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Yr 4 - ACC > Cardio: Aortic Dissection & Pericarditis > Flashcards

Cardio: Aortic Dissection & Pericarditis Flashcards

1
Q

What is aortic dissection?

A

A break or tear in the intimal (inner) layer of the aortic wall.

This allows blood to flow between the intima and media, creating a false lumen.

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2
Q

What are the 3 layers to the aorta?

A

1) intima
2) media
3) adventitia

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3
Q

Between what layers of the aorta does blood enter in aortic dissection?

A

Between the intima and media layers

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4
Q

Define intramural

A

Intramural refers to within the walls of the blood vessel.

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5
Q

Where is the most commonplace for the initial tear to occur in aortic dissection?

A

Ascending aorta

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6
Q

How will the false lumen formed in aortic dissection affect the true lumen?

A

The true lumen will often become smaller due to compression by the blood flowing into the false lumen.

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7
Q

Aortic dissection can propagate longitudinally along the aorta.

This can be either anterograde (towards the iliac arteries) and/or retrograde (back towards the aortic valve).

What are complications of propagation of the aortic dissection?

A

1) branch occlusion (either static or dynamic)

2) ischaemia of the affected arterial territory: may be referred to as aortic dissection with end-organ malperfusion.3

3) can progress to aortic valve root and cause:
- cardiac tamponade
- acute aortic regurg
- aortic rupture

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8
Q

Risk factors of aortic dissection?

A

1) HTN, male sex & increasing age

2) Connective tisue disorders:
- Marfan syndrome
- Ehlers-Danlos syndrome
- Loeys-Dietz syndrome
- Turner syndrome

3) Atherosclerosis: risk factors for

4) Inflammatory conditions:
- giant cell arteritis
- Takayasu arteritis

5) Iatrogenic e.g. cardiac surgery or catheterisation.

6) Trauma: especially blunt chest trauma

7) Pregnancy

8) Bicuspid aortic valve

9) Abrupt, transient, severe increase in blood pressure: may be related to emotional stress, pain, cocaine/amphetamine use or heavy lifting.

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9
Q

What is the most common risk factor for aortic dissection?

A

Chronic HTN

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10
Q

Which condition is giant cell arteritis often linked to?

A

polymyalgia rheumatica

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11
Q

Why are connective tissue disorders a risk factor for aortic dissection?

A

due to inherent weakness in the wall of the aorta.

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12
Q

Why is atherosclerosis a risk factor for aortic dissection?

A

This condition can lead to weakening of the aortic wall, which makes it susceptible to dissection.

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13
Q

Why can inflammatory conditions (e.g. GCA) be a risk factor for aortic dissection?

A

can result in inflammation of the aorta and make it susceptible to dissection.

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14
Q

Complications of aortic dissection?

A

1) aortic regurgitation: if extends proximally towards heart and affects aortic valve

2) end organ ischaemia: affects branches of aorta

3) rupture of outer layer (adventitia) –> life threatening

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15
Q

What 2 systems can be used to classify aortic dissection?

A

1) Stanford system

2) DeBakey system

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16
Q

Describe Stanford system classification of aortic dissection

A

Type A –> affects the ascending aorta, before the brachiocephalic artery

Type B –> affects the descending aorta, after the left subclavian artery

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17
Q

Describe Type A of the Stanford classification of aortic dissection

A

affects the ascending aorta, before the brachiocephalic artery

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18
Q

Describe Type B of the Stanford classification of aortic dissection

A

affects the descending aorta, after the left subclavian artery

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19
Q

Describe DeBakey system classification of aortic dissection

A

Type I – begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta

Type II – isolated to the ascending aorta

Type IIIa – begins in the descending aorta and involves only the section above the diaphragm

Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm

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20
Q

Dissection can be triggered by events that temporarily cause a dramatic increase in blood pressure.

What can cause this?

A
  • heavy weightlifting
  • emotional stress
  • use of cocaine
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21
Q

What 2 connective tissue disorders notably increase the risk of aortic dissection?

A

1) Marfans syndrome

2) Ehlers-Danlos syndrome

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22
Q

Clinical presentation of aortic dissection?

A

1) Chest pain:
- sudden, severe
- ‘tearing’, ‘ripping’, ‘stabbing’
- maximal at onset and then subside, or vary in intensity over time
- pain may migrate
- not ALL patients have chest pain (‘atypical’)

Other features that may suggest aortic dissection:

  • HTN
  • Differences in blood pressure between the arms (more than a 20mmHg difference is significant)
  • Radial pulse deficit (the radial pulse in one arm is decreased or absent and does not match the apex beat)
  • Diastolic murmur
  • Focal neurological deficit (e.g., limb weakness or paraesthesia)
  • Chest and abdominal pain
  • Collapse (syncope)
  • Hypotension as the dissection progresses
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23
Q

How does pain typically present in ascending vs descending aortic dissections?

A

Ascending: anterior chest pain

Descending: intrascapular back pain

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24
Q

Aortic dissection may present with organ malperfusion due to loss of blood flow in the true lumen.

Give some examples.

A
  • Stroke from carotid artery involvement
  • Myocardial infarction from coronary ostia obstruction
  • Paraplegia from spinal artery compromise
  • Mesenteric ischemia leading to abdominal pain
  • Renal failure from renal artery occlusion
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25
Q

Investigations in aortic dissection?

A

Remember that patients may present acutely and be clinically unstable. The choice of investigations will have to take account of this.

1) CXR: widened mediastinum

2) CT angiography of the chest, abdomen and pelvis is the investigation of choice
- suitable for stable patients and for planning surgery
- a false lumen is a key finding in diagnosing aortic dissection

3) Transoesophageal echocardiography (TOE)

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26
Q

What may a CXR show in aortic dissection?

A

Widened mediastinum

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27
Q

What is a key finding in CT angiography of the chest, abdomen and pelvis in aortic dissection?

A

False lumen

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28
Q

What is the investigatino of choice in aortic dissection?

A

CT angiography of the chest, abdomen and pelvis

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29
Q

What investigation is more suitable in aortic dissection in unstable patients who are too risky to take to CT scanner?

A

Transoesophageal echocardiography (TOE)

30
Q

General management of aortic dissection?

A

1) Surgical emergency (high mortality)

2) Analgesia

3) Beta blockers: control BP & HR to reduce the stress on the aortic walls

31
Q

What does surgical intervention in aortic dissection depend on?

A

The type of aortic dissection

32
Q

Surgical management of Type A aortic dissection?

A

Open surgery (midline sternotomy) to remove the section of the aorta with the defect in the wall and replace it with a synthetic graft. The aortic valve may need to be replaced during the procedure.

33
Q

Management of Type B aortic dissection?

A

1) conservative management
2) bed rest
3) reduce blood pressure IV labetalol to prevent progression
4) may require thoracic endovascular aortic repair (TEVAR): inserting a stent graft into the affected section of the descending aort

34
Q

Complications of forward vs backward tear in aortic dissection?

A

Backward:
- aortic incompetence/regurgitation
- MI: inferior pattern often seen due to right coronary involvement

Forward:
- unequal arm pulses and BP
- stroke
- renal failure

35
Q

What type of MI does aortic dissection typically cause?

A

Inferior - due to RCA involvement

36
Q

What is acute pericarditis?

A

A condition referring to inflammation of the pericardial sac (the membrane surrounding the heart).

37
Q

How long does acute pericarditis last?

A

Less than 4-6 weeks

38
Q

What are the 2 main causes of pericarditis?

A

1) idiopathic (unknown)

2) 2ary to viral infection

39
Q

What are the classical features of pericarditis?

A

1) pleuritic, retrosternal chest pain

2) pericardial friction rub

3) widespread ST elevations on ECG

40
Q

Who is pericarditis more common in?

A

Pericarditis is more prevalent in men, predominantly in young adults.

41
Q

The pericardium is composed of two parts.

What are they?

A

1) outer fibrous pericardium: surrounds the heart with tough connective tissue but remains unattached to the heart itself

2) inner serous pericardium

42
Q

What does the serous pericardium consist of?

A

1) outer parietal layer: sticks to the inner surface of the fibrous pericardium

2) inner visceral layer: attaches to the heart and forms the heart’s outer epicardium layer.

43
Q

What is the pericardial cavity?

A

A small space between the parietal and visceral layers of the serous pericardium.

44
Q

What is the purpose of the pericardial cavity?

A

A small volume of fluid is here: separates the heart from its surroundings, reducing friction and enabling a degree of freedom in heart movement and changes in shape.

45
Q

What infections can cause pericarditis?

A

1) Viruses: HIV, coxsackievirus, Epstein–Barr virus

2) Bacteria: staphylococcus, TB

3) Fungi: histoplasmosis

46
Q

Give some potential causes of pericarditis

A

1) idiopathic

2) infections: viral, bacterial, fungal

3) injury to the pericardium (e.g., after myocardial infarction, open heart surgery or trauma)

4) uraemia (2ary to renal impairment)

5) cancer: lung, breast

6) medications e.g. methotrexate

7) connective tissue disease:
- SLE
- RA

8) hypothyroidism

47
Q

What are 2 types of pericarditis that can occur post-MI?

A

1) early (1-3 days): fibrinous pericarditis

2) late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)

48
Q

What is pericardial effusion?

A

When the potential space of the pericardial cavity fills with fluid.

This creates an inward pressure on the heart, making it more difficult to expand during diastole (filling of the heart).

49
Q

What is pericardial tamponade (or cardiac tamponade) ?

A

Where the pericardial effusion is large enough to raise the intra-pericardial pressure.

This increased pressure squeezes the heart and affects its ability to function. It reduces heart filling during diastole, decreasing cardiac output during systole.

This is an emergency and requires prompt drainage of the pericardial effusion to relieve the pressure.

50
Q

What are the 2 key presenting symptoms in pericarditis?

A

1) chest pain

2) low grade fever

51
Q

Risk factors for pericarditis?

A

1) age: average is 41-60 years

2) male sex

3) idiopathic pericarditis has been found to occur most often in the spring and fall

4) steroids: recurrent pericarditis occurs more often in patients being treated with steroids

5) diabetes

6) extensive burn injuries

7) systemic infections

8) immunosuppression

9) chest trauma

10) heart surgery

11) pre-existing pericardial effusion

52
Q

Describe chest pain in pericarditis

A
  • fairly sudden onset
  • retrosternal, central
  • sharp & pleuritic
  • improved by sitting up and lneaning forward
  • worse on lying down
  • radiation to trapezius ridge
53
Q

What is a key examination finding in pericarditis?

A

Pericardial friction rub on auscultation

54
Q

What is a pericardial rub?

A

A rubbing, scratching sound that occurs alongside the heart sounds.

55
Q

What does a pericardial friction rub sound like?

A

Superficial, scratchy or squeaky quality on auscultation

56
Q

What side of the stethoscope is a pericardial rub best heard with?

A

Diaphragm

57
Q

Where is a pericardial rub best heard?

A

left lower sternal border

58
Q

How can a pericardial rub be differentiated from pleural rub?

A

by asking patient to hold their breath

59
Q

Investigations in pericarditis?

A

1) Bloods: raised inflammatory markers

2) ECG changes:
- Saddle-shaped ST-elevation
- PR depression

3) Serum troponins: elevation suggests myocardial involvement and indicates a poorer prognosis

4) U&Es: if uraemia is cause

60
Q

What can be used to diagnose pericardial effusion?

A

Echocardiogram

61
Q

Key differentials for pericarditis?

A

1) myocarditis

2) ACS

3) PE

62
Q

What is the mainstay of treatment of pericarditis?

A

1) NSAIDs e.g. aspirin, ibuprofen

2) Colchicine (taken longer-term, e.g., 3 months, to reduce the risk of recurrence)

63
Q

What can be used as 2nd line medical mangement of pericarditis?

A

Steroids e.g. in recurrent cases or associated with inflammatory conditions (e.g., rheumatoid arthritis)

64
Q

What may be required to remove fluid from around the heart if there is a significant pericardial effusion or tamponade?

A

Pericardiocentesis

65
Q

How long do most cases of pericarditis last?

A

Most cases resolve within a month.

It can be recurrent, returning after previously having resolved. Some cases may persist long-term, called chronic pericarditis.

66
Q

Complications of pericarditis?

A

1) recurrent pericarditis (15-30%)

2) acute cardiac tamponade

3) chronic constrictive pericarditis

67
Q

Purpose of giving colchicine in pericarditis?

A

reduces risk of recurrence

68
Q

Who is acute cardiac tamponade as a complication of pericarditis more common in?

A

underlying malignancy, TB or purulent pericarditis

69
Q

The prognosis of patients with acute pericarditis is generally good.

What are the major predictive factors of poor prognosis?

A

1) fever >38

2) subacute onset (over days)

3) large pericardial effusion: diastolic echo-free space >20 mm

4) lack of response to NSAIDs after at least 1 week of therapy

70
Q
A

Yr 4 - ACC (73 decks)

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