Cardiology #6: PAD, Occlusion, GCA, Thromboses, Etc.

Question 1

Peripheral arterial disease, which is atherosclerosis of the arteries of the lower extremity, has symptoms such as

Answer 1

-Intermittent claudication (with ambulation)
-Pain better with rest
-Decreased or absent pulses
-Decreased capillary refill
-Atrophic skin changes: cool limbs, thick skin, hair loss, thick nails, lateral malleolus ulcers
-Pale on elevation, dependent rubor

Question 2

Where are the ulcers located in peripheral ARTERIAL disease?

Answer 2

Lateral malleolus

Question 3

Diagnostics for PAD
-What is initially used
-What is the GOLD standard

Answer 3

-ABI < 0.90 is positive for PAD

-Definitive: Arteriography

Question 4

Treatment for PAD

Answer 4

-Supportive: exercise, smoking cessation**
-Cilostazol: most effective pharm therapy
-Revascularization: percutaneous transluminal angioplasty is definitive

Question 5

PAD can progress to an acute arterial occlusion, which is acute limb ischemia, and is considered a vascular emergency. This occurs MC due to a thrombus at one of two arteries…name them.

Answer 5

Femoral or popliteal

Question 6

Symptoms of acute arterial occlusion (6 P’s)

Answer 6

-Paresthesias, pain, pallor, pulselessness, poikolothermia, paralysis
-Decreased capillary refill, decreased pulses, cool temperature to touch

Question 7

Diagnostics for acute arterial occlusion

Answer 7

-Bedside arterial Doppler
-CT angiography

Question 8

Management for acute arterial occlusion

Answer 8

-Reperfusion (mainstay): bypass, thromboembolectomy

Question 9

Giant Cell (Temporal) Arteritis is vessel inflammation of the medium/large arteries of extracranial branches of the carotid artery (temporal). This is associated with what other condition?

Symptoms of this condition?

Answer 9

Associated with polymyalgia rheumatica

Symptoms:
-Headache
-Jaw claudication with mastication
-Vision changes (monocular vision loss, anterior ischemic optic neuritis MC)
-Scalp tenderness
-Fever, night sweats, etc.

Question 10

Although GCA is a clinical diagnosis, what do labs show and what is the definitive diagnostic?

Answer 10

Labs: Increased ESR and CRP

Temporal biopsy is definitive!

Question 11

Treatment for GCA

Answer 11

High dose corticosteroids to prevent blindness
-Urgent Ophthalmologist referral

Question 12

Superficial thrombophlebitis is….

It is MC associated with what condition and post what procedure. (Think of a patient who…)

Answer 12

Inflammation of a superficial vein

Associated with IV catheterization and pregnancy, varicose veins

Think of a patient who had IV–> venous occlusion–> inflammation

Question 13

What kind of phlebitis is associated with malignancy?

Answer 13

Trousseau Sign: Migratory thrombophlebitis

Question 14

Symptoms of superficial thrombophlebitis

Answer 14

-Pain, tendernes, induration
-Palpable cord
-Erythema along course of the vein

Question 15

Although superficial thrombophlebitis is a clinical diagnosis, you can do a diagnostic to prove it. Also, what lab should you do because it is a common cause?

Answer 15

-Venous Duplex US: noncompressible veins
-Factor V Leiden (MCC) = hyper coagulability workup

Question 16

Treatment for superficial thrombophlebitis

Answer 16

-Supportive: NSAIDs, elevation, heat

Question 17

Varicose veins are dilation of the superficial veins due to failure of _________________

Answer 17

venous valves in the saphenous veins leading to retrograde flow and pooling of blood

Question 18

Risk factors for varicose veins

Answer 18

-Female, Family history, obesity, pregnancy, OCP use

Question 19

Symptoms of varicose veins

Answer 19

-Dull ache/pressure
-Worse with standing, relieved with elevation
-Telangiectasias, swelling, dilated veins

Question 20

Management for varicose veins

Answer 20

-Compression stockings, leg elevation, pain control
-Ablation, sclerotherapy

Question 21

Chronic venous insufficiency occurs due to venous valvular incompetency –> stasis of flow. What are symptoms of this condition (PVD)?

Answer 21

-Leg pain worse with standing
-Improved with ambulation or elevation
-Heavy leg, burning, crampy pain
-Stasis dermatitis: itchy, eczematous rash, excoriation, brown/purple hyperpigmentation of skin
-Venous Stasis Ulcers; at medial malleolus
-Dependent pitting leg edema

Question 22

Where do the ulcers occur with peripheral venous disease?

Answer 22

-Medial malleolus

Question 23

Treatment for chronic venous insufficiency

Answer 23

-Conservative (initial): elevation, compression stockings, exercise
-Zinc impregnated gauze, Aspirin for ulcers

Question 24

Risk factors for a DVT (triad)

Symptoms of a DVT

Answer 24

-Virchow’s Triad: intimal damage (trauma, infection, inflammation) + stasis (immobilization, sitting) + hyper coagulability (protein C/S deficiency, Factor V Leiden, OCP, pregnancy, smoking)

-Unilateral leg swelling > 3 cm (most specific)
-Calf pain, tenderness
-Homan Sign: calf pain with foot dorsiflexion (squeezing the calf)

Question 25

Diagnostics for a DVT

Answer 25

-Venous Duplex US (Initial)
-D-Dimer: if low risk, negative D dimer rules out DVT
-If positive D-dimer –> US

-Contrast venography (GOLD) but rarely done

Question 26

Management for a DVT

Answer 26

-Anticoagulation (LMWH + Warfarin, LMWH + Dabigatran)

Question 27

When should you use an IVC Filter?

Answer 27

-Recurrent DVT
-Anticoagulation contraindicated
-RV dysfunction on echocardiogram

Question 28

What criteria is used to assess risk for a pulmonary embolism?

Answer 28

Well’s Criteria

Question 29

How long should a patient be on anticoagulation if the DVT is his/her first event and they are low risk?

Answer 29

3 months

Question 30

What is thromboangiitis obliterans (Buerger’s Disease)?

Answer 30

Nonatherosclerotic small and medium vessel vasculitis –> vasooclusion

Question 31

Who should you suspect Buerger’s Disease in?

Answer 31

Young smokers with distal extremity ischemia/ulcers/gangrene of digits

STRONG association with tobacco use and men 20-45 years old

Question 32

Symptoms of Thromboangiitis Obliterans?

Answer 32

-Distal extremity ischemia both upper and lower extremities
-Raynaud’s Phenomenon
-Superficial migratory thrombophlebitis

Question 33

Diagnostics for Thromboangiitis Obliterans

-There is a specific named test and one diagnostic that can be done

Answer 33

-Allen Test: tight fist, occlude radial and ulnar arteries to see color come back to hand. Abnormal and prolonged in this disease.
-Aortography: corkscrew collaterals

Question 34

Treatment for Thromboangiitis Obliterans

Answer 34

-Smoking cessation (First line *****)
-Iloprost: may help with limb ischemia
-CCB for Raynaud’s Phenomenon

Question 35

Explain the following three things associated with PAD

-Leg pain
-Ulcers
-Skin Changes

Answer 35

-Better with dependency and rest
-Worse with walking, elevation, and cold temp

-Lateral malleolus
-Clean Margins

-Atrophic Skin changes
-Low pulses, Cool Temp
-No edema
-Dependent rubor (red)

Question 36

Explain the following three things associated with PVD

Answer 36

-Better with walking, elevation
-Worse with standing, dependency

-Medial malleolus
-Uneven margins

-Stasis dermatitis
-Pulse/temp normal
-Prominent edema
-Cyanotic leg with dependency (blue)