Cardiovascular - Level 3 Flashcards
Definition of accelerated hypertension?
- Severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilledema (swelling of the optic nerve);
- Also known as malignant hypertension
Epidemiology of accelerated hypertension?
- Average age is 40 years
- Men more commonly
- Black ethnicity
Causes of accelerated hypertension?
o Renovascular disease – renal artery stenosis o Renin-secreting neoplasms o Renal vasculitis – scleroderma, polyarteritis, SLE o Phaeochromocytoma o Cocaine abuse o MAOIs, COCP o Glomerulonephritis o Pre-eclampsia/Eclampsia o Hyperthyroidism/Hypothyroidism o Cushing’s syndrome o Acromegaly
Symptoms of accelerated hypertension?
- May be asymptomatic
- Symptoms
o Headache
o Fits
o N&V
o Visual disturbances
o Chest pain
o Neurological changes
Initial investigations to perform in accelerated hypertension?
- Blood pressure – lying and standing and in both arms
- Fundoscopy
- Bloods
o FBC, clotting, U&E, LFTs, TFTs, glucose, troponin - Urine dipstick
- CXR – cardiac size, cardiac failure
- ECG – LVH
Investigations to find cause of accelerated hypertension?
o CT/MRI of head/kidneys o Plasma renin o Plasma aldosterone o 24-hour urine VMA and metanephrin levels o ANA
Referral in people with accelerated hypertension?
- Refer for same-day specialist assessment if >180/120 and:
o Signs of retinal haemorrhage or papilloedema OR
o Signs of new onset confusion, CP, HF, AKI
Management of accelerated hypertension?
- Reduce BP over 24-48 hours
o IV labetalol (alternatives nitroprusside /nicardipine)
Every 10 minutes according to response
o If LV failure – IV furosemide, GTN and nifedipine
Definition of pericarditis?
- Acute inflammation of pericardium (membranous sac surrounding heart) and can co-exist with myocarditis
PAthology of pericarditis?
o Pericardial vascularisation and infiltration with leukocytes
o Exudate and adhesion within pericardial sac and serous effusion
Epidemiology of pericarditis?
o 5% of ED visits with chest pain
o Usually post-viral or idiopathic
o Can become recurrent if >1 episode
Causes of pericarditis?
o Myocardial infarction (including Dressler’s syndrome)
o Viral - Coxsackie, Echovirus, EBV
o Bacterial - Pneumococcus, meningococcus, haemophilus, staphylococcus, TB
o Neoplasms, Uraemia, SLE, rheumatoid arthritis
o Drug - Hydralazine, procainamide
Symptoms of pericarditis?
o Chest pain
Sharp, central or retrosternal
Radiates to neck, trapezius ridge or shoulders
Worse on deep inspiration, exercise, swallowing and lying flat
Relieved by sitting up and leaning forward
o May have cough, chills, weakness
Signs of pericarditis?
Pericardial friction rub
Often intermittent, positional and elusive
Louder during inspiration and may be heard on systole and diastole
Scratchy superficial sound, loudest in midline and lower left parasternal edge
Low grade fever
Tachycardia
Tachypnoea
Investigations of pericarditis?
ECG
o Concave-upward ST segment elevation
o PR depression in limb and pre-cordial leads
o Reciprocal PR elevation and ST depression in aVR
CXR
o Flask-shaped cardiac silhouette sign of large pericardial effusion
Bloods
o FBC, U&Es, CRP, ESR and troponin
Blood cultures if evidence of sepsis
Echocardiogram
o If pericardia effusion or cardiac tamponade suspected
Management of pericarditis?
o Benign or self-limiting
o Rest
o High dose NSAIDs (naproxen 250mg TDS/QDS) +/- PPI cover
Give 7-14 days then taper off
Management of pericardial effusion in pericarditis?
o Senior help, immediate echocardiogram
o Pericardiocentesis under US and then drainage or open thoracotomy
Management of constrictive pericarditis in pericarditis?
o Pericardial resection
Prognosis of pericarditis?
- Most improve over days to weeks
- Recurrence in around 1 in 3 patients
Definition of pericardial effusion?
- Accumulation of fluid in pericardial sac
Causes of pericardial effusion?
o Viruses (Coxsackie, flu, EBV, mumps, varicella, HIV)
o Bacteria (pneumonia, rheumatic fever, TB, staphs)
o Fungi
o MI and Dressler’s syndrome
o Drugs – Procainamide, hydralazine, penicillin
o Others – uraemia, RA, SLE, trauma, surgery, malignancy
Symptoms of pericardial effusion?
o SOB
o Symptoms of pericarditis – sharp chest pain, radiating to scapular ridge, relieved by sitting up and worsening with inspiration
o Syncope
o Cough
Signs of pericardial effusion?
o Raised JVP (prominent X descent)
o Bronchial breathing at left base (Ewart’s sign)
o Look for signs of cardiac tamponade
Tachycardia, pulsus paradoxus, hypotension, raised JVP, muffled S1 and S2
Investigations of pericardial effusion?
- Bloods
o FBC, U&Es, CRP, cardiac enzymes
o Blood cultures if needed - CXR
o Enlarged, globular heart - ECG
o Low voltage QRS complexes and alternating QRS morphologies - Echocardiogram
o Echo-free zone surrounding heart
Management of pericardial effusion?
- Treat cause
- Oxygen if needed
- Pericardiocentesis
o Therapeutic in cardiac tamponade
o Pericardial fluid sent for culture, ZN stain/TB culture and cytology
Complications of pericardial effusion?
o Pericardial tamponade
o Chronic pericardial effusion
Definition of cardiomyopathy?
myocardial disorder in which myocardium is structurally or functionally abnormal without coronary artery disease, hypertension, valvular or congenital heart disease
Causes of cardiomyopathy?
o Primary – idiopathic and not attributed to a cause
o Secondary – associated with:
CKD, cirrhosis, obesity, stress
SLE/sarcoidosis/amyloidosis
Diabetes, thyroid, acromegaly, haemochromatosis
Cocaine, alcohol, chemotherapy
Trypanosomiasis, viruses
Malnutrition, deficient Vit B, calcium, magnesium
Hypertension, IHD, valvular disease
Duchenne
Peripartum cardiomyopathy – between last month and 5-6 months after delivery
Definition of dilated cardiomyopathy?
o Ventricular chamber enlargement and contractile dysfunction with normal LV wall thickness
o RV may be dilated and dysfunctional too
Epidemiology of dilated cardiomyopathy?
- Most frequent indication for heart transplant
- Prevalence – 0.2%
- More common in males
Associations of dilated cardiomyopathy?
o Ischaemia o Genetic (Barth syndrome) o Alcohol o Thyrotoxicosis o RA, SLE o Drugs – cocaine, amphetamines, heroin o Peri/Post-partum o Haemochromatosis, sarcoidosis, amyloidosis o Virus – adenovirus, CMV, coxsackie, Lyme, toxoplasmosis
Symptoms of dilated cardiomyopathy?
o Asymptomatic
o Heart failure symptoms – exertional SOB, orthopnoea, PND, weakness, fatigue, oedema
o AF
Signs of dilated cardiomyopathy?
o Tachycardia o AF o Low BP o Raised JVP o Displaced, diffuse apex beat o Loud 3rd and/or 4th HS o Mitral/Tricuspid regurgitation o Signs of heart failure – pleural effusion, oedema, hepatomegaly, ascites
Investigations of dilated cardiomyopathy?
- ECG
o Tachycardia, non-specific T wave changes, LBBB - Bloods
o FBC, U&E, LFT, TFTs, BNP, troponins - CXR
o Cardiomegaly, pulmonary oedema - Echocardiogram
o Globally dilated hypokinetic heart with low EF, may have MR/TR, LV mural thrombus
Diagnostic investigations of dilated cardiomyopathy?
- Cardiac Catheterisation
- Cardiac MRI
- Endomyocardial biopsy
Investigations to find cause of dilated cardiomyopathy?
o Genetics, serologies, electrophysiology, exercise testing, iron levels, vitamin levels, ANA
Management of dilated cardiomyopathy - pharmacological management?
- Bed rest
o Diuretics
Furosemide - if symptomatic with fluid overload
Spironolactone if low K with furosemide
o ACEi
o Beta-blockers
o Digoxin
Inadequate response to ACE inhibitors and diuretics if AF or tachycardia
Management of dilated cardiomyopathy - surgical management?
- Pacing Support
o Biventricular pacing (CRT)
If NYHA class 3 or 4 with QRS prolongation
With ICD - Surgical
o Heart transplant
80% one-year survival
o LV assist devices
Complications of dilated cardiomyopathy?
o Progressive heart failure
o Sudden cardiac death
Definition of hypertrophic cardiomyopathy?
o Autosomal dominant genetic disorder
o Disorganised cardiac myocytes due to mutations in genes of sarcomeric proteins (cardiac B-myosin, troponin, A-tropomyosin)
o LV hypertrophy, impaired diastolic filling and abnormalities of mitral valve
o Can cause obstruction of LVOT (HOCM), diastolic dysfunction, myocardial ischaemia and risk of tachyarrhythmias
Epidemiology of hypertrophic cardiomyopathy?
- Most common CV genetic disease
- Prevalence 0.2%
- Men, 20-30 years old, Black people
- Most common cause of SCD in young people and athletes
Symptoms of hypertrophic cardiomyopathy?
- Mostly asymptomatic
o SOB, chest pain, palpitations, syncope
o Sudden death – due to arrhythmias or obstruction of LVOT
Signs of hypertrophic cardiomyopathy?
o Forceful apex beat
Double impulse if LVOT obstructed
o Late ejection systolic murmur (augmented by standings or Valsalva)
Left sternal edge, radiating to aortic and mitral areas
o JVP ‘a’ wave prominent
o AF
o BP changes during upright exercise
ECG findings in hypertrophic cardiomyopathy?
o LVH
o Deep, narrow (“dagger-like”) Q waves in the lateral (V5-6, I, aVL) and inferior (II, III, aVF) leads
o T-wave inversion
o AF, VT
Echo findings in hypertrophic cardiomyopathy?
o Asymmetrical septal hypertrophy (>15mm) with ratio of septal to posterior of >1.4:1
o Small LV cavity
o Hypercontractile posterior wall
o Mid-systolic closure of aortic valve
o Systolic anterior motion of mitral valve
CXR findings in hypertrophic cardiomyopathy?
o Heart size normal or enlarged
o LA enlargement seen
Further testing needed in hypertrophic cardiomyopathy?
o Exercise ECG + Holter monitor
Risk stratification – increased if blunted systolic BP to exercise, ventricular arrhythmias, progressive ST depression and symptoms
o Nuclear tests and cardiac catheterisation
o Cardiac MRI
If poor visualisation on Echo
Screening in hypertrophic cardiomyopathy?
o Echocardiogram
First-degree family members of affected patients
• Repeat every 12-24 months throughout adolescence
o ECG
Athletes
Management of asymptomatic hypertrophic cardiomyopathy?
ICD
• If 1st degree relative with SCD, LV wall thickness >30mm, unexplained syncope
Restrict from high-intensity athletics
Management of symptomatic hypertrophic cardiomyopathy - drug management?
• Beta-blockers (atenolol) • Verapamil • Disopyramide o To reduce LVOT gradient and diastolic dysfunction • Amiodarone o To suppress arrhythmias • Anticoagulation – NOAC/Warfarin
Management of symptomatic hypertrophic cardiomyopathy - surgical?
Surgical
• Catheter ablation for AF if drug refractory
• Septal myomectomy (surgical or alcohol ablation)
o If refractory symptoms or elevated resting outflow gradients
• Heart Transplant if refractile
Pacing
• ICD implantation if risk factors
Prognosis of hypertrophic cardiomyopathy?
o Variable – can remain asymptomatic or progress with heart failure
o Competitive sport increases risk of sudden death
Definition of restrictive cardiomyopathy?
o Normal LV cavity size and systolic function but increased myocardial stiffness
o Ventricle incompliant and fills predominantly in early diastole
o Associated with raised LA pressure, atrial dilatation
Epidemiology of restrictive cardiomyopathy?
- Least common cardiomyopathy
- 5% of all cardiomyopathies
- Elderly
- Tropical Africans
Causes of restrictive cardiomyopathy?
o Idiopathic o Loffler’s syndrome (endomyocardial fibrosis) o Infiltrative myocardial disease o Amyloidosis (MC in West) o Sarcoidosis o Haemochromatosis o Fabry’s disease
Symptoms of restrictive cardiomyopathy?
o Heart Failure – SOB, fatigue, oedema
o Similar to constrictive pericarditis
Signs of restrictive cardiomyopathy?
o Loud 3rd HS o RVF predominate Raised JVP (prominent x and y descents) Hepatomegaly Oedema Ascites o AF
Investigations and findings of restrictive cardiomyopathy?
- ECG
o Tachycardia, non-specific T wave changes, LBBB - Bloods
o FBC, U&E, LFT, TFTs, BNP, troponins - CXR
o Cardiomegaly, pulmonary oedema - Echocardiogram
o Thickened ventricular walls, valves and atrial septum with small cavities
Diagnostic imaging in restrictive cardiomyopathy?
- Cardiac Catheterisation
- Cardiac MRI – distinguish restrictive CM and constrictive pericarditis
- Cardiac biopsy
Management of restrictive cardiomyopathy?
- Treat cause
- Management of Heart Failure
o Diuretics
Furosemide
Spironolactone
o ACEi
- Other managements o Amiodarone o Anticoagulation if AF – NOACs/Warfarin o Pacemakers/ICD o Transplantation
Definition of arrhythmogenic right ventricular cardiomyopathy?
o Fibro-fatty replacement of RV myocytes due to apoptosis, inflammation or genetics
Epidemiology of ARVC?
- Prevalence – 1 in 2000
- Presents in adolescence or early childhood
- Males
- Autosomal dominant (more common), also recessive
- Common cause of SCD in young people
Symptoms of ARVC?
- Men aged 15-35
o Palpitations
o Presyncope
o Syncope
o SCD
Signs of ARVC?
o Atrial arrhythmias
Phases of ARVC?
o Concealed – subtle RV changes, minor arrhythmias – asymptomatic or SCD
o Overt electrical disorder – symptomatic RV arrhythmias with abnormal RV wall – palpitations and syncope – arrhythmias and SCD common
o RV failure – extension of disease to whole RV causes dysfunction
o Biventricular pump failure – LV involved leads to HF
Investigations of ARVC?
- ECG o Ventricular arrhythmias, LBBB - Bloods o FBC, U&E, LFT, TFTs, BNP, troponins - CXR - Echocardiogram
Diagnostic imaging of ARVC?
- Cardiac Catheterisation
- Cardiac MRI
o RV enlargement, fatty infiltration, fibrosis and wall motion abnormalities - Cardiac biopsy
Management of non-threatening ventricular arrhythmias?
o Beta-blockers (sotalol)
o Amiodarone
Management of sustained VT/VF?
o Serial therapeutic drug trials using programmed ventricular stimulation
o ICD
If inducible or present with syncope/cardiac arrest
o Radio-frequency ablation (if localised disease)
Prognosis of ARVC?
o Progressive deterioration of RV function
o Mortality rate 1-3% per year
Pathology of aortic dissection?
o Longitudinal splitting of muscular aortic media by column of blood
o Dissection may spread proximally, distally, rupture internally back into aortic lumen or externally
Lead to:
o Aortic incompetence, coronary artery blockage, cardiac tamponade
o Rapid exsanguination
Classification of aortic dissection?
o Stanford Type A (70%)
Ascending aorta involved
o Stanford Type B (30%)
Ascending aorta not involved
Risk factors of aortic dissection?
o Hypertension (70%) o Bicuspid aortic valve o Marfan’s syndrome o Ehlers-Danlos syndrome o Recent cardiac surgery or angiography/angioplasty
Symptoms of aortic dissection?
o Abrupt onset sharp, tearing or ripping pain (maximal at onset) in anterior and posterior chest
o Syncope
o Hemiplegia (occlusion of carotid artery)
o Anuria (occlusion of renal arteries)
o Paraplegia (occlusion of spinal artery)
Signs of aortic dissection?
o Aortic regurgitation murmur (30%)
o Asymmetrical peripheral pulses or pulse deficit
o Hypertension
o Hypotension – features of tamponade or neurological signs
Investigations of aortic dissection?
- Bloods o FBC, U&E, coagulation, glucose and cross-matching - ECG o MI, LVH, ischaemia - CXR o Widened mediastinum o Double knuckle aorta o Deviation of trachea o Calcium sign – separation of two parts of wall of calcified aorta - CT Angiography o Definitive diagnosis
Management of aortic dissection?
o High flow O2 using face mask
o Insert 2 wide-bore IV cannulas and cross-match 10U of blood (inform blood bank of suspected diagnosis)
o IV morphine + Antiemetic
o Call cardiothoracic team and cardiologist early
All Type A dissections treated surgically
Type B managed medically or surgically (if leaking, ruptured, compromising vital organs)
o Insert arterial line (right radial artery) and discuss how to control BP (Aim 100-110mmHh using labetalol infusion)
Epidemiology of acute mesenteric ischaemia?
o >50 years old
o Mostly small bowel
Causes of acute mesenteric ischaemia?
Arterial (thrombotic, embolic)
AF, MI, mitral stenosis, endocarditis, arterial catheterisation
Atherosclerosis, aortic aneurysm, heart failure, dehydration
Non-occlusive (low-flow states – poor cardiac output)
Hypotension, cocaine, digitalis
Venous thrombosis
Hypercoagulability (protein C and S deficiency, tumours, infection)
Trauma, Vasculitis, Radiotherapy
Symptoms of acute mesenteric ischaemia?
Acute severe abdominal pain
• Constant, central or around RIF
No abdominal signs
Rapid hypovolaemia – then shock
Investigations of acute mesenteric ischaemia?
o Bloods Raised Hb, WCC, amylase Metabolic acidosis o AXR o CT angiography – gold standard o MR oximetric measurement of superior mesenteric vein flow
Medical management of acute mesenteric ischaemia?
Fluid resuscitation
NG tube
IV gentamicin + metronidazole
IV UFH
Surgical management of acute mesenteric ischaemia?
Prompt laparotomy if peritonitis
Arteriography and thrombolytics/Revascularisation
Resection of dead bowel
Prognosis of acute mesenteric ischaemia?
o Poor – mortality 50-90% in arterial and non-occlusive disease
Complications of acute mesenteric ischaemia?
o Septic peritonitis
o SIRS into multi-organ dysfunction syndrome
Definition of chronic mesenteric ischaemia?
- Chronic atherosclerotic disease of vessels supplying intestine
- Known as intestinal angina – usually all three major mesenteric arteries involved
Epidemiology of chronic mesenteric ischaemia?
o Low incidence – mainly females 50-70 tears old
Risk factors of chronic mesenteric ischaemia?
o Hx of CVD
o Smoking, hypertension, diabetes, hyperlipidaemia
Symptoms of chronic mesenteric ischaemia?
o Abdominal Pain Moderate-to-severe colicky or constant pain Often post-prandial o Eating hurts o Weight loss and fear of eating
Signs of chronic mesenteric ischaemia?
o Vague abdominal tenderness
o Abdominal bruit
o PR bleeding
o N&V
Investigations of chronic mesenteric ischaemia?
o Bloods – FBC, LFT, U&Es – dehydration and malnutrition
o CXR
o ECG
o CT angiography – gold standard
Management of chronic mesenteric ischaemia - asymptomatic?
Smoking cessation and antiplatelet therapy
Management of chronic mesenteric ischaemia - symptomatic?
Surgery- Percutaneous transluminal angioplasty and stent insertion (option for open)
May need TPN
Definition of ischaemic colitis?
- Compromised blood circulation supplying the colon
Epidemiology of ischaemic colitis?
o Disease of the elderly mostly – average age 70
Risk factors of ischaemic colitis?
o Thrombosis – IMA thrombosis
o Emboli – mesenteric arterial emboli, cholesterol emboli
o Decreased CO
o Shock
o Trauma
o Strangulation
o Drugs – digitalis, oestrogens, antihypertensives, cocaine, COCP
o Surgery – cardiac bypass, aortic dissection repair
o Vasculitis – SLE, polyarteritis nodosa, SCC
o Hypercoagulability – Protein C&S deficiency, PNH, antithrombin 3 deficiency
o Long-distance running
Symptoms of ischaemic colitis?
o Acute onset LIF abdominal pain
o N&V
o Bloody diarrhoea
Investigations of ischaemic colitis?
o Colonoscopy and biopsy – gold standard
o Barium enema – thumbprinting of submucosal swelling
Management of ischaemic colitis?
o Fluid replacement
o Broad-spectrum antibiotics
o Surgery – laparotomy and removal of necrotic colon
Path of SVC? Definition of SVC obstruction?
- SVC extends from the junction of the right and left innominate veins to the right atrium
- SVC provides venous drainage for the head, the neck, the upper extremities and the upper thorax
- Caused by extrinsic compression, thrombosis, or invasion of the wall of the superior vena cava
- Most commonly by extensive lymphadenopathy in the upper mediastinum (often in patients with lung cancer or lymphoma)
- Can occur with any solid tumour (rarer causes include germ cell, breast or oesophageal cancer)
- EMERGENCY
Epidemiology of SVC obstruction?
- Males > Females
- Malignant causes common when older
Aetiology of SVC obstruction - malignant?
Lung Cancers Lymphoma Mediastinal Lymphadenopathy Germ cell tumours Thymoma Oesophageal
Aetiology of SVC obstruction - non malignant?
Non-malignant tumours Mediastinal fibrosis Infection (TB) Aortic aneurysm Thrombus
Symptoms of SVC obstruction?
o Headache/“feeling of fullness” in the head o Facial swelling o Dyspnoea (often worse on lying flat) o Cough o Hoarse voice
Signs of SVC obstruction?
o Facial/upper limb oedema
o Prominent blood vessels on the neck, trunk and arms
o Cyanosis
Investigations of SVC obstruction?
- Chest X-ray
- CT chest
Management of SVC obstruction?
- Corticosteroids (dexamethasone 16mg daily) with PPI cover
- Urgent vascular stenting
- Followed by radiotherapy or chemotherapy depending on primary tumour type
- May need LMWH (if thrombus confirmed)
Management of SVC obstruction - if cause unknown?
o Bloods: tumour markers
o CT chest, abdomen, pelvis
o Bronchoscopy/OGD
o Biopsy urgently
Definition of Raynaud’s syndrome?
- Episodic vasospasm that causes digits to change colour to white (pallor) from lack of blood flow
- Brought on by cold temperatures
- Affected areas subsequently turn blue due to de-oxygenation and/or red perfusion
Types of Raynaud’s syndrome?
o Primary (idiopathic) RP – no underlying cause
o Secondary RP – associated underlying cause (usually connective tissue disorders – scleroderma, systemic lupus erythematosus, rheumatoid arthritis, Sjogren’s syndrome or polymyositis)
Epidemiology of Raynaud’s syndrome?
- Affects 1-3% of population
- Women > Men
- Occurs in 20-30s most commonly
Causes of secondary Raynaud’s syndrome?
o Scleroderma Includes ‘limited cutaneous systemic sclerosis’ – CREST (calcinosis, Raynaud’s phenomenon, oesophageal dysfunction, sclerodactyly, telangiectasia) o SLE o Rheumatoid arthritis o Sjogren’s syndrome o Dermatomyositis and polymyositis o Drugs
Causes of digital vasospasm - drugs?
Amphetamines and cocaine Beta-blockers Chemotherapy Ciclosporin Interferon-alpha/beta COCP Clonidine
Causes of digital vasospasm - vascular occlusive disease?
Buerger’s disease
Ateriosclerosis
Thromboembolic disease
Causes of digital vasospasm - haematological?
Polycythaemia
Paraproteinaemia
Leukaemia
Causes of digital vasospasm - occupation/environmental?
Vibration injury
Exposure to vinyl polychloride
Frostbite/Cold injury
Causes of digital vasospasm - infections?
Hep B and C
Mycoplasma infections
Causes of digital vasospasm - endocrine?
Hypothyroidism
Pheochromocytoma
Carcinoid syndrome
Symptoms of Raynaud’s syndrome?
o Digits turn white (pallor) then blue with deoxygenation and/or red with reperfusion
o Digital pain, paraesthesia
Diagnosis of Raynaud’s syndrome?
- Clinical Diagnosis
o Diagnose primary Raynaud’s if no features of secondary Raynaud’s present
Assessment and testing for secondary Raynaud’s syndrome?
- Assess for secondary Raynaud’s
o Connective tissue disease
Morning joint stiffness, swollen joints, rash, photosensitivity, hairloss, dry eyes/mouth, FHx
o Drugs and Medications - Testing for secondary Raynaud’s
o Abnormal nail-fold capillaries (red pen marks, often seen in cuticles) using otoscope, ophthalmoscope or dermatoscope
o Digital ulcers
o Bloods – FBC, ESR, ANA, creatinine
When to suspect secondary Raynaud’s syndrome?
o Onset >30 years o Episodes intense, painful and asymmetrical o Positive ANA o Abnormal nail beds o Ulcers
Management of severe ischaemia in Raynaud’s syndrome?
Admission
Referral to secondary of Raynaud’s syndrome?
o All secondary Raynaud’s syndrome
o Children 12 years or less
General advice in Raynaud’s syndrome?
o Keeping whole body warm (gloves/warm socks) o Smoking cessation o Regular exercise o Avoiding stress o Stop drug exacerbating Raynaud’s
Drug management of Raynaud’s syndrome?
If lifestyle advice fails
o Medication
Nifedipine 5mg TDS and titrate up to 20mg TDS
o Refer if that fails
Complications of Raynaud’s syndrome?
o Digital ischaemia
o Gangrene
o Digital Ulcers
o Infection
Definition of lymphoedema?
- Atypical collection of lymph fluid within body tissues
- Due to failure to clear fluid and macromolecules by lymphatic system
Types of lymphoedema?
o Primary lymphoedema – congenital insufficiency of lymphatic system
Milroy’s disease
Turner’s syndrome
o Secondary lymphoedema – damage to lymphatic system or removal of lymph nodes by surgery/radiotherapy/infection or injury
Malignancy (most commonly arms in breast cancer) (or its treatments)
Recurrent lymphangitis (erysipelas, chronic venous ulceration)
Lymph obstruction (tumour, TB, filariasis)
Causes of lymphoedema?
o Malignancy (or its treatment)
Symptoms of lymphoedema?
o Progressive swollen, firm limbs Arms and legs affected more often Poorly pitting o Heaviness or fullness of limb o Tight sensation in skin
Signs of lymphoedema?
o Kaposi-Stemmer sign – inability to pinch fold of skin on dorsal surface of foot at base of second toe
o Poorly pitting oedema
o Recurrent infections of limbs
Diagnosis and investigations of lymphoedema?
- Clinical diagnosis
- Lymphangosyntigraphy
o Diagnostic - Lymphangiography
o Shows lymph hypoplasia, hyperplasia or retrograde obliteration
Management of lymphoedema - general advice?
o Skin and nail care – reduce infection risk
o Elevation of limbs above level of heart when possible
o Regular exercise
Management of lymphoedema - conservative management?
o Compression stockings
o Manual lymph drainage
o Intermittent pneumatic compression
Management of lymphoedema - surgical management?
o If non-surgical methods have failed
o Liposuction, debulking and bypass operations
