Atrial & Venous Disease

Question 1

normal BP response on standing

Answer 1

upon standing, 500-1000mL of blood pools in legs/abdomen –> 5-10mmHg fall in SBP –> compensatory reflex by baroreceptors and medulla oblongata –> pulse increases 10-25bpm

Question 2

orthostatic hypotension

Answer 2

significant reduction in BP upon standing

Question 3

etiology of orthostatic hypotension

Answer 3

-neurogenic
-non-neurogenic
-40% idiopathic

Question 4

neurogenic etiology of orthostatic hypotension

Answer 4

baroreflex dysfxn d/t Parkinson’s, Lewy Body Dementia, DM, Age

Question 5

non-neurogenic etiology of orthostatic hypotension

Answer 5

-volume depletion (diuretics, hyperglycemia, V/D, hemorrhage)
-adverse medication effects (Beta blockers, TCAs)

Question 6

meds that can induce orthostatic hypotension,

Answer 6

antihypertensives (incl diuretics)
vasodilators (nitrates)
alpha-blocking agents (terazosin, doxazosin, prazosin)
AD (TCAs, SSRIs, MAOIs)
Atypical AP
PD drugs (Levodopa)
PDE-5 inhibitors

Question 7

orthostatic hypotension epidemiology

Answer 7

25% of pts >65yo

Question 8

Sx of orthostatic hypotension

Answer 8

*occur upon standing or w/ prolonged standing; also w/ exertion or after meals (blood drawn to GI)

-weakness
-dizzy/lightheadedness
-blurry/darkened vision
-posterior neck pain/HA (“coat-hanger HA”)
-syncope

Question 9

Signs (PE) of orthostatic hypotension

Answer 9

5 minutes supine, take BP; stand 2-5 minutes then repeat BP
*reduction of 20mmHg+ SBP or 10mmHg+ DBP

Question 10

dx tests for orthostatic hypotension

Answer 10

-EKG
-HCT, electrolytes, BUN, Cr, glucose
-Plasma norepinephrine level can guide med selection

Question 11

Tx of orthostatic hypotension

Answer 11

-d/c exacerbating meds (if able to)
-non-pharm: increase salt & water intake (risky if pt has HTN), modify daily activities, diet, body positioning, compression stocking & abdominal binder
-if not improved or partially improved start med

Question 12

POTS

Answer 12

*postural orthostatic tachycardia syndrome
-MC in younger to middle age females
-tachycardia, lightheaded/dizzy, and palpitations on standing; chronic fatigue, anxiety

Question 13

vasovagal hypotension

Answer 13

acute, transient hypotension d/t particular triggers (emotional distress, pain, heat)
-increase in sympNS which is overcompensated by increased parasympNS –> syncope

Question 14

what is the MC cause of syncope across all ages

Answer 14

vasovagal hypotension

Question 14

vasovagal hypotension sx

Answer 14

prodrome:
-dizziness
-epigastric pain or nausea
-palpitations
-blurry or dark vision

post-syncope fatigue is common

Question 14

PE for vasovagal hypotension
*if syncopal episode occurred do full syncope workup

Answer 14

-orthostatic vital signs
-check for neurological deficits

CV exam:
-delayed carotid upstroke (AV stenosis)
-abnormal PMI or S3 (cardiomyopathy)
-irregular or bradycardic rhythm
-midsystolic murmur (aortic stenosis, HCM)
-Holosystolic murmur (mitral regurgitation)

Question 14

diagnostic tests for vasovagal hypotension

Answer 14

EKG - usually normal if vasovagal is the cause (BBB, Q waves, LVH, long QT, delta waves suggest something much worse)

Other tests:
-if suspicious of cardiac causes order echo, coronary angiography, stress EKG, holter monitor
-if suspicious of neurologic causes order brain CT or MRI, carotid doppler, EEG

Question 14

Tx of vasovagal hypotension

Answer 14

*no tx consistently prevents vasovagal syncope
-d/c or minimize meds that may induce volume depletion
-avoid triggers
-drink lots of fluids (1.5-3L daily)
-6-10g Na daily
-compression garments (stocking, abd binder)
-counterpressure maneuvers (leg crossing w/ tensing of leg, abd, and butt; handgrip; arm tensing)

Question 15

orthostatic hypotension v. vasovagal hypotension

Answer 15

Orthostatic hypotension:
-elderly
-chronic
-BP regularly decreases upon standing

Vasovagal hypotension:
-younger, healthy
-likely to improve spontaneously
-stress, pain, heat cause hypotension

Question 16

Printzmetal’s Angina (vasospastic angina)

Answer 16

-spasm of smooth m. layer of a coronary a., resulting in high-grade obstruction, potentially cardiac arrest

Question 17

Does Printzmetal’s angina always occur at site of atherosclerotic plaque?

Answer 17

No, commonly it does but it can also occur in (angiographically) normal coronaries

Question 18

does Printzmetal’s angina occur with or without exertion?

Answer 18

it can occur w/ or w/o an increase in myocardial oxygen demand

Question 19

Unstable angina vs. Printzmetal’s angina

Answer 19

Unstable angina typically lasts longer and can result in cardiac damage

-both can occur with or without exertion

Question 20

Printzmetal’s angina RF

Answer 20

CIGARETTE SMOKING
genetics
insulin resistance (diabetes)
recreational drug use (cocaine)

Question 21

Sx of Printzmetal’s angina

Answer 21

-identical to “typical” angina (chest pressure) but context of pain is different
-occurs predominantly AT REST (midnight-early AM is MC)
-episodes last 5-15mins (STEMI angina is >15min)

Sx:
tachycardia, HTN, diaphoresis
**bradycardia & hypotension may be present if sinus nodal, AV nodal, and R ventricle arteries (r coronary) are involved

Question 22

Printzmetal’s angina: PE & Dx

Answer 22

-no specific PE or dx tests (troponin should be normal bc Printzmetal doesn’t typ last long enough to cause cell death)
-EKG is usu normal btwn episodes (if during an acute episode, maybe transient ST elevation or depression in multiple leads)
-If EKG is normal do exercise stress test
-If stress test is normal, do coronary angiography

Question 23

Printzmetal angina: Tx

Answer 23

-sublingual NTG prn
-smoking cessation
-CCB to promote vasodilation (Diltiazem or amlodipine)

Question 24

Drugs to avoid in a pt w/ Printzmetal angina

Answer 24

-nonselective B-blockers (propanolol)(exacerbates vasospasm if it blocks B2 receptors)
-high doses of prostacyclin inhibitors (ASA - blocks COX-2, prostaglandin, and prostacyclin)(prostacyclin induces vasodilation so we don’t want to block that!)
-Triptans (cause vasoconstriction, used in tx of migraines)
-5-FU (fluorouracil)(chemo)

Question 25

Varicose veins

Answer 25

-visibly dilated, tortuous LE veins that permit reverse flow of blood

Question 26

Venous HTN caused by one of 3 things:

Answer 26

1. valvular incompetence - collagen failure
2. obstruction - thromboses, anatomy
3. calf-muscle pump failure - anything that promotes immobility (age, stroke, neuromuscular conditions, arthritis, trauma)

Question 27

Varicose Veins: RF

Answer 27

FH
female
increased age
pregnancy (current or multiple) - typ temporary
standing for long periods
obesity
hx of DVT

Question 28

varicose veins sx

Answer 28

may be asymptomatic or cause aching, swelling or “heaviness”

Question 29

signs of varicose veins

Answer 29

-spider veins (flat)(early signs)
-bulging, blue veins of LE
-more severe dz, pt may have skin color changes d/t degraded Hgb (degraded from fluid/pressure build up), may even have weeping &/or ulcers

Question 30

Varicose veins: Dx

Answer 30

usu clinical
can use US to guide tx

Question 31

Varicose vein Tx

Answer 31

initial tx is conservation (elevation, exercise, and compression therapy)
-if sx persist, then may be candidate for superficial venous ablation

Question 32

phlebitis

Answer 32

inflammation of a vein

Question 33

thrombophlebitis

Answer 33

inflammation of a vein d/t a thrombus (clot)

Question 34

RF of thrombophlebitis

Answer 34

-varicose veins
-abnormal coagulation
-malignancy
-infection
-venous stasis (bad valves -> pooling, sim to varicose v.)
-IV therapy
-IV drug abuse

Question 35

Presentation of thrombophlebitis

Answer 35

-tenderness, induration (firmness), and erythema along the known course of a superficial v.
-involved v. could be an inch below the surface of normal-appearing skin (esp in obese pts)

Question 36

phlebitis vs. cellulitis vs. “red streaking” (don’t need to know)

Answer 36

Phlebitis: inflammation along v., not necessarily an infection

Cellulitis: spreads like a blanket, is an infection tx w/ Abx, lots of swelling

“Red streaking”: lymphangitis, determined through pt hx (typ of a dirty, invasive wound), typ true infection so would likely have a fever & high WBC

Question 37

Thrombophlebitis: Dx tests

Answer 37

Perform US if:
-you suspect a thrombosis (clot) of the great saphenous or small saphenous veins (because it can embolize and travel into femoral v. and up to the lungs -> PE)
-there is LE swelling that’s greater than would be expected from thrombophlebitis alone
-evidence of clinical progression during a period f/u

*remember femoral v. dumps into great saphenous v., travels medially down leg behind the knee to become the popliteal vein and then branches into small saphenous v. that travels posteriorly down the calf)

Question 38

Thrombophlebitis: Tx

Answer 38

-symptomatic care: elevate LE, warm or cool compress (whichever feels better), compression stockings, pain management (NSAIDs)
-repeat PE w/in 7-10 days
-AC based on pt risk

Question 39

if the pt has a clot in the great saphenous vein near the femoral vein (upper third of thigh) should you start the pt on AC?

Answer 39

yes, to reduce risk of PE

Question 40

Thrombophlebitis: VTE risk flowchart

Answer 40

Superficial VTE –> r/o DVT/PE –> distance from saphenofemoral junction & thrombosis RFs & length of clot will determine tx (therapeutic AC x6wks vs. prophylactic AC x2-6wks vs. no tx)