PAEA Internal Medicine Inpatient EOR Topics 2023
Questions and Answers Complete;(everything on topic list
except hematology (5%) and infectious disease (5%))
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
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 non-
productive 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
-Lasix: removes fluids- improves sx's
-Morphine: reduces preload reducing heart strain
-Nitrates: vasodilator to reduce pre/afterload
-Oxygen
-Position: upright to dec venous return
if severe may also need inotropic support
hypertension is defined as ____/____ blood pressures on ____ or more visits
≥130/80 on 2 or more visits
-stage 1 is 130-139/80-89
-stage 2 is ≥140/90
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: nifedipine, amlodipine (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 antihypertensive is good for pts with HTN and concomitant BPH? what are
this class' side effects?
-alpha blockers (prazosin, terazosin, doxazosin)
-s/e: 1st dose hypotension/syncope, dizziness, HA, weakness
*these are not used as 1st line
what are the recommendations for tx of HTN in African Americans?
DHP CCB (nifedipine, amlodipine) or thiazide diuretic (HCTZ, chlorthalidone,
metolazone)
*these are the same med recs for isolated systolic HTN in the elderly
what HTN meds are best used for pts w/ gout?
CCBs or Losartan (only ARB that doesn't cause hyperuricemia)
what is the pathophysiology behind a hypertensive urgency/emergency?
-abrupt rise in BP
-increase in SVR (systemic vascular resistance)
-endothelial cell deterioration
