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Finals > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

AAA ruptured Mx

A
  1. Standard resus measures
  2. urgent surgical repair (EVAR), or open if anatomy unsuitable

with perioperative Abx (braod spec to cover G+ and G- e.g. doxycycline, azithromycin)

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2
Q

AAA symptomatic not ruptured Mx

A

Repair indicated regardless of diameter (EVAR)
With pre-op CV risk reduction (low dose aspirin continued during peri-op period) and ongoing hypertensive management.
Plus periop Abx (doxy/azithromycin)

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3
Q

AAA asymptomatic large diameter specifications

A

(>5.5cm, OR >4cm and increased by >1cm in 12m)

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4
Q

AAA asymptomatic large diameter Mx

A
  1. Elective repair confers survival advantage. Open and EVAR are equal in survival advantage but EVAR has more secondary interventions. Fenestrated EVAR is an option for patients with juxtarenal/suprarenal AAA or those with short infrarenal aortic neck.
    1. Address modifiable RF, low dose aspirin continued in peri-op period, HTN control. Statin at least 1m before surgery and cont. indefinitely. Consider beta-blockade 1 month pre-op in pts w/IHD or MI
      Peri-op Abx (doxy/azithromycin)
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5
Q

AAA asymptomatic small

A
  1. Surveillance: annually if 3-4.4cm, 3mo if 4.5-5.4cm
    1. Lifestyle mod. (smoking offer medication, exercise programmes)
    2. Low dose aspirin continued during peri-op. HTN control. Statin
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6
Q

Cx of AAA repair

A 
MI
Arrythmia
Bleeding
Injury to bowel 
DVT
Graft infection
DEATH!
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7
Q

Cx of non-surgically Mx AAA

A

Rupture!
Increase in size
Peripheral arterial disease

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8
Q

Prognosis of AAA

A

Ruptured: NO treatment = 100% mortality, 50% with open surgery
Unruptured: rate increases with size, <5% annually if <5cm. Elective surgery confers survival advantage but mortality still slightly higher than general pop and at risk of CVD.

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9
Q

EVAR types

A
  1. Percutaneous (standard): stent inserted through femoral arteries under x-ray guidance. Stent extends from above AAA into common iliac arteries.
    1. Fenestrated: Used when juxtarenal repair needed, fenestrations in graft allow renal blood supply.
      TEVAR: stent inserted into thoracic aneurysm
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10
Q

Open repair of AAA

A

Laparotomy approach, involves dissecting through to visualise aorta, clamping above and below AAA. Before opening the AAA and inserting a stent graft into lumen extending to just above iliac bifurcation.

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11
Q

AAA repair indications

A
  1. Rupture
  2. Symptomatic
  3. > 5.5cm
  4. > 4cm and >1cm increase in last 12m
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12
Q

Aortic dissection management (acute)

A

Acute: Hb unstable suspected dissection
1. ALS with H/d support: (including fluids and oxygen)
Noradrenaline 0.5-1 microgram/min IV initially and titrate up usual dose 2-12mcg/min max of 30mcg/min AND/OR
dobutamine 0.5-1mcg/kg adjust up usual dose 2-20mcg/kg max 40 mcg/kg

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13
Q

aortic dissection management (confirmed A, or B with complications)

A

Open surgery or endovascular stent-graft repair

- Type A: open removal and replacement of ascending aorta with tube graft +/- repair/replacement of aortic valve depending on retrograde extension
- Complicated type B: resect/cover tear and restablish blood flow. Endovascular repair is becoming preferred option if presenting with fewer Cx
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14
Q

Complicated type B aortic dissection features

A

rupture, visceral/limb ischaemia, expansion, persistent pain

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15
Q

type B aortic dissection Management (uncomplicated)

A
  • Endovascular stent graft repair: usually Mx medically with BP and pain control during acure phase (less than 14d).
    However growing evidence that early intervention improves survival:
    TEVAR to promote false lumen thrombosis and prevent aneuyrsmal degeneration is an option for management
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16
Q

Type B chronic aortic dissection management

A
  • Use of TEVAR becoming more common but can also be Mx medicaclly with BP control (long term) and pain relief
17
Q

after d/c management of aortic dissection

A
  • Antihypertensives:
    ○ Metoprolol 25-100mg PO modified release OD AND/OR enalapril 5-40mg OD PO
    Can add CCB, diuretic if nec.
18
Q

Complications of aortic dissection

A
  • Visceral ischaemia: ALS and repair of dissection
    • Stroke (ischaemic)
    • Renal failure/AKI: surgery +/- dialysis
    • Acute aortic regurgitation
    • Hypovolaemic shock: ALS, vasopressors, blood transfusion
    • Retrograde type A after type B repair (reduced with TEVAR)
    • Lower limb ischaemia after surgery
19
Q

Prognosis of aortic dissection

A

Type A: without treatment is almost always fatal. 50% die before reaching specialist centre. Patients treated with surgery have a high survival rate (90%). 60% 5year survival
B: 5 year survival 50-80% . 30% chance of forming aneuyrsm.

20
Q

Aortic regurgitation severity

A

Determined by valvular anatomy (calcification, biscupid, rheumatic changes). Valve haemodynamics (jet width, flow reversal). Haemodynamic consequences (EF, and LV ESD/EDD). Symptoms (only present in severe - exertional dyspnoea or angina or HF sx)

21
Q

AR management acute

A

Inotropes (dopamine 2-5mcg/kg/min titrate to max of 20) AND
Vasodilator (nitroprusside 0.3-0.5mcg/kg/min titrate to max of 10mcg/kg/min) AND
Aortic valve replacement

Usually reserved for severe cases (presssure halftime of <200ms) or with severe symptoms (chest pain, SOB, palpitation)
Prosthetic valve replacement pts need anti-coag

22
Q

AR management Chronic mild-mod

A
  1. Asymptomatic with normal LV function: (>50%)
    DO NOT require treatment can be reassured
    1. Symtomatic or LV dysfunction:
      Investigate cause e.g. htn, CAD or cardiomyopathy
23
Q

AR Mx severe asymptomatic w/EF>50%

A

a. Compensated Dx: reassurance (provided no LV dilation)
b. Transitional Dx (LV 60-70mm EDD or 45-50mm ESD) - perform exercise test
i. Negative: reassure
ii. Positive (based on haemodynamic response): nifedipine 30-60mg OD
c. Decompensated: (LV EDD>70mm or ESD >50mm) - surgery
i. Mechanical or biological valve. If high risk consider TAVI (off label) (replacement patients will need anticoagulation)
Non-surgical candidate: Nifedipine 30-60md OD (or hydralazine 10-25mg 2-4/day) or enalapril 5-20mg BD

24
Q

AR Mx asymptomatic w Ef<50%

A

a. Mechanical or biological valve replacement with ongoing anticoagulation. (TAVI off label if high risk)
b. Non-surgical candidate: nifedipine 30-60mg OD (or hydralazine 10-25mg 2-4/day) or enalapril 5-20mg BD

25
Q

AR Mx severe symptomatic

A
  1. Surgery: indicated regardless of LV function or dilation
    a. Mechanical or biological valve. TAVI if high risk pt. While awaiting surgery consider nifedipine 30-60mg OD or hydralazine 10-25mg 2-4/day
    1. Non-surgical: nifedipine 30-60mg OD or hydralazine 10-25mg 2-4/day
26
Q

AR Cx

A

Thrombus -> stroke: anticoagulation (especially after valve replacement)
Infective endocarditis: monitor for signs and treat with (vancomycin and aminoglycoside PLUS rifampicin if prosthetic valve!)
Anticoag related bleeding; monitoring of INR
Heart failure: managed with optimal AR therapy

27
Q

AR prognosis

A

Acute: operative risk higher than in chronic because usually involves v severe disease or Cx such as IE or dissecting aneuyrsm
Chronic: prognosis good. LV dysunction likely reversible if detected early
If patients enter heart failure prognosis is much poorer (Class III HF without surgery has 30% 4 year survival)

28
Q

AS Mx clinically unstable

A
  1. Medical therapy (vasodilator eg nifedipine +/- beta blocker stopped on day of surgery) or balloon valvuloplasty to stabilise prior to surgery or TAVR
29
Q

AS Mx clinically stable symptomatic risk calculation

A

STS-PROM (mortality risk calculator) used alongside clinical picture to determine risk. Older patients wirh low-flow low-gradient AS most at risk

30
Q

AS Mx clinically stable low risk

A
  1. Surgical aortic valve replacement
    a. PLUS long term IE prophylaxis before dental procedures
    PLUS long term anticoag. w/vitamin K antagonist in prosthetic valve. NOT required in bioprosthetic valve unless there is AF.
    1. TAVR (preferred in less fit patients) awaiting long term data on durability, mortality
      a. PLUS long term IE prophylaxis before dental procedure
      PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF
31
Q

AS Mx clinically stable intermediate risk

A
  1. Surgical aortic valve replacement
    a. PLUS long term IE prophylaxis before dental procedures
    b. PLUS long term anticoag. w/vitamin K antagonist in prosthetic valve. NOT required in bioprosthetic valve unless there is AF.
    1. TAVR (preferred in less fit patients)
      a. PLUS long term IE prophylaxis before dental procedure
      PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF
32
Q

AS Mx clinically stable high risk

A
  1. REFERRAL for AV replacement (will offer sig. survival benefit so important to consider). Dobutamine stress test will show ability to improve EF and SV - will do better than patients without contractile reserve.
    a. PLUS long term IE prophylaxis before dental procedures
    b. PLUS long term anticoag. w/vitamin K antagonist in prosthetic valve. NOT required in bioprosthetic valve unless there is AF.
    1. TAVR
      a. PLUS long term IE prophylaxis before dental procedure
      PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF
33
Q

AS non surgical candidate

A
  1. TAVR
    a. PLUS long term IE prophylaxis before dental procedure
    b. PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF
    1. Medical therapy (patients with terminal illness or siginificant co-morbidity who may not benefit from from replacement)
      a. Target comorbs. CAD, lipids, htn, HF
      i. Vasodilators (nifedipine), ACEi, diuretics - but beware risk of syncope and hypotension

Balloon valvuloplasty (reasonable palliative option for highly symptomatic)

34
Q

AS clinically stable Asymptomatic

A

Severe: (based on pressure gradient, flow status (and its reversibility)

1. Clinical and echo follow up or referral to surgery
	a. Surgery indicated if: LVEF <50%, undergoing another cardiac surgery e.g. CABG or other valvular. 
	b. If not surgery repeat echo 6-12mly and r/v clincally

Non-severe:
Clinical FU and echo (every 3-5yrs, 1-2 if mod. stenosis)

35
Q

AS Cx

A 
Sudden death - valve surgery
HF: resultng from LVH and resultant diastolic dysfunction
pHTN leading to SOB and eventual RHF
Infective endocarditis
Stroke from calcific emboli - anticoag
Hypotension and syncope
36
Q

AS prognosis

A

Older patients with raised CV RFs are a/w more rapid haemodynamic regression
Doppler aortic jet velocity is best marker of progression
Prognosis excellent with replacement
Without AVR median survival is 1-3 years after Sx onset

37
Q

Arterial Ulcer management

A

Any patient with critical limb ischaemia (ie ulcers) should receive urgent vascular review.

Conservative: Lifestyle (smoking, weight loss, exercise, diabetes control)
Medical: Statin (simvastatin 40mg), antiplatelet (aspirin 75mg, clopi) and optimisation of BP and glucose. Analgesia for ischaemic pain
Surgical: angioplasty (+/- stenting) or bypass grafting for more severe disease. Any non healing ulcer despite good blood supply may be offered skin reconstruction with graft

38
Q

Arterial ulcer Cx

A

Infection: flucloxacillin 0.5-1g QDS PO or 1-2g IV every 6hrs
Can become cellulitus/erysipelas issue necrosis if untreated - will require IV and ?amputation
Worsening of ulcer: Management as listed +/- amputation

39
Q

Arterial ulcer prognosis

A

Left untreated can expect serious complications, and eventually amputation is likely
Treatment will improve blood flow to the area meaning that further worsening becomes less severe.
Outlook depends on patients ability to modify CV RFs and effectiveness of meds and surgery
Patients with arterial ulcers indicate severe arterial disease and are therefore a/w higher mortality than general population. And signficant morbidity a/w impact of ulcer.

Finals (10 decks)

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