Cardio Flashcards
1
Q
risk factors aortic dissection
A
FAT CASH
- family hx
- atherosclerosis
- takayasu
- connective tissue disease
- smoking
- HTN
2
Q
aortic dissection pathophys, path and classification
A
pathophys
- risk factors weaken vessel wall
- cystic medial degeneration
- > loss of elastic fibres
- > loss of extracellular matrix
- > increase in GAGs
- laplaces law
- > wall tension proportionate to radius and pressure
- > inversely proportional to wall thickness
- > cycle of wall degeneration and increasing stress
- intimal tear
- > creation of false lumen within laminar plane of media
- extension
- > retrograde or anterograde
- occlusion
- > static with obliteration of branching vessel by haematoma on same side
- > dynamic during diastole when true lumen collapses and intimal flap closes over ostium on opposite side
path
- stanford classification
- > A = involves ascending +/- descending and thoracic
- > B = does not involve ascending (usually distal to left subclavian)
- microscopic
- > cystic medial degeneration
- > haematoma within laminar planes of media
3
Q
aortic dissection investigations
A
ECG
FBC -anaemia with haemorrhage EUCs -ischaemia = elevated BUN LFTs -ischaemia = transaminitis lactate -ischaemia blood type and cross match trops d-dimer -sensitive but non specific
CXR
-widened medistinum
CTA
-intimal flap
TOE
-if CTA unavailable or in ED
4
Q
hx and exam AAA
A
hx:
- ruptured triad
- > back/abdo pain
- > pulsatile mass
- > hypotension
- focused on assessing risk factors
- development
- > hyperlipidaemia
- > connective tissue disease
- > COPD
- > hypertension
- expansion
- > cardiac or renal transplant
- > severe cardiac disease
- > stroke
- > older age
- rupture
- > female sex
- > previous cardiac or renal transplant
- > hypertension
- smoking
- > risk factor for development/expansion/rupture
- family hx
exam
- pulsatile and expansile mass
- peripheral pulses
- > evidence of ischaemia or emboli?
- additional aneurysms
- eccymoses
- > cullens
- > grey turners
- > fox’s (thigh)
- > bryants (scrotum)
- fevers
- > suspicion for infective AAA
5
Q
investigations AAA
A
ABG
-acidosis
FBC -anaemia ->haemorrhage -leukocytosis ->infective/inflammatory AAA EUCs -acidosis -AKI LFTS -shock and end organ damage Coags Trops D-dimer -associated with aneursym diameter ESR -infective/inflammatory AAA
Ultrasound
- high sensitivity and specificity
- thresholds
- > diameter 1.5x normal
- > 3cm
Consider
- MRA/CTA
- > surgical planning
6
Q
AAA/dissection ddx
A
Pain (RAPID MEDS)
- ruptured viscus
- AAA
- pancreatitis
- infarct (MI)
- dissection
- mesenteric ischaemia
- embolism
- diverticulitis
- stones
Mass for AAA
- lymphoma
- lymph nodes
- > lymphadenopathy
- > mets
- abscess
- hernia
7
Q
AAA treatment
A
ruptured
- surgical repair
- > endovascular (lower mortality than open)
- > open
- medical support
- > ABCD
- > blood products
- > ICU
symptomatic
-requires surgery regardless of size
small asymptomatic
- no improvement in mortality with immediate surgery
- surveillance
- > every 6-12 months
- medical management
- > cease smoking
- > cardiovascular risk factor control
large asymptomatic
- surgery indicated
- > greater than 5.5cm in men
- > greater than 5cm in women
8
Q
lipid targets
A
*every reduction reduces events
LDL
- primary prevention = 2mmol/L
- secondary = 1.8 mmol/L
HDL
-1mmol/L
non-HDL
-2.5mmol/L
Total cholesterol
-4mmol/L
Triglycerides
-2mmol/L
9
Q
investigations APO
A
ECG -arrhythmias ABG -hypoxia -acid/base -electrolytes PEFR -ddx cardiac vs pulmonary Ultrasound -B lines
FBC -anaemia -leukocytosis EUC -eGFR -electrolytes CMP -arrhythmia BNP/NT-BNP -elevated in exacerbation CCF -specific and sensitive Troponins -subendocardial ischaemia with LV pressure TSH D-dimer -strong negative predictive value
CXR
- cardiomegaly
- butterfly
- air bronchogram
- effusion
- ddx’s
Echo
- LV size and wall thickness
- LV function
- estimate EF and pulmonary wedge pressure
10
Q
ddx APO
A
Exacerbation of CCF (A Reduction In Cardiac Output) arrhythmias -AF regurgitation -mitral (endocarditis, myxoma, papillary rupture) -aortic (endocarditis, dissection) infarct/ischaemia crisis (hypertensive crisis) overload (renal, drugs, fluids)
Dyspnoea (DICTAATE)
- reconditioning
- infection/inflammatory (pneumonia, bronchiectasis, bronchitis, ILD)
- COPD/asthma
- tumour (effusion)
- anaemia
- ascities
- thyroid dysfunction
- embolism (pulmonary)
11
Q
dukes modified criteria
A
Pathologic:
- pathologic lesions (on histology)
- > vegetation
- > intracardiac abscess
Clinical:
- Definite
- > two major
- > one major + three minor
- > five minor
- Rejected
- > symptoms resolve <4 with antibiotics
- > no histo in surgery or autopsy <4 of antibiotics
12
Q
major clinical dukes criteria
A
- Positive culture
- > typical organisms from 2 seperate blood cultures
- > persistently positive blood culture
1) 2 cultures taken >12 hrs apart for typical or
2) 3/3 or 2-3/4 cultures for skin flora
3) single positive culture for Coxiella or
4) positive Q fever IgG antibody titre - Evidence of endocardial involvement
- > positive echo
1) oscillating intracardiac mass
2) abscess
3) new partial dehiscence of prosthetic valve - > new valvular regurg
13
Q
minor criteria dukes
A
1) predisposition
- typical heart condition
- IVD
2) fever
3) vascular phenomena
- major emboli
- septic pulmonary infarcts
- mycotic aneurysm
- intracranial haemorrhage
- conjunctival petechiae
- Janeway lesions
4) immunologic phenomena
- GNP
- oslers nodes
- roths spots
- rheumatoid factor
5) microbio evidence
- positive culture not meeting major criteria
- serologic evidence of typical organism infection
14
Q
IE ddx
A
PAALMER
- PE (ddx’s: EMPPATHIC)
- Atrial myxoma
- Autoimmune/vasculitis (eg. rheumatoid or scleroderma)
- Libmann saccs
- > malignancy (lung, colon, pancreatic)
- > SLE
- > antiphospholipid
- MI with mural thrombus
- Emboli (cholesterol)
- Rheumatic heart disease
15
Q
CXR findings IE
A
PE signs -hamptoms hump -westermark sign Septic emboli -cavitating nodules CCF -cardiomegaly -batwing/butterfly -airbronchogram -effusion DDx's
