vit d stored in fat, takes 3 mo to reach steady state
steroidal hormones stored in fat, also toxins
steroidal hormone messages reach DNA-->possible multigenerational effects
ocp use may affect future generations

genetic polymorphisms
will hear about MTHR and COMT catecholyl o metatransferase
factor 5 leiden clots easily
become familiar with comprehensive coagulation testing
prot c and s, factor 2 and 5
much more common that vonwillenbrand's

management of warfarin
dosing starts at 5mg, 7.5-10 mb enough or alt dose between 5-7 or 7-10
regimes all over the place depending on coag status
with factor 5 issue warfarin dose will be much higher
also depends on vit K in diet
INR target 2-3

neuroassist.com
training for Marty Heinz for popularization of his neurotrans protocol
scroll down long home page to tech guide, click, 70 page doc
mucum pruriens as dopamine source
their standards based on 10 yrs 10000 pts
urine levels don't correl w bbb levels
they don't test first
urine has nothing to do with brain chem so don't use testing for depression
epi and norepi would incr w dose
gold standard is 24 hour urine, there is no serum test

forward and backward failure
pulses
cardiovascular drugs

silent ischemia
usu has CAD and angina but may not know that heart is ischemic at rest
diabetics with peripheral nerve damage more likely to experience
soon 1/2 of all 50 year olds will be diabetic
many have CAD without chest pain
work pts up based on sig risk factors
holter monitoring push botton when sx
how many times did experience of chest pain correlate with ST depression
4-6 events of ST depression that are asx / 1 with sx

40% of heart attack victims "have no risk factors"
so start screening testing at age 40
disease process is prevalent in our culture

30% of "heart attacks" are not CAD, ischemia or infarct
rather they are sudden arrhythmic deaths
probably would have been identifiable via frequent PVCs as at risk

slide 74 lec 1 adventitious breath sounds
what is clinically significant
coughing: does it clear? b9 if clears

hyperlipoproteinemia
know type IV and II
fatt liver is risk
II high LDL
IV high TGs and VLDL

mg, coq10, carnitine
improved mitral valve prolapse
carnitine great for improving muscle tone

know b vits
active forms
cv indications
b6 vs pyridoxal 5 phosphate, really want sublingual form, some destroyed in GI
b1 must be phosphorylated to ___
if homocysteinemic must give active forms
30% of female pop has MTHFR genetic defect
he has only found pill forms of 5 methyltetrahydrofolate

iodine and selenium for fibrocystic breast changes
keep increasing dose until it works
he's never had to do anything else
had no results with vit e and caffeine restriction

pharm
he wants to be sure we don't mess up pts with drugs
don't miss sig orthostatic htn on diuretic
this is serious business: medicine can kill
he used to make this an easy course, read the final exam questions to the class
still people would fail
potassiun chlorate is gut irritating, keep citrate supp on shelf (39mEq so 10mg dose)
what diuretic with sulfur allergy? triamterine (K sparing)
"a lot of people don't notice the testosterone antagonist effects of spironolactone"
K sparing may cause hyponatremia

criteria for malignant HTN and hospitalization

lots of a fib questions
common
reasonable dosing
stroke risk
management problems
monitoring

exam has 5 ekg strips
all pretty basic
questions around the strips require knowing rate and rhythm relative to strip
exam 19 pages long! given in 3 hours
he's giving us a 5 point extra credit question
he's giving us the EKG cheat sheet

no auditory part (murmurs)
next year may give auditory quizzes
know how to recognize and chart a murmur

how menopause causes htn
est receptors in smooth muscle
est levels drop
receptors empty-->vasodilation-->hot flashes
body compensates and overproduces norepi to constrict
destabilizes autonomic nervous system
HTN
2nd mechanism
cessation of menses-->high iron
oxidizes, more vessel damage-->atherosclerosis
track ferritin
iron overload causes arthritis too
this process is insidious and progressive
hemochromatosis is genetic predisposition

SAMe is first thing you do for postmenopausal HTN
they don't sleep either so take 5htp but you must support dopamine too
else it becomes depleted

very high total chol (2500)
niacin and statin together
niacin makes small lipids big
consider large doses of plant sterols, 2-6grams/day
ground flax seeds, sunflower seeds, rich in sterols nuts and seeds

fatty liver
labcorps test called nash or fibrosure
http://carolinanewswire.com/news/News.cgi?database=topstories.db&command=viewone&id=1246&op=t
blood test to dx fatty liver
detects steatosis, inflam and fibrosis
dxd formerly by liver bx

niacin
immed release safest and best raises hdl but people can't tolerate the flush
next best wax base, more even release, tid dosing best
niaspan more harming to liver, uneven release, more side effects

part of stop smoking protocol:
Gaia product: nicotene relief
contains lobelia in alc free cap
sodium bicarb qid an hour away from food
to help alkalinize as body dumps nicotinic acid in 1st 4 days
could use alkaline water instead

CHF new research Mark
exercising n=2000 with CHF mostly stage III and IV (advanced)
randomized: usual care vs 10-20 sessions of 30 mins exercise 4x/week
at max HR minus resting HR regardless of age: a sig rate
gave exercise equipment and HR monitoring equipment to use again
nonexercise group had nonsignificant improvement
exercise group had significant improvement
study lasted 3 years
a few pts had CV events right around exercise but overall there was improvement
most severe pts were excluded

bedrest mandatory with unstable uncontrolled heart failure
sudden weight gain
chest/l side
extremities/r side
progressive worsening of edema
bedrest is diuretic
add diuretic and constitutional hydrotherapy-->10-20lbs loss/day

Milner does O2 multistep therapy on CHF pts all the time
nutrients 1/2 hours before
always does it on unstable pts in cardiac lab being EKG monitored
if arrhythmia or ST changes they stop
some pts get more PVCs with exercise
one pt stopped throwing PVCs after 3rd session
know how to calculate resting hr, for failure pts calculate using conservative
220-age x ... ??
during multistep therapy they control ramp speed and angle to get them to target in 5 mins
keep adjusting treadmill goal 15 mins at target hr
may take 10 mins to get to target, still 15 mins exercise, total 25 min workout
20L/minute O2 with non rebreather mask and goggles over eyes

"CHF isn't a diagnosis, it is an effect from another diagnosis"

ST elevation in multiple leads is injury: acute MI or pericarditis
ST depression is ischemia
(also T wave inversion: r/o ischemia, if on V5 and not ischemia then advanced ventricular hypertrophy, or flat with hypokalemia)
know about slopes of depressed ST
up: exercise?
level
down
on treadmill it depresses with CAD, not going to have an MI

he's "going dark for a while"
means he's looking at the exam
and it's not on the screen

exercise tolerance testing
discontinue morning atenolol, come into office in morning
may have a hard time getting them up to target
unless atenolol dose is only 25mg
he has pt on 150mg, way over the max, no way to get heart rate up

repeat cardioversion: less effective each time, more reverts

most pacemakers are on demand for brady and don't fire unless rate under 60
so pt with pacemaker may have irregular pulse
want to know why pacemaker was originally inserted
pacing doesn't help with a fib

sick sinus syndrome??

think about relationship between natural therapeutics and blood thinners
pt may choose to take many natural blood thinners and aspirin
and overthin the blood
monitor BT in office to make sure that garlic vit c bromelain fish oil ginkgo etc
doesn't cause poor coag
also blood may still be too thick with natural therapies: be sure

review diagnostic imaging that is definitive for each disease
what is gold standard imaging for each condition?
valve dz: echo
CHF: echo is gold standard for all types of CHF
pts have CHF with EJ% under 50%, people walk around with ej under 15% but not much
10% seen just before death
echo not dx for CHF if cause is uncontrolled HTN
CXR mb diagnostic for pure L sided failure
cardiomyopathy chamber changes can't be seen on CXR
CAD: angio
HTN:

know cardiomyopathies
main types
and treatments

big picture about dig
broad dose ranges
monitoring: what blood test, waht are criteria
if EKG change: Uing of ST
lanoxin
what is most commonly prescribed with: furosemide/lasix (high powered for CHF)

BNP blood marker for heart failure
100 pos
100-500 equivocal
over 500 diagnostic
underused as alt to echo
if BNP is at 800 and you put them to bed 3 weeks you can check BNP for $100
if it went to 200 then can get up

review homeopathics
dr broadwell's lecture
lactodectus, etc, check on the list
lauroserratius
ant tart white tongue
oxalic acid
review all but he mentioned the above

review ventilation/perfusion
pink puff emphysema
blue bloat bronch respond better to O2
asthma acute protocols
safe epi concentration, know the dose, it's a board question

pulm drugs and bot

bots for drug thinning