DIT Level 2 > Cardiovascular > Flashcards

Cardiovascular Flashcards

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1
Q

Risk factors for atherosclerosis

A 
HTN
HLD
DM
Smoking
FHx
Sedentary lifestyle and poor diet
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2
Q

Atherosclerosis role in AAA

A

a main risk factor (smoking biggest risk factor)

Plaque compresses underlying media -> problem with nutrient and waste diffusion

  • > degeneration and necrosis of media
  • > arterial wall weakness
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3
Q

Hyperhomocysteinemia clinical significance and treatment

A

risk factor for CVA, PVD, coronary heart dz

Tx: B6, B12, folic acid

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4
Q

Pathogenesis of atherosclerosis

A
  1. endothelial dysfunction (caused by HTN, HLD, DM, Smoking) leads to increased vascular permeability, leukocyte adhesion, and thrombosis
  2. Accumulation of lipoproteins - in vessel wall, mostly LDL
  3. Monocyte adhesion to the endothelium: migration of the monocytes into the intima and then transformation of these cells into macrophages and foam cells
  4. Factor release: activated platelets, macrophages, inflammatory mediators, cytokines
  5. Smooth muscle cell proliferation: migraiton of sm.m. cells into intima, deposition of elastin and collagen
  6. Lipid accumulation occurs extracelularly and within macrophages and smooth muscle cells -> bulging atherosclerotic plaque
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5
Q

Clinical presentation of atherosclerosis

A

most asx

Angina
Claudication of LE
Stroke sxs
HTN
retinal changes
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6
Q

Diagnostic tests for atherosclerosis

A 
Exercise stress test - best initial test
Nuclear stress test
Stress test with echo
Pharmacologic stress test
PET myocardial imaging test
Coronary angiogram - gold standard
Ankle brachial pressure index
Carotid U/S
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7
Q

Exercise stress test in atherosclerosis

A

best initial test to assess stable angina or worsening SOB with exertion or fatigue with exertion

Positive: CP, dizziness, claudication, decreased BP, ST changes

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8
Q

Nuclear stress test in atherosclerosis

A

Test to assess myocardial profusion

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9
Q

Stress test with Echo in atherosclerosis

A

assess wall motion abnormalities

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10
Q

Pharmacologic stress test in atherosclerosis

A

uses cardiac inotrope/chronotrope (dobutamine) or vasodilator (adenosine or dipyridamole) in place of exercise

caution with vasodilators in asthmatics and hypotensive patients

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11
Q

Positron emission tomography (PET) myocardial imaging in atherosclerosis

A

assess heart perfusion defects - lights up with adequate perfusion, black if not perfusing

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12
Q

Coronary angiogram in atherosclerosis

A

gold standard test

Assess degree of coronary artery occlusion - more invasive

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13
Q

Ankle brachial pressure index

A

Pt supine, ankle BP/brachial BP
assess peripheral artery disease
abnormal if less than 0.9 -> stress test or angiogram

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14
Q

Carotid ultrasound in atherosclerosis

A

assess carotid stenosis leading to TIA or stroke

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15
Q

Treatment of atherosclerosis

A 
Stop tobacco use
Normalize BP
Control hyperglycemia
Control hypercholesterolemia
Low-fat diet
exercise
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16
Q

Chylomicrons

A

lipoprotiens absorbed from gut travel to liver

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17
Q

VLDL

A

produced by liver, high in TGs

can become IDL and LDL

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18
Q

HDL

A

produced by liver

take up cholesterol deposited by LDL particles

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19
Q

LDL

A

high in cholesterol
made from VLDL

taken up into cells by endocytosis - part of atherogenesis

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20
Q

Secondary causes of hypercholesterolemia

A 
T2DM
Excess etOH
Primary biliary cholangitis
CKD
Hypothyroidism
Medications: oral estrogens, thiazide diruetics, B-blockers, atypical antipsychotics (clozapine, olanzapine), protease inhibitors
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21
Q

Xanthoma

A

deposits of lipid in tendons and under skin

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22
Q

Xanthelasma

A

deposits of lipid around eyes

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23
Q

Arcus senilis

A

deposits of lipids in the periphery of the corneas

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24
Q

Treatment of hypercholesterolemia

A

Goal: reduce risk of atherosclerosis and pancreatitis (TGs)

Lifestyle modifications:
Wt loss
aerobic exercise
diet
smoking cessation
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25
2013 AHA/ACC guidelines for treating hypercholesterolemia - who gets treated?
Clinical atherosclerotic CV dz (ASCVD) - need mod-high intensity statin: - ACS - MI - stable or unstable angina - Revascularization procedures - Stroke or TIA - Peripheral artery disease LDL >190 T1 or T2DM ages 40-75 10 yr ASCVD risk >7.5% ages 40-75
26
Causes of Angina
Decreased O2 supply: atherosclerosis obstructing blood flow, shock, hypoxemia, anemia, prinzmetal angina Increased O2 demand: vigorous exertion, tachycardia, htn, ventricular hypertrophy, increased catecholamines
27
Clinical features of angina
chest discomfort/pressure - left sided or midsternal, radiates to back, jaw, or left arm diaphroesis SOB Palpitations
28
Atypical sxs of angina
older patients, females, DM pts Abdominal pain, exercise intolerance, worsening generalized fatigue
29
Stable angina
predictable CP that resolved with rest No initiation of CP at rest Dx: stress test - cardiac enzymes always normal
30
Unstable angina
Unpredictable chest pain that can occur at rest Pain more severe and lasts longer 1/3 will have MI within 3 years Dx: Give aspirin and transport to ED ECG and cardiac enzymes initially normal, sometimes ST depression Stress test or cardiac cath when stable
31
MI
occlusion of coronary vessels d/t thrombus formation following a plaque rupture Pressure sensation radiates to jaw or left arm Tachycardia, diaphoresis, N/V, impending doom Possible new S3, S4, or systolic murmur Abnormal cardiac enzymes - trp I most specific (elevates within 4 hours, lasts 2 weeks)
32
STEMI vs NSTEMI
ECG gold standard within 6 hrs of sxs STEMI: ST elevation, cardiac cath to locate occlusion, new LBBB NSTEMI: no ST elevation, cardiac cath to locate occlusion
33
Evolution of MI on ECG
Acute: ST elevates - tomb stoning (also seen with prinzmetal angina) Hours: ST elevated, R wave decreases, Q wave appears Day 1-2: T wave inverts, Q wave deepens Days later: ST normal, T wave inverted Weeks later: ST normal, T wave normal, Q wave persists
34
Anterior wall MI on ECG
V2-V5 - LAD
35
Septal wall MI on ECG
V1-3 - LAD
36
Inferior wall MI on ECG
II, III, aVF - posterior descending a.
37
Lateral wall MI on ECG
I, aVL, V5, V6 - LAD or circumflex
38
Prinzmetal angina (Variant angina)
Coronary artery vasospasm RF: smoking More often younger pt, fewer CAD RFs CP at rest - midnight to morning, lasts 5-15 min Dx: recurrent CP at rest, transient ST elevation, no sign of high grade coronary artery stenosis
39
DDX for CP
``` MSK Costochondritis GERD Esophageal spasm - nitrates relieve spasms Cocaine hyperventilation Herpes zoster aortic stenosis trauma PE pneumonia pericarditis pancreatitis angina aortic dissection aortic aneurysm Infarction Neuropsych dz - depression, anxiety ```
40
Indications for CABG
>50% stenosis in left main artery | 3 vessel disease
41
Complications of MI
arrhythmia d/t electrical irritability - Vfib MC and lethal LVF and pulmonary edema - decreased heart function Cardiogenic shock - high risk of mortality Ventricular free wall rupture -> tamponade Papillary muscle rupture -> severe MR Interventricular septal rupture -> VSD Aneurysm formation 2/2 scar tissue Fibrinous pericarditis - friction rub 3-5 days after MI Dressler syndrome - autoimmune pericarditis weeks after MI
42
Equations for Cardiac output
CO = SV x HR SV= EDV - ESV
43
Factors determining stroke volume
Preload Afterload Myocardial contractility
44
Preload
stretch of myocytes at the end of diastole influenced by EDV and venous return Increase intravascular volume increases preload Dehydration decreases preload
45
Afterload
pressure against which the ventricles contract to eject blood influenced by aortic pressure after load and stroke volume inversely related, lower after load allows more blood to get out of the ventricle
46
Myocardial contractility influences
catecholamines, intracellular Ca2+, extracellular Na+ Independent of pre- and after-load Increase calcium = increased contractility Low extracellular sodium makes for higher intracellular calcium, increasing contractility
47
Fick principle
CO = (rate of O2 consumption)/(Ao2 - Vo2)
48
How does exercise change cardiac output?
1st: increased stroke volume | later - increased heart rate - which sustains increased cardiac output
49
Mean arterial pressure equations
MAP = CO - TPR (total peripheral resistance) MAP = 2/3 DBP + 1/3 SBP
50
Pulse pressure equation
PP = SBP - DBP
51
LV ejection fraction
Normal 55-75% EF = SV/EDV = (EDV-ESV)/EDV
52
Causes of systolic heart failure
Systolic heart failure - CO doesn't meet systemic demands Increased preload Increased after load Decreased contractility Brady or tachycardia High output conditions: - decreased O2 carrying capacity (anemia) - Increased metabolic demand (hyperthyroidism, beriberi (thiamine deficiency))
53
Causes of diastolic heart failure
Filling problem LVH - 2/2 chronic htn -> S4, S3, summation gallop Hypertrophic cardiomyopathy Restrictive cardiomyopathy
54
Hypertrophic cardiomyopathy (HOCM)
AD Chaotic, disordered hypertrophy of the LV myocytes with interstitial fibrosis - muscle fibers oriented in different directions Hypertrophy of the inter ventricular septum -> LV outflow tract obstruction Clinical features: - Exertional syncope, dyspnea, CP - Sudden cardiac death in a young athlete - Systolic murmur (like AS), LOUDER with Valsalva (decreased preload), SOFTER with squatting (increased after load) - Forceful, enlarged apical impulse - silver dollar sized Dx: ECHO Tx: B-blocker (decrease HR, prolong diastole); restrict physical exertion AVOID volume depletion, NO diuretics
55
Dilated cardiomyopathy
MC Dilation of ventricles -> systolic dysfunction Clinical features: - fatigue, dyspnea, systolic dysfunction - S3 - Systolic and diastolic murmurs - leaflets separate - CXR: globular heart Tx: diuretics, ACE inhibitors, B-blockers
56
Causes of dilated cardiomyopathy
``` Ischemic heart disease! Idiopathic etOH Cocaine Doxorubicin Coxsackie virus B Myocarditis HIV Chagas disease (Trypanosoma cruz) Beriberi (thiamine deficiency) - wet = edema Hemochromatosis (most commonly causes dilated CM) Pregnancy - "permpartum CM" ```
57
Restrictive cardiomyopathy
Least common CM Ventricular walls become stiff and noncompliant -> diastolic dysfunction Causes: usually d/t infiltration of the myocardium - Sarcoidosis - Amyloidosis - Hemochromatosis (less likely than dilate) Clinical features: Right-sided heart failure - edema, JVD, ascites Diagnosis: ECHO, myocardial bx Tx: identify and tx underlying cause; Diuretics, ACE-i, B-blockers
58
Symptoms of left heart failure
Left = lungs ``` DOE Orthopnea Paroxysmal nocturnal dyspnea Rales (crackles) Displaced PMI S3 heart sound - apex ```
59
Causes of left heart failure
Ischemic heart disease | HTN
60
Symptoms of right heart failure
JVD Hepatomegaly Lower extremity edema
61
Causes of right heart failure
Left heart failure Valvular heart disease COPD -> cor pulmonale Pulmonary hypertension
62
Tests used to diagnosis CHF
``` ECHO BNP CXR Cardiac enzymes ECG ```
63
BNP and how to interpret
Hormone produced in response to ventricular stretch -> vasodilation and urinary excretion of Na+ and H2O (little) BNP less than 100 - r/o CHF BNP 100-400 - indeterminate BNP >400 indicates CHF
64
CXR in CHF
``` Cardiomegaly Pulmonary edema Cephalization of pulmonary vasculature - bigger in upper lungs, normally hard to see Kerley B lines - peripheral, lower lungs Pleural effusion ```
65
Treatment of acute decompensated CHF presenting with pulmonary edema
NOLIP Nitrates - redistributes blood outside pulmonary vasculature O2 - only if hypoxemic Loop diuretic - takes long time to work d/t low CO = low kidney perfusion, only help volume overload Inotropic drugs - Dobutamine, milrinone - not first line d/t increased mortality Positioning - pool blood in legs
66
Drugs proven to reduce mortality in CHF
ACE inhibitors - decrease preload and after load, increase CO -candesartan and valsartan if intolerant to ACE-i d/t cough B-blockers - bisoprolol, carvedilol, extended-release metoprolol - prevents cardiac remodeling - Avoid with acute decompensated CHF Aldosterone antagonists - spironolactone, eplerenone -Start after ACE-i and B-blocker
67
Drugs used for symptom relief in chronic CHF
Loop diuretics - decrease preload, fluid overload Digoxin - improve contractility Vasodilators - isosorbide dinitrate, hydrazine (decreased mortality in AA)
68
Cardiac resynchronization therapy
Pacemaker leads in each ventricle -> synchronized ventricular contraction Can improve mortality and reduce sxs in patients with LVEF at or below 35%
69
Pulmonary capillary wedge pressure (PCWP) is a good approximation of what other pressures?
LA pressure | LV diastolic pressure
70
Two most common sites of pulmonary artery catheter placement
L subclavian v. | Right internal jugular v.
71
Causes of myocarditis
MC- viruses: parvovirus B19, coxsackie, echoviruses, adenovirus, EBV, CMV, influenza Trypanosoma cruz - Chagas disease Drug toxicity - chloroquine, PCNs, sulfonamides, cocaine, radiation, cyclophosphamide, doxorubicin, daunorubicin
72
Clinical features in myocarditis
``` Asx -> sudden death fatigue CP HF sxs - edema, SOB palpitations fever S3 or S4 Signs of CHF - edema, pulmonary rales, JVD ```
73
Diagnostic tests in myocarditis
ECG: normal or signs of MI - ST elevation, Q waves; peripheral or ectopic beats Cardiac enzymes - normal or elevated - troponin I CXR: CM or pulmonary congestion ECHO: impaired ventricular function Cardiac magnetic resonance (CMR) - detect inflammatory hyperemia, edema, myocyte necrosis Definitive dx: endomyocardial bx - cx and viral PCR
74
Chagas disease
Trypanosoma cruz MEGA -3 cardioMEGAly MEGAesophagus MEGAcolon
75
Treatment of myocarditis
``` treat underlying cause - abx for bacterial Stop offending agents Tx any significant arrhythmias Tx HF sxs +/- immunosuppressant agents ``` Supportive treatment - usually viruses
76
Acute rheumatic fever causes
2-4 weeks after untreated group A strep pharyngitis - 3% Due to autoantibodies that attack heart and joints - sterile vegetations MC: MV>AV>TV=PV
77
Diagnosis of acute rheumatic fever
JONES criteria -Hx of recent strep and 2 major or 1 major and 2 minor Major: JONES - Joints - polyarthritis - hot swollen - Heart - pancarditis, pericarditis, endocarditis, myocarditis - Nodules - subcutaneous on extensor surfaces - painless, back wrist, elbow, anterior knee - Erythema marginatum - painless, trunk or medial limbs; multiple lesions with central clearing - Sydenham chorea Minor: PEACE - Previous rheumatic fever - ECG with PR prolongation - Arthralgias - CRP and ESR elevation (nonspecific) - Elevated temperature
78
Diagnostic testing for acute rheumatic fever
Elevated ESR and CRP Elevated WBC 90% ASO titer
79
Treatment for acute rheumatic fever
NSAIDs - joint inflammation Corticosteroids - carditis severe B-lactams (PCN) - ongoing infection
80
Endocarditis ppx prior to surgery or dental procedure - patient population and tx
Prosthetic cardiac valve Previous infective endocarditis Congenital heart disease - unrepaired cyanotic defect, palliative shunts, repaired with prosthetic device/material Cardiac transplant with cardiac valvuloplasty Tx: amox 2 g x1 30-60 min prior to procedure No longer recommended if hx of rheumatic HD unless previous endocarditis
81
Endocarditis vegetation composition
platelets, fibrin, microorganisms, inflammatory cells
82
Risk factors for endocarditis
``` Damaged heart valves - rheumatic HD, congenital HD IV drug users poor dentition age >60 yo Male ```
83
Presentation of endocarditis
Fever, malaise, weakness, anorexia, new heart murmur, wt loss Jane way lesions - contender, erythematous macule on palms and soles - septic emboli Osler nodes - tender nodules on fingers and toe pads; caused by immune complexes (also in lupus and disseminated gonococcal infections) Roth spots - retinal hemorrhages with pale centers - immune complexes Splinter hemorrhages - nonspecific Conjunctival hemorrhages
84
Bacterial causes of endocarditis
``` S. aureus - 31% Viridan group Strep 17% - assoc with dental procedures Enterococci 11% Coagulase-negative staph 11% S. bovis 7% ``` HACEK - Haemophilus spp - Actinobacillus - Cardiobacterium - Eikenella - Kingella Culture negative - intracellular - Coxiella burnetii - Q fever - Bartonella spp. - cat scratch - Brucella spp - unpasturized milk, zoonotic
85
Complications of endocarditis
severe damage to endocardium and valves -> valve repair/replace Septic emboli - Right side -> PE; Left side -> stroke, spleen, kidney, anywhere
86
Duke criteria
Endocarditis - definitive dx - positive culture/histo of vegetation Clinical criteria - 2 major; 1 major 3 minor; 5 minor Major: Serial blood cultures positive Vegetations or cardiac abscesses on ECHO - TEE New valve regurgitaiton - MC MR Blood cx positive for Coxiella burnetii (closely associated) Minor: Predisposing heart condition or IV drug use Temp >38C Vascular phenomenon - arterial emboli, conjunctival hemorrhages, Janeway lesions Immunologic phenomenon - glomerulonephritis, Osler nodes, roth spots Positive cx not meeting requirements for major criteria Serologic evidence of infection without positive cx
87
Empiric antibiotic most often used for infective endocarditis
Vancomycin until sensitivities back | 4-6 weeks
88
Nonbacterial thrombotic endocarditis (marantic)
Occurs on non-damaged valves - sterile vegetations Associated with: sepsis, pregnancy - hyper coagulable states venous catheters mutinous adenocarcinoma
89
Libman-Sacks endocarditis
Associate with SLE both sides of the valve Due to deposition of immune complexes
90
Chronic constrictive pericarditis
Scarred, fibrous pericardium becomes rigid -> decreased diastolic filing and cardiac output Risk factors: cardiac surgery, radiation Presentation: HF sxs - DOE, fatigue, peripheral edema Physical exam: JVD, Kussmaul's sign (JVD with inspiration) Confirm with ECHO - thickening of pericardium, most ventricle filling in early diastole CXR: calcification of pericardium - specific, not sensitive Tx: pericardiectomy - high mortality - 10%
91
Conditions with Kussmaul's sign
JVD with inspiration - impaired RV relaxation and filling ``` Restrictive CM RV infarction tricuspid stenosis massive PE right sided CHF Chronic constrictive pericarditis ```
92
Left atrial myxoma
MC cardiac tumor in adults 75-80% left atrium ball valve - obstruct blood flow into LV -> syncope Physical exam: rarely - early diastolic "tumor plop" Dx: ECHO Tx: surgical resection
93
Atrial fibrillation Risk factors
``` Hyperthyroidism pulmonary dz CAD HTN anemia valvular disease pericarditis Rheumatic HD sepsis alcoholism ```
94
Afib
rapid, irregularly irregular rhythm ECG: no distinct p waves asx or SOB, CP, palpitations, irregularly irregular pulse
95
Afib managment
Acute: new onset less than 48 hours - electrocardioversion Chronic: -evaluate for thumbs with TEE Anticoagulate with heparin and warfarin Rhythm control with sotalol or amiodarone -> sinus rhythm Rate control with B-blockers, NDP CCBs or digoxin
96
Atrial flutter
re-entrant rhythm in right or left atrium - can degenerate to afib ECG - sawtooth pattern, >150bpm Risk: CAD, CHF, COPD, valve dz, pericarditis Sxs: Asx or palpitations, syncope Tx: rate control - b-blockers, CCB; cardioversion - electrical or chemical; catheter ablation
97
PVCs
causes: hypoxemia, abnl electrolytes, hyperthyroidism, caffeine Clinical: asx or palpitations, syncope, sensation of skipped, heavy, or dramatic beat ECG: wide QRS Tx: none if healthy - b-blockers in CAD More than 3 in a minute concerning for other ventricular arrhythmias
98
V-tach
sustain -> vfib ECG: series of 3 or more PVCs, HR of 160-240 Tx: electrocardioversion, followed by antiarrhythmic medication Recurrent -> internal defibrillator Clinical: asx if brief -> palpitations, syncope, hypotension
99
Torsades de pointes
ECG: vtach with sine wave Tx: IV magnesium rapid bolus -> lidocaine, phenytoin
100
Vfib
lack of ordered ventricular contractions leading to NO cardiac output ECG: erratic, no identifiable p waves or QRS Tx: CPR, immediate shock
101
Treatable causes leading to a code - H's
Hypovolemia -> rapid volume resuscitation through multiple IV sites and/or central lines Hypoxemia -> correct via intubation, chest tube, or O2 H+ (acidosis) -> IV push 1-2 amps bicarbonate (common in prolonged code) Hyperkalemia -> CaCl2 IV push, bicarbonate, insulin/glucose (common in prolonged resuscitation due to acidosis) Hypoglycemia -> 1 amp D50 IV push - always check finger stick Hypothermia -> warming
102
Treatable causes leading to a code - T's
Tamponade -> pericardiocentesis Tension PTX -> needle decompression then chest tube Thombus - MI -> cardiac cath or thrombolytic Thombus - PE -> thrombolytic or thombectomy Trauma -> follow ATLS protocols Toxins
103
Prehypertension vs hypertension BP readings
Pre: 120-139/80-89 htn: over 140/90 Diagnosis HTN after 3 separate occasions
104
Complications of uncontrolled htn
``` atherosclerosis -> CAD, ischemic stroke hemorrhagic stroke LVH -> diastolic dysfunction Thoracic aortic dissection AAA CKD (also can cause the htn) hypertensive retinopathy (AV nicking, cotton wool spots, retinal hemorrhages-flame hem) ```
105
Most likely cause of htn refractory to multiple meds? Next step to dx? tx options?
renal a. stenosis - over 50 - atherosclerosis - under 50, women - fibromuscular dysplasia of renal a (needs on string) MRA of renal a. - best, least invasive Spiral CT with con renal a. duplex scan renal arteriogram - gold standard, but invasive Tx: medical management - avoid ACE/ARBs if bilateral (decreased GFR and worsening renal fxn) Angioplasty Surgical revascularization - bypass
106
Causes of secondary hypertension
renal a. stenosis CKD or ESRD Drugs - OCPs over 35, NSAIDs, antidepressants, glucocorticoids Hypercortisolism - Cushing - dx: serum cortisol, serum ACTH, dexamethasone suppression test Primary hyperaldosteronism - Conn - Triad: htn + hypokalemia + metabolic alkalosis Dx: high plasma aldosterone:plasma renin ratio Pheochromocytoma: episodic htn with diaphoresis, tachy, palpitations, HA Dx: 24 hr urine catecholamines and metanephrins, CT abd Hypo- or hyperthyroidism - dx TSH Hyperparathyroidism - calcium drives sm.m. contraction -> peripheral vasoconstriction Dx: serum calcium, PTH Coarctation of aorta -BP high in arms, low in legs; weak dorsals pedis pulses Dx: ECHO OSA - Dx: polysomnography
107
Hypertensive urgency vs emergency
BP >180/120 urgency- no sxs, no end organ damage emergency - end organ damage -renal dz, AMS, papilledema, retinal vascular changes, unstable angina, MI, aortic dissection, pulmonary edema
108
Treatment of hypertensive urgency
Goal: reduce BP to 160/100 initially Reduce MAP no more than 25% in first 2-3 hours - risk ischemia ``` IV drugs: Nitroprusside Labetalol Nicardipine Clonidine Captopril Enalapril ```
109
``` JNC8 bp goals: Gen pop under 60 Adults with CKD Adults with DM Gen pop over 60 no CKD, no DM ```
less than 140/90 for: Gen pop under 60 Adults with CKD Adults with DM less than 150/90 for: Gen pop over 60 no CKD, no DM
110
Aortic dissection - mechanism, risk, features and dx
Tear in intimate of aorta -> blood dissects into media -> forms false lumen Risk factors: HTN Dz weakening aorta - Marfans, Ehlers-Danlos, syphilis Features: Severe, sharp or tearing CP radiating to back May cause syncope, TIA or decreased peripheral pulses Dx: Normal ECG Widening mediastinum on CXR Best test: CT chest with contrast - two lumens; classify as Stanford A (involves ascending aorta) or Stanford B (distal to L. subclavian A)
111
Aortic dissection - management
Stabilze BP with beta-blockers - decreases slope of rise in BP - anti-impulse treatment Morphine for pain control Stanford A - emergency surgical repair - high risk Stanford B - treat medically unless LE ischemia, uncontrolled pain
112
AAA - risk factors, features, dx, screening
Focal dilation of the abdominal aorta, distal to renal a. ``` Risk: Tobacco use Age >55 Male Caucasian Atherosclerosis HTN FHx ``` Features: Asx - possible abd/lower back pain Exam: pulsatile abdominal mass, abdominal bruit Ruptured AAA: hypotension, severe abd pain, pulsatile mass Dx: Best first test: abd u/s CT or MRI with con Screen: one time abd u/s all men 65-75 with hx of smoking
113
Indication for repair of AAA
Diameter > 5.5 cm in men or >5 cm in women Increase in diameter by more than 0.5 cm in 6 mo - should be having abd u/s q6mo Symptomatic - tenderness, pain in abdomen or back
114
Peripheral artery disease (PAD) - risk, features, dx
Atherosclerosis of peripheral arteries - legs ``` Risk: Smoking HTN DM HLD ``` Claudication - exertion leg pain improves with rest Non-healing foot ulcers Erectile dysfunction Skin changes - dry, shiny skin, decreased hair growth on legs decreased pulses in legs ``` Dx: ABI ratio - ankle SBP to brachial SBP -ABI >= 0.9 normal; less than 0.9 = vascular insufficiency; less than 0.4 = severe disease U/S or CT angiogram or MRA Arteriogram ```
115
Management of peripheral artery disease
Conservative medical management: - smoking cessation - Glucose and BP control - Daily exercise to increase collateral flow - Cilostazol - improves blood flow to LE and decreases claudication via arteriovasodilation; more effective than pentoxifylline (makes RBC more flexible); contra in HF d/t increased mortality - daily aspirin or clopidogrel to reduce CV events - Statin to reduce CV events, increase pain-free walking distance If not responding to medical management -> angioplasty, bypass grafting, or amputation -may have concurrent CAD
116
DVT - risk, features, dx, tx
Blood clot developing in deep vein - usually LE Risk: -virchow's triad - Hemostasis - immobilization from illness, surgery, travel - Hypercoagulability - inherited, cancer, high estrogen states (pregnancy, OCPs) Features: Often asx Pain, warmth, and/or swelling in LE -calf Homan's sign - pain with dorsiflexion, found in less than 1/3 Dx: Positive D-dimer (also high in post op) - negative r/o Best test: doppler u/s of extremity Tx: elevate leg Anticoagulate - LMWH (enoxaparin) or unfractionating heparin -> warfarin x3 mo If anticoagulant contraindicated (high fall risk) - IVC filter
117
Treatment of varicose veins
Weight reduction, avoid prolonged standing, leg elevation Compression stockings Sclerotherapy - inject substance to cause injury and thrombosis Thermal ablation - laser Surgery ligation of long saphenous v or short saphenous v - lose option for CABG
118
Giant cell arteritis (temporal arteritis)
Large vessel vasculitis elderly woman Associated with polymyalgia rheumatica (PMR) HA, tenderness of temples, jaw claudication Transient or permanent vision loss Histo: granulomas - multinucleate giant cells Elevated ESR - normal r/o Definitive dx: temporal a. bx Tx: prednisone 1-2 mo, with long taper 9-12 mo; don't delay start, risk blindness Aspirin Calcium, vit D to reduce risk of osteoporosis due to steroids
119
Takayasu arteritis
Large vessel vasculitis - arch of aorta and major branches off arch Asian woman - 10-40 yo Cerebrovascular ischemia, coronary ischemia, syncope, vertigo Poor pulses in UE - pulseless disease Tx: glucocorticoids
120
Kawasaki disease (mucocutaneous lymph node syndrome)
Medium vessel vasculitis Asian infant, kid "CRASH and Burn" Conjunctivitis - b/l non exudative, painless Rash on trunk Adenopathy of cervical LN Strawberry tongue and diffuse erythema of mucous membranes Hands and feet - edema with induration, erythema or desquamation Fever - >40 C or 104 lasting at least 5 days coronary artery aneurysm within weeks of illness onset - risk rupture or thrombosis -> MI Tx: IVIG within first 10 days of illness High dose aspirin until 48 hr after fever resolution Low dose aspirin until inflammatory markers (platelets, ESR) return to normal (usually 6 weeks) ECHO in acute phase and 6-8 weeks later Steroids NOT indicated, no benefit
121
Polyarteritis nodosa
Necrotizing inflammation of small and medium sized arteries -> ischemia - Kidneys, GI tract - SPARES lungs Associated with Hep B/C - Hep with renal dz - proteinuria, hematuria ANCA negative Angiography - aneurysms in affected organs
122
Thormboangiitis obliterates (Buerger disease)
Small/medium sized arteries and veins Heavy smoker, young male 30-40s Ischemia of digits, Raynaud's Tx: stop smoking
123
Henoch-Schonlein purpura (IgA vasculitis)
Small vessel vasculitis ``` Kids - recent URI, strep Palpable purpura of LE Arthritis and arthralgia Abd pain d/t intestinal hemorrhage Renal dz (IgA nephropathy) - microscopic hematuria, mild proteinuria ``` Tx: hydration, pain control
124
Mixed cyroglobulinemia syndrome (essential mixed cyroglobulinemia)
Small vessel vasculitis Polyclonal IgG and IgM against IgGs precipitate out at cool temps Associated with Hep C Melzer's triad: palpable purpura, weakness (peripheral neuropathy), arthralgia ``` Raynauds Liver involvement (hep C) ``` 20-30% kidney dz - hematuria, proteinuria
125
Granulomatosis with polyangiitis (Wegners)
Granulomas in: Lung - pulmonary nodules, infiltrates, hilar LAD Upper airway - ENT, soft palate Kidneys c-ANCA + (PR3-ANCA) Dx: Kidney or lung bx Tx: steroids and cyclophosphamide
126
Eosinophili granulomatosis with polyangiitis (Chrug-Strauss)
Allergic! Assoc with asthma Lung dz - opacities, nodules Upper airway disease Skin - tender skin nodules, palpable purpura 20% renal involvement Histo: Eosinophilic inflammation + granulomas on lung bx p-ANCA + (MPO-ANCA) Eosinophilia
DIT Level 2
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