0 Family Medicine: 7, 8, 9

Smoking

BMI 30-35 reduces life expectancy by 2-4 years

BMI >40 reduces life expectancy by

Lung cancer
Ischemic heart disease
COPD

Can even result in infant death during pregnancy

Cardiovascular disease
Chronic renal failure

Endometrial Cancer
Breast Cancer
Colon Cancer

Distal symmetric polyneuropathy (impaired sensation)
Diabetes vasculopathy and peripheral artery disease (impaired perfusion)

Peripheral artery disease; assessed through pedal pulses

Grade 1: superficial, involves full skin thickness, no underlying tissue involved

Grade 2: Deep ulcer, penetrates to ligaments, muscle; no involvement of bone, no abscess

Treat Grade 1 and 2: Outpatient, debridement, local wound care, if significant erythema or exudate, treat for infection

Grade 3: Deep ulcer; cellulitis, abscess formation, often with osteomyelitis
May require hospitalization prior to resoln of ulcer

Grade 4: localized gangrene
Grade 5: Extensive gangrene of whole foot

Grade 4-5 require emergent hospitalization and surgical consultation, often resulting in amputation

Larger wounds, ulcers, abscesses-->staph

Small breaks of skin-->strep

Homan's sign: pain on passive dorsiflextion of foot, edema, tenderness, warmth

Generally painless, pts experience chronic dull, heavy sensation in leg
Initially involves foot and progresses up leg so entire limb becomes edematous

In early stages, edema is soft and pits easily with pressure
in chronic stages, limb has woody texture and tissues become indurated/fibrotic

Presence of systemic atherosclerosis in arteries distal to aortic arch; as a result, pts with PAD develop narrowing of arteries

Pts with PAD have h/o claudication, which manifests as cramp-like muscle pain occurring with exercise and subsiding rapidly with rest

Increases risk for foot ulcer, skin color changse, night pain

negative d-dimer r/o DVT
positive d-dimer may indicate thrombosis, but does not r/o other causes

3 points = high prob
1-2 points = mod prob
0 or below = low prob

1 point if:
Cancer within 6 months
Paralysis, paresis, immobilization of legs
Bedridden more than 3 days or major surgery within past 4 weeks
Tenderness along deep venous system
Entire leg swollen
Calf swelling by 3 cm or more compared with asyx leg
Pitting edema
Collateral superficial veins (non-varicose)

-2 points if alternative diagnosis as likely or more likely than DVT

LMWH:
Longer half-life so administer SQ qd or bid
Lab monitoring not required, dosing if fixed
Thrombocytopenia less likely
May be used as outpt

Unfractionated heparin:
Administered IV based on body weight
Titrated based on aPTT
Thrombocytopenia more likely
Requires hospitalization

Short-term: LMWH or unfractionated heparin

Long-term: Oral warfarin for prophylaxis; duration of tx:
-isolated calf thrombophlebitis: 6-12weeks
-first time event as result of trauma/surgery: >3 months
-first episode of idiopathic thromboembolic dz: >6 months
-Recurrent thromboembolic disease or inherited thrombophilia: 12 months to indefinitely

40 hour half-life, takes 5 to 7 days to reach stable state
Check INR 3 days after warfarin initiation

If INR between 5 and 9, d/c warfarin and repeat INR in 24 hours

If INR>9, d/c warfarin and give oral vitamin K

Initial thrombosis prior to age 50 without risk factor
Family history of venous thromboembolism
Recurrent venous thrombosis
Thrombosis in unusual vascular beds, such as portal, hepatic, mesenteric, or cerebral veins

High BP in adult is systolic pressure >140 mmHg or diastolic pressure >90 mmHg

Must have at least 2 elevated measurements, at least 5 minutes apart, one in each arm, on two or more visits; cannot be diagnosed if patient is acutely ill or in acute pain

Chronically elevated BP readings with no underlying identifiable cause

Sleep apnea
Chronic renal dz
Renovascular dz
Drug-induced causes
Pheochromocytoma
Primary aldosteronism
Chronic steroid use
Cushing's
Thyroid or parathyroid disease
Coarctation of aorta

Beginning at age 18

Normal: <120/<80
Pre-HTN (normal): 120-139/80-89
HTN Stage I: 140-159/90-99
HTN Stage II: >160/>100

1) assess presence or absence of target end-organ disease (heart--h/o CHF, CVD; brain, kidneys, BVs--peripheral vasc dz, eyes--retinopathy)

2) assess lifestyle and ID other CV risk factors or concomitant disorders that may affect prognosis and guide treatment (metabolic syndrome, h/o premature CV death, smoking, EtOH, cocaine, ketamine use/withdrawal)

Reveal identifiable causes of HTN

EKG: assess rate/rhythm (abnl rhythms may contraindicate beta blockers or CCBs), ischemic dz, hypertrophy

UA: proteinuria can indicate nephropathy (target-organ damage), glucosuria

HCT: low HCT may reveal anemic states in HTN pts; also makes likelihood of major CV event more likely

Serum K: need baseline K level for determining poential changes from antiHTN tx

Serum Cr or estimated GFR: may indicate end-organ damage (HTN nephropathy) from long-term uncontrolled HTN

Fasting serum cholesterol: total cholesterol, LDL, HDL, TG

Serum Calcium: 1/3 of pts w/hyperpara and HTN may have illness attributable to renal damage due to nephrolithiasis

HTN: <140/90
HTN + DM or chronic renal dz: <130/80

Pre-HTN: weight reduction (decreases systolic BP by 5-20 mmHg/10 kg lost

DASH eating plan (decreases systolic BP by 8-14 mmHg)
Dietary sodium reduction (decreases systolic BP by 2-8 mmHg)
Moderate consumption of EtOH, physical activity

Stage 1: Thiazide; may consider ACEI, ARB, BB, CCB, or combination

Stage 2: Two drug combination: thiazide + ACE/ARB/BB/CCB

HCTZ

May cause hyponatremia (monitor blood electrolytes)
Avoid in pts with h/o gout (may precipitate flares)

Doses of HCTZ >25 mg do not decrease BP further or further reduce morbidity and mortality rates

If BP not at goal, continue to titrate dose in upward increments until BP control is achieved or maximum effective dose of drug has been reached.

If BP has not been achieved at maximum effective dose, add another agent from another class.

Can then start titrating dose of second agent.

Mexican American and Native Americans

AAs

AAs demonstrate somewhat reduced BP responses to monotherapy with BB/ACEI/ARBs compared to diuretics or CCBS; eliminate differences by adding adequate dose of diuretic

AAs are 2-4 times more likely to develop angioedema from ACEI than other groups

LDL 70-100

Risk equivlaents include:
Clinical CHD
Symptomatic CAD
Peripheral arterial dz
AAA
DM

patients with CHD and CHD equivs should simultaneously start lifestyle modifications and an LDL-lowering drug.

Male gender

Smoking
Men >45, women >55
HTN >140/90
Elevated LDL
FMH Premature CHD (in male first degree <55, or female first degree <65)

Sedentary lifestyle, obesity

Framingham Risk Score identified 10-year risk of CHD event into three levels:
<10%
10-20%
>20%

Person with CHD or CHD risk equivalent such as DM or peripheral vascular dz is in highest risk group, meaning that pt has greater than 20% chance of having CVD within next 10 years

Screen adults >18 for HTN
Screen men over 35, women over 45 for lipid disorders

Do not routinely screen with ECG, exercise treadmill test.

Typical: more likely to be associated with acute coronary syndrome or ischemic cardiac pain; radiates to one or both shoulders or arms and pain precipitated by exertion

Atypical: Less easily characterized, no standard definition

Pleuritic pain (worsened by respiration, exacerbated by lying down; causes include PE, pneumothorax, viral or idiopathic pleurisy, pneumonia, pleuropericarditis)

Positional pain: could be pericarditis, which improves w/sitting up and leaning forward

Reproduced by Palpation: MSK pain

Stabbing Pain

Atpical:
Fatigue, dyspnea, neck/jaw pain, palpitations, cough, nausea, vomiting, indigestion, back pain, dizziness, numbness

Differences in presentation may lead to disparities in CV tx and outcomes in women; seem to be less aggressively treated than men and have worse outcomes

Women are usually older at presentation than men and wait longer in seeking tx; also are less likely to participate in cardiac rehabilitation

Radiation to both arms

Most patients with dysrhythmias unlikely to report having palpitations; physical exam and EKG DO NOT rule out dysrhythmia

Must do loop monitoring for two weeks

MV prolapse; classically a midsystolic click followed by crescendo-decrescendo murmur, usually best heard at apex

Enhanced by Valsalva maneuver and dec'd by squatting

Sedentary lifestyle
Use of exogenous estrogens (eg oral contraceptives)
Obesity

Patients at low risk for CHD; helps exclude disease

Symptomatic women if at intermediate risk of having CHD based on rifks factors and syx; have normal EKG, and are capable of maximal exercise

If have CHD or CHD risk equiv: <100

If 2+ risk factors: <130

If 0 to 1 risk factor: <160

<7%

<200 mg qd

10-25 g fiber a day
2g plant stanols/sterols a day

After 3 months in absence of improvement

Moderately intense cardio 30 minutes qd, five days a week or
Vigorously intense cardio 20 minutes a day, three days a week, and
8-10 strength-training exercises, 8-12 repetitions of each exercise, twice a week

In men age 45-79 to reduce risk MI
In women age 55-79 to reduce risk ischemic stroke