Cardiology #12 (GCA, Thrombophlebitis, DVT, Varicose Veins, Venous Insufficiency) Flashcards
What are some risk factors for giant cell (temporal) arteritis?
-Women > 50 years old
-Northeastern Europeans
Symptoms of GCA
-Headache
-Jaw claudication with mastication
-Visual changes (monocular vision loss, amaurosis fugax, CRAO, anterior ischemic optic neuritis is MC)
-Scalp tenderness
-Temporal artery may be tender, pulseless, or normal.
-Fever, fatigue, weight loss, night sweats, malaise.
Although GCA is primarily a clinical diagnosis, what labs can be drawn for further evidence?
Increase ESR and CRP. Normocytic normochromic anemia.
What is the definitive diagnostic for GCA?
Temporal biopsy
What treatment should be started for GCA once suspected. Do not delay treatment to biopsy or while waiting for biopsy results.
High-dose corticosteroids
What is the MC complication of GCA
Blindness
What are other options for treatment for GCA if the patient cannot take steroids?
Methotrexate
Azathioprine
Low dose Aspirin
What is superficial thrombophlebitis?
Inflammation and/or thrombosis of a superficial vein
Etiologies of superficial thrombophlebitis
-Associated with IV catheterization, pregnancy, varicose veins, venous stasis
What is Trousseau Sign?
Migratory thrombophlebitis associated with malignancy (pancreatic cancer, etc.)
Symptoms of superficial thrombophlebitis
Pain, tenderness, induration, edema, and erythema along the course of the vein.
May feel a palpable cord
Although superficial thrombophlebitis is a clinical diagnosis, what can be done for further evaluation?
Venous Duplex US: noncompressible vein with clot and wall thickening
MCC of superficial thrombophlebitis
Factor V Leiden
Treatment for superficial thrombophlebitis
-Supportive is mainstay: NSAIDs, elevation, warm compresses
-Vein ligation/excision (phlebectomy)
-If septic (febrile), give IV ABX
Most DVT’s originate in
the calf
What are the risk factors (Virchow’s Triad) for a DVT?
-Venous stasis (immobilization or prolonged sitting)
-Hypercoagulability (Protein C or S deficiency, Factor V Leiden mutation, OCP, malignancy, pregnancy, smoking)
-Intimal Damage (trauma, infection, inflammation)
Symptoms of a DVT
-Unilateral swelling and edema of the lower extremity > 3 cm (MOST SPECIFIC SIGN)
-Calf pain and tenderness
-Warm to palpation
-Homan sign: deep calf pain with foot dorsiflexion while squeezing the calf (not reliable)
First-line imaging for a DVT
Venous Duplex US
Explain a D-dimer and specificity for a DVT
-highly sensitive but not specific.
Negative D-dimer with low-risk for DVT can exclude DVT as diagnosis.
Positive D-dimer should be followed by ultrasound
What is the gold standard diagnostic for DVT
Contrast venography
-However, it is invasive, difficult to perform, and rarely used.
First-line treatment for patients with a DVT
Anticoagulation: LMWH + Warfarin, LMWH + either Dabigatran or Edoxaban, or mono therapy with Rivaroxaban or Apixaban
When should an IVC filter be placed in a patient with DVT? 3 reasons
1) recurrent DVT/PE despite adequate anticoagulation
2) Stable patients in whom anticoagulation is contraindicated
3) Right ventricular dysfunction with an enlarged RV on echocardiogram
When should an IVC filter be placed in a patient with DVT? 3 reasons
1) recurrent DVT/PE despite adequate anticoagulation
2) Stable patients in whom anticoagulation is contraindicated
3) Right ventricular dysfunction with an enlarged RV on echocardiogramWhen is
When is thrombolectomy or thrombolysis considered in a patient with a DVT?
Massive DVT or severe cases
If the patient has a DVT, is is their first DVT and they have a modifiable risk factor, what is the time frame in which they should stay on treatment?
at least 3 months
-Modifiable risk factor: OCP, surgery, trauma, etc
If the patient is pregnant and gets a DVT, what is the preferred treatment?
LMWH
If the patient has malignancy, what is the medical therapy for DVT?
LMWH
Warfarin or direct oral anticoagulants are alternatives but LMWH is the preferred method
According to the 2016 ACCP guidelines, what is preferred over Warfarin therapy as the management of DVT/PE if the patient does not have cancer?
Novel oral anticoagulants (Apixaban, Dabigatran, Edoxaban, Rivaroxaban)
What is the mechanism of action of LMWH?
Potentiates antithrombin III (works more on factor Xa than thrombin (Factor IIa)
What is the antidote to LMWH?
Protamine Sulfate
What is one major contraindication to use of LMWH?
Renal failure because LMWH is excreted by the kidneys
Regarding the Well’s Criteria for DVT, what score is associated with low probability of DVT? Moderate probability? High probability?
Low: -2 to 0
Moderate: 1-2
High: 3-8
Explain what some of the points are that are given for Well’s Criteria for a DVT
Active cancer or treatment within last 6 months : 1 point
Paralysis or immobilization of lower extremity: 1 point
Bedridden for more than 3 days due to surgery (within 4 weeks) : 1 point
Localized tenderness along deep veins: 1 point
Swelling of entire leg: 1 point
Unilateral calf swelling of greater than 3 cm: 1 point
Collateral superficial veins: 1 point
Unilateral pitting edema: 1 point
Another diagnosis more likely than DVT: -2 points
Explain the pathophysiology of varicose veins
Dilation of superficial veins due to failure of the venous valves in the saphenous veins, leading to retrograde flow, venous stasis, and pooling of blood
Risk factors for varicose veins
Family history
Female gender
Increased age
Standing for long periods
Obesity
Increased estrogen (OCP use, pregnancy)
Chronic venous insufficiency
Symptoms of varicose veins
Most are asymptomatic but may present due to cosmetic issues
-Dull ache or pressure sensation
-Pain is worse with prolonged standing or sitting with the leg flexed. Relieved with elevation.
-Dilated visible veins
-Telangiectasias
-Swelling, discoloration
-Mild ankle edema
Treatment for varicose veins
Conservative: compression stockings, leg elevation, pain control
-Ablation: laser or radiofrequency
-Ligation and stripping
-Sclerotherapy
When does chronic venous insufficiency occur and what is it?
Changes due to venous hypertension of the lower extremities as a result of venous vavular incompetency
Occurs after superficial thrombophlebitis, DVT, or trauma to the leg
Explain the pain associated with chronic venous insufficiency
-Worse with prolonged standing or sitting with the feet dependent
-Better with ambulation and leg elevation
-Burning, aching, throbbing, cramping, or “heavy leg”
What does the skin look like on the associated leg with chronic venous insufficiency?
-Stasis Dermatitis: itchy eczematous rash, excoriations, brownish or dark purple hyperpigmentation of the skin
-Venous stasis ulcers: at medial malleolus
-Dependent pitting leg edema
-Increased leg circumference
-Normal pulse and temperature
-Atrophie blanche: hypo pigmented areas with punctuate red dots
Where are ulcers associated in chronic venous insufficiency?
Most times at the medial malleolus
Treatment for chronic venous insufficiency
-Conservative: initial management. Leg elevation, compression stockings, exercise and weight management
-Surgical intervention only for non-response to conservative therapy
-Ulcer management: Zinc impregnated gauze, wound debridement, Aspirin
Why give aspirin for an ulcer associated with chronic venous insufficiency?
It accelerates the healing process of the ulcer
