Cardiovascular Flashcards
1
Q
aortic dissection etiology and sxs
A
- ascending = type A; descending = type B
- etiology: weakening of the aortic wall that may lead to the development of aneurysmal dilation
- bimodal: young pt with connective tissue disorders, age 50+ w chronic HTN
- sxs: presentation predicts intimal disruption
- abrupt severe CP radiates to area between scapulae (feeling of impending doom, ant chest pain = type A, abd pain = type B, 64% describe as sharp, 50% describe as tearing or ripping
- syncope = type A; dysphageia, hoarseness, Horner syndrome
- signs: HTN, aortic insuff, pulse def in radial or femoral arteries
2
Q
aortic dissection dx and tx
A
- dx: EKG (ro ACS), biomarkers (D-dimer), CXR (widened mediastinum, abnl aortic contour), CT with and without (preferred - anatomy, loc, extension, signs of rupture, end organ damage
- TEE (as sensitive and spec as CT), CT angio (dx CAD, PE, and aortic dissection - requires special contrast, increased radiation), MRI (GOLD STANDARD)
- tx: neg inotropic agent to lower BP without inc shear force on intimal flap
- B-blocker (propran, labet, esmolol), Definitive = segmental resection of dissection with interposition of a synthetic graft
- complications: stroke, cardiac tamp, paraplegia, back, flank, abd pain, death
3
Q
thoracic aortic aneurysm
A
- ascending aneurysms: medial degeneration
- descending aneurysms: atherosclerosis
- sx/s: asxatic, CP, SOB, cough, hoarseness, dysphagia
- dx: CXR (widened mediastinal shadow, displacement of trachea or left main stem bronchus), echo (TTE), contrast CT, MRI, invasive aortography
- tx: if asxatic, follow with contrast CT or MRI q6-12mos, B-blockers for Marfan syndrome or bicuspid aortic valve, repair 4-5cm, descending = >6cm, increasing 1cm/y
- prognosis: worse if associated Marfan syndrome or dissection
4
Q
abdominal aortic aneurysm
A
- aortic aneurysms result from conditions that cause degradation or abnormal production of the structural components fo the aortic wall (elastin and collagen)
- MC pathology: atherosclerosis (older males >50)
- RF: smoking, high cholesterol, aging, HTN, male sex
- sxs: asxatic, if rupture acute pain and hoTN
- signs: palpable, uplsatile, expansile, and nontender mass - becomes painful with expansion (chest, back, lower scrotum)
- dx: CXR (calcified outline), abd US (serial doc of size), CT w contrast, MRI to determine loc and size
- tx: medical emergency, endovasc placement of aortic stent graft or open surg repair with prosthetic graft (expanding rapidly, asx >5.5cm), serial noninvasive FU for <5cm
- prognosis: related to size and severity of coexisting CAD and CVD
- screening: men 65-75 who have smoked, siblings of indivs with thoracic aortic or peripheral arterial aneurysms
5
Q
arterial embolism or thrombosis
A
- emboli that arise from ventricular aneurysm or from dilated cardiomyopathy can be very large and can lodge at aortic bifurcation (saddle embolus), thus rendering both legs ischemic
- a palpable femoral pulse and absent pop and distal pulses may either be dt distal common femoral embolus (pulse being palpable above level of occlusion) or embolus to superficial femoral or pop arteries
- Thrombolysis: absolute CI = recent stroke, intracranial malig, brain mets, intracranial surg intervention; relative CI = renal dz, allergy to contrast, cardiac thrombus, diabetic retinop, coagulop, recent arterial puncture, surg
- embolectomy: absolute CI = cerebrovascular events within last 2 mos, active bleeding diathesis, recent (<10d) GI bleed, neurosurg within last 3mo, intracranial trauma in last 3mo, intracranial malig or met
6
Q
Peripheral vascular dz or peripheral arterial dz
A
- in absence of limb-threatening ischemia, sxs of PAD tend to remain stable with med tx
- if revascularization is needed, percutaneous revasc first, reserve surgery for when arterial anatomy is unfavorable
- clinical features used to determine if thrombolytic therapy or surg revasc is most appropriate:
- presumed etiology (embolus vs thrombus)
- location
- duration of sxs
- availability of autologous vein for bypass grafting
- suitability of pt for surg
- proximal embolus at bifurcation of common fem artery is ideal lesion for embolectomy
- embolus to distal vessel Ii.e. tibial a.) may be tx with thrombolytic agent
- major use of percutaneous transluminal angioplasty (PTA) is in the tx of underlying lesion after clot has been lysed with thrombolytic tx
- Leriche syndrome: triad of 1) claudication, 2) absent or diminished femoral pulses, and 3) erectile dysfunction
7
Q
Asx PAD
A
- screen in pts with abnormal/absent pedal pulses, age >70, age 50-69y with hx of smoking or DM
- sxs: none
- dx: ABI - if <0.9 is dx; if 0.91-1.3 normal and no further testing; if >1.3 doppler ankle waveforms and toe pressures
- tx: preventative = ASA, lipid lowering, blood pressure control
8
Q
PAD or PVD etiology, RF, and sxs
A
- occlusive atherosclerotic dz of lower extremities
- superficial femoral artery is MC, popliteal, aortoiliac
- RF: smoking HLD, DM, HTN
- Men >40y, AA
- MCC: atherosclerosis
- Considered to be a coronary artery disease risk equivalent
- Common in pts with ESRD
- 20-50% are asx and 40-50% present with atypical leg pain
- Sxs: pain in one or more lower extremity muscle groups (cramping thigh, calf, or buttock pain’ intermittent claudication; worse with elevation (reclining))
- Rest pain felt over distal metatarsals, prominent at night (wakes pt up from sleep), hangs foot over side of bed or stands to relieve pain
- signs: diminished/absent pulses, muscular atrophy, hair loss distal to obstruction, thick toenails, decreased skin temp, localized skin necrosis (toes), nonhealing, infarction, or gangrene, pallor of elevation and rubor of dependency
9
Q
PAD or PVD dx and tx
A
- dx: hypercholesterolemia >240, hypertTG >250
- ABI testing - if <0.9 = dx
- doppler - reduced or interrupted flow
- Arteriography (gold standard)
- tx: prevention of atherosclerosis (control HLD, HTN, weight, DM
- manage primary HLD: statins, diet exercise (walk to point of claudication, rest, then continue walking), foot care
- reduce BP, STOP SMOKING (most important)
- Medical intervention: ASA and ticlopidine or clopidogrel (sx relief), cilostazol (PDE inhib)
- Surgery: angioplasty (preferred), adjunctive stenting, bypass grafting
10
Q
chronic venous insufficiency (venous stasis) etiology, sxs
A
- mostly dt valvular dysfn - leads to loss of compartmentalization of veins, leads to distention and increased pressure - transmitted to microvasc - basement membrane thickening, inc capillary elongation, skin changes
- varicose veins, postphelbitic syndrome
- age 30-40, F > M, 2% of gen pop
- aggravating factors: preg, inc blood volume, inc cardiac output or venocaval pressure, progesterone
- RF: family hx, DVT, female, estrogen, age, obesity, prolonged standing
- sxs: heaviness or aching of leg (lower extrem edema) - worse with prolonged standing and relieved by walking, relief with elevation, edema worse at end of day and with standing, shoes feel tight in evening, night cramps, itching 2/2 irritation
- signs: hyperpig, distal edema, erythema, dry tight skin, ulceration
- complications: 50% have varicose veins, fibrosis, atrophy
11
Q
chronic venous insufficiency (venous stasis) dx and tx
A
- duplex US to assess valve closure (nl = 0.5-1s), <0.5s = diagnostic, CEAP classification
- tx: conservative = for at least 3 mos, graduated compression hose (1st line), compression for open ulcer
- vein ablation tx = indications are vein hemorrhage superficial thrombophlebitis, CIs are preg, DVT, mod to severe PAD, and joint dz
- injection sclero (initial) - for telangiectasias (CEAP cat 1), reticular veins, small varicose veins
- vein ligation/excision for CEAP cat 2 (>3mm)
- thermal ablation, venous reconstruction
12
Q
varicose veins
A
- “blow out” of incompetent veins, 10-30% of gen pop, MC in F
- sxs: enlarged, tortuous superficial leg veins (seen best with standing), painful and itchy
- dx: tourniquet test: applied to leg that has been elevated; release after pt stands and veins fill instantly
- tx: injection sclero with prolonged compression, vasc surg for ligation and removal saphenous veins, endoscopic subfascial dissection of perforating veins
13
Q
venous ulcers
A
- prevalence = 1%, occur on medial lower calf, single or multiple, medial > lateral over malleolus
- RF: DM, PAD
- sxs: irreg shaped, sharply defined, shallow with sloping border, painful (mild), occurs over medial and lateral malleolar area, posterior calf
- signs: irreg margins, pink or red base that may be covered with yellow fibrinous tissue, exudate common, warm, pulses and sensation intact, erythema, brown-blue hyperpig, edema, dry skin, varicose veins
- tx: correct underlying risk factors, corrective surg +/- elastic stockings daily, distribute weight in special shoes
14
Q
arterial ulcer
A
- associated with PAD, occur on lower leg (pretibial, supramalleolar, toes)
- sxs: severe pain at night (worse when legs elevated, over toe joints, malleoli, anterior shin, base of heel, pressure points)
- signs: punched out, with sharply demarcated irregular borders (base dry and often pale or necrotic), tissue slough at base (see tendon), pulses absent, warm or cool, shiny, taut, loss of hair, dependent rubor of leg and foot, pale with elevation
- tx: endarterectomy or bypass surgery to correct arterial flow
15
Q
intermittent claudication
A
- means “limping”, occurs distal to the level of stenosis or occlusion, for example calf pain with walking, 10-35% of people with PAD
- sxs: reproducible pain in single or multiple muscle groups, aggravated by sustained exercise, relieved with rest, aching dull pain, leg pain that occurs after certain walking distance causing pt to stop walking, resolving within 10 mins, cramping, numbness, weakness, giving way
- physical: hair loss on bilat lower extremities, thinning of skin, diminished pulses
- dx: treatmill testing using ABIs at rest and after - <0.9 = dxic
- tx: stop smoking (first line) - graduated exercise (walk to pnt of claudication, rest, then continue walking), foot care, control HLD, HTN, weight, DM, avoid extremes of temp, ASA + ticlopidine or clopidogrel (sxatic relief), cilostazol (PDE inhib)
- surgery: angioplasty, bypass grafting
