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Internal Medicine > 4) Cardiology (Part 3) > Flashcards

4) Cardiology (Part 3) Flashcards

1
Q

Clinical signs/symptoms of aortic coarctation in older infants and children

A
  • Usually asymptomatic

- May have chest pain, cold extremities, and lower extremity claudication with physical activity

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2
Q

Clinical signs/symptoms of aortic coarctation in young adults

A
  • Classic presentation = Hypertension
  • Complications of HTN: Headache, epistaxis, heart failure, or aortic dissection may occur
  • May also have lower extremity claudication
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3
Q

Clinical signs and symptoms of aortic coarctation general

A
  • 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)
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4
Q

> 70% of patients also have a bicuspid aortic valve coarctation & will have

A
  • Aortic Stenosis (AS)
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5
Q

Coarctation of the aorta CXR

A
  • 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
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6
Q

Diagnostic studies for coarctation of the aorta

A
  • Echocardiogram
  • CT or MRI
  • Angiogram
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7
Q

Anatomy and epidemiology of abdominal aortic aneurysm (AAA)

A
  • Infrarenal aorta most common
  • Most common in older men
  • Often co-exist with CAD & carotid vascular disease
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8
Q

Risk factors for abdominal aortic aneurysm

A
  • HTN
  • Smoking
  • Family hx
  • Connective tissue disease
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9
Q

PE of abdominal aortic aneurysm

A
  • Pulsatile mass on abdominal exam
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10
Q

AAA diagnosis

A
  • Abdominal US or CT with contrast
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11
Q

AAA Tx

A
  • 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
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12
Q

AAA complications

A
  • Enlargement & rupture (very high mortality rate)
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13
Q

Peripheral Vascular Disease (PVD)/Peripheral Arterial Disease (PAD) Clinical Presentation

A
  • 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
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14
Q

PE findings in PVD (1)

A
  • Pulses weak & thready, or absent
  • Dependent rubor (redness)
  • Localized pallor & cyanosis
  • Ischemic ulcers or gangrene of toes
  • Foot or leg may be cold & numb
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15
Q

PE findings in PVD (2)

A
  • Thin atrophied skin; or loss of hair (long term insufficiency)
  • Muscles atrophy
  • Systolic bruits that may extend to diastole
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16
Q

Long term venous insufficiency (PVD) accentuates

A
  • Skin mottling

- Increases likelihood of ulceration, localized anesthesia, & tenderness

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17
Q

ABI ratio values

A
  • 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
18
Q

PVD arteriography

A
  • Provides detailed anatomic information

- Reserved for patients warranting invasive intervention such as PTA or vascular surgery

19
Q

PVD CT angiography (CTA)

A
  • Alternative to traditional contrast arteriography (avoids arterial puncture)
20
Q

PVD magnetic resonance angiography (MRA)

A
  • Delineate arteries without using contrast
21
Q

Medical management of PVD

A
  • Pletal (Cilostazol)
  • Daily exercise program, careful foot care, treatment of hypercholesterolermias & local debridement of ulcerations
  • Must stop smoking
22
Q

Tx of PVD

A
  • Medical management
  • Percutaneous transluminal angioplasty (PTA) for selected pts
  • Arterial Reconstructive surgery (severe claudication, rest pain or gangrene)
23
Q

Pathophysiology of arterial embolic disease

A
  • 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
24
Q

Arterial embolic disease Hx

A
  • Sudden pain or numbness in an extremity in absence of previous history of claudication
25
Q

Arterial embolic disease PE

A
  • Pain, pallor, pulselessness, paresthesias, & paralysis

- Decreased temperature of limb distal to occlusion

26
Q

Arterial embolic disease Tx

A
  • Angiography to identify lesion & immediate anticoagulation & removal of clot
27
Q

Surgical embolectomy

A
  • 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
28
Q

Arterial insufficiency characteristics

A
  • 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
29
Q

Venous insufficiency characteristics

A
  • 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
30
Q

DVT risk factors (Virchow’s triad)

A
  • Venous stasis
  • Vascular damage
  • Activation of coagulation system
31
Q

DVT risk factors (1)

A
  • 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)
32
Q

DVT risk factors (2)

A
  • 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
33
Q

DVT prevalence by location

A
  • Inpatients = 20% distal; 80% proximal

- Outpatients = 50-70% distal; 30-50% proximal

34
Q

D-dimer

A
  • High sensitivity (~97%)

- Low specificity (~61-64%)

35
Q

DVT diagnostic test of choise

A
  • Compression ultrasonography (CUS) with doppler
36
Q

Compression ultrasonography (CUS) with doppler

A
  • 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
37
Q

Calf vein thrombus

A
  • 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

38
Q

Iliac vein thrombus

A
  • 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
39
Q

Initial DVT anticoagulation options

A
  • Subcutaneous low molecular weight (LMW) heparin
  • Subcutaneous fondaparinux,
  • Oral factor Xa inhibitors rivaroxaban or apixaban or edoxaban
  • Unfractionated heparin (UFH)
40
Q

Long-term DVT anticoagulation (maintenance)

A
  • Oral direct factor Xa inhibitors, [rivaroxaban, apixaban, edoxaban]
  • Oral thrombin inhibitors [dabigatran]
  • Oral vitamin K antagonists [warfarin])
  • Subcutaneous agents (LMW heparin and fondaparinux)

Internal Medicine (14 decks)

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