

Lipitor increases BP effects

Decreases the effects of ARB (Irbesartan)

Increases water pill affect of furosemide

What is 2nd and 3rd choic for HF

BB

ARB or (aa) aldosterone inhibitor

1. BB, ACEi
2. Aldosterone antagonist

Diuretic/ACE

BBB

AA or ARB

• Drugs for HTN with DM

1. ACE/ARB
2. Diuretic
3. CCB or BB

Decrease Na CL- symporter at distal tube,

in short term, decrease preload

in long term decrease afterload

Age below 30 or above 50

3-4 meds are not improving HTN

If you see low K (hyperaldosterone), bruits, differential BP (Aortic dissection), epigastric bruits (renal stenosis)

Thiazide diuretics given once daily are recommended in patients with GFR ≥30 mL/min/1.73 m² (CKD Stages 1-3) (A);

12.1.b Loop diuretics given once or twice daily are recommended in patients with GFR <30 mL/min/1.73 m² (CKD Stages 4-5) (A);

12.1.c Loop diuretics given once or twice daily, in combination with thiazide diuretics, can be used for patients with ECF volume expansion and edema (A).

K sparing and aldosterone antagonists (eptironone, spirolactone)

d/t hyperkalemia

Nephrotic syndrom

LV dysfunction

reduces proteinuria

BOLO of hyperkalemia

Norvasc, HCTZ, ACEi, ARBs

advantage: do not block bradykinin

decrease preload, prevent hypertrophy of lV

decrease renin

do not reduce CO, dec. HR and SVR

a1 blocker that retains Na

bad dreams

Dyslipidemia

hypertension

DM

What makes HTN more complicated these days?

DM: insulin resistence,

dyslipidemia,

microalbuminuria,

obesity

BUN, SeCreatin, fasting lipid panel, review drugs, aldosterone, and TSH, T4, T3, electrolytes, CBC, Glucose

, microproteinuria, maybe EKG or Echocardiogram

Increases SVR, increases BP

With time, insulin causes arteries to be stickier, inflammation created by white cells adhering to your arterial walls makes the arteries less pliable. This loss of elasticity increases your blood pressure --

artherosclerosis

Blood clot

Fibromuscualr dysplasia

Pelvic radiation

CVD

CC: chief complaints were fatigability and weakness of the lower extremities

Onset: sudden

Age above 55, below 30

low potassium

 P/E: Epigastric bruits, pulmonary adema, unilateral small kidney, BP 180/120

Angiography, patency

Ultra sound, CT scan =size of kidney

Kidney panel: BUN, seCreatine, GFP rate

plasma renin levels, high

electrolytes: low potassium

Look at the uptake of radioligands in the kidney before and after captopril?

Asymmetry of DTPA uptake, time to peak uptake, or retention seen on a single post-captopril renogram is a highly sensitive and specific finding in detecting renal artery stenosis but does not distinguish unilateral from bilateral disease. If renograms are obtained both before and after captopril administration, the presence of captopril-induced change is a highly specific finding for the detection of renal artery stenosis, but the sensitivity of this finding is low.

Fibrogen is layed down weird, making an irregular shape

Autosomal dominant

ARBs/Ace combo: C/I in bilateral

Stent

Hypokalemia

high Na

HA

muscle cramps

polyuria

hypertension (180/ 120)

suppressed plasma renin activity,

and increased aldosterone excretion

Give ace-inhibitor

Direutics

Fix electrolytes

CT scan brain (stroke) and adrenals and kidney

24 urine for catecholamines (pheo)

urine cort

Kidney panel

HTN intermittently, palpitations, weating, anxiety

recently ate cheese, wine, trauma, clonidine

Snoring

daytime somnolescence

am headaches

apneic episodes

BP diffrent in different arms

diminished femoral pulse

Turners sydrom

Tx: Stent

Urgency has no target organ injury

Urgency is chronic

HA, anxiety, SOB

fluresemide

torsemide

bemetanide

Give metolazone 30 min prior (thiazide like)

loops can be used under 30, kidney failure

The improve insulin sensitivity

Prevent proteinuria in DM

high levels of K (5.5)

Pt doesn't want breasts

Kidney problems (CrCl below 50) or proteinuria

1. smoking

2. Men above 45, women over 55

3. blood pressure over 120/80
4. Family history

5. HDL below 40

6. Diabetes, FBG =126

7. inactive

8. poor diet

9. If HDL is above 60, subtract 1 risk factor

Acetylcholine (parasympathetic)

Bradykinin

histamines

thrombin

EDV-ESV/EDV or stroke volume/EDV

normally 55%

ETOH

Estrogen

Steroids

Fatty foods

• Normal: Less than 150 mg/dL
• Borderline High: 150 - 199 mg/dL
• High: 200 - 499 mg/dL (start to turn cloudy)
• Very High: 500 mg/dL or above

Total Cholesterol

5 to 40 is normal

below 40 bad

Above 60 is good (negates 1 risk factor)

Chloromicrons: triglycerides, little protein

VLDL: endogenous triglycerides

LDL: cholesterol, some protein

HDL, cholesterol, more protein

1. Clinical CHD

2. Symptomatic carotid artery disease, bruit?

3. Peripheral arterial disease? extremity pressure change?

4. Abdominal aortic aneurym

1. Smoking
2. BP of 140/90
3. HDL below 40
4. Grandfather had CHD at 55
5. Grandmother had CHD at 65
6. If pt is older than 45 m or 55 f
7. HDL greater than 60 negates 1 risk factor

If you had any of the CHD risks (CHD or aneurym) 

LDL = 100 (give TLC), = 130 give drugs.

If you have two major risk factors

(i.e. FAH and on antihypertension medication)

LDL = 130 (give TLC), LDL 160 = drugs

If you have 1 risk factor

(i.e. on smoking or antihypertension med)

160 (give TLC); 190 (give drugs)

*if they are above their goal, and you question motivation, you have the option to give drugs earlier.

Daily cholesterol: below 200

Fat calories: 7% of total

Fiber intake 10-25 g/day (ouch)

Increase Plant stanol margarins

Lose weight

Workout

If there is not increase after 6-8 hrs, it rules out MI for 80-100%

It's not specific (could be muscle or heart)

false positives (working out could confound)

CK-MB

Previous gold standard test

both, bitches

most sensitive at 6hr (97%, peak it 25 times bigger)

takes 7-10 days to clear, making it sensitive

only cardiac muscle, making it specific (95%)

2hr to 48hr

1. Normal range:  below 1.0 mg/dL
2. above 1 = lowest risk of artherosclerosis diseaes
   
3. between 1.0–3.0 mg/L middle tertile, average risk
4. above 3.0 mg/L highest tertile, highest risk.
5. above 10 mg, retest, Noncardiovascular cause

1. to determine the cause of diagnostic symptoms (eg, dyspnea)
2. to estimate the degree of severity of heart failure
3. to estimate the risk of disease progression
4. to screen for less symptomatic disease in high-risk populations.

When do CK-MK peak and fall?

When do cTnl fall?

CK  (4 hours after infarction,Peaks at 12–24 hours,Declines over 48–72 hours)

cTNl (detectable 4 hours and 6 hours, peak at 2 days, lasts 7-10)

1st. Niacin is the most effective agent currently available. However, many patients do not respond well to niacin. 

2. Fibrates (fenofibrates)

1. Fibrates (fenofibrate)

2. stop drinking, you lush

fenofibrate (Lofibra, TriCor) and gemfibrozil (Lopid) 

1. reducing your liver's production of VLDL

2. Turns VLDLs into HDL, increases HDL

3. Speeding up triglyceride removal

(Niaspan) decreases triglycerides by limiting your liver's ability to produce LDL and VLDL cholesterol.

1. Prescription and over-the-counter niacin is available, but prescription niacin is preferred as it has the least side effects.

2. Dietary supplements containing niacin that are available over-the-counter are not effective for lowering triglycerides, and may damage your liver.

1. Liver problems
2. pregnancy
3. breast feeding

Liver AST (needs to be less than 3 fold baseline), except Zocor

Kidney CK (needs to be less than 10 fold baseline)

check 3 mths, 6 ths

Screws up your liver (can't drink)

Rhabdomylysis (muscle problems)

HA

Rash

Diarrhea

Atorvastatin (Lipitor)

Lovastatin (Mevacor)

Simvastatin (Zocor)

from 3 am to 4 am, A Loser shits sims self on a macroslide when he drinks grapefruit juice or macrolides or non-dihydropyridine (verapamil)

next time he should take less take lest lipitor

pravastatin, Simostatin, fluvastin,  rosuvastatin, Pitavastatin

Pratixis is So F#ing Renal, it's the Pits

Pitavastatin is the more potent

Lipitor is more effective

Sequester cholesterol by chloride exchange

increase LDL receptors on liver cells

With Statins, great at decreasing LDLs

Colestipol, cholesevelam, cholestyramine sucrose

all have choles in them

it's cool to be a resin

Cholestyramine

If you have a partial biliary obstruction, be chole, best try a miney

GI problems: ab pain, heartburn, constipation

That's why you they are C/I bowel obstructions.

Niacin

so you don't itch, GI distress, flush

C/I: liver, gout, diabetes, hyperuricemia, peptic ulcer

Fibrates (Fenofibrate and Gemfibrozil)

Fibrates flip the lip on lipase

Liver and kidney problems

(they have to be adjusted for renal clearance)

they give people gall stones

(you just need to ultrafibrate those gall stones out)

I'm Tri G'ing to Fibrate, so I can get my HDLs together!

(decrease triglycerides to make HDLs)

Zetia (zetia blocks my baked ziti!)

and by blocking my baked ziti, it fixed everything, (decreased LDL, decreased triglycerides and inc. HDL)

zetia (ziti) is good by itself or with a nice cold statin

I ate so much ziti my kidneys failed!

 Vytorin (ezetimibe-simvastatin),

Statin + Zetia, which is

If someone can't tolerate Statins, what do you give them?

Zetia (ezetimibe)

If you don't want a nice cold statin, have some ziti.

above 500 triglycerides

Interact with coumadin

GI problems

Lovaze Increase your LDLs!

I would lovaze some fish

Check for target organ damage!

headache, papilledema, microalbumemia, SOB, etc

It's urgent if they are watching TV, it's emergent if they are complaining.

1% of HTN pts, but 25% of ER visits

Remember HTN crisis is an umbrella term!

Yes, they apparently don't work as well in African Americans.

Give them BB and Non Dihyrdrate calium channel blockers.

HTN stage 1,

it always goes to the highest bidder.

Captopril (Capoten) Ace inhibitor

Clonidine (Catapres) alpha 2 agonist

Labetalol (Tradate) Beta blocker

Hydrazaline (Torres)

There are also Nifedipine (Procardia) dihyradrapyrine CCB, but they cause ischemia! Don't prescribe

No, S/E

C/I: if they are a psych pt or have carotid artery stenosis

Nitroprusside (causes cynide poising, UV sensitive)

Nitroglycerin (vasodilates coronary arteries!)

Hydralazine (Torres favorite)

Enalaprilat (only IV Ace)

Labetolol (good for strokes)

They get Thicyanate toxicity

Fun fact: Nitroprusside is a brown bag special (cheap and UV sensitive)

Congested heart failure

Aortic dissection

Pheochromaffin! (excessive catecholamines)

Unstable angina

Acute MI

Acute LV failure

if they have chest pain

Strokes or head (ask if their head hurts!)

Fun fact: must be stored in glass

Pt with glaucoma (push on eye balls)

Sulfa allergy!

Fenoldopam (has old in it for glaucoma, had dopa in it for dopamine agonist)

Fenoldopam (IV)?

Wish I would have known this one for the app session

Hydralazine (IV or IM bolus, q4hr)

Torres afterloads when he talks about this drug.

Pre-eclampsia and eclampsia

increases heart rate

There are apparently no C/I

acute renal failure!

Hypertensive encephalopathy,

Dihydrapyridine calcium blocker

Phentolamine

Fendopamine

Labetalol

Hydrazaline (vasodilator, afterload, for pregnancy)

Nicardipine (after load, no encephalopathy, se: N/V)

*Labetalol (non-selective BB, for strokes, c/i asthma)

phentolamine (C/I: Cornary Insufficiency)

fendoldpam (C/I: sulfa, glaucoma)

Clevidipine butyrate (Cleviprex)

Cleveland smells like rotten eggs! Sorry!

Have to adjust TPN with this drug

Preload:Nitroglycerine (opens up coronary artery, protects heart from running out of O2)

Intrinsic: Phentolamine, Labetalol, Clevidipine,

Afterload: Nitroprussive mostly, Fenoldopam, Hydralazine, Enalaprilat, Nicardipine,

Nitroprusside (liver too)

Enalaprilat

Beta blocker (Esmolol) and Minoxil (vasodilator)

Need to get the BP normal in 5 to 30 min!!!, so I chose the quickiest acting ones.

Ischemic stroke, so don't treat!

The brain is just trying to protect itself

Front: Anterior Median line, Mid-Clavicular lines

Back: Posterior Median line, Mid Scapular lines

1. Marks the top of the subcostal angle
2. Tells you were the bottom of the heart is
3. Tells you where the top of the diaphram is
4. Tells you where the top of the liver is
5. The 7th rib is articulates with the xiphoid
6. Tells you where T-10 is

The great vessels

Trachea

Esophagus

Thymus gland

Anterior: blood vessels, nerves, lymph, and fat, thymus

Middle: Pericardium, heart, and root of great vessels

Posterior: Esophagus, trachea, aorta

It's a fibrous sack with the top hanging from the great vessel and the bottom anchored to the diaphragm!

It's not going anywhere.

Epicardium

Verceral Paricardium

Left, 5th intercostal space, 9 cm from midline

(base it at the top of the heart)

What is the name of the groove that divides the hear into top and bottom?

What is the name of the groove the divides the heart into left and right?

Top/Bottom: Coronary Sulus

Left/Rt: Intraventricular sucli (there is an ant and post)

Left Branch

a. Anterior ventricular artery

b. circumflex (posterior)

Right Branch:

a. Margin (ant) marg simpson is always right!

b. Posterior ventricular artery

Cornary Sinus lies in the cornary groove, posterior

a. collects blood from all regions of heart

Great Cardiac vein drains from left branches

Small cardiac vein drains from right branches

Fossa ovale

The commonest holes are VSD (Ventricular Septal defect), ASD (Atrial Septal Defect) and PDA (Patent Ductus Arteriosus). VSD is a hole in the interventricular septum or wall between two lower chambers (RV and LV). ASD is the name of the hole in interatrial septum and PDA is actually an extra pipe connecting   Aorta and Pulmonary Artery

On anterolateral surface, deep to epicardium, at the junction of the supra vena cava and right atrium

On the posteroinferior region, between the atria

Outside: Tunica Adventitia (it adventerous, outdoorsy)

Middle: Tunica media: (middle of smooth muscle)

Inner: Tunica intima

What are the three vessels off the celiac trunk?

1. Left gastric

2. splenic

3. hepatic

The silly celiac left his splen at home

Fist over chest

I. No limitation - hurts when jogging

II. Slight limitation- hurst when walking upstairs

III. - when walking to fridge

IV. When sitting on coach

2-10 fold

33% false positives and false negatives

Why is know about 

If your grandfather had a MI at 60?

Is that a risk factor?

Nope 55!; F = 65

Patients with NO CVD RISK FACTORS do NOT need screening!

unless they are diabetic or high LDL

Depends on their risk factors? Don't put in water suppy!

 Throw statins at pts with CHD, Diabetes, and Kidney Diz (under 60 GFR)

Diabetes!!!!!, aortic aneurism

Clinical or symptomatic coronary heart disease

Peripheral Vascular disease

Goal is 100 LDL

Statins, Statins, Statins,

Anti-platelets (plavix, asa)

Why would you use Ranolazine/Renexa?

No effect on BP/HR

QTc prolongation

           1) angina does go away with meds

Diabetes = CABG

Left side problem (EF below 50) = CABG

More than 2 arteries in trouble = CABG

 If it is a simple/ less severe case, PCI

If there is no severe stenosis, EF good = meds only

Ischemia = inverted T wave

Injury/death= elevated (when you die you are elevated to heaven)

Q waves are forever

Transmural = Q

Subendothelial w/ out O2 = inverted 7

Subendothelial w/out living tissue = elevated ST

Unstable:  no patttern (at rest), no biomarkers, with ECG abnomal

NSTEMI (no elevation = ischemia) = no pattern, with markers, ischemia, no infart

Death: STEMI (elevation = infart) = no patter, with markers, with Q or elevated. new LBBB

Burns

Renal failure

Hypertrophic

HF

Critically ill

HTN Plus

A) Kidney problems (DM/CKD) = 1. ACE (ARB) ab 2. a. Diruretics 3. a. Calcium blockers 4. BB

B) Coronary (Pre/Post MII): 2. a,b BB, ACE 2. a. diuretic/ccb; b AA (after artery failed)

C) Fluids (HF/Stroke): 1. Diuretic/ACE, 2a BB , AA

**for some reason ARBs are third on the HF paradigm!!!

Need Tpn and ST elevated (Q waves)

Or you saw damage (imaging)

Tpn + 1 more visual finding

You have to SEE the cell death

NOOOO!

You give them anti -Pain, -Platelet - anti thrombus

Pain: Nitroglycerin,

Platelet: ASA, Plavix, (fibatide fiban if bad ,or hx)

Thrombus: High Hepartin (kidney), low (kidneynormo)

What is your treatment plan for unstable angina/ NSTEMI?

Low Risk (no smoking): pharm stress test

High risk  w/ : TIMI score =3 (i.e. smoking, DM),

If TIMI gets a score of three he gets the L.G.E.

LM Heparin,

GP IIb/IIIa inhibitor (Tirofiban, Eptifibatide)

Coronary angiography

monitor EKG overnight

Coronary revasculization CABG/Stint in 48 hrs!!

GP IIb/IIIa inhibitor (Tirofiban, Eptifibatide)

Coronary angiography

monitor EKG overnight

Coronary revasculization in 48 hrs!!

Make her MONO in 5 minutes and EKG stat

Door to balloon in 90 minutes

ST elevation or BBB:

IV NG, BB (unless HF/Asthma), Clopidogrel 

PCI:

Anything that involves HTN

GI Bleeding

Brain bleeds

Trauma

Hx of bleeds

Aortic aneurism

Basically anything involving week blood vessels

Right Ventricular Failure fluids

no NITRO/DIURETIC

90% of all Nine risk factors accounted for 90% of risk of CAD:

LDL/HDL ratio

–Smoking

–HTN

–DM

–Obesity

Psychosocia

wine

exercise

diet

What would you put somone on G IIa/IIIb, Integrilin, aggreastat, Repro

Blood pressure =