Cardiovascular conditions 2 Flashcards
2nd half of cardiovascular conditions Valve and vascular conditions
What is aortic regurgitation?
Reflux of blood from the aorta into the left ventricle during diastole, due to a weakened aortic valve. Also known as aortic insufficiency
What causes aortic regurgitation?
Abnormal backflow of blood leads to pathological changes - left ventricular chamber enlargement and hypertrophy takes place to maintain a normal CO
What are the Risk factors for aortic regurgitation?
Aortic valve leaflet abnormalities or damage
- Bicuspid aortic valve
- Infective endocarditis
- Rheumatic fever
- Trauma
- Age
Aortic root/ascending aorta dilatation
- Systemic hypertension
- Aortic dissection
- Aortitis
- Arthritides (e.g. RA, seronegative arthritides)
- Connective tissue disease (Marfan’s, Ehler-danlos)
- Pseudoxanthoma elasticum, osteogenesis imperfecta
What are the symptoms for aortic regurgitation?
Chronic
- Initially asymptomatic
- Late symptoms of heart failue (e.g. exertional dyspnoea, orthopnoea, fatigue)
- Palpitations, angina and syncope, CCF
Acute
- Sudden cardiovascular collapse (left ventricle cannot adapt to rapid increase in end-diastolic volume)
What are the signs of aortic regurgitation?
Collapsing pulse
Wide pulse pressure
Thrusting and heaving displaced apex beat
Early diastolic murmur over the aortic valve region (heard best when sitting forward with breath help at top of expiration)
An ejection systolic murmur may also be heard due to increased flow across the valve
What Eponymous signs are seen in Aortic regurgitation?
- Austin-flint mid-diastolic murmur (Heard over apex)
- Quincke’s sign (pulsation on nail bed)
- De Musset’s sign (Head nodding with pulse)
- Becker’s sign (pupil and retinal artery pulsation)
- Muller’s sign (Pulsation of uvula)
- Corrigan’s sign (Pulsation in neck)
- Traube’s sign (Pistol shot [loud systolic and diastolic sounds] on auscultation of femoral arteries)
- Durozies’s sign (systolic and diastolic bruit heard on partial compression of femoral artery)
- Rosenbach’s sign (systolic pulsations of liver)
- Gerhard’s sign (Systolic pulsation of the spleen)
- Hill’s sign (Popliteal cuff systolic pressure exceeding brachial pressure >60)
What are the investigations for Aortic regurgitation?
CXR (Cardiomegaly, dilatation of ascending aorta, signs of pulmonary oedema)
ECG (LVH)
Echocardiogram (show underlying cause, or effects of aortic regurgitation, doppler echo)
Cardiac catheterisation with angiography (functional state of ventricles or the presence of coronary artery disease) - helps assess severity of lesion, aortic root anatomy, LV function
How can you see left ventricular hypertrophy on ECG?
Deep S in V1/2
Tall R in V5/6
Inverted T waves in Lead I, aVL, V5/6
Left axis deviation
What is Aortic stenosis?
Narrowing of the left ventricular outflow at the level of the aortic valve?
What causes aortic stenosis?
Stenosis can be secondary to Rheumatic heart disease (most common worldwide)
Congenital: Calcification of a congenital bicuspid aortic valve, william’s syndrome
Calcification/degradation of a tricuspid aortic valve in the elderly (Senile calcification)
What are the risk factors for Aortic stenosis?
Age > 60
CKD
What are the symptoms of aortic stenosis?
May be asymptomatic initially
Aortic stenosis in elderly patients with chest pain, exertional dyspnoea or syncope
Angina (due to an increased Oxygen demand of the hypertrophied left ventricle)
Syncope or dizziness on exercise
Symptoms of heart failure
What are the signs of Aortic stenosis?
Narrow pulse pressure with slow-rising pulse
Heaving, undisplaced apex beat
Ejection systolic murmur at the aortic area, radiation to the carotid artery
Second heart sound may be softened or absent
A bicuspid valve may produce an eejiton click
What are the investigations for aortic stenosis?
ECG
- P mitrale
- LVH
- LBBB or complete AV block
CXR
- Post-stenotic enlargement of ascending aorta
- Calcification of aortic valve
- LVH
Echocardiogram (diagnostic)
- visualises structural changes of the valves and level of stenosis (valvar, supravalvar or subvalvar)
- Estimation of aortic valve area and pressure gradient across the valve in systole
- Assess left ventricular function
Doppler echo can estimate gradient across valves
Severe stenosis if gradient >/= 50mmHg and valve area <1cm^2
If aortic jet velocity >4ms risk of complications is increased
What is Mitral regurgitation?
Retrograde flow of blood from left ventricle to left atrium during systole due to mitral valve insufficiency
What are the causes of mitral regurgitation?
Caused by mitral valve damage or dysfunction, which in turn could be caused by any of the following:
- Rheumatic heart disease
- Infective endocarditis
- Mitral valve prolapse
- Papillary muscle rupture or dysfunction (Secondary to IHD or cardiomyopathy)
- Chordal rupture and floppy mitral valve associated with connective tissue disease
- Functional: LV dilatation
- Annular calcificaiton
- Congenital
- Cardiomyopathy
- Appetite suppressants (fenfluramine)
What are the symptoms for Mitral regurgitation?
Acute MR - May present with symptoms of LVF
Chronic MR - asymptomatic or present with:
- Exertional dyspnoea
- Palpitations if in AF
- Fatigue
Mitral valve prolapse - asymptomatic or atypical chest pain or palpitations
What are the signs of mitral regurgitation?
Pulse may be irregularly irregular (AF) Laterally displaced apex beat with thrusting Pansystolic murmur - Loudest apex beat - Radiates to axilla - Soft S1 - S3 may be heard due to rapid ventricular filling Signs of LVF in acute Mitral valve prolapse - Mid-systolic click - Late systolic murmur - The click moves towards S1 when standing and away when laying down
What investigations are done for Mitral regurgitation?
ECG (Normal, may show AF or P mitrale)
CXR
- Acute MR shows signs of LVF
- Chronic (Left atrial enlargement, cardiomegaly, mitral valve calcification, pulmonary oedema)
Echo (Perform 6-12 months)
Doppler Echo
Cardiac catheterisation to confirm diagnosis, exclude other valve disease, assess CAD
What is Mitral Stenosis?
Mitral valve narrowing causes obstruction to blood flow from the left atrium to the left ventricle
What causes Mitral stenosis?
Mainly: Rheumatic heart disease Rarer causes: - Congenital mitral stenosis - Mucopolysaccharidoses - Endocardial fibroelastosis - Prosthetic valve - SLE - Rheumatoid arthritis - Endocarditis - Atrial myxoma
What are the symptoms of Mitral stenosis?
Fatigue Exertional dyspnoea Chest pain Orthopnoea Palpitations (related to AF) Systemic emboli Rarer symptoms (chronic bronchitis type picture) - Cough -Haemoptysis - Hoarseness caused by compression of left recurrent laryngeal nerve by an enlarged left atrium
What are the signs of Mitral stenosis?
Peripheral cyanosis
Malar flush (decreased CO)
Irregularly irregular pulse
Low volume pulse
Apex beat in right place and tapping
Parasternal heave (RV hypertrophy, secondary to pulmonary hypertension)
Loud S1 with opening snap
Mid-diastolic murmur heard best in expiration with patient laying on their left
Graham steel murmur may occur
Evidence of pulmonary oedema on lung auscultation
What are the investigations for mitral stenosis?
ECG
- Normal
- May see P mitrale
- May see AF - Evidence of RVH if severe pulmonary hypertension)
CXR
- Left atrial enlargement [double shadow in Right cardiac sillhouette]
- cardiac enlargemen
- pulmonary congestion/oedema
- Mitral valve calcification [occurs in rheumatic cases])
Echocardiography
- Assess functional and structural impairments
- Transoesophageal echocardiogram (TOE) gives a better view
Cardiac catheterisation
- Measure severity of heart failure
What is tricuspid regurgitation?
Backflow of blood from the right ventricle to the right atrium during systole
What causes tricuspid regurgitation?
Congenital
- Ebstein’s anomaly
- Cleft valve in ostium primum
Functional
- Consequence of Right ventricular dilatation (e.g. due to pulmonary hypertension)
- Valve prolapse
Rheumatic heart disease
Infective endocarditis (IV drug user)
Other: Carcinoid syndrome, traume, cirrhosis, iatrogenic
Drugs e.g. Ergot-derived dopamine agonists i.e. bromocriptine, cabergoline, pergolide
What are the risk factors for Tricuspid regurgitation?
Right ventricular dilatation from pulmonary hypertension for left heart failure Rheumatic heart disease Infective endocarditis Carcinoid syndrome Permanent pacemaker Congenital
What are the symptoms of Tricuspid regurgitation?
Fatigue Breathlessness Palpitations Headaches Nausea Anorexia Epigastric pain made worse by exercise Jaundice Lower limb swelling Ascites Oedema
What are the signs of tricuspid regurgitation?
Irregularly irregular pulse Raised JVP (Giant V waves) Palpation Auscultation - Pansystolic murmur - Louder on inspiration (Carvallo sign) - Loud P2 component of second heart sound Chest exam: - Pleural effusion - Cases of pulmonary HTN Abdominal exam: - Palpable liver - Ascites - Jaundice
What investigations are done for Tricuspid regurgitation?
FBC LFT Cardiac enzymes Blood culture ECG - P pulmonale [R atrial hypertrophy] Echo - Extent of regurgitation can be estimated using doppler US - May show valve prolapse and RV dilation Right heart catheterisation - Rarely needed
What is aortic dissection?
A condition where a tear in the aortc intima allows blood to surge in the aortic wall, causing a split between inner and outer tunica media, creating a false lumen.
How do you classify aortic dissection?
Type A: Ascending aorta (most common - 70%)
Type B: Descending aorta (distal to left subclavian artery - 30%)
What causes aortic dissection?
Preceded by degenerative changes in the smooth muscle of aortic media
Expansion of false lumen leads to obstruction of branches of the aorta: Subclavian, carotid, coeliac and renal arteries
- Hypoperfusion of target organs give rise to symptoms
- Unequal arm pulses and BP
- Anterior spinal artery (acute limb ischaemia, paraplegia)
- Renal arteries (anuria)
- If moves proximally, develop aortic valve incompetence, inferior MI and cardiac arrest
What are the risk factors for aortic dissection?
Hypertension Aortic atherosclerosis Connective tissue disease (e.g. Marfan's, Ehlers-Danlos, SLE) Congenital cardiac abnormalities (coarctation of the aorta) Aortitis Iatrogenic Trauma Crack cocaine
What are the symptoms of Aortic dissection?
Main symptom: Sudden central 'tearing' pain, may radiate to the back in between shoulder blades (can mimic MI) Other symptoms caused by obstruction of branches of aorta: - Hemiparesis, dysphasia, black out - Chest pain - Ataxia, loss of consciousness - Paraplegia - Severe abdo pain - Anuria, Renal failure
What are the signs of aortic dissection?
Murmur on back (below left scapula) Hypertension Blood pressure difference between 2 arms Wide pulse pressure Hypotension suggests tamponade - Check for pulsus paradoxus - Include: Tamponade, pericarditis, chronic sleep apnoea, obstructive lung disease Signs of aortic regurgitation (high volume collapsing pulse, early diastolic murmur over aortic area)
What are the investigations of aortic dissectoin?
FBC Cross-match 10 units of blood U&Es (check renal function) Clotting screen CXR (Widened mediastinum) ECG ( Maybe signs of LVH and inferior MI) Echo (TOE allows visualisation)
What is an Abdominal Aortic Aneurysm?
A localised enlargement of the abdominal aorta such that the diameter is >3cm or >50% larger than normal diameter.
A true aneurysm is an abnormal dilatation involving all layers of the arterial wall
- Can be fusiform [most] or sac-like
What is a pseudo aneurysm?
False aneurysms involving a collection of blood in the outer layer only (adventitia) which communicates with the lumen e.g. after trauma
What causes an AAA?
No specific causes
Unruptured aneurysms occur due to degeneration of elastic lamellae and smooth muscle loss
Ruptured AAAs leak into the retroperitoneal space (relatively stable) or intraperitoneal space (results in shock)
What are the Risk Factors for AAA?
Severe atherosclerotic damage to aortic wall
Family history
Smoking
Male
Age
Hypertension
Hyperlipidaemia
Connective tissue disorders (marfan’s, Ehlers-Danlos)
Inflammatory disorders (Behcets, Takayasu arteritis)
What are the symptoms of AAA?
Unruptured - No symptoms - Incidental finding - May have pain in back, abdomen, loin or groin Ruptured - Pain in abdomen - intermittent or continuous - Pain may be sudden or severe - Syncope - low bp - Shock
What are the signs of AAA?
Pulsatile and laterally expansile mass on bimanual palpitation of the abdominal aorta
Abdominal bruit
Retroperitoneal haemorrhage (Can cause Grey-turner’s)
Hypotension
Tachycardia
What are the investigations for AAA?
FBC Clotting screen Renal function Liver function Cross-match Doppler US CT with contrast MRI angiography
At what size AAA is needed for management?
Women - 5cm
Men - 5.5cm
What are Arterial ulcers?
A localised are of drainage and breakdown of skin due to inadequate arterial blood supply.
Usually seen on feet of patients with severe atheromatous narrowing of the arteries supplying the legs
What causes arterial ulcers?
Ulcers are caused by a lack of blood flow to the capillary beds of the lower extremities
What are the risk factors for arterial ulcers?
Coronary heart disease History of stroke or TIA Diabetes mellitus Peripheral artery disease (e.g. intermittent claudication, critical limb ischaemia) Obesity and immobility
What are the symptoms of arterial ulcers?
Often distal (Dorsum of foot or between toes)
Punched-out appearance
Often elliptical with clearly defined edges
Ulcer base contains grey, granulation tissue
Night pain - hallmark of arterial ulcers (worse when supine, relieved by dangling leg off end of bed)
What are the signs of arterial ulcers?
Night pain Punched out appearance Hairlessness Pale skin Absent pulses Nail dystrophy Wasting of calf muscles
What investigations are done for arterial ulcers?
Duplex ultrasonography of lower limbs - assess patency of arteries and potential for revascularisation or bypass surgery
ABPI
Percutaneous angiography
ECG
Fasting serum lipids, fasting blood glucose and HbA1c (diabetes is major RF)
FBC (anaemia can worsen ischaemia)
What is DVT?
Formation of thrombus within deep veins (most commonly in calf or thigh)
What causes DVT?
Deep veins in the legs are more prone to blood stasis hence clots are more likely to form
Virchow’s triad
What is Virchow’s triad?
Stasis of blood flow
Endothelial injury
Hypercoagulability
What are the Risk factors for DVT?
Medical hospitalisation in last 2 months Major surgery within 3 months Lower-extremity trauma Severe trauma Factor V lieden Smoking Obesity Family history Use of specific drugs (Contraceptive pill, tamoxifen, thalidomide) Increasing age Medical comorbidity
What are the symptoms of DVT?
Swollen limb
May be painless
Mild fever
What are the signs of DVT?
Local erythema, warmth and swelling, tenderness Difference in leg circumference Varicosities (Swollen/tortuous vessels) Skin colour changes Homan's sign Pitting oedema Mild fever Risk stratified using Well's criteria
What is Homan’s sign?
Forced passive dorsiflexion of the ankle causes deep calf pain
What is Well’s score?
Active cancer Bedridden >3 days or major surgery in last 12 weeks Calf swelling >3cm Collateral veins present Entire leg swollen Localised tenderness along the DVT Pitting oedema Paralysis, paresis Previously documented DVT Alternative diagnosis as likely or morye likel
What are the investigations for DVT?
Well's score (if <2 - D-dimer) - If normal excluded - If raised do duplex USS If pregnant do duplex USS straight away INR and aPTT Urea and Creatinine LFTs FBC if PE suspected (ECG, CXR, ABG)
How do you manage DVT?
Anticoagulation
Offer LMWH or Fondaparinux
- Severe renal impairment / CKD stage 4/5 offer unfractionated heparin (UFH) with dose adjustments
- Increased risk of bleeding consider UFH
LMWH those with active cancer and confirmed proximal DVT or PE
Oral anticoagulant with confirmed DVT or PE - traditionally warfarin, now NOACs (rivaroxaban, dabigatran and apixaban)
Below-knee stockings manages symptoms
Inferior vena cava filters to those with DVT or PE and no anticoagulation available
Look for thrombophilia in those with no cause under 40
Over 40, think of cancer
What are the complications of DVT?
Pulmonary embolism Bleeding during initial treatment Heparin-induced thrombocytopenia Heparin resistance/aPTT confounding Post-thrombotic syndrome Bleeding during long-term/extended term Osteoporosis due to heparin treatment
What is post-thrombotic syndrome?
20-40% of those with DVT
Presents with pain, swelling, hyperpigmentation, dermatitis, ulcers, gangrene and lipodermatosclerosis
Risks: Older age, obesity, history of previous ipsilateral DVT
Low risk in asymptomatic DVT
What is dyslipidaemia?
Hypercholesterolaemia
Raised total cholesterol and/or low-density lipoprotein cholesterol or non-high density lipoprotein cholesterol in the blood.
What causes dyslipidaemia?
Lipid travels in blood packaged with proteins as lipoproteins
4 classes: Chylomicrons, VLDL, LDL, HDL
What are the types of dyslipidaemia?
Those with Raised high-LDL: Familal primary hyperlipidaemia, secondary: Cushing’s, hypothyroidism, nephrotic syndrome or cholestasis.
Mixed hyperlipidaemia: Both LDL and TG high, due to T2DM, metabolic syndrome, alcohol abuse, chronic renal failure
What are the risk factors for Dyslipidaemia?
Insulin resistance and type 2 diabetes mellitus Excess body weight (BMI>25) Hypothyroidism Cholestatic liver disease Cigarette smoking Nephrotic syndrome Use of certain medications
Which medications cause dyslipidaemia?
Thiazide diuretics Oral Oestrogen Glucocorticoids Anabolic steroids Atypical antipsychotics such as: Olanzapine
What are the symptoms for Dyslipidaemia?
No own symptoms but does lead to symptomatic vascular disease such as: CAD, stroke and PVD
What are the signs for dyslipidaemia?
Corneal arcus Xanthomas Metacarpophalangeal joints Xanthelasma Familial hypercholesterolaemia Milky white appearance of retina
What are the investigations for dyslipidaemia?
Lipid profiles
Serum TSH
Lipoprotein (>50mg/dL)
What is the management for dyslipidaemia?
Lifestyle advice (BMI 20-25; Diet of <10% calories from fats, Exercise)
Treatments differ for familial or secondary hyperlipidaemia
Medications
- 1st: Simvastatin
- 2nd: Fibrates e.g. Bezafibrate or cholesterol absorption inhibitors e.g. ezetimibe
(Hypertriglyceridaemia responds best to fibrates, nicotinic acid or fish oil)
What are the treatment priorities for dyslipidaemia?
Using statins in primary prevention
1st: All those with known CVD
2nd: All with DM
3rd: Those with 10 years risk of CVD >20%
Aim for target plasma cholesterol of less than or equal to 4
What are the complications for dyslipidaemia?
Ischaemic heart disease Periphreral vascular disease Acute coronary syndrome Stroke Erectile dysfunction
What is Gangrene?
Gangrene tissue necrosis, either wet with superimposed infection, dry or gas gangrene (due to poor vascular supply)
What is dry gangrene?
Necrosis without infection
What is wet gangrene?
Tissue death and infection
What is gas gangrene?
Subset of necrotising myositis caused by spore-forming clostridial species
What causes gangrene?
Tissue ischaemia and infarction
Physical trauma
Thermal injury
Gas gangrene is caused by clostridia perfringens
What are the risk factors for Gangrene?
Diabetes Peripheral vascular disease Atherosclerosis Smoking/alcohol Renal disease Leg ulcers Malignancy Immunosuppression Steroid use Puncture/surgical wounds Trauma
What are the symptoms of gangrene?
Pain
Discolouration of affected area (black)
Often affects extremities of areas subject to high pressure
Gas gangrene: Rapid onset of myonecrosis, muscle swelling, gas production, sepsis, severe pain
What are the signs of gangrene?
Painful area - erythematous region around gangrenous tissue
Gangrenous tissue - Black due to haemoglobin break down products
Wet gangrene - Tissue becomes boggy with pus and smelly caused by active anaerobes
Gas gangrene - spreading infection and destruction of tissues causes overlying oedema, discolouration and crepitus
What are the investigations for gangrene?
FBC U&Es Glucose CRP Blood culture Wound swab Pus/fluid aspirate Xray of affected area - may see gas gangrene
What is Hypertension?
Systolic pressure >140mmHg and/or diastolic >90mmHg on 3 seperate occasions
What is malignant hypertension?
> 200/>130 mmHg
What causes hypertension?
Disturbance of auto-regulation Excess sodium intake Renal sodium retention Dysregulation of the RAS axis with elevated plasma renin activity Increased sympathetic drive Increased peripheral resistance Endothelial dysfunction Cell membrane transport perbutations Insulin resistance/hyperinsulinaemia
What are secondary causes of Hypertension?
Renal artery stenosis Chronic glomerulonephritis Chronic pyelonephritis PKD Chronic renal failure Renovascular disease Diabetes mellitus Hyperthyroidism Cushing's syndrome Conn's syndrome Hyperparathyroidism Phaeochromocytoma CAH Acromegaly Coarctation of the aorta Increased intravascular volume Sympathomimetics Corticosteroids COCP Pre-eclampsia Isolated systolic hypertension (due to stiffening of large arteries) Malignant (Rapid rise in BP leading vascular damage, usually severe HTN + B/L retinal haemorrhages
What are the risk factors for Hypertension?
Obesity Aerobic exercise <3 times a week Moderate/high alcohol intake Metabolic syndrome Diabetes mellitus Black ancestry Age >60 years Family history of HTN or CAD Sleep apnoea Sodium intake >1.5g/day Low fruit and vegetable intake Dyslipidaemia
What are the symptoms of hypertension?
Often asymptomatic Symptoms of complications Symptoms of cause Accelerated or malignant hypertensiton - Scotomas (visual field loss) - Blurred vision - Headache - Seizures - Nausea and vomiting - Acute heart failure
What are the signs of hypertension?
Blood pressure measured 2/3 times
Examination reveals information on the causes:
- Radiofemoral delay
- Renal artery bruit
- Palpable kidneys
- Signs of phaeochromocytoma or Cushing’s
- End organ damage (LVH, Retinopathy, proteinuria)
- S4 and heave
How is hypertensive retinopathy classified?
Using Keith-Wagner classification
- Grade I: Silver wiring
- Grade II: Silver wiring + AV nipping
- Grade III: Flame haemorrhage, sometimes cotton wool spots
- Grade IV: Papilloedema
What are the investigations for hypertension?
U&Es Glucose Lipids Check Renin, aldosterone and 24hr urine for catecholamine Exclude secondary causes Dipstick (Bloods and protein) Ambulatory BP monitoring Others if secondary cause suspected: - Renal angiography - Urinary free cortisol - Renin - Aldosterone - MR aorta
What is the management of Hypertensoin?
Conservative management
- Stop smoking
- Lose weight
- Reduced alcohol intake
- Reduced dietary sodium
Medicines.
What is the medicines used for hypertension (140-159/90-99)?
Black patients or >55:
- CCB or thiazide
- Then add ACEi or ARB or combine thiazide and CCB
- Then CCB + Thiazide + ACEi/ARB
Non-black patients:
- ACEI/ARB
- Then add CCB or thiazide
- Then CCB + Thiazide + ACEi/ARB
If still needed: Spironolactone, Beta blockers
What medicines are used if their BP >160/100?
All patients start with 2 drugs
- CCB / Thiazide + ACEi / ARB
- If needed: CCB + Thiazide + ACEi
What is the target BP you are aiming for?
<80: 135/85
80
What is used for severe hypertension management?
Atenolol and Nifedipine
How do you manage acute malignant hypertension?
IV beta blocker
Labetolol
Hydralazine sodium nitropusside
What is the problem with rapidly lowering BP?
Causes cerebral infarction
What are the comlpications for hypertension?
Coronary artery disease Cerebrovascular accident Left ventricular hypertrophy Congestive heart failure Retinopathy Peripheral artery disease Chronic kidney disease Aortic dissection Malignant hypertension
What is Peripheral vascular disease?
Occurs due to atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors
What causes peripheral vascular disease?
Atherosclerosis in peripheral arteries
Intermittent claudication and ciritcal limb ischaemia, seperate to acute limb ischaemia.
Leads to tissue loss (Gangrene/ulceration)
What are the risk factors for peripheral vascular disease?
Smoking Diabetes Hypertension Hyperlipidaemia Physical inactivity Obesity Family history Renal failure
What are the symptoms of peripheral vascular disease?
Intermittent claudication
Which vein is affected in calf claudication and buttock claudication?
Calf claudication = Femoral disease
Buttock claudication = Iliac disease
What are the signs of peripheral vascular disease?
Acute limb ischaemia - Pain - Pale - Pulseless - Paralysis - Paraesthesia - Perishingly cold Others: - Atrophic skin - Hairless - Punched-out ulcers (often painful) - Colour change when raising leg (Buerger's angle)
What investigations are done for peripheral vascular disease?
History + Vascular exam First line: ABPI - Normal is 1-1.2 - Peripheral arterial disease is 0.5-0.9 - Critical limb ischaemia is <0.5 - Tissue loss is <0.2 THEN colour duplex ultrasoun - Non-invasive - shows stenosis GOLD STANDARD: MRI/CT ANGIOGRAM Blood pressure FBC Fasting glucose Lipid levels ECG Thrombophilia screen U&E
What is Pulmonary hypertension?
An increase in mean pulmonary arterial pressure which can be caused by or associated with a wide variety of other conditions
What causes pulmonary hypertension?
- Idiopathic
- Left ventricular failure
- Lung disease
- Thromboses/Emboli in lungs
What are the risk factors for pulmonary hypertension?
Obesity
Family history of pulmonary hypertension
Cocaine use
Predisposing diseases (COPD/Interstitial lung disease/Fibrosis)
What are the symptoms for pulmonary hypertension?
Progressive breathlessness Weakness/tiredness Exertional dizziness and syncope Angina and tachyarrhythmias Late stage - oedema and ascites
What are the signs of pulmonary hypertension?
Right ventricular heave Loud pulmonary second heart sound Murmur (Pulmonary regurgitation) Tricuspid regurgitation Raised JVP Peripheral oedema Ascites
What are the investigations for pulmonary hypertension?
CXR (exclude lung disease) ECG - RVH and strain Pulmonary function tests LFTs Lung biopsy - interstitial lung disease Echocardiography - assess right ventricular function Right heart catheterisation
What are varicose veins?
Varicose veins are subcutaneous, permanently dilated veins 3 mm or more in diameter when measured in a standing position
What are the causes of varicose veins?
Venous valve incompetence is most common aetiology
Blood pools left when valves don’t function properly, leading to increased pressure and distention of the veins
Primary causes:
- Genetic or developmental weakness in vessel walls.
- Results in increased elasticity, dilatation and valvular incompetence
- Congenital valve absence.
Secondary causes:
- Pregnancy
- DVT
- Ovarian tumours
- Pelvic malignancy
- Ovarian cysts
- Ascites
- Lymphadenopathy
- Retroperitoneal fibrosis
What are the risk factors for varicose veins?
Increasing age Family history Female sex Increasing number of births DVT Occupation with prolonged standing Obesity
What are the symptoms of varicose veins?
Complaining about cosmetic appearance Aching/cramps in the legs Aching worse at end of day Swelling Tingling Heaviness and restless legs Itching Bleeding Infection Ulceration
What are the signs of Varicose veins?
- Inspect when standing
- Oedema, eczema, phlebitis, atrophies’ blanche, lipodermatosclerosis
- Trendelenburg test (allow localisation of sites of valvular incompetence)
- Signs of venous insufficiency (Varicose eczema, haemosiderin staining, atrophie blanche, lipodermatosclerosis, oedema, ulceration)
What are the investigations for varicose veins?
Duplex ultrasound - assess for reversed flow, roughly, valve closure time >0.5 seconds indicates reflux while valve closure time >1 second
What is the management for varicose veins?
Symptomatic superficial vein insufficiency
- 1st line: Graduated compression stockings
- If ineffective: Phlebotomy or sclerotherapy
- If effective: Ablative procedures +/- phlebotomy or sclerotherapy
For Deep vein insufficiency (Phlebotomy and compression stockings)
What are the management types for DVT?
Conservative
Endovascular treatment
Surgery
What are the conservative management for DVT?
Exercise - improves skeletal muscle pump
Elevation of legs at rest
Support stiockings
What are the endovascular treatments for DVT?
Radiofrequency ablation: Catheter inserted into vein and heated
Endovenous laser ablation
Injection sclerotherapy
Phlebectomy
What are the Surgical treatments for DVT?
Saphenofemoral ligation
Stripping of the long saphenous vein (groin to upper calf)
Avulsion of the varicosities
Post op: Bandage legs tightly and elevate for 24 hours
What are the complications for varicose veins?
Chronic venous insufficiency Haemorrhage Venous ulceration Lipodermatosclerosis Haemosiderin deposition DVT Pulmonary embolus Paraesthesia from injury to sural nerve
What are venous ulcers?
Large, shallow, sometimes painful ulcers usually found superior to the medial malleoli.
They are caused by incompetent valves in the lower limbs leading the venous stasis
What causes venous ulcers?
Associated with varicose veins, varicose enzymes, haemosiderin pigmentation, atrophie blanche and venous flare
Oedema of lower leg present and chronic venous stasis lead to warty hyperplasia
Caused by incompetent valves in the veins of the lower leg, especially in perforaters. Causes blood to be squeezed out into superficial veins, when calf muscles are contracted, instead of upwards to the heart.
Dilation of superficial veins occurs (varicosities) and the subsequent raised venous pressure resulting in oedema, venous eczema and ulceraton
What are the risk factors for venous ulcers?
Obesity Immobility Recurrent DVT Varicose veins Previous injury / surgery to the leg Age
What are the symptoms of venous ulcers?
Large, shallow, relatively painless ulcer with an irregular margin above the medial malleoli
What are the signs of venous ulcers?
Stasis eczema
Lipodermatosclerosis
Haemosiderin deposition
What are the investigations of venous ulcers?
ABPI (<0.8)
Measure surface area of ulcer
Swab for microbiology
Biopsy (if possibly mahorlin’s ulcer)
What is Majorlin’s ulcer?
Aggressive squamous cell carcinoma, presenting in an area of previously traumatized, chronically inflamed , or scarred skin
How do you manage venous ulcers?
Graduated compression (reduced venous stasis)
Debridement and cleaning
Antibiotics (if infected)
Topical steroids
What are the complications of venous ulcers?
Recurrence
Infection
