FINAL EXAM 01 Almost-all-you-need-for-usmle-step-2-ck-review
USMLE STEP 2
CK
UW NOTES
CARDIOLOGY:
Hypertension/Hypotension
For pts with HTN, in
... [Show More] the absence of a specific indication or contraindication, diuretics and beta
blockers are still recommended as the initial drug treatment.
• diabetics and pts with reduced lv systolic dysfunction should always be started with an aceinhibitor first.
• post-mi patients should be on a beta blocker and an ace inhibitor..
• studies have shown that black patients respond better to diuretics and calcium channel
blockers.
• Hydralazine should not be used as a first-line therapy for HTN because it requires up to 4 times
daily dosing.
• ACE inhibitors are the 1 st line agent for HTN in pts with diabetes, chronic kidney disease, and
CHF.
• Beta blockers such as atenolol are indicated as 1 st line antihypertensive in pts with angina,
status post MI, or low ejection fraction.
• If they have intermittent claudication and other stenotic issues throughout their body, the best
initial choice for tx of HTN in this pt seems to be a dihydropyridine calcium channel blockers,
ie amlodipine. They are also metabolically neutral, not affecting plasma lipid profile.
Beta blockers can worsen the symptoms of peripheral vascular disease
• In pts with benign essential tremors use propranolol as anti hypertensive
• In pts with aortic dissection, lower the BP using Beta Blockers. Don’t use vasodilators like
hydralazine,CCBs,Nitrates etc because they cause reflex tachycardia.
• Pt with ANGINA and HTN, give Beta blockers. . If the effect of a beta blocker is not
satisfactory, a nitrate can be added to the regimen.
Isolated systolic HTN is an important cause of AHN in elderly patients. The mechanism leading to this is
believed to be decreased elasticity of the arterial wall, which leads to an increased systolic BP, without
concurrent increase (and even decrease) in diastolic BP. Normally during systole, the heart ejects the
blood under a certain pressure that is dumped by elastic properties of the aorta and major arteries. Then,
this elastic recoil of the arterial wall contributes the diastolic flow of the blood and diastolic pressure.
When elastic properties of the arterial wall diminish and arteries beome more rigid, this “dumping” of
pressure changes during the cardiac cycle also decreases. As a result of increased arterial rigidity,
patients with ISH have a widened pulse pressure (the difference between systolic and diastolic pressure).
Widened pulse pressure was recently recognized as an important cardiovascular risk factor.
Therefore it should be treated appropriately, in spite of the fact that diastolic pressure is not
elevated sometimes. HCTZ is considered to be the drug of choice for this condition.
Peripheral artery disease.
Measurement of the ankle-brachial index (ABI) is the first step in diagnosing PAD. The ABI is
calculated by dividing the systolic blood pressure obtained by Doppler in the posterior tibial and dorsalis
pedis arteries by that in the brachial artery. Ratios of 1 to 1.3 are considered normal. An ABI less than
0.9 is highly sensitive and specific for greater than 50% occlusion in a major vessel. ABI less than 0.4
is consistent with limb ischemia. After PAD is diagnosed by ABI, a number of different imaging studies
may be performed to more accurately identify the occluded vessel.
In pts with HTN, look at other symptoms. If they have intermittent claudicating that significantly restricts
their daily activities and other stenotic issues throughout their body, the best initial choice for tx of HTN
in this pt seems to be a dihydropyridine calcium channel blockers, ie amlodipine. They have a good
peripheral vasodilating properties .They are also metabolically neutral, not affecting plasma lipid profile.
Beta blockers can worsen the symptoms of peripheral vascular disease. [Show Less]