Exam 4 Flashcards
Dyslipidemia
Increase total LDL
Increased triglycerides
Decreased HDL
What are triglycerides packaged into?
Chylomicrons
What organ plays the biggest role in triglyceride metabolism?
The liver
What is released from chylomicrons?
Fatty acids
Atherosclerosis pathophysiology
Damage to vascular endothelium, recruits platelets/monocytes, LDL accumulates
Macrophages ingest oxidized lipids making foam cells
Fatty streak develops
Metabolic syndrome
High triglycerides Insulin resistance Abdominal obesity Hypertension Low HDL
Coronary artery disease equivalents
AAA
Diabetes
Peripheral vascular disease
Carotid artery disease
Clinical findings of coronary artery dz
Angina
MI
Cerebrovascular dz clinical findings
Stroke
Transient ischemic attack
Peripheral artery dz clinical findings
Ischemic extremities
Claudication
Mesenteric ischemia clinical findings
Pain out of proportion to exam
Death of intestine due to ischemia
Patient is sick
Eruptive xanthomas
Elevated chylomicrons or VLDL
Red-yellow plaques, lipid deposits, especially on butt
Tendinous xanthomas
Elevated LDL
Nodular yellow/skin-toned lesions
Lipid deposits
Arcus senilis
Opacity of peripheral iris
Can be normal (aging)
Lipid deposits in younger pts
Xanthelasma
Lipid deposits around eyelid
Can be hereditary (asian, Mediterranean)
Or hyperlipidemia
Lipemia retinalis
Orange-yellow retinal vessels
Pancreatitis
Caused by markedly elevated TGs, often >500
Alcohol abuse compounds risk
Who is screened for dyslipidemia?
Men >35
Women >45
Non fasting lipids
HDL and total cholesterol
Fasting lipids
HDL, total cholesterol, LDL, TGs
Fractionated lipids
More detailed estimate of risk
Smaller particles are more atherogenic
CRP
High sensitivity is suggestive of CVD risk, and very high CRP is plaque rupture
Statin groups
Clinical ASCVD
LDL >190
Diabetics
ASCVD risk of >7.5%
What is the reduction is risk with lifestyle modifications?
12-14%
DASH
Dietary approaches to stop hypertension
High produce, low fat, low sodium
What do statin toxicities cause?
Hepatotoxicity
Myopathy
Fibrates
TG >200
Also good for excess VLDL
Slight increase in HDL
Slight decrease in LDL
What is the most modifiable risk factor for heart attack and stroke?
Hypertension
Normal BP
<120 <80
Prehypertension
120-139 80-89
Stage 1 HTN
140-159 90-99
Stage 2 HTN
> 160 >100
Refractory HTN
Uncontrolled BP despite 3 antihypertensive medications
OR
BP that requires at least 4 antihypertensive medications to achieve control
Emergency HTN
Severe HTN plus acute end organ damage
urgent HTN
Severe HTN in asymptomatic patient
Moderate-severe hypertensive retinopathy
Severe HTN with retinal exudates, hemorrhages, or papilledema
Gestational HTN
HTN that develops after the 20th week of pregnancy and returns to normal postpartum
Preeclampsia
Development of HTN with proteinuria and edema after 20 weeks of pregnancy
Headache, visual disturbances, epigastric pain
Eclampsia
Additional presence of convulsions with preeclampsia that is not explained by neurological reasons
Primary factors to determine BP
Sympathetic nervous system
RAA system
Plasma volume (kidneys)
Peds secondary HTN
Primary renal disease
Young adults secondary HTN
Thyroid disease
Middle aged adults secondary HTN
Aldosteronism
Elderly secondary hypertension
atherosclerotic renal artery stenosis
Primary hyperaldosteronism triad
HTN
Unexplained or easily provoked hypokalemia or potassium wasting
Metabolic alkalosis
Cushing syndrome
Hypercortisolism
Usually iatrogenic, could be a tumor
Moon face, buffalo hump, ecchymosis
Pheochromocytoma
Catecholamine secreting tumor
Paroxysmal BP elevations
Triad: HA, palpitations, sweating
Necessary diagnostics in hypertensive patients
CMP Hgb and Hct Lipids Urinalysis EKG
What is the definitive test to diagnose renal artery stenosis?
Renal arteriography
If you are greater than 60, according to JNC 8 guidelines, the what is the threshold for SBP?
150 mm Hg
What is the recommended BP goal for patients with DM or CKD?
<140/90
What is the recommended BP goal in all HTN patients greater than 60 yo?
<150/90
Urgent BP management
Need to lower BP over hours to days to <160/100
Emergency HTN management
Lower pressure by 10-20% in the first hour, 5-15% over the next 23 hours
Follow up for HTN treatment
4-6 week intervals until goal achieved
Absolute hypotension
SBP <90
Relative Hypotension
Drop in SBP >40
Postural/orthostatic hypotension
Drop in BP when going from supine to standing position with associated symptomatolgy
Orthostatic response values
> 20 fall in SBP
>10 fall in DBP
Symptoms of orthostatic hypotension
Generalized weakness, dizziness, lightheadedness, visual changes, syncope
Maybe even angina or stroke
Blood pressure
Cardiac output x systemic vascular resistance
PCWP
Pulmonary capillary wedge pressure
Shock
Reduction in systemic tissue perfusion, decreased oxygen delivery
Hypovolemic shock
Decreased preload induced by volume loss
Decreased CO
Increased SVR
Decreased PCWP
Cardiogenic shock
Consequence of cardiac pump failure
Decreased CO
Increased SCR
increased PCWP
Distributive shock
Most common, severely decreased SVR
Increase CO
Obstructive shock
Extracardiac causes of cardiac pump failure
Pulmonary vascular or mechanical
Cardinal findings of shock
Hypotension Oliguria Cool, clammy skin Abnormal mental status Metabolic acidosis
Management of shock
First, resuscitative efforts (ABCs)
Then IV fluids
Primary varicosities
Inherent wall defect
Secondary varicosities
Results from valve damage
Thrombophlebitis, trauma, DVT, etc.
Is symptom severity related to number or size of varicosities?
No!!
Varicose veins symptoms
Dull, aching heaviness, leg fatigue, pruritus, dark blue/twisted veins, maybe edema
Most common posterior/medial
What is the gold standard diagnosis for varicose veins?
Duplex ultrasonography
Superficial thrombophelbitis
Venous inflammation, thrombus develops in a superficial vein
Superficial thrombophlebitis clinical findings
Usually self limiting
May have dull pain, maybe mild swelling, tenderness, redness
Fever if septic version from IV catheter
Virchow’s triad
Venous stasis
Endothelial injury
Hypercoaguable state
Deep venous thrombosis
Venous thromboembolism- DVT- PE
80% in deep veins of the calf
DVT clinical findings
Edema
Calf pain on dorsiflexion (homan’s sign)
Low grade fever, tachycardia
Unilateral
DVT diagnosis
Well’s criteria
Low protest probability- D dimer
Intermediate to high probability- ultrasound
Chronic venous insufficiency
Result of sustained venous hypertension in the leg
Primary: valve failure
Secondary: post thrombotic syndrome from DVT
Chronic venous insufficiency clinical
Varicose veins or telangiectasias
Ankle and calf dependent edema
Hyperpigmentation
Stasis dermatitis
Superior vena cava obstruction clinical findings
Dyspnea Swelling of arms and face Cough/hoarseness/dysphagia Chest pain Distended neck and chest veins Head fullness/headaches Syncope
Classic SCV obstruction picture
Elderly male with increased risk for lung cancer
Acute arterial occlusion
Surgical emergency
Golden period of 4-6 hours
Caused by embolis, thrombosis, trauma, or cardiac
6 P’s of acute ischemic limb
Pain Pallor Pulselessness Perishing cold Parasthesias Paralysis
Acute arterial occlusion clinical findings
Absence of distal pulses Pallor Weakness/paralysis Pain- sudden and severe Cold
Gold standard diagnosis for acute arterial occlusion
Angiography
Peripheral vascular disease
Claudication, arterial insufficiency, etc.
Systemic atherosclerosis
Objectively defined as an ankle-brachial index < .9
Leriche’s syndrome
Aortoiliac occlusive disease
PVD clinical findings
Intermitten claudication Impotence Rest pain Smoker dependent rubor Poor nail growth Absent pulses
Aneurysm
Stretched and bulging section of the vessel wall (focal dilation >50% enlargement)
AAA
> 90% are below renal arteries
> 3 cm diameter
Classic triad of AAA rupture
Pain
Hypotension
Abdominal pulsatile mass
May have tachycardia and severe back or flank pain
Flank ecchymosis
Grey turner’s sign
Periumbilical ecchymosis
Cullen’s sign
Thoracic aortic aneurysm
<10% of aortic aneurysms
Seen more with chest pain, cough or stridor, hoarseness, or dysphagia
Type A thoracic aortic aneurysm
Ascending aorta, more concerning
Tearing chest or mid back pain is characteristic of …
Thoracic aortic dissection
What is a good test for thoracic aortic aneurysm ?
Transesophageal echo
Arteritis of Takayuki
Pulselessness disease
Asian women under age of 40
Large vessel vasculitis!
Usually aorta and main branches
Arteritis of takayasu symptoms
Fever, myalgia, arthralgia
Pain over involved artery
Physical exam findings arteritis of takayasu
Hypertension
Vascular bruins
Diminished peripheral pulses
Raynaud’s
Vasospastic disorder
Episodic ischemia of the digits of the hands and sometimes feet
Primary phenomenon- disease
Secondary (underlying connective tissue disorder)- syndrome
Raynauds symptoms
Pallor, cyanosis, then rubor
Discomfort, throbbing pain with rubor
Thromboangiitis obliterans aka buerger disease
Nonatherosclerotic vascular disease
Inflammatory occlusive disease of arteries of limbs
Usually male smokers < age of 50
Inflammatory process
Thromboangiitis obliterans symptoms
Resting pain, ischemic ulcerations, gangrene of digits, decreased distal pulses, buerger color
Thromboangiitis obliterans test
Angiogram showing collateralization and blockage
Thromboangiitis obliterans traetment
Smoking cessation
Giant cell arteritis/temporal arteritis
Chronic vasculitis of large and medium vessels
Giant cell arteritis presentation
Temporal headache Scalp tenderness Thickened temporal arteries Jaw claudication Acute visual loss
Diagnosis for giant cell arteritis
Temporal artery biopsy
Kawasaki disease
Acute inflammatory process involving multiple organs
Vasculitis in medium sized arteries
Kawasaki disease. Clinically
Febrile child with rash and multiple visits
Coronary artery aneurysms
Abrupt fever onset, rash, LAD
Thoracic outlet syndrome
Condition of compression on nerves or vessels in the region around the neck and clavicle (thoracic outlet)
TOS risk factors
Trauma
Presence of extra rib
Poor posture
Increased muscle bulk
TOS clinical findings
Neurogenic- most common, pain and paresthesias in upper back, inner arm
Venous- arm claudication, cyanosis, swelling
Arterial- not common. Thrombosis, embolism, aneurysm
Roos test
Tests for TOS
Patient slowly opens and closes hands for three minutes, positive if arm becomes heavy of paresthesias
