Cardiology #6: PAD, Occlusion, GCA, Thromboses, Etc. Flashcards
Peripheral arterial disease, which is atherosclerosis of the arteries of the lower extremity, has symptoms such as
-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
Where are the ulcers located in peripheral ARTERIAL disease?
Lateral malleolus
Diagnostics for PAD
-What is initially used
-What is the GOLD standard
-ABI < 0.90 is positive for PAD
-Definitive: Arteriography
Treatment for PAD
-Supportive: exercise, smoking cessation**
-Cilostazol: most effective pharm therapy
-Revascularization: percutaneous transluminal angioplasty is definitive
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.
Femoral or popliteal
Symptoms of acute arterial occlusion (6 P’s)
-Paresthesias, pain, pallor, pulselessness, poikolothermia, paralysis
-Decreased capillary refill, decreased pulses, cool temperature to touch
Diagnostics for acute arterial occlusion
-Bedside arterial Doppler
-CT angiography
Management for acute arterial occlusion
-Reperfusion (mainstay): bypass, thromboembolectomy
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?
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.
Although GCA is a clinical diagnosis, what do labs show and what is the definitive diagnostic?
Labs: Increased ESR and CRP
Temporal biopsy is definitive!
Treatment for GCA
High dose corticosteroids to prevent blindness
-Urgent Ophthalmologist referral
Superficial thrombophlebitis is….
It is MC associated with what condition and post what procedure. (Think of a patient who…)
Inflammation of a superficial vein
Associated with IV catheterization and pregnancy, varicose veins
Think of a patient who had IV–> venous occlusion–> inflammation
What kind of phlebitis is associated with malignancy?
Trousseau Sign: Migratory thrombophlebitis
Symptoms of superficial thrombophlebitis
-Pain, tendernes, induration
-Palpable cord
-Erythema along course of the vein
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?
-Venous Duplex US: noncompressible veins
-Factor V Leiden (MCC) = hyper coagulability workup
Treatment for superficial thrombophlebitis
-Supportive: NSAIDs, elevation, heat
Varicose veins are dilation of the superficial veins due to failure of _________________
venous valves in the saphenous veins leading to retrograde flow and pooling of blood
Risk factors for varicose veins
-Female, Family history, obesity, pregnancy, OCP use
Symptoms of varicose veins
-Dull ache/pressure
-Worse with standing, relieved with elevation
-Telangiectasias, swelling, dilated veins
Management for varicose veins
-Compression stockings, leg elevation, pain control
-Ablation, sclerotherapy
Chronic venous insufficiency occurs due to venous valvular incompetency –> stasis of flow. What are symptoms of this condition (PVD)?
-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
Where do the ulcers occur with peripheral venous disease?
-Medial malleolus
Treatment for chronic venous insufficiency
-Conservative (initial): elevation, compression stockings, exercise
-Zinc impregnated gauze, Aspirin for ulcers
Risk factors for a DVT (triad)
Symptoms of a DVT
-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)
Diagnostics for a DVT
-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
Management for a DVT
-Anticoagulation (LMWH + Warfarin, LMWH + Dabigatran)
When should you use an IVC Filter?
-Recurrent DVT
-Anticoagulation contraindicated
-RV dysfunction on echocardiogram
What criteria is used to assess risk for a pulmonary embolism?
Well’s Criteria
How long should a patient be on anticoagulation if the DVT is his/her first event and they are low risk?
3 months
What is thromboangiitis obliterans (Buerger’s Disease)?
Nonatherosclerotic small and medium vessel vasculitis –> vasooclusion
Who should you suspect Buerger’s Disease in?
Young smokers with distal extremity ischemia/ulcers/gangrene of digits
STRONG association with tobacco use and men 20-45 years old
Symptoms of Thromboangiitis Obliterans?
-Distal extremity ischemia both upper and lower extremities
-Raynaud’s Phenomenon
-Superficial migratory thrombophlebitis
Diagnostics for Thromboangiitis Obliterans
-There is a specific named test and one diagnostic that can be done
-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
Treatment for Thromboangiitis Obliterans
-Smoking cessation (First line *****)
-Iloprost: may help with limb ischemia
-CCB for Raynaud’s Phenomenon
Explain the following three things associated with PAD
-Leg pain
-Ulcers
-Skin Changes
-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)
Explain the following three things associated with PVD
-Better with walking, elevation
-Worse with standing, dependency
-Medial malleolus
-Uneven margins
-Stasis dermatitis
-Pulse/temp normal
-Prominent edema
-Cyanotic leg with dependency (blue)
