Cardiology: Valvular Heart Disease

Question 1

name leading cause of valvular heart disease? what used to be the leading cause?

Answer 1

mechanical degeneration

used to be rheumatic fever (affecting mitral valve more than aortic valve)

Question 2

how is aortic aneurysm defined?
associated with?
most are located where?
what percentage below renal arteries?

Answer 2

defined as >50% dilation of all 3 layers of aortic wall
associated with atherosclerosis
abdominal
>90% below renal arteries

Question 3

name signs and symptoms of aortic aneurysm

Answer 3

usually asymptomatic

pulsatile abdominal mass of abdominal bruits

Question 4

name risk factors of aortic aneurysm

Answer 4

HTN, high cholesterol, other vascular disease, + family history, smoking, gender (male>female) and age

Question 5

how does ruptured aneurysm present

Answer 5

hypotension, severe tearing abdominal pain that radiates to back

Question 6

when should men be screened for aortic aneurysm

Answer 6

all men 65-75yrs with history of smoking should be screened once by ultrasound for AAA

Question 7

70 year old male with HTN presents for routine appointment. He quit smoking 20 yrs ago but has a 20 pack yr history. What screening if any is indicated?

Answer 7

the US Preventative Services Task Force (USPSTIF) guidelines recommend one-time screening for AA by ultrasound in males ages 65-75 who have ever smoked

Question 8

how should pts with aortic aneurysm be treated?

Answer 8

asymptomatic pts monitor for lesions 5cm

Question 9

when should aortic aneurysm be surgically repaired?

Answer 9

• surgical repair if >5.5 (abdominal), >6 cm (thoracic), or smaller but rapidly enlarging
• emergent surgery for symptomatic or ruptured aneurysm

Question 10

how is aortic dissection defined

Answer 10

transverse tear in the intima of a vessel that results in blood entering the media creating a false lumen and leading to a hematoma that propagates longitudinally

Question 11

what is most common cause of aortic dissection?
the most common sites (2)?
most common age?
gender?

Answer 11

• HTN
• mc sites above the aortic valve and distal to left subclavian artery
• 40-60yrs
• females more than males

Question 12

how does aortic dissection present?

Answer 12

sudden tearing/ripping pain in anterior chest (ascending) or back (descending)

Question 13

what is BP of pts with aortic dissection?

Answer 13

usually HTN

if hypotensive consider tamponade, blood loss, or other cardiopulmonary etiologies

Question 14

what may be found on PE in pt with aortic dissection?

Answer 14

asymmetric pulses
murmur of aortic regurgitation if aortic valve is invovled
neurologic deficits may be seen if aortic arch or spinal arteries are involved

Question 15

name gold standard of imaging for aortic dissection? if contraindicated what is indicated

Answer 15

CT angiography

use MRA if CT is contraindicated

Question 16

how can TEE be helpful in aortic dissection

Answer 16

can provide details of thoracic aorta, the proximal coronary arteries, the origins of arch vessels, presence of pericardial effusion, and aortic valve ingetrity

Question 17

what system is used to classify aortic dissection? which should be treated surgically?

Answer 17

Stanford system is used to classify dissection
type A:proximal to left subclavian artery (proximal or ascending)
type B: all others (descending)
treat all ascending aortic dissections with surgery

Question 18

how should aortic dissection be treated? what should be avoided? what should be given to avoid reflex tachy?

Answer 18

• monitor and medically manage BP and HR
• avoid thrombolytics
• begin beta-blockers before starting vasodilators to prevent reflex tachy

Question 19

how is deep venous thrombosis (DVT) defined?

Answer 19

clot formation in large veins of the extremities or pelvis

Question 20

what is triad of DVT?

Answer 20

venous stasis (plane flights, bed rest, incompetent venous valves in lower extremities), endothelial trauma (surgery, injury to lower extremities) and hypercoagulable states (malignancy, pregnancy, OCP use)

Question 21

how does DVT present

Answer 21

-unilateral extremity pain and swelling

Question 22

what is Homans’ sign

Answer 22

calf tenderness with passive foort dorsiflexion (poor sensitivity and specificity for DVT)

Question 23

how is DVT diagnosed? PE?

Answer 23

DVT: doppler US,
PE: a spiral CT or V/Q scan

Question 24

how is DVT treated?

Answer 24

• anticoagulation (IV unfractionated heparin, or SQ low molecular weight heparin (LMWH)
• follow this by PO for a total of 3-6 months

Question 25

how is DVT treated in pts which anticoagulation is contraindicated?

Answer 25

IVC filters

Question 26

what is DVT prophylaxis for pts that are hospitalized?

Answer 26

exercise as tolerated
anti-thromboembolic stockings
SQ unfractionated heparin or LMWH

Question 27

what can be used to rule out possibility of PE in low risk pts

Answer 27

d dimer

Question 28

how is peripheral arterial disease defined? which area is most common affected?

Answer 28

• restriction of blood supply to extremities by artherosclerotic plaque
• lower extremities

Question 29

how does peripheral arterial disease present? how does limb ischemia present?

Answer 29

• intermittent claudication (reproducible leg pain that occurs with walking and is relieved with rest)
• dorsal foot ulcerations
• painful cold, numb foot=limb ischemia

Question 30

name signs and symptoms of aortoiliac disease

Answer 30

buttock claudication, decreased femoral pulses, male impotence (Leriche’s syndrome)

Question 31

name signs and symptoms of femoropopliteal disease

Answer 31

calf claudication; decrease pulses below the femoral artery

Question 32

what is mc cause of acute ischemia? what is mc location name another cause?

Answer 32

-embolization from heart,
occurs a bifurcations distal to last palpable pulse
-cholesterol atheroembolism (“blue toe syndrome”)

Question 33

name 6 P’s of acute ischemia?

Answer 33

Pain
Pallor
Paralysis
Pulse deficit
Paresthesias
Poikilothermia (limb’s temperature equalizes with the surrounding environment)

Question 34

name signs and symptoms of chronic ischemia

Answer 34

lack of blood perfusion causes muscle atrophy, pallor, cyanosis, hair loss, and gangrene/necrosis

Question 35

name how BP measurement can be used to provide evidence of atherosclerosis

Answer 35

• measure ankle and brachial systolic BP (ABI)
• ABI=Pleg/Parm
• rest pain occur with and ABI<0.4
• a high ABI indicated calcification of arteries

Question 36

what does doppler US help to identify in peripheral arterial disease?

Answer 36

• helps identify stenosis and occlusion

- normal ankle doppler readings are >90% of brachial readings

Question 37

what is necessary for surgical evaluation

Answer 37

arteriography and digital subtraction angiography

Question 38

what is treatment for peripheral arterial disease?

Answer 38

control underlying condition exercise helps develop collateral circulation

Question 39

what medications can help with symptoms of peripheral arterial disease?

Answer 39

ASA, cilostazol, and thromboxane inhibitors

Question 40

what should be done for pts with peripheral arterial disease when conservative treatment fails?

Answer 40

angioplasty and stenting

surgical arterial bypass or amputation

Question 41

how is lymphedema defined

Answer 41

disruption of lymphatic circulation that results in peripheral edema and chronic infection of the extremities

Question 42

what is lymphedema caused by?

Answer 42

complication of surgery invovling lymph node dissection

Question 43

when does lymphedema present in childhood?

Answer 43

Milroy’s disease (congenital malformation of lymphatic system)

Question 44

what is condition of immigrants with progressive swelling of lower extremitiess with no cardiac abnormalities

Answer 44

filarisis

Question 45

how is lymphedema treated? what medications should be contraindicated. what complication would be monitored for?

Answer 45

symptom management- exercise, massage therapy, pressure garments
diuretics are ineffective and
maintain villagence for cellulitis with prompt gram + antibiotics coverage for infection