Hazard Ratio and LDL Goals

Biostats

• Hazard ratio gauges the magnitude of an effect.
• A result of 1.00 shows no intergroup difference.
• Ratio < 1, suggests a protective effect.
• Ratio > 1, indicates a detrimental effect.
• Statistical insignificance occurs if the hazard ratio's confidence interval encompasses 1.00; a significant difference occurs if it does not.

Cardiology

Community Health Centers

• LDL goals: <100 mg/dL for patients with known CHD or equivalent risks (CAD, MI, PVD, or DM).
• For patients with 0-1 risk factors and no CHD, LDL goal is <160 mg/dL.
• LDL goal is <130 mg/dL if there are >=2 risk factors and no CHD.
• Initiate drug therapy only if LDL remains 30 mg/dL above target, unless there are >2 risk factors.
• First-line treatment for new hypertension is thiazide diuretics.
• Photosensitivity is a common side effect of thiazide diuretics, resulting in rash on sun-exposed skin, managed by stopping the medication or reducing sun exposure.
• LDL level modification offers the greatest CAD risk reduction.
• Other modifying factors that also help are exercise, stop smoking, and control DM.
• Secondary hypertension consideration: consider if the patient is young with high blood pressure, typically cause is due to unidentified causes.
• Most common identifiable cause is renovascular hypertension. Examine for abdominal or flank bruits. Other causes: pheochromocytoma, Cushing's, advanced renal disease.
• Retinal abnormalities indicate long-term hypertension effects.
• Diabetes is the leading predictor of adverse cardiovascular outcomes, making it a CHD equivalent.
• Target blood pressure is <130/85 mm Hg for people with diabetes and it is <140/90 mm Hg for healthy individuals.
• AAA surgery criteria: diameter exceeds 5 cm (smaller aneurysms monitored via periodic imaging). Rapid growth requires intervention. Smoking is another significant risk factor.

Office

• Amlodipine can cause edema and urticarial rash.
• ACE inhibitors can cause angioedema and urticaria; rash tends to be psoriatic. ARBs might cause angioedema in patients who had angioedema on ACEIs.
• A-fib paroxysmal presentation: episodic palpitations potentially accompanied by symptoms. The CVA risk is same as normal a-fib so need warfarin.
• Rate or rhythm control are equally effective in asymptomatic patients. Rhythm control is prioritized if symptoms are persistent or significant (palpitation, dizziness, dyspnea).
• Amiodarone is preferred for rhythm control when structural heart disease exists (cardiomyopathy, CHF, CAD); flecainide is ONLY suitable when there is NO structural heart disease.
• Ibutilide is used to acutely convert atrial fibrillation.
• Fibrinogen levels correlate with CV risk. A level exceeding 3.43 doubles the risk; therapy hasn't demonstrably provided prevention. Elevated levels indicate intensified monitoring and lifestyle intervention.
• Among Statins, lovastatin and atorvastatin elevate fibrinogen levels, use pravastatin or simvastatin when high fibrinogen levels exist.
• In cases when high fibrinogen and LDL coexist, consider the specific statin choice.
• Non-sustained ventricular tachycardia involves at least 3 consecutive beats at a rate exceeding 120 bpm, lasting less than 30 seconds. This is likely with underlying heart conditions.
• To investigate, an echo and stress test is recommended to rule out ischemia.
• CHF: ACE is primary treatment, with tolerance and renal status is closely monitored. Contraindications for ACEis are in patients with intolerance, renal failure, or hyperkalemia.
• The standard CHF drug regimen include Diurectics, ACE inhibitors, beta blockers, digoxin, or spironolactone.
• Hydralazine and isosorbide dinitrate is typically prescribed when intolerance to ACE inhibitors exist. The effects of Hydralazine may induce lupus like effects.
• Antihistone antibodies serve as a lupus indication. Hydralazine treatment is considered safe during pregnancy; so is labetalol and dopa.
• CHF-related Hyponatremia: elevated antidiuretic hormone and renin production. Volume overload exists; treat through water restriction gradual correction.
• CHF is characterized by impaired ventricular action; look for fatigue and edema. Test results may show distention, raised JVP, rales, and a CXR that shows vascular silhouette silhouette.
• Digoxin toxicity is marked with visual impairment, a loss of appetite, anorexia, and confusion. Drugs such as amiodarone and spironolactone can induce digoxin toxicity.
• For Hypercholesterolemia with hypertriglyceridemia levels above 200, prescribe statins. When statins are unsuccessful, consider gemfibrozil or niacin.
• Lone AFib should be considered when no other source of heart disease exists. Warfarin not always necessary and use depends on case. Aspirin is good enough.
• Angio unstable risk should be ASAP no matter what. If it revels high risks consider PCI and CABG. Progession is increased by patient DM.
• If a prior CABG exists, and the patient is being checkekd for cardiac ischemia, use adenosine or dipyriamole. Sestamibi will help identify any cardiac ischemia. Stress echo if adenosine does not work.
• Bronchospasms can be induced by adenosime. Avoid bronchodilaors to treat asthma as well.. Use dobutamine instead.
• orthostatic hypotension: 20 SBP or 10DMP after standing. Happens 2-5 min.
• Two typical Hypto causes: intravasca contraction and dysfuntion.

Additional Info

• Side effects can be eased using Ca channel blockers.
• Best non-drug to lower BP is weight loss. CV effects are unclear.
• As an alternative to ACE, first use BB to treat hypertensive symptoms.
• Do a cardiac cath to see the leisions and determine stenting if positive results.
• R side heart endocarditis is due to embolisms and IVDU causes.
• FFP and Vit K are needed for coumadin.
• Amiodarone increases wf. WF should be reduced.
• LV is best heard over MIT regurgitation. Increases grip when you lower.
• Low pitch noise by pt indicates mit stenosis. R fever and hemop can occur. L atric is found left clavide to heare beste at rumbles.
• Use duiretiocs for polypharm.
• Cardiac cause d is higher. Arrythimis are not.
• D/C metformin with kidney and liver insuffiecent.

Acute MI & Similar Conditions

• Sinus bradycardia may occur post-MI. First-line is IV atropine. If ineffective, consider thrombolysis or PTCA with transvenous pacing. Recent abdominal surgery (2 weeks) contraindicates thrombolysis.
• CABG preferable to angio in DM patients due to higher restenosis rate with angio or stent.
• Multifocal Atrial Tachycardia: >3 P-wave morphologies, narrow QRS, variable PR segment. Typically linked to hypoxia and COPD. Manage by optimizing O2 levels. If ineffective, beta-blockers such as verapamil should only be adminsitered if asthma is not present.
• Heart Failure: Common causes include mitral rupture, pericarditis, or chord rupture. Consider IE, ischemia, and MV.
• Mitral valve degeneration can occur in Ehler, leading to chordae rupture. May also cause Pes planus, hyper mobility, and hyper extension.
• Mechanical valves require INR 2.5-3.5 to prevent complications.
• Torsades de Pointes: Indicated by QTc. Treat hemodynamically or immediate defibrillation, followed by MgSO4. If this fails, transvenous pacemaker is next.
• Cardioversion should be performed on VT and Afib. Synchonized is a fib.
• S/P should avoid sex until check up.
• CC Blocker with A-fib: Try Deltiazem.
• Carditoic cancer drugs w/: Use RVG.

Acute MI Management

• Provide oxygen, IV access, aspirin, and nitroglycerin. ACE inhibitors are not used acutely but reduce mortality if used long term. Beta-blockers help by reducing myocardial demand and HR, given after aspirin, nitro and morphine.
• Thrombolytics are indicated if EKG shows ST elevation in two contiguous leads, within 12-24 hours of symptoms. Contraindications of active bleed. NO should be given. Do not confuse with ischemia.
• Flash pulmonary edema presents with acute SOB with no previous history; hypertensive crisis can trigger this. CXR shows edema, with diffuse crackles. To treat, provide O2, morphine, and IV furosemide. If due to hypertension, administer IV NO or nitroprusside. Beta-blockers are contraindicated in acute heart failure may cause death.
• Initial treatment for cardiogenic pulmonary edema: O2, morphine, and loop diuretic. Complicated by hypotension: dopamine is a good choice.
• Acute Pericarditis: Caused by infarction, position.

General Cardia Info

• Dressler occurs after MI (weeks). Fever. Look over time.
• Q waves show an old infarct.
• Valve of aorta should be 1cm. The symptoms are prompt.
• Miosis is one side. Seatbelts are a cause.
• Heart Failure is cause be other things.
• Aortic Dissection: Older, male with long standing hypertension.