Cardiovascular COPY Flashcards
Epidemiology thoracic aortic aneurysm
6th-7th decade MALE w/ hx HTN
Ascending aortic aneurysm = MC (60%) - 2/2 cystic medial necrosis
Descending aortic aneurysm (40%) - 2/2 atherosclerosis
CP thoracic aortic aneurysm
MC asymptomatic
If compression of local anatomy - back pain, flank pain, abd pain
Cold foot = thromboembolism preventing blood flow to area
PE thoracic aortic aneurysm
Commonly normal
Rupture = hemorrhagic shock (tachy, dec BP)
Dx thoracic aortic aneurysm
CT ANGIOGRAM = best imaging study
MRI if cannot receive contrast for CTA (renal fxn, preggers)
CXR may be first indication of aneurysm if large enough (widened mediastinum)
Treatment aortic aneurysm
Medical prevention:
- Beta-blockers (esp if a/w marfan synd) - decreased HR = limits rate of expansion
- ACEI/ARB - limit expansion
Surgery indications - catheter guided stent graft placement (closed endovascular repair) IF:
Symptomatic
Ascending > 5.5cm
Descending >6.5 cm
Abdominal aortic aneurysm risk factors (6)
Age > 60 HTN Smoking Atherosclerosis Other aneurysms HLD
CP AAA
**ASX until rupture
Rupture = back pain, flank pain, groin pain
Sudden cold or blue distal extremities - thromboembolism = limb ischemia
PE AAA
Vitals normal until rupture - then hemorrhagic shock (tachy, low BP)
ABD: Rupture = palpable pulsatile mass, distension, tenderness
Skin: Rupture = Cullen’s sign (periumbilical bruising) or Turner’s sign (bruising on flank/back)
Sudden cold or blue extremity 2/2 limb ischemia or thromboembolism
Indications for US to screen for AAA (4)
ABD ultrasound indicated for:
[1] Men 65-74 YO w/ hx smoking
[2] Siblings or offspring w/ AAA
[3] Pt w/ presence of thoracic AA or peripheral arterial aneurysms
[4] Pt w/ hypermobility syndromes (marfan, ehler-danlos)
Dx AAA
Abdominal US = BEST IMAGING STUDY
What size to we start following AAA closesly? At what size is intervention required?
Follow closely > 3cm
Intervene > 5-5.5 cm
(at risk for rupture)
Repair options AAA
Open surgery vs closed endovascular repair - closed preferred (lower short term morbidity)- based on anatomy & comorbidities
Follow up s/p repair of AAA
Long term surveillance w/ CTA or MRA after endovascular repair
If ruptures before scheduled surgery - has 50% mortality during surgery
Aortic dissection risk factors (6)
Review: dissection = tear in intima separation of intima from media = false lumen
RF: [1] HTN [2] Atherosclerosis [3] Collagen disorder [4] Aortic valve replacement [5] Aortic aneurysm [6] Cardiac catheterization
CP aortic dissection
Sudden severe sharp or tearing CP in posterior chest or back pain
HTN
Wide pulse pressure
Dx aortic dissection
Essentials for dx:
[1] clinical presentation c/w dissection
[2] evidence of dissection via imaging:
- CXR - probs the initial study done - will show widened mediastinum
- CTA - BEST IMAGING STUDY
Initial management of dissection
HR and BP control w/ esmolol, pain relief w/ morphine
Management of acute Stanford type A dissection
Stanford type A dissection = dissection starts at ASCEND-ing aorta = SURGICAL EMERGENCY
Endovascular (closed) repair vs open repair
Management of acute Stanford type B dissection
Stanford type B dissection = one that starts in descending aorta - less serious than type A
Try to medically manage first - esmolol, pain relief (morphine)
Indications for surgery - aortic rupture, end organ ischemia, continued hemorrhage into pleural or retroperitoneal space, continued HTN/pain despite management, early false lumen expansion, large single entry
Long term management of aortic dissection
Long term medical therapy - minimize aortic wall stress w/ lifelong BB therapy and goal BP <120/80
Serial imaging: 3mo - 6mo- 12mo then q1-2 years after
Indications for reoperation after aortic dissection repair
Recurrence of dissection
Aneurysm formation
Leakage at anastomosis or stent
Sources of arterial EMBOLI in acute limb ischemia 2/2 arterial occlusion?
Sources of arterial THROMBUS?
Arterial EMBOLI 2/2
Afib, MI, endocarditis, valvular disease, prosthetic valves
Arterial THROMBUS 2/2: vascular grafts, atherosclerosis, hypercoagulable state, entrapment syndrome, arterial trauma
MC vessels affected by arterial thrombus/emboli
Femoral 28%
Popliteal 17%
Arm 20%
Aortoiliac 18%
Risk factors acute limb ischemia 2/2 arterial occlusion
Afib Recent MI DVT Arterial trauma Large vessel aneurysm
RF of aortic dissection ([1] HTN [2] Atherosclerosis [3] Collagen disorder [4] Aortic valve replacement [5] Aortic aneurysm [6] Cardiac catheterization)
CP acute limb ischemia 2/2 arterial occlusion (6 P’s of limb ischemia)
CP depends on course of vessel occlusion, location, and presence or absence of collaterals for blood supply
6 P’s:
Pain, pallor, paralysis, pulselessness, poikilothermia, paresthesia
After how many hours does arterial occlusion result in irreversible damage?
After 6 hours
Dx acute limb ischemia 2/2 arterial occlusion
History and PE
Ankle brachial index testing - pressure in foot/pressure in arm (foot normally higher than arm).
Nl value 1.0-1.4. 0.8-0.9 = some arterial dz. 0.5-0.8 = moderate arterial disease, <0.5 = severe arterial disease
Vascular imaging (revascularization may supersede need for imaging study)
Indications for ABI (ankle brachial index) testing for PAD (peripheral arterial disease) & when to refer/intervene based on results
Indications:
Anyone > 70 YO
Every smoker > 50 YO
Every diabetic > 50 YO
Ankle Brachial Index Results:
Nl value 1.0-1.4
0.8-0.9 = some arterial dz - modify risk factors
- *0.5-0.8 = moderate arterial disease
- *<0.5 = severe arterial disease
Refer anyone < 0.9 w/ moderate arterial disease or severe arterial disease to vascular specialist
Treatment acute limb ischemia 2/2 arterial occlusion
Emergent or urgent revascularization -
Anticoagulation w/ IV heparin
Thrombolytic therapy
Thrombectomy, embolectomy
Endovascular surgery - angioplasty or stent placement
Open surgical intervention
- limb loss rate = 30%
- *Mortality rate = 20%
Follow up care after treatment of acute limb ischemia 2/2 arterial occlusion
Post-revascularization, must look into the cause of the clot
Chronic venous disease pathophysiology
Inadequate muscle pump function, incompetent
venous valves, elevated venous pressure
Venous pooling → edema → ischemia
Chronic venous disease types (3)
[1] Telangiectasia - dilated sm superficial veins = MOST COMMON FORM of chronic venous disease
[2] Varicose veins - dilated, tortuous superficial veins (MC greater saphenous)
[3] Chronic venous insufficiency - edema, skin changes, ulceration
CP Chronic venous disease
Leg pain, heaviness, swelling, muscle cramps, tightness, irritation, discoloration, bleeding from varicose veins or telangiectasia
PE Chronic venous disease
Pitting edema w/ dorsal pedal hump
skin changes - lipodermatosclerosis of the skin w/ discoloration (brawny, hemosiderin color)
Ulcers - irregular borders w/ surrounding induration & significant change
Dx Chronic venous disease
Venous duplex ultrasound - dx = retrograde flow > 0.5 s in duration (suggests venous reflux)
Treatment Chronic venous disease
Compression therapy - compression stockings or unna bot w/ 20-30 mmHg compression
Stasis dermatitis - steroid creams
Surgery - slcerotherapy, phlebectomy or ligation, laser ablation or radiofrequency ablation
Indications for surgical intervention Chronic venous disease (3)
[1] failure of conservative therapy
[2] bleeding from dilated veins
[3] phlebitis or thrombosis of superficial veins
Types of surgical options (3) for chronic venous disease and indications for each
[1] Sclerotherapy - for <4mm diameter veins
[2] Phlebectomy or ligation
[3] Endovenous laser ablation or readiofrequency ablation - for chronic venous dz of great saphenous vein w /intact deep venous system
Summary: SCLEROTHERPY = SMALL VEINS ONLY
ABLATION FOR LARGE VEINS (great saphenous)
When to refer person w/ Chronic venous disease to specialist
[1] significant saphenous vein reflux
[2] open wounds - send to wound clinic/specialist
[3] cosmetic concerns
PAD: Claudication - RF
Age Smoking Male Family hx Homocysteinemia Metabolic syndromes
PAD: Claudication - pathophys
Claudication = ischemic type pain with exercise (inc demand) due to supply/demand mismatch - relieved by rest
Atherosclerosis = MCC - fibromuscular dysplasia = renal artery stenosis, arterial embolism, vasculitis
CP PAD: Claudication
Extremity pain
Claudication (exertional pain cuased by supply/demand mismatch)
Ischemic rest pain (worse dz)
Dependent rubor (purple/red color on dependent areas)
Non-healing wound or ulcer (no bl flow to site = no healing)
Skin discoloration
Erectile dysfunction (any pt w/ ED should be screened for PAD)
PE PAD: Claudication
Smooth shiny skin, cool skin, pallor, cyanosis, mottling
Buerger test - leg elevated 30 deg x 30 sec - turn blue?
Lower extremity neuropathy
Dec/absent distal pulses
Bruits
Dry gangrene
Classification PAD: Claudication
WIFI classification - Wound, Ischemia, Foot Infection = lower extremity threatened limb loss classification system to assess risk for amputation risk w/in 1 year
Dx PAD: Claudication -
3 techniques/options & 5 essentials for dx
ABI:
- Ankle SBP/brachial SBP
- Normally Ankle SBP > brachial SBP
- Arterial dz = lowers lower ext BP, level lower is proportional to disease severity
Arterial duplex US:
- assesses pulses/bl flow in arteries
CTA/MRI:
- helps to localize where artery blockage is
Essentials for diagnosis:
[1] ischemic rest pain [2] tissue loss [3] ABI < 0.9, [4] abnormal pulse pressure, [5] claudication
Treatment PAD: Claudication
Conservative: modify RF, smoking cessation, consistent moderate exercise
Medical: ASA & Statin +/- cilostazole (minimizes platelet clotting, improves walking distance)
Surgery:
Revascularization - angioplasty, stent, endarectomy, open bypass
Indications for surgical intervention: PAD: Claudication
Disabling claudication, ischemic rest pain, ulceration, gangrene
Types of surgical interventions PAD: Claudication - how to decide based on classification
Surgical revascularization options:
Angioplasty, stent, endarterectomy, surgical open bypass
Use TASC classification to determine percutaneous vs open surgery
A/B lesions - less severe - percutaneous
C/D lesions - more severe - require open surgery (endarterectomy or bypass)
