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Cardiology 2 > Arterial Vascular Disease > Flashcards

Arterial Vascular Disease Flashcards

1
Q

Four main arterial vascular diseases and one minor

A
  • Giant cell Arteritis
  • Polymalgia Rheumatica
  • Arterial Insufficiency
  • Peripheral Arterial Disease
  • Aortic Aneurysm/Dissection
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2
Q

Giant Cell Arteritis

  • aka
  • who does it affect
  • what can it cause
  • how treat
A
  • temporal arteritis
  • primarily people over 50
  • blindness
  • high-dose steroids
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3
Q

Polymyalgia rheumatica

  • who does it affect
  • what other dz is it associated with
  • how treat
  • where see sx on body
A
  • primarily people over 50
  • 50% pts with giant cell arteritis have polymyalgia rheumatica
  • low dose steroids
  • sx below the neck
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4
Q

Pathophysiology of GCA

A
  • exact etiology unknown
  • theories: age, ethnicity, genetic disposition (maladaptive response to endothelial injury= inappropriate activation of cell-mediated immunity)
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5
Q

What is the progression of GCA

A
  • vessel wall damage
  • intimal hyperplasia
  • stenotic occlusion
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6
Q

What blood cell is seen in GCA

A

eosinophils

- likely but not always high WBC

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7
Q

GCA

  • which vessels are affected
  • epidemiology
A
  • medium and large arteries, most often the temporal artery
  • older than 50, mean age 72
  • Women > men
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8
Q

GCA

classic presentation

A
  • HA (temporal region)
  • scalp tenderness
  • vision: loss of sight in one eye, diplopia
  • jaw claudication
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9
Q

what is the highest positive predictive value sx for GCA

A

jaw claudication

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10
Q

GCA

Non-classic sx

A
  • dry cough (inflammation of aortic arch)
  • mononeuritis multiplex, often in shoulder
  • idiopathic fever
  • > 65
  • normal WBC
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11
Q

GCA

- how does blindness occur

A

occlusive arteritis of posterior ciliary branch of the ophthalmic artery

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12
Q

Timing of funduscopic findings in GCA

A

might not appear in first 24-48 hours

**don’t rely heavily on funduscopic exam for dx

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13
Q

GCA

- PE head findings

A
  • scalp tenderness
  • temporal artery can be normal, nodular, enlarged
  • erythema, warmth, swelling
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14
Q

GCA

- PE eye findings

A
  • iritis, fine vitreous opacities
  • optic nerve edema
  • swollen, pale disc with blurred margins
  • pallor
  • hemorrhage
  • scattered cotton-wool spots
  • vessel engorgement/exudates later in dz
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15
Q

GCA

- lab findings

A
  • ESR (90% >50mm/h, typically see >100mm/h)
  • CRP
  • CBC (mild normochromic anemia, thrombocytosis, WBC normal or elevated)
  • Elevated liver function tests, PT
  • NL CPK, renal fn, UA
  • Elevated interleukin-6 during flairs
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16
Q

ESR vs CRP - which is more sensitive for GCA

A

CRP is slightly higher

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17
Q

GCA

- imaging

A
  • doppler US to show vascular occlusion, stenosis, edema
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18
Q

What is GCA gold standard for dx

A

temporal artery biopsy (min length 2 cm d/t incidence of skip lesions)

  • will see giant, multinucleated cells
  • do contralateral biopsy if suspicion is high but first biopsy was negative
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19
Q

GCA

- Treatment

A
  • 1st line: HIGH dose steroids
  • rheumatology and neuro referral
  • consider ASA to avoid clots
  • PPI for GI protection
  • Ca2+, Vit D, bisphosphonate for bone protection
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20
Q

GCA

- major complications (3)

A
  1. irreversible blindness
  2. aortic aneurysms
  3. polymyalgia rheumatica
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21
Q

Polymyalgia Rheumatica

  • describe
  • 3 common sx and pertinent negative
  • pts won’t be able to do what
A
  • pain and stiffness below the neck
  • fever, malaise, weight loss, NO muscular weakness
  • pts will have trouble combing hair, putting on coat, getting out of chair
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22
Q

Polymyalgia Rheumatica

- two common lab findings

A
  • anemia
  • elevated ESR
  • most, not all cases
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23
Q

Polymyalgia Rheumatica

- treatment

A
  • LOW dose steroids
  • no improvement in 72 hours f/u
  • flair ups can occur
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24
Q

What sx should cause you to put GCA in differential

A
  • > 50
  • HA
  • Jaw claudication
  • fever
  • vision changes
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25
Q

what medical hx might find with GCA

A

DM
Cardiac dz
HTN

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26
Q

Thrombus/thrombi def

A

clot (platelets and/or fibrin) that forms and is stationary in vessel

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27
Q

embolus/emboli def

A

piece of thrombus breaks off and travels through bloodstream until it gets stuck
(can be plaque, fat, air, etc.)

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28
Q

Thromboembolism

A

clot formed in blood vessel and breaks loose, carried by blood stream until gets stuck in another vessel

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29
Q

Arterial insufficiency

  • def
  • acute, chronic, or both?
A
  • loss of perfusion
  • distal to occlusion of major artery due to embolus
  • acute AND chronic
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30
Q

Arterial insufficiency

- secondary to what

A
  • emboli
  • thrombosis
  • trauma
  • infection
  • inflammation
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31
Q

Arterial insufficiency

- epidemiology

A
  • > 65
  • male
  • More common in AA
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32
Q

Arterial insufficiency

- leading cause of what in the elderly

A

limb loss

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33
Q

Arterial insufficiency

- risk factors

A
  • Tobacco use (vasoconstriction)
  • endocarditis (clots from affected valves)
  • DM
  • drug abuse
  • cardiac arrhythmia (most likely a fib)
  • atherosclerotic dz
  • trauma
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34
Q

Arterial insufficiency

- how is genetics related

A

can be associated with inheritable hyper coagulable states and premature atherosclerotic syndromes

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35
Q

Arterial insufficiency will cause what in the:

- Heart

A

chest pain

MI

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36
Q

Arterial insufficiency will cause what in the:

- Brain

A

weakness

CVA

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37
Q

Arterial insufficiency will cause what in the:

- LE

A

severe claudication

PAD

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38
Q

Arterial insufficiency will cause what in the:

- Mesenteric arteries

A
  • pain after eating
  • pain out of proportion to exam
  • MAI (mesenteric artery ischemia)
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39
Q

Arterial insufficiency will cause what in the:

- Renal arteries

A

CVA tenderness

RAI (renal angina index OR renal artery ischemia)

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40
Q

Arterial insufficiency

- four classifications

A
  1. Asymptomatic - ex. DM
  2. Claudication - inadequate blood flow during exercise
  3. Critical limb ischemia - compromise of blood flow to extremity, limb pain at rest. Often ulcers or gangrene
  4. Acute limb ischemia - sudden decrease in perfusion that threatens limb viability
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41
Q

What is associated with acute limb ischemia

A

5 P’s

  • pain
  • paralysis
  • paresthesia
  • pulselessness
  • pallor
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42
Q

Arterial insufficiency

- Lab tests

A
  • CK/CKMB/Troponin
  • PT/INR, PTT
  • ABG - look for acidosis
  • CBC, CMP
  • UA
  • Lipids - atherosclerosis
  • ESR/CRP
43
Q

Arterial insufficiency

- Imaging

A
  • CT angiography
  • arteriography
  • EKG
  • ECHO
  • Doppler US
  • ankle/arm index (AAI) *unequal blood pressure
  • ankle/brachial index (ABI) *unequal blood pressure
44
Q

Arterial insufficiency

- treatment

A
  • Heparin (not coumadin, takes too long)
  • Thrombolysis (stent, PTCA, etc.)
  • Angioplasty
  • Stenting
  • Endarterectomy
  • peripheral bypass sx
45
Q

Arterial insufficiency

Major treatment goals

A
  1. don’t let it get worse, “thin” blood

2. if occluded, return blood flow around or through

46
Q

Absolute contraindications for thrombolytic therapy (6)

A
  1. recent major bleeding
  2. recent stroke
  3. recent major surgery or trauma
  4. irreversible ischemia of end organ
  5. Intracranial pathology
  6. Recent ophthalmologic procedure
47
Q

Relative contraindications for thrombolytic therapy (5)

A
  1. Hx of GI bleed or PUD
  2. Coagulopathy
  3. Uncontrolled HTN
  4. Pregnancy
  5. Hemorrhagic retinopathy
48
Q

What sort of onset is Arterial insufficiency

A

Always sudden

49
Q

Peripheral arterial disease

- def

A
  • systemic arterial atherosclerosis with partial/total blockage in the arteries. Exclusive of the coronary and cerebral vessels
  • resting ankle-brachial index (ABI) <0.90
50
Q

Describe peripheral arterial disease

A
  • arterial stenosis secondary to atherosclerotic plaque formation
  • plaque formation causes inadequate blood flow in distal limbs
  • fail to meet metabolic demand during exertion
  • acidic products build up and result in claudication
  • also causes distal pressures
51
Q

Most common arteries affected by PAD

A
  • superficial femoral
  • deep femoral
  • popliteal arteries
    80-90%

(tibial and fibular/peroneal arteries 40-50%)

52
Q

Intermittent claudication

define

A
  • reproducible discomfort within a defined group of muscles that is induced by exercise and relieved by rest
  • Sx resolve 2-5 min after pt rests
  • leg pain worse when raise leg
  • leg pain better with pt lowers leg
53
Q

Peripher arterial disease

- 5 common findings

A
  1. intermittent claudication
  2. erectile dysfunction
  3. leg/foot weakness, numbness, tingling
  4. skin changes - ulcers that won’t heal
  5. gangrene
54
Q

Peripheral artery disease

- Fontaine stages of classification

A

Stage 1: asymptomatic
Stage 2a: intermittent claudication after 200 meters no pain
Stage 2b: intermittent claudication after <200 meters walking
Stage 3: rest pain
Stage 4: Ischemic ulcers/gangrene

55
Q

Peripheral artery disease

- Diagnostic labs

A
  • check for co-morbidities: serum glucose or HgbA1c

- fasting lipid profile

56
Q

Peripheral artery disease

- imaging

A
  • duplex ultrasonography and doppler color-flow imaging
  • contrast angiography
  • CT angiogram
  • MR angiogram
57
Q

what is the best imaging option for Peripheral artery disease

A

contrast angiography

58
Q

Peripheral artery disease

- other tests

A
  • Ankle branchial index <0.90
  • Toe brachial index <0.6
  • segmental limb pressures
  • treadmill exercise tests
  • segmental volume plethysmography :)
59
Q

Peripheral artery disease

- treatment goal

A
  • improve quality of life
  • improve walking capacity
  • decrease morbidity/mortality
60
Q

Peripheral artery disease

- lifestyle changes

A
  • smoking cessation
  • diet
  • exercise
  • control blood sugar
  • control HTN
  • decrease lipids
  • foot care/appropriate shoes
61
Q

Peripheral artery disease

- pharm tx

A
  • Antiplatelet
  • Clopidogrel
  • Ticlopidine
  • prostaglandins
  • statins
62
Q

Peripheral artery disease

- intervention tx

A
  • bypass sx

- PTCA w/wo stent placement

63
Q

Peripheral artery disease graft treatment

4 common complications

A
  • graft occlusion
  • infection
  • massive bleeding
  • limb loss
64
Q

Peripheral artery disease

- PTA (PTCA)

A
  • less invasive
  • lower procedure risk
  • lower cost
  • preserves sx option if needed later
  • improves latency rates with stent vs. angioplasty alone
65
Q

What is appropriate 1st line tx for aortoiliac obstructive dz

A

PTA (aka PTCA)

66
Q

Complications of PTA

A
  • groin hematoma
  • pseudoaneurysm
  • AV fistula formation
  • distal embolization
  • thrombotic occlusion
  • arterial rupture
67
Q

Aortic Aneurysm Disease

- two types

A
  • Fusiform: whole circumference or wall of artery

- saccular: not full circumference, asymmetrical bleb or blister on side of aorta

68
Q

Four types of Aortic Aneurysm Disease

A
  • suprarenal
  • pararenal
  • juxtarenal
  • infrarenal
69
Q

Aortic Aneurysm Disease

- epidemiology

A
  • > 50

- Males 5: females 1

70
Q

Aortic Aneurysm Disease

- risk factors

A
  • older age
  • male
  • family history (1st degree relative)
  • smoking
  • HTN
  • Hyperlipidemia
  • PVD
  • obsesity
  • Marfan
  • Ehlers-Danlos
  • polycystic kidney dz
71
Q

Aortic Aneurysm Disease

- etiology

A
  • Atherosclerosis (80%)
  • inflammatory dz (5%)
    also:
  • trauma
  • connective tissue disorders
  • infection
72
Q

Aortic Aneurysm Disease

- pathophysiology

A
  • vascular inflammatory degenerative dz
  • gradual/sporatic expansion of aneurysm
  • accumulation of mural thrombus
  • localized hypoxia further weakens aneurysm
  • tend to expand over time
73
Q

Aortic Aneurysm Disease

- patient sx

A
  • severe abdominal pain radiating to lower back
  • gnawing, burning
  • CONTINUOUS
74
Q

Aortic Aneurysm Disease

- PE findings

A
  • pulsatile supraumbilical mass
  • vague abdominal tenderness with palpation
    (30-40% detected by PE)
75
Q

Aortic Aneurysm Disease

- what can the aneurysm encroachment cause?

A
  • vertebral body erosion
  • gastic outlet obstruction
  • ureteral obstruction
76
Q

What secondary issue can occur with Aortic Aneurysm Disease

A
  • lower extremity ischemia secondary to embolization of mural thrombus
77
Q

Aortic Aneurysm Disease

- labs

A
  • CBC
  • CMP
  • UA
  • Amylase (pancreatic enzyme)
  • Lipase (pancreatic enzyme)
78
Q

Aortic Aneurysm Disease

- imaging

A
  • US
  • CT angiography
  • MRI/MRA
  • Abd xray
  • aortography
79
Q

what is best imaging option for sizing/preop planning, what is its downside

A

CT angiography

- downside is requires contrast, problem with renal failure

80
Q

Aortic Aneurysm Disease

- pharm tx

A
  • BB
  • Statin
  • ASA
  • smoking cessation, lipid control, diet, exercise
81
Q

Aortic Aneurysm Disease

- surgical tx

A
  • open repair: good or average surgical candidates

- Endovascular Aortic Repair (EVAR): high risk pts d/t co-morbidities

82
Q

Compare EVAR and open repair

A
  • similar survival rates
  • EVAR has less short-term complications
  • EVAR has more long term complications (thrombosis)
83
Q

Aortic Aneurysm Disease

- elective repair threshold size

A
  • 5.5 cm average pt
  • 5 to 5.4 cm younger, low risk pts with long life expectancy
  • 4.5 to 5 cm women or high risk of rupture
84
Q

Aortic Aneurysm Disease

- factors of high risk for rupture

A
  • expansion of > 0.6 cm/year
  • smoking, severe COPD, steroids
  • family hx
  • HTN poorly controlled
  • shape is non-fusiform
85
Q

Aortic Aneurysm Disease

- also have CAD, what should do before aneurysm repair

A

consider coronary revascularization

86
Q

Aortic Aneurysm Disease

- screening

A
  • one time US in men 65-75 who have ever smoked
  • Men >60 with fam hx
  • not for women bc risk so much lower than men
87
Q

Aortic Aneurysm Disease

- Triad indicative of rupture

A
  • hypotension/shock
  • pulsatile mass
  • abd pain
88
Q

Aortic Aneurysm Disease rupture tx

A

immediate vascular surgery consult

  • IV access and resuscitation
  • type and cross for multiple units
  • bedside US
  • endovascular AAA repair
89
Q

Thoracic aneurysm disease

- parts of aorta

A
  • aortic root
  • ascending aorta
  • descending aorta
90
Q

Thoracic aneurysm disease

- hx/PE findings

A
  • most detected incidentally
  • Aortic insufficiency - early diastolic murmur, heart failure
  • cough, dysphagia, hoarseness
91
Q

Thoracic aneurysm disease

- imaging

A
  • CXR
  • CT Angiogram
  • MRA
  • Aortography
  • TTE/TEE
92
Q

Thoracic aneurysm disease

- CXR findings

A
  • loss of aortic knob

- widened mediastinum

93
Q

What is most common imaging for Thoracic aneurysm disease

A

CT Angiogram

- excellent anatomical detail and sizing

94
Q

Thoracic aneurysm disease

- sx treatment

A
  • open repair in proximal TAA

- thoracic endovascular aortic repair (TEVAR) in descending aorta

95
Q

Thoracic aneurysm disease

- non surgical tx

A
  • low-normal BP via BB, ARBS, ACEI

- annual surveillance imaging

96
Q

Aortic dissection

- def

A

begins with a tear in aorta intimal, blood enters media, divides it into two layers

97
Q

Aortic dissection

- pathophysiology

A
  • tear in aortic intima is likely precipitating factor
  • aortic media degenerates
  • dissection can extend distally and proximally (can involve aortic valve and branch vessels)
  • progression - tamponade, ischemia of vessels
  • communications might form between true and false lumen
98
Q

Aortic dissection

- risk factors

A

LOTS

  • HTN
  • tobacco
  • marfan
  • etc etc etc
99
Q

Aortic dissection

- sx

A
  • acute chest pain “ripping, tearing”
  • back or abd pain
  • syncopal episodes
  • distal ischemia
100
Q

Aortic dissection

- signs

A
  • cardiac tamponade
  • hemothorax (L > R bc heart is on left)
  • > 20 mmHg diff in systolic pressure btwn arms
  • neurologic deficits
  • renal insufficiency
101
Q

Aortic dissection

- Diagnostic imaging

A
  • CT scan
  • Aortography
  • MRI
  • TEE
102
Q

Aortic dissection

  • auto admission where?
  • pain control via what?
  • BP and HR tx
A
  • ICU
  • morphine
  • reduce systolic BP to 100-120 or lowest tolerable
  • HR <60

**goal is to reduce aortic shear stress

103
Q

Aortic dissection

- pharm tx

A
  • IV beta blockers (Esmolol is best bc drip and short half life makes titration easier)
  • Cardioselective CCB (Verapamil and diltiazem)
  • direct vasodilators
104
Q

Aortic dissection

- what is definitive tx?

A

surgical repair

Cardiology 2 (13 decks)

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