4) Cardiology (Part 3) Flashcards
Clinical signs/symptoms of aortic coarctation in older infants and children
- Usually asymptomatic
- May have chest pain, cold extremities, and lower extremity claudication with physical activity
Clinical signs/symptoms of aortic coarctation in young adults
- Classic presentation = Hypertension
- Complications of HTN: Headache, epistaxis, heart failure, or aortic dissection may occur
- May also have lower extremity claudication
Clinical signs and symptoms of aortic coarctation general
- High BP in the Upper Extremities
- Low or unobtainable BP in the Lower Extremities
- Diminished or delayed femoral pulses (brachial-femoral delay)
- Cardiac exam may be normal or there may be a murmur if another cardiac defect is present (i.e, AS, PDA, VSD etc)
> 70% of patients also have a bicuspid aortic valve coarctation & will have
- Aortic Stenosis (AS)
Coarctation of the aorta CXR
- Indentation of aorta wall at the site of coarctation can produce a 3 sign
- Notching of the ribs: from erosion by the large collateral arteries
Diagnostic studies for coarctation of the aorta
- Echocardiogram
- CT or MRI
- Angiogram
Anatomy and epidemiology of abdominal aortic aneurysm (AAA)
- Infrarenal aorta most common
- Most common in older men
- Often co-exist with CAD & carotid vascular disease
Risk factors for abdominal aortic aneurysm
- HTN
- Smoking
- Family hx
- Connective tissue disease
PE of abdominal aortic aneurysm
- Pulsatile mass on abdominal exam
AAA diagnosis
- Abdominal US or CT with contrast
AAA Tx
- 4 cm AAA annual risk of rupture < 5 %
- Monitor with Serial Ultrasounds
- Repair recommended when risk of rupture > risk of surgery; occurs with a AAA > 5.5 cm in males or >5.0 in females OR if rapid increase in size
AAA complications
- Enlargement & rupture (very high mortality rate)
Peripheral Vascular Disease (PVD)/Peripheral Arterial Disease (PAD) Clinical Presentation
- Intermittent Claudication
- Dull ache with accompanying muscle fatigue
- Will usually appear during sustained exercise ( walking a distance or climbing several flights of stairs)
- Continued activity causes worsening pain
- Amount of exercise necessary to cause discomfort is predictable (occurring each time same distance is walked)
- Pain usually relieved with a few minutes of rest
- Site of pain is distal to occlusion
- More advanced atherosclerotic obstruction results in pain at rest
PE findings in PVD (1)
- Pulses weak & thready, or absent
- Dependent rubor (redness)
- Localized pallor & cyanosis
- Ischemic ulcers or gangrene of toes
- Foot or leg may be cold & numb
PE findings in PVD (2)
- Thin atrophied skin; or loss of hair (long term insufficiency)
- Muscles atrophy
- Systolic bruits that may extend to diastole
Long term venous insufficiency (PVD) accentuates
- Skin mottling
- Increases likelihood of ulceration, localized anesthesia, & tenderness
ABI ratio values
- 1.0 to 1.4 = normal.
- 0.9 to 1.0 = borderline
- 0.9 or less = PAD
- 0.4 to 0.7 = moderate PAD
- Less than 0.4 = severe PAD
PVD arteriography
- Provides detailed anatomic information
- Reserved for patients warranting invasive intervention such as PTA or vascular surgery
PVD CT angiography (CTA)
- Alternative to traditional contrast arteriography (avoids arterial puncture)
PVD magnetic resonance angiography (MRA)
- Delineate arteries without using contrast
Medical management of PVD
- Pletal (Cilostazol)
- Daily exercise program, careful foot care, treatment of hypercholesterolermias & local debridement of ulcerations
- Must stop smoking
Tx of PVD
- Medical management
- Percutaneous transluminal angioplasty (PTA) for selected pts
- Arterial Reconstructive surgery (severe claudication, rest pain or gangrene)
Pathophysiology of arterial embolic disease
- Thrombus or vegetation within heart or aorta
- MR => LA dilatation =>AF & thrombus formation within LA
- If clot unstable, emboli may be disbursed throughout arterial system, with occlusion of smaller arteries
Arterial embolic disease Hx
- Sudden pain or numbness in an extremity in absence of previous history of claudication
Arterial embolic disease PE
- Pain, pallor, pulselessness, paresthesias, & paralysis
- Decreased temperature of limb distal to occlusion
Arterial embolic disease Tx
- Angiography to identify lesion & immediate anticoagulation & removal of clot
Surgical embolectomy
- Preferred treatment for patients with severe acute ischemia
- Least delay in reestablishing perfusion
- Arteriotomy at site of embolism
- Extraction with a baloon(Fogarty) catheter inserted through a proximal arteriotomy
- Requires removal of embolism & tail of thrombus that extends distally or proximal from it
- Intraoperative infusion of thrombolytic agents useful adjunct
Arterial insufficiency characteristics
- A unilaterally cool extremity, a prolonged venous filling time, shiny atrophied skin, and nail changes
- Diminished pulses
- Classic Claudication — Exertional calf pain that does not begin at rest, causes the patient to stop walking, and resolves within 10 minutes of rest
- Thromboangiitis obliterans (Buergers): Smokers with distal extremities claudication
Venous insufficiency characteristics
- Limb discomfort (i.e., tired, heavy legs), pain and limb swelling
- Pain associated with venous disease is typically worse when standing, or when seated with the feet dependent for prolonged periods of time, and improves with limb elevation and walking
DVT risk factors (Virchow’s triad)
- Venous stasis
- Vascular damage
- Activation of coagulation system
DVT risk factors (1)
- Active cancer or cancer treatment
- Age over 60 years
- Critical care admission
- Dehydration
- Known thrombophilias
- Obesity (body mass index [BMI] over 30 kg/m2)
- One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)
DVT risk factors (2)
- Personal history or first-degree relative with a history of VTE
- Use of hormone replacement therapy
- Use of oestrogen-containing contraceptive therapy
- Varicose veins with phlebitis
DVT prevalence by location
- Inpatients = 20% distal; 80% proximal
- Outpatients = 50-70% distal; 30-50% proximal
D-dimer
- High sensitivity (~97%)
- Low specificity (~61-64%)
DVT diagnostic test of choise
- Compression ultrasonography (CUS) with doppler
Compression ultrasonography (CUS) with doppler
- Sensitivity and specificity of proximal CUS is greater than 95 percent
- However, proximal CUS has limited utility and lower sensitivity in patients with calf and iliac venous thrombosis
Calf vein thrombus
- Veins in the calf are harder to assess than proximal veins
- Proximal CUS does not image the calf veins while whole leg US images both the proximal and calf veins
Iliac vein thrombus
- Iliac vein often cannot be assessed for compressibility
- Consequently, these veins are also usually assessed with doppler imaging or may require computed tomography (CT) venography
Initial DVT anticoagulation options
- Subcutaneous low molecular weight (LMW) heparin
- Subcutaneous fondaparinux,
- Oral factor Xa inhibitors rivaroxaban or apixaban or edoxaban
- Unfractionated heparin (UFH)
Long-term DVT anticoagulation (maintenance)
- Oral direct factor Xa inhibitors, [rivaroxaban, apixaban, edoxaban]
- Oral thrombin inhibitors [dabigatran]
- Oral vitamin K antagonists [warfarin])
- Subcutaneous agents (LMW heparin and fondaparinux)
