The Failing Heart
Irregular Irregular
"No Padezco de Nada"
LDL disaster
Christian Special
100
What are the labs values that justify IV Iron replacement in HF patient? Hint (2 criterias)
Ferritin: <100
Ferritin: 200-300 with Transferrin saturation <20%
100
In Eliquis dosing for Atrial Fibrillation, what are the criteria for dose reduction from 5.0mg BID to 2.5mg BID?
Age: 80 or more
Body weight: 60kg or less
Creatine: 1.5 or more
Must have 2/3 criteria
100
At what age per USPTF should HTN be screened for?
18
100
What LDL Value merits urgent treatment
190 or more
100
What is the clinical presentation for MM?
C- Hypercalcemia
R- Renal insufficiency
A- Anemia
B- Bone lesion (CT or PET-CT)
200
In management of acute decompensated HF what is your urinary Na goal and urine volume goal? If diuresis unsatisfactory, what is the next best step?
Na: 50-70
Urine Volume: 100-150mL/hr in 2-6 hours
Double IV diuresis
200
What is the HR goal in symptomatic AF?
What is the HR goal in asymptomatic AF?
Symptomatic: <80bpm
Asymptomatic: <110bpm
200
What solitary BP value confirms diagnosis of HTN without need for other previous BP value?
180/110
200
What agent is recommended for patient that are in HS and are not at LDL goal
Zetia
200
Initial work up for Thrombocytosis? When to refer to hematology/Oncology?
Work up: Repeat CBC with peripheral smears, C reactive protein, Iron studies with ferritin, JAK2 if essential thrombocythemia suspected, pertient labs based on hx and PE.
300
Patient with recently diagnosed HFrEF of 20% started on GDMT and at 3-month reevaluation remains symptomatic despite reaching target dosing and EF remains unchanged. What is the next best step?
Refer to Cardiology for implantable cardiovert-defibrillator or cardiac resynchronization therapy.
300
Patient is a 65 y/o male with hx of PAD without revascularization who recently was diagnosed with Atrial fibrillation. Currently on HS, ASA 81mg + Xarelto 2.5mg. Presents to your clinic for medication reconciliation. What would be the empiric regimen?
Hold ASA
Continue HS
DOAC monotherapy
300
What is the recommended work up for routine evaluation of HTN?
ECG, Fasting Glucose, Creatinine, Urine micro albumin to creatine ratio, Lipid panel, UA,
300
What is considered High dose statin?
Lipitor 40-80mg
Crestor 20-40mg
300
Name 5 common causes of neutropenia? Give initial work up/presentation for each
Autoimmune neutropenia: CBC + Antineutrophil antibodies
Cyclic neutropenia: CBC- periodic CBC x2 in a week for 6 weeks to document nadirs and return to normal
Hematological malignancy: Peripheral smears
Infection: HIV, Hep B or C, EBV, CMV, Influenza
Nutritional: Vitamin B12, Folate, Copper
RA: C- reactive protein, RA, Anti CPP
Sjogren syndrome: Anti RO, Anti LA, RA
SLE: ANA, Anti-dsDNA, Anti smith, Anti cardiolipin antibodies
400
In patients with Hx of Hypotension in what order is recommended to GDMT be started? What is the target dose of each medication? (Jardiance, Lisinopril, Coreg, Spironolactone)
Sequence: Jardiance + Coreg>Lisinopril>Spironolactone
Target Dosing: Coreg: 25-50mg BID, Spironolactone: 25-50mg, Jardiance: 10mg, Lisinopril: 40mg
400
Patient is a 60 y/o male with hx of CAD with recent stent placement (1 month ago) currently on ASA + Clopidogrel. Recently discharged with diagnosis of Atrial Fib and started on DOAC + BB. Presents to your clinic for medication reconciliation. What is the recommended regimen at current moment?
1 month: Hold ASA, continue BB, Clopidogrel and DOAC. AVOID triple therapy at 1-4 weeks.
400
Name 5 causes of secondary HTN/Resistant HTN
OSA, Renal parenchymal disease, Primary aldosteronism, Drug/Alcohol induced, Atherosclerotic RAS, Fibromuscular dysplasia, Pheochromocytoma, Hyperthyroidism, Cushings, CAH
400
Name common condition that causes Hyperlipidemia
Hypothyroidism
400
What are the diagnostic criteria for Heparin induced thrombocytopenia? Management and confirmatory lab?
500
Case of a 55 y/o male with PMHx of HFrEF 35% with home regimen of Lasix 40mg BID, Metoprolol succinate 100mg, Lisinopril 30mg, Spironolactone 50mg and Jardiance 10mg. Presents in acute decompensated HF? Admit Patient to FM ward full management? VS: BP: 165/95, HR: 80, SPO2: 93-95%, RR: 20.
Labs: Ferritin, Transferrin saturation, BNP, CBC, BMP, Mg, Troponin, Urinary Sodium
EKG, I/O, Foley catheter (accepted)
Imaging: 2d Echo, POCUS, Chest Xray
Management: Lasix 40-60mg IV Q12H, DVT ppx (Lovenox 40mg SUBQ-daily, Unfractioned heparin 5000U Q8-12H) Controversial: Continue GDMT, consider halving BB dosing if HF refractory to diuresis. BB contraindicated in setting of Cardiogenic shock, symptomatic bradycardia and/or inotropes needed.
OPTIMIZE-HF
500
Case of a 55 y/o male with PMHx of HTN, Dyslipidemia, and CAD who presents to ED with 1-week hx of intermittent palpitations, progressive dyspnea on exertion, orthopnea and peripheral edema. At ED patient at atrial fibrillation with RVR. PE patient in overt volume overload (pitting edema, crackles and ascites). Findings consistent with Severe ADHF and atrial fibrillation with RVR (140bpm). Admit this patient to FM ward.
HF: Lasix 20-40mg, ECHO
Atrial fib: Digoxin, Lovenox 1mg/Kg Q12H, Mg 2-4 gm IV 20-60 mins. Telemetry
Labs: CBC, BMP, EKG, Mg, TSH, Troponin, BNP, PT, PTT, INR, Ron work up, Lipid profile and A1C
500
Patient is a 55 y/o male with PMHx of HTN and Dyslipidemia, current 1 pack daily smoker who presents to your clinic for HTN management. Patient currently on Losartan 100mg, Amlodipine 10mg and HTZ 50mg. Reports strict adherence to medication and lifestyle modifications but home BP remains at 160/100 after weeks on medication. Build a detail plan for management of this patient? (Specific)
Screen for secondary causes: OSA/STOP BANG, Albumin/Creatinine ratio, Plasma aldosterone/renin ratio, Renal Duplex doppler ultrasound
Switch HTZ to Chlorthalidone
If Primary aldosteronism confirmed or patient remains uncontrolled Spironolactone 12.5-25mg
500
What conditions merit immediate statin use?
Hx of ASCVD, LDL equal or >190, DM2, HIV, CKD stage 3 or more
500
Common Causes of microcytic, normocytic and macrocytic anemia? Work up for each cause?
Micorcytic: IDA, Anemia of chronic disease, Thalassemia, Lead poisoning, Copper/Zinc deficiency,
Ferritin, TSAT + CRP/ESR, Electrophoresis, RDW, Lead levels, coper/zinc levels. In Unknown IDA in older patient consider GI pathologies and malignancy
Normocytic: Acute hemorrhage, Early IDA, Anemia of chronic disease, CKD, hypothyroidism, hemolysis
Reticulocyte count, LDH, Indirect bilirubin, haptoglobin, peripheral smears, TSH, CRP/ESR, Iron studies, medication review.
Macrocytic: B12, Folate deficiency, alcohol use, liver disease
B12, Folate levels, MMA and homocysteine, LFTs, Alcohol hx, reticulocyte and medication review.