Clin Med: Cardio IV Flashcards
Describe is AAA?
abnormal full-thickness dilation of the AA w/ diameter >3cm or over 50% of normal vessel diameter
What is normal aortic diameter?
varies based on age, sex, body size, BP
infrarenal aortic diameter of 2.7cm represent 95% of men w/ women have slightly smaller diameters
AAA: RFs
- *smoking
- *male sex
- *family history of AAA
- *older age
- Hx of aortic aneurysm
- HTN
- hyperlipidemia
- Genetic conditions (Marfan Syndrome)
AAA: Pathophys
- Abnormal structural PROs of the aorta, elastin & collagen (age)
- Inflammation & immune responses (smoking)
- Biomechanical wall stress (hypertension)
- Atherosclerosis causes weakening of the aortic wall w/ loss of elastic recoil
Describe prevalence and area of AAA
80% of AA occur b/t the renal arteries & the aortic bifurcation
AAA: Screening
1-time screening for AAA w/ US in men 65-75yo who have ever smoked
If AAA found on screening, FU depends on size:
- > 2.5 cm but < 3.0 cm, rescreening after 10yrs
- For AAA 3.0 to 3.9 cm, imaging at 3yr intervals
- For AAA 4.0 to 4.9 cm, imaging at 12mo intervals
- For AAA 5.0 to 5.4 cm, imaging at 6mo intervals
AAA: S/S
- usually asymptomatic
- Symptomatic w/o dissection/rupture
—> chronic abdominal pain or discomfort
—> low back pain
—> flank pain (may radiate to back, groin, scrotum, legs) - W/ dissection/rupture
—> sudden onset abdominal, back, flank pain w/ syncope or shock
AAA: PE
80% of 5-cm infrarenal aneurysms & palpable on exam
—> Pulsatile mass
First line imaging for AAA?
US
Second line imaging for AAA?
CT w/ IV contrast
- better operative planning
How are AAA usually discovered?
incidentally by physical exam, abdominal US, CT or other imaging
AAA: Tx
- risk reduction (X smoking, PA)
- elective repair for AAA >5.5cm or rapid expansion or symptomatic
- endovascular vs open repair
What constitutes as rapid expansion?
growing 0.5 cm in 6 months
When do we do endovascular repair?
preferred in patients who are at a high level of perioperative risk.
When do we do open surgical repair?
preferred for younger patients who have a low or average perioperative risk.
What can rupture?
an aneurysm or dissection
AAA rupture mortality rate
90%
AAA rupture classic triad?
- abdominal pain
- hypotension,
- pulsatile mass
What is a thoracic aneurysm?
a permanent dilation of a segment of the thoracic aorta to ≥ 150% normal diameter usuallycaused by atherosclerosis
What % of AA are thoracic?
10%
Is screening recommended for thoracic aneurysms?
NO
Which genetic syndromes are associated w/ thoracic AA or dissection?
- Marfan syndrome
- Ehlers-Danlos syndrome (EDS)
- Turner syndrome
- autosomal dominant polycystic kidney disease
TAA: S/S
- Usually asymptomatic until dissection or rupture
- Pressure on the trachea, esophagus, or SVC can result in the following s/s: dyspnea, stridor, or brassy cough; dysphagia; and edema in the neck & arms as well as distended neck veins
TAA: PE
Aortic regurgitation possible
TAA: Dx
- seen incidentally on imaging (CT or US)
- May also be seen as abnormalities is aortic size/contour on CXR
TAA: Tx
surgery if:
- symptomatic
- rapidly growing (>0.5cm/year)
- depends on location
- open or endoscopic repair
What is a dissection?
a tear in the intima, allowing blood to separate the intima & media
Aortic Dissection: S/S
- sudden tearing chest or abdominal pain w/ radiation to back, abdomen, or neck in a HTN pt.
Aortic Dissection: PE
pulse discrepancy in extremities, possible aortic regurgitation, elevated BP
Aortic Dissection: Dx imaging
CT is imaging of choice, widened mediastinum on x-ray
Aortic Dissection: Tx
aggressive lowering of BP w/ BB, surgical vs medical management
What is a Standard Type A dissection? Px & Tx?
- dissection of the ascending aorta
- worse prognosis
- manage surgically
What is a Standard Type B dissection? & Tx?
- dissection of the descending aorta
- manage medically (strict BP control & serial imaging)
PAD refers to the…
stenosis, occlusion, or aneurysmal dilation of lower-extremity arterial branches
What is the #1 cause of atherosclerosis?
PAD
Pts w/ PAD may be asymptomatic or present with what symptoms?
- intermittent claudication
- ischemic rest pain
- ulceration/gangrene of the lower extremities
PAD: RFs
- Increasing age
- DM
- Hx of smoking
- HTN
- Hyperlipidemia
Primary sites of involvement are for PAD?
- iliac arteries
- femoral & *popliteal arteries
- tibial & peroneal arteries
PAD: S/S
- About 50% of pts w/ PAD have symptoms
- intermittent claudication or atypical leg pain
- Advanced disease could present w/ non healing ulcers or limb ischemia
PAD: PE for mild/mod dz
- decr or absent pulses distal to the obstruction
- bruits over the narrowed artery
- muscle atrophy
PAD: PE for severe dz
- hair loss,
- smooth & shiny skin
- reduced skin temp
- pallor or cyanosis
What can happen if pt. has critical limb ischemia?
ulcers or gangrene
What is dependent Rober
when the foot is elevated the foot is pale & when it is in a dependent position the foot is very red
PAD: Dx
- angle-brachial index (ABI)
–> systolic pressure in upper extremities vs limb of concern - CTA or MRA
What are the two pulses in the foot?
dorsalis pedis or posterior tibia
What do you uses if you can’t feel the pulses in the foot?
doppler
Chronic PAD: Tx
- Risk modification
- Anti platelet (ASA or clopidogrel (Plavix))
- Cilostazol (vasodilator)
- Revascularization
—> Endovascular
—> Bypass surgery
What medication all pts w/ PAD get?
systemic anticoag (Heparin)
What are the 3 categories of ALI?
- Viable (urgent revascularization
- Threatened (emergent revascularization)
- Irreversible (amputation)
Describe viable ALI
- limb not immediately threatened; - - no muscle weakness or sensory loss
- audible arterial & venous Doppler
Describe viable ALI
- mild/mod motor or sensory loss
- audible venous Doppler & inaudible arterial Doppler
Describe irreversible ALI
- permanent nerve damage or major tissue loss inevitable
- profound sensory loss, muscle weakness or paralysis (rigor)
- inaudible venous & arterial Doppler
NOTE
Emboli from the heart can be large enough to occlude proximal arteries in the lower extremities–> think AFib
NOTE
Emboli from peripheral circulation are usually smaller & go to the distal extremities (toes)
Arterial embolism/thrombus: S/S
Arterial embolism/thrombus: PE
Arterial embolism/thrombus: Dx
- CTA or MRA to localize occulusion
- Cath based ateriography w/ fluoroscopy
Arterial embolism/thrombus: Tx
VTE includes which conditions?
- PE
- DVT
- SVT
Some RFs for developing venous thrombosis
- OCP
- HRT
- Severe liver dz
- Cancer
- Heart stuff
Describe Virchow’s Triad
Alterations in:
–> blood flow (ie, stasis)
–> the constituents of the blood (ie, inherited or acquired hypercoagulable state)
–> Vascular endothelial injury
DVTs occur where?
most in lower extremities, then upper extremities or splanchnic veins
DVT: S/S
- cramps & heaviness, esp in calf
- incr visible skin veins
- cyanotic discoloration
- swelling or pitting edema
- unilateral leg tenderness
- Homans’ sign (pain during dorsiflexion of foot)
- May have palpable cord in the calf
What veins make up the deep vein system?
- Iliac
- femoral
- popliteal
- deep femoral vein
What are the commonly effected veins in lower extremities?
- posterior tibial
- peroneal
Describe a (+) Homan’s sign
pain w/ dorsi flexion of the foot
With DVT, a (-) D-dimer result can…
exclude DVT in pts w/ low pretest probability
What is the most accurate noninvasive test for DVT?
compression US
What dx testing do you use for uncertain dx of DVT?
Contrast venography
What dx testing is used to dx splanchnic DVT?
CT w/ IV contrast
STUDY
Clin Med Cardio IV slid 42
DVT: Tx guidelines
- distal DVT + no symp + low risk for extension = no tx
- distal + no symp &/or risk for extension: tx needed
ALL proximal DVT require tx
DVT: Tx meds
Anticoag
- 3-6mos if provoked by transient RF, no previous DVT
- Indefinite if not provoked or non transient risk factor
If anticoag is contraindicated for DVT tx, what is the alternative?
IVC filter
Most common type of meds used for DVTs
DOACs
SVT: S/S
- painful, warm, erythematous, tender, palpable cord-like structure
- usually found in the lower extremities, but can occur anywhere on the body
SVT: RFs
similar to DVT, with the addition of varicose veins
SVT: Dx
US to evaluate extent of SVT & to look for DVT
SVT: Tx
- Compression stockings
- Encourage walking
- dependent of location (NSAIDS or anticoag)
Describe varicose veins.
dilate, palpable, > tortuous subcutaneous veins >3mm in diameter in upright position
Varicose Veins: RFs
- older age
- pregnancy
- female
- FHx of varicose veins
- upright position/prolonged standing
- tall people
- chronic constipation
- DVT
Varicose Veins: pathophys
valves in the veins become damaged or incompetent therefore regurgitation occurs & blood starts to pool & dilates the veins
Varicose Veins: S/S
- unappealing look
- if symptoms present:
–> pain, burning, itching, tingling
–> achiness, heaviness, tiredness, cramping, throbbing, restlessness, swelling
Varicose Veins: PE
- Dilated, torturous veins better w/ standing
- Long standing varicose veins can have associated venous insufficiency w/ ankle edema, hyperpigmentation
Varicose Veins: Dx
- clinically if varicosity >/= 3mm in upright position in saphenous veins, tributaries or non-saphenous superficial leg veins
- Duplex US to assess severity
Varicose Veins: Tx
- First compression therapy
- avoid long periods of standing
- If no relief:
—> Endovascular thermal (heat) ablation
—> Endovascular chemical ablation (called sclerotherapy)
—> Surgery
Chronic Venous Insufficiency is characterized by…
venous valves not working & venous HTN
Chronic venous insufficiency may be caused by…
- primary venous dz
- secondary to venous dz (DVT)
- congenital abnormality
When should you suspect venous insufficiency?
pts w/ lower limb symptoms
- pain
- swelling
- heaviness/fatigue
- itchiness
- burning/tingling
- nocturnal leg cramping
- progressive pitting edema
What may develop with chronic venous insufficiency?
- chronic ulcers of ankle
- hyperpigmentation
- stasis dermatitis
Chronic venous insufficiency: Dx
Duplex US
Chronis venous insufficiency: Tx
- compression
- treat underlying issues
- wound care for ulcers
What is arteriovenous malformation?
- Congenital defect in the vascular system which causes tangles of abnormal BVs; arteries & veins are connected w/o a capillary bed
- Can occur anywhere in the body, but brain & spinal cord are at high risk of hemorrhage
Define shock
sudden large decrease in BP which results in organs not getting enough blood then organ failure
List the 4 types of shock
- hypovolemic
- cardiogenic
- obstructive
- distributive
Describe Hypovolemic Shock
- Can result from:
–> Traumatic blood loss
–> Nontraumatic blood loss
(GI bleed, aneurysm)
–> Volume loss
(severe dehydration)
- Usually occurs after about 15% loss of volume
- Treatment depends on etiology
Describe Cardiogenic Shock
- Heart can’t perfuse the tissues good enough resulting in a drop of BP
- Can result from:
–> Myocardial dz (MI)
–> Mechanical heart dz (HF, valvular dz)
–> Dysrhythmias
- Treat underlying issue
Describe Obstructive Shock
- Obstruction blood flow through the heart and/or great vessels
- Can result from:
–> Pericardial tamponade
–> Tension pneumothorax
–> Massive PE
–> Severe pulmonary hypertension - Treat underlying issue
Describe Distributive Shock
- The result of systemic vasodilation (all BVs)
- Can result from:
–> Septic Shock**
–> Neurogenic shock (spinal cord injury)
–> Anaphylactic shock (give epi to counteract vasodilation) - Treat underlying issue
