Aortic Stenosis Flashcards
Requirement for valve replacement in aortic stenosis
Severe AS Criteria:
- aortic jet velocity > 4.0 m/sec or
- mean transvalvular pressure gradient > = 40 mmHg
- valve area usually <= 1.0 cm2 but not required
Indication for AVR:
Severe AS with 1 of the following:
* onset of symptoms (e.g. angina or syncope)
* left ventricular ejection fraction >= 50%
* undergoing other cardiac surgery (e.g. CABG)
Preload vs diastolic pressure
Preload: required to maintain cardiac output
Diastolic pressure: required to maintain perfusion of coronary artery
Vasodilators ( amlodipine, hydralazine, ACE inhibitors)
Reduce diastolic pressure
Diuretics ( eg, furosemide)
Reduce preload
Severe aortic stenosis diagnosis
Physical examination shows:
- late-peaking
- crescendo-decrescendo systolic murmur (best heard at the right upper sternal border) and diminished
- . Delayed pulses ( pulsus parvus et tardus)
- pt. With severe AS has symptoms of: angina, syncope/pre-syncope, or heart failure (eg, dyspnea)
Some patients with AS are asymptomatic, why ?
Patients have sedentary lifestyle; when subjected to exertion (stress testing), they typically have severe AS symptoms
Risk factors for atherosclerosis
- Diabetes
- Hypertension
- Smoking
Claudication
A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries
Ankle-Brachial Index (ABI)
ABI = SBP (Dorsalis pedis or posterior tibial artery) / SBP (brachial artery)
> 0.9 : Diagnostic of peripheral artery disease (PAD)
0.91-1.3 : Normal
1.3 : suggests calcification & uncompressed vessel (other testing should be considered)
Peripheral artery disease (PAD)
Most common manifistation of systemic atherosclerosis (lumen of lower extremities become occluded with plaque)
Steps:
1. Diagnosed with Ankle-Brachial Index (ABI)
2. Factor modification
3. Symptoms relief
4. Secondary prevention strategies with anti-platelet agents
Diagnosing Aortic Aneurysm
Via abdominal ultrasound
Requirement:
1. Screening recommended for men age 65-75 with history of smoking
Diagnosing Peripheral artery disease (PAD)
Initial diagnosis:
Ankle-brachial Index (ABI) —> diagnosed when less than 0.9 !!
Alternatives:
Arterial duplex ultrasound of lower extremities
* used to localize the site & severity of vascular obstruction
** performed in symptomatic patients with abnormal ABI, who are being considered for interventional
procedure
Acute cholecystitis
Def.
- Inflammation of the gallbladder
- gallstone blocks the cystic duct
Signs:
- severe pain in the RUQ or center abdomen
- pain spread to right shoulder or back
- tenderness over the abdomen
- fever
- N/V
- Previous history of biliary colic
- worst with meals (eg, large or fatty meals)
Complication:
* gallbladder rupture
Surgical intervention:
Cholecystectomy
Dupuytren Contracture (DC)
Def:
- progressive fibrosis of the palmer fascia due to fibroblast proliferation & disordered collagen deposition.
- patients develops contractures that limit extension at the metacarpophalangeal & proximal interphalangeal joints
Risk factors:
- age > 50
- male
- family history
- smoking
- alcohol
- diabetes
- northern European ancestry
- manual work ( eg, gardeners)
Plantar fasciitis
Def.
- inflammation of the ligament that connects the heel bone to the toes —> causing pain in the heels
- degeneration of plantar aponeurosis (deep plantar fascia; extends from the calcaneus to the toes) due to overuse or repetitive stress
Signs:
- heel pain with longer period of standing or walking ( pain with prolonged weight bearing)
- pain worst at first steps of the day, but gets better during the day
- pain does not occur with normal activity
- middle age adults
- obese
Examination:
- tenderness at the insertion of the plantar fascia on the calcaneus —> worst during passive dorsiflexion of the toes
- x-ray shows calcification in the proximal fascia (heel spurs)
Initial management:
- activity modification (eg, avoid walking barefoot)
- Stretching
- padded heal insertion
- symptoms takes months to completely resolve
