Adult Circulatory Flashcards
Describe the different kinds of Acute Coronary Syndrome
Stable angina
Unstable angina
Non-ST elevation MI (NSTEMI)
ST elevation MI (STEMI)
- Stable angina: chest pain or discomfort that is associated with physical activity
- Unstable angina: chest pain that can occur at rest, can be a precursor to an MI
- Non-ST elevation MI (NSTEMI): Partial occlusion of a major coronary vessel or complete occlusion of a minor coronary vessel causing reversible partial thickness heart muscle damage. EKG reveals ST depressions or T wave inversions without Q waves. Usually accompanied by elevated cardiac markers.
- ST elevation MI (STEMI): Complete occlusion of a major coronary vessel resulting in irreversible full thickness heart muscle damage. EKG reveals ST elevationsAccompanied by elevated cardiac markers
Pathophysiology of Acute Coronary Syndrome
- The development of any acute coronary syndrome begins with the rupture or erosion of plaque - an unstable and lipid-rich substance.
- The rupture results results in platelet adhesions, fibrin clot formation, and activation of thrombin.
- An acute coronary syndrome most commonly results when a thrombus progresses and occludes blood flow.
- The effect is an imbalance in myocardial oxygen supply and demand.
Risk Factors of Acute Coronary Syndrome
Non-modifiable
- Male gender
- Postmenopausal female
- Family history
Modifiable
- Smoking
- Obesity
- High fat, high carbohydrate diet
- Sedentary lifestyle
- Hypertension
- Type II diabetes
Mrs. Dixon is a 62-year-old female in
the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country. VS:
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
What should you ask Mrs Dixon?
- How long have you had symptoms?
- Do you have chest pain? Location?Quality? Scale from 1-10? Duration?
- Nausea and/or vomiting?
- Medical/surgical history?
- Family history?
- Do you smoke?
- Are you taking any medications?
Symptoms: 3-4 days
No chest pain
No vomiting, occasional nausea
History of iron-deficiency anemia, C-section X 2 & appendectomy
She does not smoke
She is not taking any medications
Father had coronary artery disease and had an MI at age 59
Women with MI: fatigue, diaphoresis, indigestion, arm or shoulder pain, nausea, and vomiting.
Mrs. Dixon is a 62-year-old female in
the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country. VS:
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
No chest pain
No vomiting, occasional nausea
History of iron-deficiency anemia, C-section X 2 & appendectomy
She does not smoke
She is not taking any medications
Father had coronary artery disease and had an MI at age 59
What are your priority assessments?
- Mental Status: A&O x 3, a little anxious
- Skin (look for perfusion): Cool, moist
Decreased pulses and cold, clammy, pale skin are signs of inadequate tissue perfusion and inadequate CO. Activation of the sympathetic system with low CO will stimulate diaphoresis. - Respiratory: Regular and unlabored, breath sounds clear
- Vital signs: Stable
- Pulses: Strong and regular
- Heart sounds: Regular S1, S2;
no murmurs
Mrs. Dixon is a 62-year-old female in
the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing significantly wrong before leaving the country. VS:
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
What orders do you anticipate?
- You place her on telemetry monitoring
- Oxygen 2 L/min via NC
- 12-lead EKG: shows ST depression on inferolateral leads (Left Coronary Artery)
- CXR
- ABG
- Complete blood count (CBC)
- Comprehensive metabolic panel (CMP)
- Lipid panel
- Cardiac enzymes
*Troponin I & Troponin T
*CK and CK-MB
*Myoglobin - Lipid panel
- Coagulation studies (in case she needs anticoagulants)
*Prothrombin time (PT)
*Partial thromboplastin time (PTT)
*International normalized ratio - IV access (to get meds to her quickly)
*Can also do an echo or coronary angiography
Mrs. Dixon is a 62-year-old female in the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing significantly wrong before leaving the country.
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
EKG reveals NSTEMI. How do you explain her symptoms?
Men and women have different kinds of symptoms when it comes to MI
MEN
- Burning
- Squeezing
- Crushing tightness in the substernal chest that may radiate to the left arm, neck, jaw, or shoulder blade
WOMEN
- Atypical chest pain
- Vague or a lack of chest pain
- More likely to experience a toothache or pain in the arm, shoulder jaw, neck or throat, back, breast or stomach
- Fatigue
- SOB
Mrs. Dixon is a 62-year-old female in the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country.
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
EKG reveals NSTEMI.
You receive several stat orders, what do you anticipate these to be?
“MONA”
- Morphine: control pain and relax coronary arteries, improving blood flow
- Oxygen: heart needs oxygen
- Nitroglycerin: dilates coronary arteries, increasing blood supply to the heart in an attempt to limit myocardial muscle damage and control pain. One tablet may be administered gradually every 5 minutes for a maximum of three doses as long as the patient maintains adequate BP. If pain is not controlled with three doses, IV Nitroglycerin will be started.
- Aspirin: helps prevent platelets from enlarging the existing clot or new clots from forming
- Beta-blockers (Metoprolol): decrease myocardial workload and myocardial oxygen demand, limiting extension of injury. Not to be used with a right coronary artery MI with bradycardia!
- Heparin drip: Prevent new clot formation
- Consult cardiology
Mrs. Dixon has a NSTEMI. Labs:
WBC: 4,000 – 10,000 uL; 5,000
Hemoglobin: 12.0 – 17.0 g/dL; 11.2 L
Hematocrit: 36.0 – 51.0%; 34.1 L
RBC: 4.2 – 5.9 cells/L; 3.80 L
Platelets: 150,000 – 350,000 uL; 245,000
Calcium: 9 – 10.5 g/dL; 9
Chloride: 98 – 106 mEq/L; 98
Magnesium: 1.5 – 2.4 mEq/L; 2.0
Phosphorus 3.0 – 4.5 mg/dL; 3.1
Potassium 3.5 – 5.0 mEq/L; 3.5
Glucose 70 – 100 mg/dL ;112 H
BUN 8 – 20 mg/dL; 20
Creatinine 0.7 – 1.3 mg/dL; 1.0
Creatine Kinase 30 – 170 U/L; 384 H
CK-MB 3–5 %; 7 % H
Cholesterol < 200 mg/dL; 268 H
Triglycerides < 150 mg/dL; 298 H
Troponin I < 0.5 ng/mL; 0.12 H
Troponin T < 10 ng/mL; 15 H
Myoglobin < 170 ng/mL; 203 H
PT 11 – 12.5 seconds; 11.5
INR 0.8 – 1.1; 0.8
aPTT 25 – 35 seconds; 32
What is significant about these labs?
All cardiac enzymes are elevated
- Evidence of myocardial ischemia
All values are elevated in the lipid profile
- Most cases are secondary to atherosclerosis
- Growth of cholesterol plaques slowly block blood flow in arteries
- Rupture of plaques results in thrombus formation and obstruction of coronary artery flow
H&H slightly low
- History of iron-deficiency anemia
- Not taking medications
- Possible decreased iron-binding capacity
Mrs. Dixon has an NSTEMI. You have started a 20 gauge IV in Mrs. Dixon’s left hand. The ER physician orders 25,000 units of heparin in 500 mL NS to infuse at 1,000 unit/hr. At what rate should the pump be set?
20 mL/hr
Mrs. Dixon is a 62-year-old female in
the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country.
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
EKG reveals an NSTEMI
Is she a candidate for fibrinolytic therapy (tPA)? Why not?
- Symptoms must be present for less than 12 hours
- Best outcomes occur in those treated in 1-2 hours
- Fibrinolysis is not effective for treatment of a MI without ST segment elevation (NSTEMI)
- Mrs. Dixon has an NSTEMI and has had symptoms for 3-4 days
Mrs. Dixon is a 62-year-old female in the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country.
BP: 140/82
PULSE: 84
RR: 16
O2 SAT: 97% RA
TEMP: 98.2 F
EKG reveals an NSTEMI.
The cardiologist arrives within 30 minutes and has elected to take the pt to the cardiac cath lab for percutaneous coronary intervention. Why is the timing significant?
What happens in the percutaneous coronary intervention?
- Door-to-balloon time is a key performance quality metric in the treatment of MI.
- The American Heart Association’s guidelines recommends that the artery be reopened within 90 minutes for best outcomes.
- Remember: door to balloon – 90 minutes!
- Balloon angioplasty is performed using a thin tube called a catheter, with a small deflated balloon at its tip. The catheter is inserted into a large artery in the leg or via the radial artery in the forearm, and then carefully guided to the blocked portion of the artery. The balloon is then inflated to push the accumulated plaque against the walls of the artery, restoring normal blood flow to the heart muscles.
- Pt must lay down 2-6 hours afterward
- Coronary artery stenting, a small wire mesh, is often used to prevent the blocked artery from re-narrowing after a balloon angioplasty.
Mrs. Dixon is a 62-year-old female in
the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country. EKG reveals an NSTEMI.
The cardiologist arrives within 30 minutes and has elected to take the pt to the cardiac cath lab for percutaneous coronary intervention. It is successful and she is discharged home.
What medications do you anticipate at discharge?
Aspirin 81 mg or 325 mg daily
- Inhibits clotting mechanisms within the clotting cascade or prevents platelet aggregation; used for unstable angina, acute myocardial infarction, and coronary interventions.
Plavix 75 mg daily
- Inhibits clotting mechanisms within the clotting cascade or prevents platelet aggregation; used for unstable angina, acute myocardial infarction, and coronary interventions.
Lisinopril 10 mg daily (ACEI)
- Prevents the conversion of AI to AII, resulting in lower levels of AII, which causes an increase in plasma renin activity and a reduction of aldosterone secretion; also inhibits the remodeling process after myocardial injury.
Metoprolol 25 mg daily
- Results in decreased SNS response such as decreased heart rate, blood pressure, and cardiac contractility;
Atorvastatin 80 mg daily
- To lower lipid levels
NTG SL 0.4 mg PRN
- Directly relaxes smooth muscle, causing vasodilation of the systemic vasculature bed; decreases myocardial oxygen demands; secondary effect is vasodilation of responsive coronary arteries
Stool softeners (Docusate sodium)
- We don’t want her to be straining
Iron sulfate?
- For her anemia, need to increase binding sites for O2
Mrs. Dixon is a 62-year-old female in the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing significantly wrong before leaving the country. EKG reveals an NSTEMI.
The cardiologist arrives within 30 minutes and has elected to take the pt to the cardiac cath lab for percutaneous coronary intervention. It is successful and she is discharged home.
What are priority discharge instructions/teaching for Mrs. Dixon?
- Regular follow-up with cardiologist or PCP
- Purpose, dose, and side effects of medications
- Cardiac rehabilitation including progressive exercise
- Immediately report signs and symptoms of MI such as chest pain and chest discomfort or increased shortness of breath.
- Diet low in cholesterol and sodium, high in fiber (breaks down fat)
- Healthy weight
- Smoking cessation if pt smokes
Mrs. Dixon is a 62-year-old female in the emergency department for “achiness” in the elbows that is atypical and worsening over the last 3 - 4 days. She says that the feeling awakens her in the middle of the night. Mrs. Dixon complains of increased fatigue, shortness of breath, and stress at work. She and her husband have a cruise planned in a couple of days and wants to confirm that there is nothing
significantly wrong before leaving the country. EKG reveals an NSTEMI.
The cardiologist arrives within 30 minutes and has elected to take the pt to the cardiac cath lab for percutaneous coronary intervention. What would an alternative treatment be if PCI was not possible or she had extensive multivessel disease?
Coronary artery bypass grafting (CABG)
* Surgical revascularization intervention that bypasses blockages in the coronary arteries causing the myocardial muscle damage.
* Indications for CABG include unsuccessful PCI or not a candidate for PCI, failure of medical management, or critical left main or three vessel disease.
* During CABG, a healthy artery or vein, typically the internal thoracic (mammary) artery or saphenous vein, is grafted to the blocked coronary artery. One end is attached to the aorta, with the other end attached to the blocked coronary distal to the occlusion, thereby bypassing the blocked portion of the artery allowing blood flow to the cardiac tissue.
Valvular Heart Disease
3 Types: Pathophysiology
- Stenosis: stiffening and thickening of the valve leaflets, caused by calcium deposits or scarring, narrow the opening, and obstruct flow
- Regurgitation: blood flows or leaks backward – ventricle to atria, aorta to the left ventricle, pulmonic circulation to the right ventricle – because of incomplete closing of the valve
- Prolapse: valve leaflets bulge backward and do not close, causing regurgitation
Risk Factors of Valvular Heart Disease
- Infectious diseases
- Infective endocarditis (IE)
- Rheumatic fever (from untreated
streptococcal infections) - Coronary artery disease
- Myocardial infarction
- Heart failure
- Congenital defects
- Cardiomyopathy
- Degenerative changes (older age)
- Pregnancy: Due to increased workload on the heart
Valvular Heart Disease
Clinical Manifestations
- One of the first clinical signs is the auscultation of a murmur.
- A murmur can be the result of a high rate of blood flow through a valve, forward blood flow through a narrowed valve (stenosis), or backward blood flow through an incompetent valve (regurgitation).
- They can be classified as systolic, diastolic, or continuous based on where in the cardiac cycle it is best heard.
- Others:
SOB, dyspnea, orthopnea
Crackles
Angina
Syncope, dizziness
Dysrhythmias (Atrial fibrillation most common)
Palpitations
Fatigue
Weight gain
Edema
Cool, pale extremities with weak pulses
Valvular Heart Disease
Systolic Murmurs
- When are they heard?
- Systolic murmurs can be heard during S1 or lub when
the ventricles are contracting. - During this time, the aortic and pulmonic valves should
be open, and the mitral and tricuspid valves should be
closed. - Therefore, a systolic murmur can be heard with aortic or pulmonic stenosis or mitral or tricuspid
regurgitation.
Valvular Heart Disease
Diastolic Murmurs
- When are they heard?
- Diastolic murmurs can be heard during S2 or dub when
the ventricles are relaxing, and the heart is filling. - The mitral and tricuspid valves should be open to allow
for ventricular filling, and the aortic and pulmonic valves should be closed. - Therefore, a diastolic murmur can be heard with aortic or pulmonic valve regurgitation or mitral or tricuspid stenosis.
Mr. Spitale is a 54-year-old male who presents to your
clinic with complaints of intermittent episodes of
dyspnea, chest pain, palpitations, and dizziness for 6 months. He says that he used to exercise regularly but cannot tolerate increased physical activity. He is concerned and does not know what to do. He is alert and oriented currently and is asymptomatic. Vital signs:
BP: 176/87
HR: 82 (irregular)
RR: 20
O2 sat: 98% RA
Temp: 98.6 F
What should you ask Mr. Spitale?
Do you have any medical history?
- “Small” heart attack 5 years ago. Never followed up with cardiology.
- I “might” have high blood pressure, but I don’t take anything for it.
Do you smoke, drink alcohol or use illicit drugs?
- Smoked a pack per day for 15 years but quit 5 years ago.
- Drinks 2 beers each night. Never used drugs.
Do you take any medications?
- None
Family medical history?
- Unknown. Adopted as a child.
Social history?
- Married for 25 years with 2 grown children.
- Works as a foreman for a construction company.
- Denies outside stressors.
Mr. Spitale is a 54-year-old male who presents to your
clinic with complaints of intermittent episodes of
dyspnea, chest pain, palpitations, and dizziness for 6 months. He says that he used to exercise regularly but cannot tolerate increased physical activity. He is concerned and does not know what to do. He is alert and oriented currently and is asymptomatic. Vital signs:
BP: 176/87
HR: 82 (irregular)
RR: 20
O2 sat: 98% RA
Temp: 98.6 F
What are your priority physical assessments?
Vital Signs
- BP 176/87, HR 82 and irregular
Pain assessment
- None currently
- Could have chest pain, palpitations
Breath sounds
- Clear bilaterally
- Crackles are indicative of pulmonary congestion
Heart sounds (and rhythm)
- Systolic murmur, 2nd ICS right sternal border (aortic stenosis)
Peripheral vascular assessment
- Warm, dry and intact. No edema.
- Strong pulses.
- Poor color, cool extremities, weak peripheral pulses, delayed capillary refill, and edema can indicate inadequate cardiac output
Activity tolerance
- Dyspnea, fatigue and dizziness
Mr. Spitale is a 54-year-old male who presents to your
clinic with complaints of intermittent episodes of
dyspnea, chest pain, palpitations, and dizziness for 6 months. He says that he used to exercise regularly but cannot tolerate increased physical activity. He is concerned and does not know what to do. He is alert and oriented currently and is asymptomatic. Vital signs:
BP: 176/87
HR: 82 (irregular)
RR: 20
O2 sat: 98% RA
Temp: 98.6 F
Priority labs/diagnostics?
- EKG
- CXR - may indicate cardiomegaly and pulmonary edema
- CBC
- CMP
- Cardiac enzymes
- Echocardiogram with TEE can identify valve abnormalities
- Hearth cath is definitive for stenosis
Mr. Spitale is a 54-year-old male who presents to your
clinic with complaints of intermittent episodes of
dyspnea, chest pain, palpitations, and dizziness for 6 months. He says that he used to exercise regularly but cannot tolerate increased physical activity. He is concerned and does not know what to do. He is alert and oriented currently and is asymptomatic. Vital signs:
BP: 176/87
HR: 82 (irregular)
RR: 20
O2 sat: 98% RA
Temp: 98.6 F
Labs are normal, CXR is clear. What further testing can be done?
Transesophageal Echocardiography
(TEE)
- Patient lies on bed on left side
- Doctor places TEE probe into mouth and down esophagus
- Sound waves create a picture of the heart
- Identifies valve abnormalities and Ejection Fraction
Mr. Spitale has completed a TEE and the study reveals aortic stenosis and will be referred to cardiology for potential valve replacement.
What are the most common valvular diseases?
- The most common valvular diseases are aortic stenosis and mitral regurgitation.
- The least commonly affected valves are the tricuspid and pulmonic valves because of the low-pressure system in the right heart.
- Valvular disease can affect one or more valves at the same time.
Mr. Spitale has completed a TEE and the study reveals aortic stenosis and will be referred to cardiology for potential valve replacement.
What medications do you anticipate for him?
Beta-blockers (Metoprolol, atenolol, esmolol)
- Reduce heart rate and blood pressure
ACE inhibitors (Lisinopril)
- If side effects (annoying cough, angioedema), go to ARBS
- Decrease BP
Angiotensin II receptor blockers (Losartan, valsartan)
- Decrease BP
Anticoagulant (Warfarin)
- Patients who undergo valve replacement with a mechanical prosthetic valve will need to be anticoagulated for life to prevent thrombotic events such as stroke
NTG
- Vasodilator
Mr. Spitale has completed a TEE and the study reveals aortic stenosis and will be referred to cardiology for potential valve replacement. What education/teaching do we need to provide for Mr. Spitale?
- Medication teaching
- Restrict sodium and caffeine (so Afib does not become worse)
- Monitor for signs and symptoms of heart failure (dyspnea, pedal edema, orthopnea, and fatigue)
- Daily weight monitoring
- If on warfarin, anticoagulant precautions:
- Use electric razor for shaving
- Limit alcohol consumption
- Fall precautions
- Regular PT/INR checks
- Limit green leafy vegetables (High in vitamin K) - Regular follow-up with cardiologist, PCP
Carotid Artery Disease
Pathophysiology
Severity
- Like atherosclerotic changes in other arteries, carotid artery disease is characterized by vessel wall thickening, plaque formation, and a progressive narrowing of the carotid artery.
- Plaque disruption and thrombus formation contribute to progressive narrowing of the lumen of the artery, which can cause adverse clinical events.
- Stenosis is most significant at the carotid bifurcation. This area is known as the carotid bulb, where the common carotid artery branches into the internal and external carotid arteries. The carotid bifurcation is an area of low-flow velocity and low-shear stress.
- When blood circulates through the carotid bifurcation, there is separation of flow into the low-resistance internal carotid and the high-resistance external carotid artery.
- With increasing degrees of stenosis in the internal carotid artery, flow becomes more turbulent, increasing the risk of atheroembolization.
- The severity of stenosis is commonly divided into three categories according to the luminal diameter reduction: Mild (<50%), Moderate (50% - 69%) & Severe (70% - 99%
Carotid Artery Disease
Risk Factors
Modifiable
* Smoking
* Hypertension
* Diabetes
* Dyslipidemia
* Sedentary lifestyle
* Obesity
* Ineffective stress management
* People with coronary artery disease have a greater risk of developing carotid artery disease
Nonmodifiable
* Age
* Gender: Male
* Ethnicity
* Family history
Mr. Hamilton is a 75-year-old man with a history of hypertension for 10 years treated with Amlodipine 10 mg and Lisinopril 20 mg daily. Mr. Hamilton considers his hypertension controlled. He also has a 5-year history of hyperlipidemia and takes
Atorvastatin 10 mg daily. His PCP has recommended a carotid duplex ultrasound of his carotid arteries as part of a systematic screening because of his vascular risk factors. Vital signs:
BP: 152/101
HR: 92
RR: 20
O2 sat: 97% RA
Temp: 97.4
What key physical assessment might make you suspicious that Mr. Hamilton has carotid artery disease?
What other cues might indicate that Mr. Hamilton will need this study?
Auscultation of the carotid arteries. Asymptomatic carotid artery stenosis may be identified by the presence of carotid bruits, sounds created by blood flow through a stenosed vessel on auscultation. This can be done by placing the bell of the stethoscope over the side of the neck anterior to the sternocleidomastoid muscle.
Other cues:
- Hypertensive (152/101)
- Advanced age (75)
- Male
- History of hyperlipidemia (Takes Atorvastatin 10 mg daily)
Mr. Hamilton is a 75-year-old man with a history of hypertension for 10 years treated with Amlodipine 10 mg and Lisinopril 20 mg daily. Mr. Hamilton considers his hypertension controlled. He also has a 5-year history of hyperlipidemia and takes
Atorvastatin 10 mg daily. His PCP has recommended a carotid duplex ultrasound of his carotid arteries as part of a systematic screening because of his vascular risk factors. Vital signs:
BP: 152/101
HR: 92
RR: 20
O2 sat: 97% RA
Temp: 97.4
Mr. Hamilton is not currently symptomatic. If he was symptomatic, what clinical manifestations might we observe?
Stroke symptoms
- Symptoms resembling a CVA or TIA (altered cerebral perfusion)
- Weakness (sometimes on one side)
- Dizziness
- Loss of coordination
- Difficulty talking
- Facial droop
- Vision problems
- Headache
Mr. Hamilton is a 75-year-old man with a history of hypertension for 10 years treated with Amlodipine 10 mg and Lisinopril 20 mg daily. Mr. Hamilton considers his hypertension controlled. He also has a 5-year history of hyperlipidemia and takes
Atorvastatin 10 mg daily. His PCP has recommended a carotid duplex ultrasound of his carotid arteries as part of a systematic screening because of his vascular risk factors. Vital signs:
BP: 152/101
HR: 92
RR: 20
O2 sat: 97% RA
Temp: 97.4
Mr. Hamilton undergoes a carotid duplex ultrasound of his carotid arteries. His ultrasound showed an atherosclerotic stenosis at the site of the left carotid bifurcation. Data was consistent with a severe carotid stenosis estimated about 70%.
What additional tests do you anticipate?
- Lipid profile
- CBC
- Comprehensive metabolic profile
- CTA, MRA, MRI, Carotid angiography (invasive)
- all but MRI use contrast dye -> BUN/Cr
- CTA: Utilizes IV contrast dye to highlight the carotid arteries
- MRA: Utilizing IV contrast dye, the MRA uses magnetic fields and radio waves to show blockages inside the arteries.
- Carotid Angiography: Involves inserting a catheter into an artery. Contrast dye is injected through the catheter that allows visualization of the carotid arteries via radiographical imaging.
- EKG
- Cardiac echocardiogram
- Heart catheterization
Mr. Hamilton is a 75-year-old man with a history of hypertension for 10 years treated with Amlodipine 10 mg and Lisinopril 20 mg daily. Mr. Hamilton considers his hypertension controlled. He also has a 5-year history of hyperlipidemia and takes
Atorvastatin 10 mg daily. His PCP has recommended a carotid duplex ultrasound of his carotid arteries as part of a systematic screening because of his vascular risk factors. Vital signs:
BP: 152/101
HR: 92
RR: 20
O2 sat: 97% RA
Temp: 97.4
Mr. Hamilton undergoes a carotid duplex ultrasound of his carotid arteries. His ultrasound showed an atherosclerotic stenosis at the site of the left carotid bifurcation. Data was consistent with a severe carotid stenosis estimated about 70%.
What treatment do you anticipate for Mr. Hamilton?
- Antiplatelet therapy
- Aspirin
- Clopidogrel (Plavix) - Increase antihypertensive
therapy - Increase Statin therapy
