Cardiovascular Flashcards
what’s the 2 types of thoracic aortic aneurysms? which one is more common?
ascending (more common) and descending
what’s the MCC of ascending aortic aneurysm?
cystic medial necrosis
what’s the MCC of descending aortic aneurysm?
atherosclerosis
what are the s/s of thoracic aortic aneurysm?
commonly asx
Chest, back, flank, abdominal pain: compression or distortion of local anatomy
Cold foot: thromboembolism preventing blood flow to area
what’s the PE of thoracic aortic aneurysms?
commonly normal
if rupture -> hemorrhagic shock (tachy and decreased. BP)
what’s the best imaging study for dx of thoracic aortic aneurysm?
CT angiogram
what will you see on CXR if it’s a thoracic aortic aneurysm?
wide mediastinum (only if aneurysm is large enough)
what type of thoracic aortic aneurysm can ECHO (TTE) dx?
proximal ascending aorta
when do you use MRI for dx of thoracic aortic aneurysm?
if pt can’t get IV contrast for CTA
what’s the tx for thoracic aortic aneurysm?
Beta blockers(especially for pts w/ Marfan)
ACEIs/ARBs
(limit expansion and r/o rupture)
Endovascular repair→ catheter guided stent graft placed
-Closed procedure (preferred)
when do you do surgical repair or placement of prosthetic graft for thoracic aortic aneurysm?
Symptomatic
Ascending aneurysm >5.5 cm
Descending aneurysm >6.5 cm
where does abdominal aortic aneurysm MC occur?
infrarenally - at level of renal arteries
at what size is part of the abdominal aorta considered an aneurysm?
> 3.0 cm
what is the MC RF for development of AAA? what’s a major RF?
atherosclerosis = MC RF
smoking = major RF
what are the RFs for development of AAA?
***Atherosclerosis = MC RF
***Age >60 y/o
***Smoking: major RF - promotes rate of aneurysm formation, growth and rupture
Male, Caucasians
Hyperlipidemia, ***connective tissue d/o (Marfan’s syndrome), Syphilis, HTN
what’s the s/s of AAA?
Most are asx until they rupture
(often incidental finding on US, CT, MRI)
Acute leakage/rupture
Classic presentation: older male (>60 y/o) with:
- Severe back or abdominal pain who presents with syncope or hypotension & tender, pulsatile abd mass
- +/- Cullen’s sign (flank ecchymosis)
what’s the classic presentation of AAA?
older male (>60 y/o) with: -Severe back or abdominal pain who presents with syncope or hypotension & tender, pulsatile abd mass
- +/- Cullen’s sign (flank ecchymosis)
at what size of AAA is there an increased rupture risk?
> 5cm
how and who do you screen for AAA?
Abd U/S indicated for:
- Men 65-74 y/o with h/o smoking
- Sibling or offspring of persons w/ AAA
- Pts w/ thoracic aortic or peripheral arterial aneurysms
- Pts w/ connective tissue d/o’s → Marfan’s and Ehlers-Danlos
how do you dx AAA?
Abd U/S → best imaging study
-Alternatively: CT or MRI
Angiography = gold standard
what’s the BEST imaging study for AAA?
Abd U/S
what’s the GOLD STANDARD imaging study for AAA?
angiography
what’s the definitive tx of AAA?
surgical repair
what’s the tx for AAA 3-4 cm?
monitor by U/S every year
what’s the tx for AAA 4-4.5 cm?
monitor by U/S every 6 months
what’s the tx for AAA >4.5 cm?
vascular surgeon referral
what’s the tx for AAA >/= 5.5 cm OR >0/5 cm expansion in 6 months?
IMMEDIATE SURGICAL REPAIR (even if asx), symptomatic pts or pts w/ acute rupture
what’s the tx after endovascular repair of AAA?
long-term surveillance w/ CTA or MRA
what’s an aortic dissection?
tear in the innermost layer of aorta (intima) -> creates false lumen (channel)
what’s the MC place to have an aortic dissection?
ascending aorta (high mortality)
what’s the MOST IMPT. predisposing factor of aortic dissection?
HTN
what’s the s/s of aortic dissection?
Chest Pain: MC; sudden onset of severe, tearing (ripping, knife-like)* chest/upper back pain*
-a/w N/V, diaphoresis
Decr. peripheral pulses
-Variation in pulse (>20mmHg difference b/w the right and left arm)***
what sx is MC in distal ascending aortic dissection?
HTN
what sx occurs in a ascending dissections?
acute new-onset aortic regurgitation
what’s the BEST imaging study for aortic dissection? what’s the GOLD STANDARD?
CTA = best imaging study
MRI angiography = gold standard
what do you see on CXR for aortic dissection?
WIDENING OF THE MEDIASTINUM
what’s the initial tx for aortic dissection?
HR and BP control w/ Esmolol
Pain relief w/ morphine
what’s the tx for acute dissection of ascending aorta?
surgical emergency!!!
what’s the tx for acute dissection of descending aorta?
Treat medically first
Surgery → progression w/ organ ischemia or continued hemorrhage into pleural or retroperitoneal space
what’s the long-term management for aortic dissection?
Medical therapy: minimize aortic wall stress (lifelong BB and maintaining goal BP <120/80)
Serial imaging: 3mo → 6mo → 12mo
q1-2 yrs thereafter
what are the indications for re-operation for aortic dissection?
Recurrence of dissection
Aneurysm formation
Leakage at anastomosis or stent
what is acute limb ischemia/arterial occlusion? what’s it caused by?
Sudden decr. In limb perfusion that causes potential threat to limb viability
Caused by progression of PAD, arterial emboli, or thrombus
what are the RFs for acute limb ischemia/arterial occlusion?
- A-fib
- Recent MI
- Large vessel aneurysmal disease
- RFs for aortic dissection
- Arterial trauma
- DVT
what’s the s/s of acute limb ischemia/arterial occlusion?
SIX Ps OF LIMB ISCHEMIA:
- Pulselessness
- Pain
- Poikilothermia
- Pallor
- Paresthesia
- Paralysis
how do you dx acute limb ischemia/arterial occlusion?
ABI <0.90
Vascular imaging
what’s the tx for acute limb ischemia/arterial occlusion?
***Emergent or Urgent Revascularization
- Anticoags → IV Heparin
- Thrombectomy/Embolectomy
- Endovascular surgery
- Surgical intervention
- Thrombolytic therapy
what’s the post-revascularization tx for acute limb ischemia/arterial occlusion?
Medical eval for source of embolus
- EKG and telemetry
- Vascular U/S
- Hypercoagulable eval
- Cardiac eval w/ TEE to r/o cardiac thrombus
- Chest CT
what’s chronic venous insufficiency?
Vascular incompetency of either the deep and/or superficial veins
what are the causes of chronic venous insufficiency?
MC occurs after superficial thrombophlebitis, after DVT, or trauma to the affected leg
what’s the s/s of chronic venous insufficiency?
- Leg pain: burning, aching, throbbing, cramping, muscle fatigue, **“heavy leg”
- Pain/color worse with: prolonged standing/sitting, foot dependency
- Pain/color improves with: leg elevation & walking - Leg edema: incr. Leg circumference, pitting edema, varicosities, erythema.
- Stasis dermatitis: eczematous rash, itching, scaling, weeping, erosions w/ crusting
- **BROWNISH HYPERPIGMENTATION: hemosiderin deposition in the skin from damaged vessels
- Venous stasis ulcers w/ uneven margins may occurs, esp. at the ***MEDIAL malleolus
where do venous stasis ulcers occur? what are they a/w?
medial malleolus - a/w chronic venous insufficiency?
what d/o has sx’s of a “heavy” leg?
chronic venous insufficiency
what d/o has sx’s of brownish hyper pigmentation?
chronic venous insufficiency
how do you dx chronic venous insufficiency?
Trendelenburg test: shows slow filling at the ankle
U/S: done for confirmation and if procedures planned
what’s the MAINSTAY of tx for chronic venous insufficiency?
Compression
-periods of leg elevation, compression stockings, avoid long periods of standing or sitting
how do you manage venous ulcers?
Wet to dry dressings, Unna boot, edema control
Severe → skin grafting, hyperbaric oxygen
what is peripheral arterial disease (PAD)?
Atherosclerotic disease of the LEs
Symptomatic ischemic d/t supply/demand imbalance
-Ischemic type pain with exercise → Claudication
what are the RFs for PAD?
Age, smoking, M > F
Family hx
Homocysteinemia
Metabolic syndrome
what’s the s/s of PAD?
INTERMITTENT CLAUDICATION***
- MC sx
- Reproducible pain/discomfort in the LEs brought on by exercise/walking & relieved w/rest
Ischemic rest pain = advanced disease
-Occurs while lying in bed at night
Non-healing wound or ulcer (no blood flow to site, decr. ability to heal)
what’s the MC sx of PAD?
intermittent claudication
what’s the PE like for PAD?
Pulses: decr./absent pulses; decr. cap refill
Skin: atrophic skin changes:
-Thin/shiny skin, no hair
Color: pale on elevation, dusky red w/ dependency (dependent rubor)
how do you dx PAD?
ABI (compare SBP in ankle w/ that of the arm) - <0.90 = PAD
Arteriography (GOLD STANDARD)
Doppler U/S (used in ER)
what’s the GOLD STANDARD to dx PAD?
Arteriography
what’s the tx of PAD?
Platelet inhibitors:
- Cilostazol = mainstay of tx
- Aspirin, Clopidogrel (Plavix)
Revascularization:
-If rest pain
Surgery (when meds fail):
- Angioplasty (TOC for mild-mod disease)
- Endarterectomy (mod-severe disease)
- Surgical open bypass procedure (sim to CABG) (-for severe disease when other tx’s fail)
- Amputation (last resort)
what’s the MAINSTAY of tx for PAD?
Cilostazol (platelet inhibitor)
what’s the TOC for mild-moderate disease PAD?
Angioplasty (surgery)
when is surgery the tx for PAD?
when meds fail
what are the main meds used for PAD?
Platelet inhibitors:
- Cilostazol (mainstay)
- ASA, Clopidogrel
when is CABG done for PAD?
in severe disease once other tx’s fail
what are varicose veins?
Dilated, tortuous superficial veins 2/2 defective valve structure & fxn of the superficial veins (esp. the superficial saphenous veins)
varicose veins are seen with what?
Incr. estrogen: OCPs, pregnancy; incr. stress on legs: prolonged standing, obesity
what’s the s/s of varicose veins?
Dilated, tortuous veins
Dull ache or pressure sensation worsened w/ prolonged standing & relieved with elevation
Venous stasis ulcers
what’s the tx for varicose veins?
Conservative:
-Leg elevation, elastic compression stockings, avoid prolonged standing & girdles
Sclerotherapy, radiofrequency or laser ablation & ambulatory phlebectomy commonly used
what is acute mesenteric ischemia?
Ischemic bowel disease
sudden decrease of mesenteric blood supply to the bowel -> inadequate perfusion esp. @ splenic flexure (b/c of less collateral blood perfusion)
what is acute mesenteric ischemia due to?
MC due to occlusion -> embolus (a-fib), thrombus (atherosclerosis)
Non-occlusive causes are shock and cocaine
what’s the MC cause of acute mesenteric ischemia? MC what artery is involved?
due to occlusion -> embolus (a-fib), thrombus (atherosclerosis) MC at SMA
what’s the s/s of acute mesenteric ischemia?
SEVERE abd pain out of proportion to PE findings***
-also: N/V, diarrhea
what’s the definitive dx of acute mesenteric ischemia?
angiogram
what’s the tx for acute mesenteric ischemia?
surgical revascularization (angioplasty with stunting or bypass)
surgical resection if the bowel is not salvageable
what is chronic mesenteric ischemia?
Ischemic bowel disease
mesenteric atherosclerosis of the GIT -> inadequate perfusion especially @ splenic flexure during post-prandial states during POST-PRANDIAL STATES (W/IN 1 HR)
what’s the s/s of chronic mesenteric ischemia?
chronic dull abdominal pain WORSE AFTER MEALS (W/IN 1 HR) - “intestinal angina”***
weight loss (anorexia)*** b/c afraid of pain and so limit PO intake
how do you dx chronic mesenteric ischemia?
CT angiogram or MR angiogram -> confirms dx (best dx studies)
can do Duplex U/S
what’s the tx for chronic mesenteric ischemia?
bowel rest & surgical revascularization (angioplasty w/ stunting or bypass)
what is coronary artery disease?
inadequate tissue perfusion/ischemia d/t imbalance b/w decr. coronary blood supply & increased demand
what is the MC cause of coronary artery disease?
atheroscleross
what are risk factors of CAD?
DM (worst RF)
cigarette smoking (most impt. modifiable RF)
hyperlipidemia, HTN, males, age (>45 y in men, >55 y in women), family hx of CAD
what’s the worst RF for CAD?
DM
what’s the most important modifiable RF for CAD?
cigarette smoking
what is angina?
substernal chest pain usu. brought on by exertion (d/t decr. supply and incr. demand of heart)
what is class 1 of angina pectoris?
angina only with unusually strenuous activity.
No limitations of activity
what is class 2 of angina pectoris?
angina with more prolonged or rigorous activity
slight limitation of physical activity
what is class 3 of angina pectoris?
angina with usual daily activity
marked limitation of physical activity
what is class 4 angina pectoris?
angina at rest
often unable to carry out any physical activity
how long does stable angina last?
<15 mins
what’s the difference b/w stable and unstable angina
stable angina - occurs with physical exertion only and not at rest
unstable angina - occurs even at rest and more often
what are EKG findings of unstable angina/NSTEMI? what about troponin levels?
ST depression and/or T wave inversion
EKG can be normal
Troponin levels are normal
what is the s/s of ACS?
retrosternal pain >30mins NOT RELIEED WITH REST/NITROGLYCERIN
what is zener’s diverticulum?
pharyngoesophageal pouch (false diverticulum - only involves the mucosa)
weakness at the junction b/w cricopharynxgeus muscles and lower inferior constrictor -> herniation/outpouching
what are the s/s of zener’s diverticulum?
***dysphagia
regurgitate of undigested food, feeling at if there is a lump in neck, choking sensation
how do you dx zener’s diverticulum?
barium esophagram
what’s the tx of zener’s diverticulum?
diverticuloectomy, cricopharyngeal myotomy
observation if small & asx
