Cardio 3 - valvular and vascular diseases

Question 1

MCC mitral stenosis

Answer 1

rheumatic heart disease

Question 2

mitral stenosis results in

Answer 2

elevated left atrial pressure and pulmonary venous pressure

longstanding –> Afib due to increased left atrial pressure/size

Question 3

murmur for mitral stenosis

Answer 3

opening snap
low-pitched diastolic rumble
loud S1

Question 4

tx mitral stenosis

Answer 4

medical - diuretics, BB (to decrease HR), anticoagulation if Afib

surgery - percutaneous balloon valvuloplasty and open mitral valve surgery

Question 5

aortic stenosis results in

Answer 5

LV outflow obstruction –> LVH

longstanding/severe –> pulls apart mitral valve –> mitral regurgitation

Question 6

Murmur of aortic stenosis

Answer 6

harsh crescendo-decrescendo systolic murmur
2nd ICS on the RIGHT
radiates to carotid arteries
soft S2
parvus et tarsus - diminished and delayed carotid upstrokes

Question 7

tx aortic stenosis

Answer 7

aortic valve replacement

Question 8

aortic regurgitation is also called

Answer 8

aortic insufficiency

Question 9

murmur for aortic regurgitation

Answer 9

diastolic decrescendo murmur at LEFT sternal border
widened pulse pressure – markedly increased SBP and decreased DBP

corrigan pulse/water-hammer pulse

Question 10

tx aortic regurgitation

Answer 10

if sx - salt restriction, diuretics, ACEI or ARBs for after load reduction

surgery - aortic valve replacement

Question 11

murmur of mitral regurgitation

Answer 11

holosystolic murmur at the apex
Afib is a common finding

Question 12

tx mitral regurgitation

Answer 12

after load reduction
anticoagulation if Afib

mitral valave repair or replacement

Question 13

what is the MCC mitral regurgitation

Answer 13

MVP

Question 14

murmur for mitral valve prolapse

Answer 14

mid to late systolic click
mid to late systolic murmur

Question 15

tx MVP

Answer 15

asx = reassurance
sx = BB

Question 16

sx aortic dissection

Answer 16

severe, tearing, stabbing pain
typically abrupt
anterior or back of the chest
(back pain for type 2)
(chest pain for type 1)

Question 17

PE for aortic dissection

Answer 17

pulse or BP asymmetry > 20 btwn arms
HTN more common with descending
Hypotension MC with ascending
aortic regurgitation

Question 18

dx aortic dissection

Answer 18

CXR - widened mediastinum > 8 mm on AP view
CTA or MRA (MRA takes longer) - performed if stable
TEE - can be performed at bedside; noninvasive - performed if unstable
aortic angiography was once the gold standard and has largely been replaced by CTA

Question 19

tx aortic dissection

Answer 19

surgery - usually for type A
medical - usually for type B; IV beta blockers - can add sodium nitroprosside or nicardipine to reach target BP

Question 20

target BP for aortic dissection

Answer 20

SBP < 120 and HR < 60 within 20 minutes

Question 21

debakey vs Stanford classifications for aortic dissection

Answer 21

debakey:
type 1 - originates in ascending aorta, propagates at least to he aortic arch and often beyond it distally
type II - originates in and is confined to the ascending aorta
type III - originates in descending aorta, rarely extends proximally but will end distally

stanford:
A - involves ascending aorta and/or aortic arch and possibly descending aorta
B - involves the descending aorta (distal to the left subclavian artery origin), without involvement of the ascending aorta or aortic arch

Question 22

sx AAA

Answer 22

usually asx and discovered on exam
sense of “fullness”
may have hypogastric pain and LBP – usually throbbing
pulsatile mass on exam

Question 23

sx suggesting expansion and impending rupture of AAA

Answer 23

sudden onset of severe pain in back/lower abdomen - radiates to groin, butt, legs
grey turner sign (back/flanks) and Cullen sign (umbilicus)

Question 24

triad for rupture of AAA

Answer 24

abdominal pain
hypotension
palpable pulsatile abdominal mass

Question 25

Dx AAA

Answer 25

US
CT scan - test of choice for preop planning

Question 26

tx AAA

Answer 26

unruptured - if 5.5 cm or more or sx, growth in 6 mos > 0.5 cm or 12 mos > 1 cm – surgical resection with synthetic graft placement

ruptured - emergency surgical repair; open repair is the gold standard but can do endo-vascular repair

Question 27

Monitoring progressing of AAA with US

per U2D

Answer 27

one time screening for men 65-75 who have ever smoked

For initial ultrasound screening aortic diameter >2.5 cm but < 3.0 cm, rescreening after 10 years
●For AAA 3.0 to 3.9 cm, imaging at 3-year intervals
●For AAA 4.0 to 4.9 cm, imaging at 12-month intervals
●For AAA 5.0 to 5.4 cm, imaging at 6-month intervals

Question 28

what is the MC affected artery in acute arterial occlusion

Answer 28

common femoral artery

Question 29

MCC of acute arterial occlusion

Answer 29

embolus from Afib

Question 30

sx of acute arterial occlusion

Answer 30

Pain - acute onset
pallor
polar (cold)/poikilothermia
paralysis
paresthesias
pulselessness (use doppler to assess pulse)

Question 31

dx acute arterial occlusion

Answer 31

bedside arterial doppler
duplex US often the first imaging choice
CT angiography

EKG to see if Afib etc

Question 32

tx acute arterial occlusion

Answer 32

supportive - fluids and pain control
urgent anticoagulation with UFH
revascularization - thrombectomy with a balloon catheter (Fogarty), bypass surgery, endarterectomy, patch angioplasty, intra-operative thrombolysis are all options

catheter-directed thrombolysis - used for patients with a salvageable limb

open revascularization - for immediately threatened or nonviable limb

amputation - profound paralysis and absent pain with inaudible arterial and venous pulses

Question 33

what is the major cause of DVT

Answer 33

virchow’s triad:
endothelial damage
hyper coagulability
venous stasis

Question 34

what hereditary hyper coagulable states could cause DVT

Answer 34

factor V leiden
proteins C and S deficiency
antithrombin III deficiency

Question 35

sx DVT

Answer 35

lower extremity pain and swelling
humans sign (calf pain rom ankle dorsiflexion)
palpable cord
fever

Question 36

dx DVT

Answer 36

doppler analysis and duplex US
D dimer
contrast venography

Question 37

tx DVT

Answer 37

anticoagulation choices:
LMWH + warfarin
LMWH + dabigatran or edoxaban
mono therapy with rivaroxaban or apixaban - minimum of three months for all options
LMWH preferred for pregnancy and malignancy

IVC filter - if recurrent or anticoagulation is contraindication and RV dysfunction

thrombosis or thrombectomy generally reserved for massive or severe

Question 38

MC veins affected in DVT

Answer 38

superficial femoral *** MC
popliteal
peroneal
posterior tibial

Question 39

what criteria can be used for DVT

Answer 39

well’s criteria and PERC (rules out PE)

Question 40

well’s criteria for DVT

Answer 40

active cancer (including treatment within 6 mos or palliation (1)

paralysis, paresis, immobilization of LE (1)

bedridden or more than 3 days bc of surgery within 4 weeks (1)

localized tenderness along distribution of deep veins (1)

swelling of entire leg (1)

unilateral calf swelling of greater than 3 cm below the tibial tuberosity (1)

unilateral pitting edema (1)

collateral superficial veins (1)

alternative dx as likely or more likely than DVT (-2)

Question 41

Interpretation of well’s criteria

Answer 41

low probability -2 to 0
moderate probability 1-2
high probability 3 or more

Question 42

PERC rule out criteria

Answer 42

age < 50
HR < 100
O2 sat on room air > 95%
no hemoptysis
no estrogen use
no prior DVT or PE
no unilateral leg swelling
no surgery.trauma requiring hospitalization within the last 4 weeks

if they answer NO to any of these, PE cannot be ruled out

Question 43

risks for superficial thrombophlebitis

Answer 43

varicose veins
malignancy
IV catheter use

Question 44

what is trousseau sign for superficial thrombophlebitis

Answer 44

migratory thrombophlebitis associated with underlying malignancy

Question 45

sx superficial thrombophlebitis

Answer 45

tenderness, pain, induration, erythema along the course of a superficial vein
palpable cord due to thrombus

Question 46

dx superficial thrombophlebitis

Answer 46

venous duplex US - vein well thickening and perivenous or subcutaneous edema; non compressibility of the vein if thrombosis is present

Question 47

tx superficial thrombophlebitis

Answer 47

generally just NSAIDs, extremity elevation, warm/cool compress, compression stockings if no PAD

if risk for DVT - anticoagulation