Peripheral Artery Disease and Pericardial Disease Flashcards
PAD presentation example
- lower leg pain; can be bilateral; one side can hurt more than the other
- exercise-induced pain, relieved by rest (intermittent claudication)
- hanging of foot over bed = gravity helps blood flow
- High BP and heart failure = good signs of PAD
Is intermittent claudication necessary for PAD diagnosis?
No; only experienced by 1/3 of patients
PAD vs CAD treatment
PADs are not getting proper care; higher mortality than breast cancer
PAD physical exam
Auscultate abdomen and femoral arteries = look for bruits
Palpate for abdominal aortic aneurysm, and normal pulses
Inspect foot for ulcers, xanthomas, etc.
General appearance of PAD leg
Hair loss Thickened/brittle toenails Smooth/shiny skin Loss of subcutaneous fat Gangrene Ulceration
Non-invasive evaluation techniques of PAD
Most commonly used initial test:
Ankle-Brachial Index
Ankle-Toe index
Further:
Ultrasonography - identifies location
What is the equation for ankle-brachial index
ABI = Highest ankle systolic pressure/highest brachial systolic pressure
What do ABI values mean
Low ABI = PAD; degree of ABI reduction correlates w/ disease severity
ABI >1.30 is also abnormal
Treatment of PAD
- Biggest = risk factor modification
- Exercise
- Antiplatelet therapy
- phosphodiesterase inhibitors; Cilostazole
Risk modification in PAD
- Smoking cessation
- Exercise
- Lower LDL = <140/90; use ACE inhibitors/beta-blockers
- Control diabetes
- Antiplatelet therapy - aspirin or clopidogrel
Smoking and PAD
- 2-5X increased risk of PAD
- 84-90% of patients w/ claudication are current or ex-smokers
Diabetes and PAD
- 2 to 4X increase of PAD
- Significant risk reduction per 1% reduction of HgA1c
PAD-specific drugs
- Pentoxifylline; not very effective
- Cilostazole; phosphodiesterase inhibitor = inhibits platelets (cAMP), vasodilation (cGMP); more effective
Do not use warfarin; no benefit
Cilostazole; contraindications
Do not give to those w/ HF = increased mortality
Benefits of walking program
- formation of collaterals
- improvement of vasodilation, muscle metabolism, walking efficiency
- Much longer and more prolonged walking distances
General PAD treatment plan
- Aspirin or Clopidogrel
- Statin
- Walking program
When is revascularization indicated w/ PAD
- lifestyle-limiting symptoms
- Continued disability
When to consider aortic dissection?
All patients w/:
- chest, back, abdominal pain
- syncope
- perfusion deficit symptoms; CNS = depression, ischemia, etc.
Acute aortic dissection risk factors/assesment
- High risk condition - marfans, CT disorder, family history of aortic disease/valve disease, etc.
- High risk pain = acute onset, ripping/tearing/sharp in nature
- High risk exam = deficient pulse, low BP, focal neurologic deficit, murmurs
Which drug increases risk of dissection?
Cocaine
Aortic dissection treatment prior to surgery
- DO NOT drain/pericardiocentesis
- DO NOT increase HR
- IV metoprolol to lower HR; do not use w/ aortic insufficiency
- CCBs if can’t tolerate beta blocker
- IV ACE inhibitors/vasodilators after BP is controled
- DO NOT GIVE VASODILATORS BEFORE BP/HR CONTROL - reflex tachycardia increases stress
Pericardial Characteristics/Anatomy
- Visceral pericardium reflects back near great vessels to become parietal pericardium
- Pericardial space = normally contains 50mL serous fluid
- Derived from mesoderm
- Phrenic nerve runs in the pericardium
Irritation of the phrenic nerve causes what?
Hiccups
Function of the pericaridum
- Maintains heart position
- Barrier to infection
- Secretes prostaglandin = coronary vascular tone
- Restrains cardiac volume
Pericardium compliance
Normal - minor volume changes lead to signficant complaince changes; resistant to change
Chronic volume increase - expands; more compliant
Acute pericarditis; etiology
- Most are idiopathic
- Viral
Common viruses to cause acute pericarditis
- Coxasckie B - causes myopericarditis
- HIV - africa
- Tuberculosis - africa
Acute pericarditis; symptoms
Sharp, pleuritic pain
-substernal, epigastric, left chest, trapezius muscle
Acute pericarditis; physical exam
Three component friction rub; ventricular systole, atrial systole, diastole
-at LSB with patient leaning forward
Acute pericarditis ECG
Dynamic;
- ST elevation
- PR depression
- Low voltage QRS
- Electrical alternans
Acute pericarditis CXR
Pleural effusion
CHF
Big heart
Acute pericarditis Echo
-not required for diagnosis
Acute pericarditis treatment
- NSAIDs = sufficient to treat
- NSAIDs + Colchicine = better recovery and decreased recurrence
- Steroids = rapid response; increased recurrence
- For secondary pericarditis - treat primary disorder
Colchicine mechanism
- anti-inflammatory
- Inhibits microtubule assembly; preferentially targets leukocytes
- -inhibits intercellular granular movement and secretion
Acute pericarditis diagnosis
Two of the following:
- friction rup
- typical sharp chest pain
- Suggestive ECG
- New or worsening pericardial effusion
What is incessant pericarditis?
Pericarditis that is persistent
Pericarditis that shows symptom free intervals of less than 6 weeks and then returns
Treatment for incessant pericarditis?
NSAIDs + Colchicine
SE of Cholchicine
Major GI side effects
Hepatotoxic
Non-inflammatory causes of pericardial effusion
Hydropericardium - serous transudate; associated w/ CHF, hyponatremia, CKD, liver disease
-Hemopericardium - trauma, MI, myocardial rupture, dissection
Most common cardiac manifastation of HIV
Pericardial effusion - seen in advanced stages
- most are small, asymptomatic
- Larger effusions occur secondary to infection or neoplasm (kaposi’s, etc)
What to do after obtaining pericardial ECG?
Catheterization tests
What is a feature of pericarditis?
Pulsus paradoxes - fall of >30 mmHg or more in BP w/ inspiration
