{"id":118731,"date":"2023-09-05T20:31:05","date_gmt":"2023-09-05T20:31:05","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=118731"},"modified":"2023-09-05T20:31:07","modified_gmt":"2023-09-05T20:31:07","slug":"full-summary-usmle-step-2-ck-uworld-notes-2022","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2023\/09\/05\/full-summary-usmle-step-2-ck-uworld-notes-2022\/","title":{"rendered":"Full Summary USMLE Step 2 CK UWorld Notes 2022"},"content":{"rendered":"\n<p>CARDIOLOGY:<br>Hypertension\/Hypotension<br>For pts with HTN, in the absence of a specific indication or contraindication, diuretics and beta<br>blockers are still recommended as the initial drug treatment.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>diabetics and pts with reduced lv systolic dysfunction should always be started with an ace\u0002inhibitor first.<\/li>\n\n\n\n<li>post-mi patients should be on a beta blocker and an ace inhibitor..<\/li>\n\n\n\n<li>studies have shown that black patients respond better to diuretics and calcium channel<br>blockers.<\/li>\n\n\n\n<li>Hydralazine should not be used as a first-line therapy for HTN because it requires up to 4 times<br>daily dosing.<\/li>\n\n\n\n<li>ACE inhibitors are the 1st<br>line agent for HTN in pts with diabetes, chronic kidney disease, and<br>CHF.<\/li>\n\n\n\n<li>Beta blockers such as atenolol are indicated as 1st<br>line antihypertensive in pts with angina,<br>status post MI, or low ejection fraction.<\/li>\n\n\n\n<li>If they have intermittent claudication and other stenotic issues throughout their body, the best<br>initial choice for tx of HTN in this pt seems to be a dihydropyridine calcium channel blockers,<br>ie amlodipine. They are also metabolically neutral, not affecting plasma lipid profile.<br>Beta blockers can worsen the symptoms of peripheral vascular disease<\/li>\n\n\n\n<li>In pts with benign essential tremors use propranolol as anti hypertensive<\/li>\n\n\n\n<li>In pts with aortic dissection, lower the BP using Beta Blockers. Don\u2019t use vasodilators like<br>hydralazine,CCBs,Nitrates etc because they cause reflex tachycardia.<\/li>\n\n\n\n<li>Pt with ANGINA and HTN, give Beta blockers. . If the effect of a beta blocker is not<br>satisfactory, a nitrate can be added to the regimen.<br>Isolated systolic HTN is an important cause of AHN in elderly patients. The mechanism leading to this is<br>believed to be decreased elasticity of the arterial wall, which leads to an increased systolic BP, without<br>concurrent increase (and even decrease) in diastolic BP. Normally during systole, the heart ejects the<br>blood under a certain pressure that is dumped by elastic properties of the aorta and major arteries. Then,<br>this elastic recoil of the arterial wall contributes the diastolic flow of the blood and diastolic pressure.<br>When elastic properties of the arterial wall diminish and arteries beome more rigid, this \u201cdumping\u201d of<br>pressure changes during the cardiac cycle also decreases. As a result of increased arterial rigidity,<br>patients with ISH have a widened pulse pressure (the difference between systolic and diastolic pressure).<br>Widened pulse pressure was recently recognized as an important cardiovascular risk factor.<br>Therefore it should be treated appropriately, in spite of the fact that diastolic pressure is not<br>elevated sometimes. HCTZ is considered to be the drug of choice for this condition.<br>Peripheral artery disease.<br>Measurement of the ankle-brachial index (ABI) is the first step in diagnosing PAD. The ABI is<br>calculated by dividing the systolic blood pressure obtained by Doppler in the posterior tibial and dorsalis<br>pedis arteries by that in the brachial artery. Ratios of 1 to 1.3 are considered normal. An ABI less than<br>0.9 is highly sensitive and specific for greater than 50% occlusion in a major vessel. ABI less than 0.4<br>is consistent with limb ischemia. After PAD is diagnosed by ABI, a number of different imaging studies<br>may be performed to more accurately identify the occluded vessel.<br><br>In pts with HTN, look at other symptoms. If they have intermittent claudicating that significantly restricts<br>their daily activities and other stenotic issues throughout their body, the best initial choice for tx of HTN<br>in this pt seems to be a dihydropyridine calcium channel blockers, ie amlodipine. They have a good<br>peripheral vasodilating properties .They are also metabolically neutral, not affecting plasma lipid profile.<br>Beta blockers can worsen the symptoms of peripheral vascular disease.<br>When pts have longstanding HTN, they can develop diastolic dysfunction (impaired ventricular<br>relaxation) and then develop LV failure. They can get paroxysmal nocturnal dyspnea. Nitroglycerin,<br>either IV, sublingual, or topical, relieves the dyspnea and tachycardia associated with cardiogenic<br>pulmonary edema by rapidly reducing preload. Stuies have suggested that it works quicker than<br>morphine or loop diuretics. NTG is not part of the long-term management for patients with heart failure<br>but can be beneficial in acutely alleviating symptoms. It should be cautiously in pts with hypotension.<br>Beyond NTG, loop diuretics are the mainstay of therapy for decompensate heart failure and principally<br>work by reducing total body volume.<br>Beta blockers are relatively contraindicated in pts with obstructive lung disease such as asthma or COPD<br>but can be used in restrictive lung disease.<br>In systemic HTN, lifestyle modification can help. Weight loss is the most beneficial lifestyle intervention<br>for obese individuals. Every 10kg reduction in weight can decrease the systolic blood pressure by 5-20<br>mmHG.<br>Regular aerobic exercise (at least 30mins per day on most days of the week) can decrease systolic BP by<br>4-9.<br>Smoking will not significantly decrease BP but will markedly decrease a pts overall cardiovascular risk.<br>Improved glycemic control will decrease the risk of developing micro vascular disease (neuropathy,<br>nephropathy, and retinopathy). But it will not improve BP control, however.<br>Limiting alcohol ocnsumption to no more than 2 drinks per day for a man or 1 drink per day for a<br>woman will decrease systolic BP by 2-4mmHG.<br>Restricting the daily sodium intake to no more than 2.4g daily will decrease the systolic BP by 2-8mmHg.<br>Traditionally a goal blood pressure is considered to be below 140\/90 mmHg. But it is recently recognized<br>that BP needs more tight control in diabetics and patients with chronic renal failure. These 2 groups of<br>pts are especially sensitive to high BP, that\u2019s why the values of systolic BP for these pts should be kept<br>lower than 130mmHG and diastolic BP lower than 80 mmHG to prevent end organ damage.<br>Statins are known to cause increased liver enzymes and sympathy. They inhibit HMG-CoA reductase, a<br>rate-limiting enzyme in the synthesis of cholesterol that converts HMG-CoA to mevalonate.<br>Mevalonate is used not only for the synthesis of cholesterol, but also for the production of several other<br>products including dolichol and CoQ10. Reduced CoQ10 production has been implicated in the<br>pathogenesis of statin-induced myopathy; therefore the decrease in the synthesis of such products<br>may be responsible for some adverse effects of statin therapy.<br>The dx of HTN requires at least 3 separate blood pressure readings greater than 140\/90 mmHg,<br>preferabley measured over a period of months. Once the dx is made, the goal of therapy is to maintain<br>BP below 140\/90 in patients with uncomplicated HTN and below 130\/80 in patients with DM or<br>renal disease.<\/li>\n\n\n\n<li>For pts ranging from 120-139\/80-89, (pre-HTN), lifestyle modification in the form of weight<br>loss, exercise, and decreased salt intake is recommended.<\/li>\n\n\n\n<li>Patients with a BP in excess of 140\/90 should also undergo a trial period of lifestyle<br>modification, and if the BP still remains elevated, then it is appropriate to initiate<br><br>antihypertensive therapy.<\/li>\n\n\n\n<li>When the BP is in the range of 140-159\/90-99 (stage I HTN), single drug therapy should be<br>attempted. Hydrochlorothiazide is the most common first-line agent, and like calcium channel<br>blockers, is particularly effective in elderly patients and blacks.<\/li>\n\n\n\n<li>Two-drug combinations are appropriate when the BP exceeds 160\/100 (stage II HTN).<br>Continuous (systolic and diastolic) murmur in the per umbilical area, or in the flanks, is characteristic of<br>renal artery stenosis; the diastolic component makes this murmur more specific, compared to the<br>systolic component alone. If you carefully auscultate the per umbilical area of such a pt with advanced<br>atherosclerosis and resistant HTN, you have a good chance to arrive at a correct dx.<br>Nor epinephrine has alpha-1 agonist properties which cause vasoconstriction; this property is useful<br>when trying to increase the blood pressure of hypotensive patients. However, in some patients with<br>decreased blood flow, vasoconstriction can result in ischemia and necrosis of the distal fingers and toes.<br>A similar phenomenon can occur in the intestines (resting in mesenteric ischemia) or kidney (causing<br>renal failure).<br>Orthostatic hypotension Defined as a postural decrease in blood pressure by 20mmHg systolic or<br>10mmHg diastolic (sometimes accompanied by an increase in HR) that occurs on standing. In<br>general, it results from insufficient constriction of resistance and capacitance blood vessels in the LE on<br>standing, which may be due to a defect in autonomic reflexes, decreased intravascular volume, or<br>meds. Some baroreceptor sensitivity is lost as a normal part of aging. Arterial stiffness, decreased<br>norepinephrine content of sympathetic nerve endings, and reduced sensitivity of the myocardium to<br>sympathetic stimulation all contribute to a tendency toward orthostatic hypotension with age.<br>Remember that beta blockers may worsen Peripheral vascular disease and are therefore relatively<br>contraindicated in some settings. The mechanism is thought to involve beta2mediated vasoconstriction<br>of peripheral arteries. The first step in management is to switch the metropolis to a different<br>antihypertensive.<br>Rhythm defects<br>Prolonged, tachysystolic atrial fibrillation causes significant left ventricular dilation and a depressed<br>EF. LV dysfunction results from tachycardia, neurohumoeral activation, absence of an atrial<br>\u201ckick\u201d (that accounts for up to 25% of LV end-diastolic volume), and atrial-ventricular<br>desynchronization. Controlling the rhythm in such patients usually improves the LV function<br>significantly.<br>Ventricular tachycardia: it is a regular, wide complex tachycardia. The most common cause of v\u0002tach is due to coronary artery disease. The best tx for a pt who has no homodynamic compromise is<br>loading with either lidocaine or amiodarone. Either of these 2 agents will aid in the conversion to<br>normal sinus rhythm. However, amiodarone has become the drug of choice.<br>In the presence of a ventricular tachycardia, digitalis should never be administered as the<br>arrhythmia can worsen. Digoxin is only used to treat atrial arrhythhmias.<br>Cardio version is an option for sustained v-tach with hemodynamic compromise.<br>IV diltiazem should not be used for ventricular arrhythmia. Its only indicated only for atrial<br>arrhythmias.<br>Carotid massage is useful for SVT (narrow complex), not for ventricular tachycardia. It has<br>no role in the management of ventricular tachycardia. It carries the risk of releasing emboli from the<br>carotid plaques to the brain and is no longer a recommended technique<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>CARDIOLOGY:Hypertension\/HypotensionFor pts with HTN, in the absence of a specific indication or contraindication, diuretics and betablockers are still recommended as the initial drug treatment.<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-118731","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/118731","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=118731"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/118731\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=118731"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=118731"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=118731"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}