PAEA Emergency Medicine EOR Exam Study Guide.

PAEA Emergency Medicine EOR Exam Study Guide. what is the most common cause of heart failure? specifically left sided? right sided? - - MC is CAD (coronary artery disease) -L sided: *CAD* & HTN -R sided: *L sided HF* & pulmonary dz decreased ejection fraction, thin ventricular walls, dilated LV chamber, and an S3 gallop (filling of dilated ventricle) is associated with systolic or diastolic heart failure? - systolic (MC form of CHF) *(the sound is actually heard in the diastole though) -memory trick: "sys-to-lic" 3 consonants = S3 normal ejection fraction, thick ventricular walls, narrowed LV chamber, and an S4 gallop (atrial contraction into a stiff ventricle) is associated with systolic or diastolic heart failure? - diastolic -memory trick: "di-a-sto-lic" 4 consonants = S4 what are the causes of systolic vs diastolic heart failure? - -systolic: post *MI*, *dilated cardiomyopathy*, myocarditis -diastolic: *HTN*, *LVH*, *elderly*, valvular heart dz, hypertrophic or restrictive cardiomyopathy, constrictive pericarditis when the metabolic demands of the body exceed normal cardiac function (d/t thyrotoxicosis, wet beriberi, severe anemia, AV shunting, Paget's disease of the bone) this is termed ________ heart failure - high-output *fairly uncommon -low-output HF is just d/t problem w/ myocardial contraction, ischemia, or chronic HTN what are some causes of acute vs chronic heart failure? - -acute: *largely systolic*; hypertensive crisis, acute MI, papillary muscle rupture -chronic: dilated cardiomyopathy (systolic), valvular dz (diastolic) explain class I-IV New York Heart Association functional classes - -class I: *no sx's*, *no limitation* during ordinary physical activity -class II: *mild sx's* (dyspnea or angina), *slight limitation* during ordinary activity -class III: *comfortable only at rest* (sx's caused maked limitation in activity even with minimal exertion -class IV: *sx's even while at rest*, severe limitations, inability to carry out physical activity PAEA Emergency Medicine EOR Exam Study Guide what compensations does the body make when heart failure (can be due to something that causes either inc pre/afterload or dec contractility) begins? - 1. sympathetic nervous system activation 2. myocyte hypertrophy/remodeling 3. RAAS activation: fluid overload the following are signs/sx's of what sided heart failure? inc pulmonary venous pressure, dyspnea, orthopnea, rales/rhonchi, chronic nonproductive cough with pink frothy sputum, HTN, Cheyne-Stokes breathing, S3 or S4, pale skin/cool extremities, sinus tachy, fatigue - L-sided HF the following are signs/sx's of what sided heart failure? inc systemic venous pressure, peripheral edema, JVD, anorexia, N/V, hepatosplenomegaly, RUQ tenderness, hepatojugular reflex (inc JVP with liver palpation) - R-sided HF -CXR showing Kerley B lines (alternate flow tracts), cardiomegaly, pleural effusion, pulmonary edema -echo with dec EF -inc BNP on labs are all signs of? - heart failure *BNP released from atrium with preload too high (volume overload) what drugs have shown to decrease mortality rates in pts with heart failure? - *ACE inhibitors* (-prils), ARBs, *beta-blockers* (-lols), hydralazine + nitrates, spironolactone in pts who experience the following common side effects of an ACE inhibitor to treat heart failure, what is the alternative medication? -1st dose hypotension, renal insufficiency, hyperkalemia, cough, angioedema - ARBs (- sartans) what vasodilators are often used to treat heart failure? - hydralazine + nitrates -good for african americans -safe in pregnancy -acts to dec pre/afterload -used if pt not able to tolerate ACEi/ARBs/BB or if more control needed what is the most effective treatment for symptoms of heart failure? - diuretics -loop diuretics (-semides) act on inc excretion of Na, Cl, K, H2O (so can go hypo on these electrolytes), other s/e: hyperglycemia, hyperuricemia -K-sparing diuretics (spironolactone, eplerenone) aldosterone antagonists; s/e: hyperkalemia, gynecomastia with spirono -HCTZ or metolazone (thiazide like diuretic)- s/e: hyponatremia/kalemia, hyperuricemia, hyperglycemia what medications are used to treat acute severe heart failure? - *sympathomimetics* (positive inotropes to inc contractility) -*digoxin*: but has a narrow therapeutic index (can cause arrhythmias, seizures, dizziness, GI upset, visual disturbances, gynecomastia); toxicity = downsloping ST segment; antidote: Digoxin Immune Fab -*dobutamine*: inc contractility (B1 agonist), peripheral vasodilation -*dopamine*: inc contractility giving a synthetic BNP, Nesiritide, works by what mechanism to treat heart failure? - - dec RAAS activity -inc Na+/H2O excretion why are beta-blockers started after ACE inhibitors/diuretics in heart failure? - want to decrease afterload/preload before slowing down the heart rate at what EF do heart failure patients need to receive an implantable cardioverter defibrillator? - EF <35% because they tolerate arrhythmias poorly and there is inc mortality rate what medication used to treat *systolic* heart failure is a selective sinus node inhibitor that slows the sinus rate? - *ivabradine*: dec mortality rate in pts w/ EF ≤35%, in sinus rhythm, w/ resting pulse ≥70bpm, & already maxed out on BB dose or unable to take BB what medication used to treat *systolic* heart failure works by increasing levels of natriuretic peptides? - *sacubitril-valsartan*: decreases mortality rate in class II-IV HF w/ reduced EF what is the treatment for acute pulmonary edema/congestive (aka decompensated) heart failure? - *LMNOP* -*L*asix: removes fluids- improves sx's -*M*orphine: reduces preload reducing heart strain -*N*itrates: vasodilator to reduce pre/afterload -*O*xygen -*P*osition: upright to dec venous return if severe may also need inotropic support although primary HTN makes up 95% of cases, when should secondary HTN be considered? what are some causes of secondary HTN? - -if refractory to antihypertensives or severely elevated -causes: *renal artery stenosis*, fibromuscular dysplasia, atherosclerosis, 1° hyperaldosteronism, pheochromocytoma, cushing's syndrome, coarctation of the aorta, sleep apnea, EtOH, OCPs, COX-2 inhibitors what are the complications of HTN? - -CV (CAD, HF, MI, LVH, aortic dissection, aortic aneurysm, PVD) -neurologic (TIA, CVA, rutured aneurysms, encephalopathy) -nephropathy (renal stenosis & sclerosis leading to ESRD) -optic (retinal hemorrhage, blindness, retinopathy) thiazide type diuretics (HCTZ, chlorthalidone, metolazone) act on what part of the nephron to increase water excretion? what are the side effects? - -distal diluting tubule -s/e: hyponatremia/kalemia/calcemia, hyperuricemia/glycemia (use w/ caution in gout and DM pts) *these are 1st line in uncomplicated HTN loop diuretics (furosemide, bumetanide) are the strongest class of diuretics and can cause s/e's of volume depletion, hypokalemia/natremia/calcemia, hyperuricemia/glycemia, hypochloremic metabolic alkalosis, and ototoxicity; what are they contraindicated in? - sulfa allergy what are the DHP (dihydropyridine) and non-DHP calcium channel blockers? what are they indicated and contraindicated in? - -DHP CCBs: nife*dipine*, amlo*dipine* (potent vasodilators) -non-DHP CCBs: verapamil, diltiazem (vasodilators but also act on heart to dec contractility and conduction/HR) so often used in pts w/ HTN w/ concomitant Afib -indications: HTN, angina, raynauds -contraindications: CHF (esp non-DHPs), 2nd/3rd degree heart block what are the cardioselective and nonselective beta blockers? - -cardioselection (B1): atenolol, metoprolol, esmolol -nonselective (B1, B2): propranolol -a, B1, B2: labetalol, carvedilol what are contraindications for using beta-blockers? - -2nd/3rd degree heart block, decompensated heart failure -specifically in nonselective agents: asthma/COPD, may worsen PVD or raynauds, hypotension, or pulse <50 what is the pathophysiology behind a hypertensive urgency/emergency? - -abrupt rise in BP -increase in SVR (systemic vascular resistance) -endothelial cell deterioration a murmur that is accentuated by sitting up and leaning forward is due to what valve malfunctioning? murmur accentuated by lying on left side? - -sitting up/leaning forward = aortic murmurs (AS, AR) -lying on left side = mitral (MS, MR) what is the MC valvular disease? - aortic stenosis (can lead to obstruction, LVH then LV failure) what are the causes of aortic stenosis? - -degenerative: calcifications (atherosclerotic/wear & tear in pts >70y -congenital heart dz: bicuspid valve in pts <70y -rheumatic heart dz: from strep what are the clinical manifestations of symptomatic (<1cm^2) aortic stenosis? - - dyspnea -*angina* -*syncope* (extertional) -*CHF* a systolic "ejection" crescendo-decrescendo murmur at right upper sternal border that *radiates to carotid/neck*; decreases in intensity with valsalva/standing/handgrip (inc venous return) and increases with squatting/leg raise/sitting/leaning forward (dec venous return); *narrowed pulse pressure* - aortic stenosis for aortic stenosis, what diagnostic studies can be ordered? what can be seen? - - *echo*: small aortic orifice during systole, LVH, thickened/calcified valve -*EKG*: LVH -*CXR*: calcifications -*cardiac cath*: definitive diagnosis; usually used prior to surgery what are the management options for aortic stenosis? - -*valve replacement* (AVR): mechanical last longer but requires long term anticoagulants, bioprosthetic does not -*percutaneous aortic valvuloplasty* (PAV): results in 50% inc in area but 50% restenosis at 6-12 mos; used as bridge to AVR -*intraortic balloon pump*: temporary stabilization; bridge to AVR -*medical therapy* (although not truly effective): avoid things that may decrease preload- physical exertion, venodilators (nitrates), negative inotropes (CCBs, BBs) what are the causes of aortic regurgitation/insufficiency? - 1. valve disease- rheumatic heart dz, endocarditis, bicuspid AoV 2. aortic root disease- *HTN*, marfan syndrome, syphilis, RA, SLE, aortic dissection, ankylosing spondylitis.