Cardiology 4

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HuskerDevil
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Cardiology 4
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2011-07-18 16:22:36
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DPAP2012 Cardiology
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Cardiology flashcards made by previous students
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  1. 2 components of Aorta
    thoracic (ascending, arch, descending); Abdominal
  2. 3 layers of aorta:
    Intima; Media; Adventitia
  3. Intima:
    thin, inner layer (delicate, easily traumatized)
  4. Media:
    thick middle layer (*strength of the aorta comes from media)
  5. Adventitia:
    somewhat thin outer layer (contains mainly collagen)
  6. Strength of the aorta lies in:
    media (= laminated, intertwining elastic tissue/ multiple layers, in a spiral manner, max tensile strength w/ distensible & elastic
  7. Pseudoaneursym
    well defined collection of blood & conn tissue outside vessel wall
  8. Atherosclerotic vs inflammatory
    inflame = extreme of atherosclerotic aneurysm
  9. pathogenesis of AAAs:
    multifactorial: genetic, environ, hemodynamic & immunological; Chlamydia pneumoniae?
  10. Aorta most affected by atherosclerotic process:
    infrarenal abdominal aorta
  11. most common site of AAA formation:
    infrarenal abdominal aorta
  12. Atherosclerotic dz of aorta may produce:
    stenotic obstrusion or aneurysmal dilatation
  13. Aneurysm types
    Saccular; fusiform
  14. Most common aneurysm type
    Fusiform
  15. Has a fairly symmetrical dilation (involves full circumference of aortic wall)
    Fusiform
  16. More localized dilation (outpouching of a portion of aortic wall)
    Saccular aneurysms
  17. Flow disturbance thru the aneurysmal aortic segment:
    blood may stagnate along walls, cause mural thrombus (may embolize)
  18. Aneurysm defn:
    1.5x or > the normal diameter of the vessel.
  19. Aneurysm type cf prevalence
    Abdominal more common than thoracic aneurysm
  20. Half of newly detected AAAs are:
    <5cm (& 2/3 eventually require repair)
  21. AAA & COPD:
    COPD pts: rupture of smaller AAAs more likely
  22. AAAs usually involve:
    aortic bifurcation (& often involve common iliac arteries)
  23. AAA & Rupture
    80% rupture into left retroperitoneum (may contain it); remainder rupture into peritoneal cavity (=> uncontrolled hemorrhage & rapid circulatory collapse)
  24. Healthy, young normal aorta: size
    about 2 cm
  25. Considered Aneurysm at size:
    > 3 cm
  26. AAA Incidence in Men vs Women
    10:01
  27. AAA: men over 55
    2%
  28. AAAs arise in areas of:
    dense athero-sclerosis, eroding & weakening the wall which leads to dilatation then rupture
  29. 90% of AAAs originate where:
    below renal arteries (infrarenal); 10% suprarenal
  30. Infrarenal aneurysm may exhibit:
    stenosis (narrowing) of aorta
  31. AAA: Surgery recommended when:
    >5 cm*
  32. Decline of aortic elasticity & distensibility is accelerated in pts with:
    HTN, hyperlipidemia, & atherosclerosis of coronaries & other arteries.
  33. Loss of aortic elasticity
    loss of elastin & increase in collagen (=> lack of distensibility)
  34. AAA: Risk Factors
    Tobacco; Age; HTN; lipid; Atherosclerosis; Male; FH
  35. FH in AAA:
    1/4 of AAA pts have first degree relative with hx of AAA
  36. Initial dx test to screen for & follow known AAA =
    Abdominal US:
  37. Abdominal US: advantages
    100% sensitivity, no contrast, low cost
  38. AAA: CT scan
    pre-op or if US indeterminate; better defines shape & location/ extent of AAA
  39. AAA: Catheter aortography may:
    underestimate diameter
  40. AAA Risk Factors for Rupture
    Size (5cm female, 6 cm male); rapid progression (>1cm/yr); female; FH; unctrld HTN; SMK; COPD
  41. AAA Surveillance
    Trend: bigger AAA, more frequent surveil
  42. AAA: for average risk pts, a threshold of ?? cm in diameter is appropriate for elective repair
    5.5 cm
  43. AAA: what may prompt earlier endovasc repair?
    Rapid expansion (>1 cm/yr) & pt preference (in 4.5-5.5 cm range)
  44. AAA Endovascular repair: No justification for:
    endovascular repair at smaller diameters
  45. AAA: for women, elective endovasc repair is appropriate at:
    4.5 or 5.0 cm
  46. AAA Prognosis
    80% mortality with rupture
  47. AAA mgmt:
    Risk factor mod (stop SMK, aggressive HTN & Lipid Rx), med mgmt to slow progression
  48. AAA operative mortality:
    Elective = 2-5%, Expanding = 5-15%, Ruptured: >50%
  49. Criteria for Endovascular Repair: Proximal neck:
    length: min 15 mm; diameter: max 28 mm; angulation: <60 degrees
  50. Criteria for Endovascular Repair: Iliac arteries
    Common iliac a.: variable diameters; ext iliac a. <7 mm
  51. USPSTF Screening Guidelines: repair what in who?
    large AAA (> 5.5 cm) in men btw 65-75 w/ Hx of SMK; No gdln for men 65-75 no hx SMK; gdln against screen in women
  52. USPSTF AAA Screen Consensus stmt
    All M 60-85; All F 60-85 w/ 1 or more CVD risk factor; M&F > 50 w/ FH AAA
  53. Thoracic aneurysm: prevalence
    Far less common than AAAs
  54. Thoracic aneurysm: classified by:
    pt of aorta involved ( ascending, arch or descending TA)
  55. Thoracoabdominal AA =
    desc TA extends distally to involve AA
  56. TAAA: prevalence
    Less common than AAA w/ diff pathogenesis; 60% = aortic root & ascend A; 40% desc A; 10% arch
  57. Sm mx cell drop out & elastic fiber degen w/ media of cystic spaces filled w/ mucoid matl =
    Cystic medial necrosis
  58. Cystic medial necrosis occurs most frequently in:
    ascending aorta
  59. Cystic medial necrosis leads to:
    aortic wall weakening => fusiform aneurysm
  60. Aneurysm from cystic medial necrosis often involve:
    aortic root & may consequently result in AI
  61. CMN is accelerated by:
    HTN (occurs somewhat w/ aging)
  62. CMN assoc with:
    conn tissue dz (Marfan, Ehlers-Danlos syndrome, RA); aortic valve replacement
  63. Asc TA: Etiologies
    CMN, Bicuspid valve; AI; Arteritis/ Vasculitis; Collagen vasc dz (RA, Marfan, Ehlers-Danlos, Reiter); HTN; Syphilis; Atherosclerosis
  64. Ascending aneurysms usually caused by:
    CMN
  65. If Asc aneurysm due to atherosclerosis, assoc with:
    diffuse aortic atherosclerosis
  66. Aortic Arch aneurysms often contiguous with:
    aneurysms of asc OR desc A & can be caused by any of the etiologies above.
  67. Desc TA: predominant cause =
    atherosclerosis
  68. Desc TA: tend to originate:
    just distal to origin of L subclavian; may be fusiform or accular
  69. A Arch A: Etiologies
    Ext of Asc or Desc aneurysms; Hx trauma or deceleration injury
  70. Desc TA: called thoracoabdominal if they:
    extend below level of diaphram into abd aorta
  71. TAA: Spontaneous rupture prevalence
    less common than AAA (bc inc of Sx due to compression of surrounding structures)
  72. TAA: Tx: >5 cm
    surgery (if Sx or rapid expansion: then sooner)
  73. Sx pts or w/ AI:
    Inc incidence of rupture
  74. TAA: Clinical Findings
    > 50% pts ASx at dx; Sx due to vascular consequence or mass effect
  75. TAA: Vascular Sx
    AI with CHF, or thromboembolism causing stroke, lower extremity or mesenteric ischemia, renal infarct
  76. TAA: Mass Effect
    SVC syndrome, tracheal deviation, cough, hemoptysis, dysphagia, hoarseness
  77. Ascending or arch An can cause compression of:
    SVC or innominate v. => obstruction of venous return
  78. Desc/ arch An: may cause compression of:
    trachea or main stem bronchus => tracheal deviation, wheezing, cough & positional dyspnea, hemoptysis or recurrent pneumonitis
  79. Desc/ arch An: Compression of esophagus can cause:
    dysphagia & compression of recurrent laryngeal n. can cause hoarseness
  80. TAA: Clinical Findings
    Pain ( 25% pts) from direct compression of intrathoracic structures or chest wall; substernal or in back/ neck; steady, deep & severe?
  81. TAA Rupture:
    excruciating pain; may be assoc w/ aortic dissection
  82. Rupture occurs most commonly into:
    L intrapleural space or mediastinum; results in severe hypotension
  83. Desc An rupture into:
    adjacent esophagus => life threatening hematemesis
  84. TAA Evaluation
    CXR; Echo (TTE vs TEE); CT/ MRI
  85. TAA: CXR for dx:
    CXR NOT dx alone (need CT or MRI to r/out if CXR neg)
  86. TAA: Pos CXR:
    Must differentiate from anterior mediastinal mass (ie thymoma, lung CA)
  87. TAA: if surgery required, need:
    coronary angiography
  88. Echo: TTE vx TEE
    TTE only good to visualize aortic root (good for Marfan); TEE to visualize entire aorta, but is semi invasive (CT/ MRI better)
  89. TAA Mgmt: major factors in rupture risk
    Size & rate of growth
  90. TAA Mgmt: Annual growth rate for <5cm aneurysm
    2%
  91. TAA Mgmt: Annual growth rate for 5-5.9 cm
    3%
  92. TAA Mgmt: Annual growth rate for >6 cm
    7%
  93. TAA: Inc rupture risk at smaller diameters with:
    Marfan; bicuspid valve
  94. Asc Aorta: surgery indicated at:
    ≥ 5.5 cm (=/> 5.5)
  95. Marfan/ Bicuspid Valve: surgery indicated at:
    ≥ 5.0 cm (=/> 5.0)
  96. Aortic valve replacement: surgery indicated at:
    ≥ 4.0 cm (=/> 4.0)
  97. Desc Aorta: surgery indicated at:
    ≥ 6.0 cm (=/> 6.0)
  98. Aortic Root Replacement: Bentall:
    Dacron graft w/ prosthetic valve sewn directly into aortic annulus; coronary arteries reimplanted into the graft (op mortality risk 5%)
  99. Aortic Root Replacement: David =
    valve sparing Bentall (re-implant native valve within dacron graft)
  100. TAA: Prognosis
    M&M higher than with AAA; 5 yr if unrepaired (>6 cm) is 20-25% (most deaths due to rupture or CAD)
  101. TAA: 1 month op mortality =
    8-20%
  102. TAA: op complications
    pulmo comps & damage to laryngeal or phrenic n., carotid or subclavian a. poss
  103. Aortic dissection: incidence
    3/100,00/yr (at least 7,000 cases/yr in the US)
  104. Aortic dissection: usual direction of extension
    antegrade (driven by the forward force of aortic blood flow); sometimes retro from site of intimal tear
  105. Tear in aortic intima usu preceded by medial wall degen/ CMN =
    aortic dissection
  106. Aortic dissection: intimal tear in aorta creates a false lumen between:
    media & adventitia
  107. Aortic dissection: time course
    May be acute or chronic
  108. Aortic dissection: >95% occur in the:
    Ascend aorta just distal to aortic valve or just distal to L subclavian at lig arteriosum
  109. Intimal tears resulting in dissection: prevalence:
    65% Ascend A; 20% Desc A; 10% A Arch; 5% Abd A.
  110. Aortic Dissection: M vs F
    Men > women 2:1 (peak incidence 60-70 y.o.); 2,000-3,000 cases/yr
  111. Aortic Dissection: Increased risk in:
    pregnancy (1/4 of all female cases <40 yrs & most in last trimester); conn tissue dz (Marfan, Ehlers Danlos); Bicuspid Aortic Valve or Coarctation
  112. Aortic Dissection: 80% of pts are:
    Hypertensive
  113. Aortic Dissection: Debakey I =
    Ascending A extending to distal
  114. Aortic Dissection: Debakey II =
    Ascending aorta only
  115. Aortic Dissection: Debakey III =
    Descending aorta only
  116. Aortic Dissection: Stanford A =
    Any involvement of ascending aorta
  117. Aortic Dissection: Stanford B =
    Not involving ascending aorta
  118. Aortic Dissection: Proximal =
    DeBakey Types I & II or Stanford Type A
  119. Aortic Dissection: Distal =
    DeBakey Type III & Stanford type B
  120. Aortic Dissection: Clinical Findings
    Acute: sudden, severe excruciating ripping chest pain (ascending) or scapular (descending); most hypertensive or nml
  121. Aortic Dissection: PE
    Pt appears to be in shock; pulse discrepancy or syncope (tamponade)
  122. Aortic Dissection: poss Sx devt
    Acute aortic regurgitation (CHF indicates valve involvement); focal neuro (CVA may develop)
  123. Aortic Dissection Eval: CXR =
    wide mediastinum, poss L sided pleural effusion
  124. Aortic Dissection Eval: Echo =
    98% sensitive, 99% specific, +/- pericardial effusion, done bedside
  125. Aortic Dissection Eval: CT helpful in:
    acute presentation
  126. Aortic Dissection Eval: MRA/MRI useful for:
    serial follow up
  127. Aortic Dissection Eval: EKG =
    LVH, nonspecific or inferior abnormalities (dissections preferentially extend into Right coronary ostium)
  128. Aortic dissection: CXR =
    Wide aortic silhouette & mediastinum; Left pleural effusion; 10%-20% normal
  129. Aortic Dissection: mgmt: Type A =
    Surgical repair, may require AVR
  130. Aortic Dissection: mgmt: Type B =
    Medical therapy
  131. Aortic Dissection: mgmt: Type B: Exceptions to med tx:
    Rupture, Limb/ visceral ischemia, Saccular morphology, ongoing pain, uncontrolled HTN, Marfan, AI
  132. Aortic Dissection: mgmt: Chronic & asymptomatic =
    medical Rx
  133. Aortic Dissection: mgmt: All pts =
    aggressive BP control; yearly imaging or if increased Sx
  134. Aortic Dissection: Prognosis
    Op mortality of type B 2x that of type A (bc comorbid illness)
  135. Aortic Dissection: 5 yr survival: repaired Type A =
    70-80% repaired type A
  136. Aortic Dissection: 5 yr survival: repaired Type B =
    50-70% repaired type B
  137. Aortic Dissection: Prognosis: chronic type B
    30% => progressively enlarging aneurysm that eventually requires repair
  138. Most common cause of chronic lower limb occlusive disease
    Atherosclerosis
  139. PAD hx
    Hx of intermittent claudication or rest pain
  140. PAD location: Buttock/Hip:
    Aortoiliac disease
  141. PAD location: Thigh:
    Common femoral artery
  142. PAD location: Upper calf:
    superficial femoral artery
  143. PAD ad location:
    Lower calf: popliteal artery
  144. PAD location: Foot:
    tibial/peroneal artery
  145. PAD S/S
    Diminished peripheral pulses, femoral bruits, cool skin temp, abnormal skin color, poor hair growth
  146. PAD Clinical Findings
    Intermittent Claudication; ischemic rest pain; ulceration; tTissue necrosis
  147. Intermittent Claudication:
    mx pain in LE induced by exercise and relieved with rest; highly reproducible
  148. Intermittent Claudication: contrasts with:
    pseudoclaudication of spinal stenosis (normal pulses/color)
  149. PAD: Diff dx
    Baker Cyst; Chronic compartment syn; Arthritis; Nerve root compression; Spinal stenosis; Venous claudication
  150. PAD Screen: ABI: Normal
    1.0+ (blood pressure augments distally)
  151. PAD Screen: ABI: < 0.9
    dx of peripheral vascular dz
  152. PAD Screen: ABI: < 0.7
    intermittent claudication
  153. PAD Screen: ABI: < 0.4
    rest pain
  154. PAD Screen: ABI: < 0.1
    impending tissue necrosis
  155. PAD Mgmt:
    Risk factor mod; SMK cessation; Walking program; antiplt tx (aspirin & clopidogrel); Pletal Trental; revascularization (Surgery vs Stenting)
  156. ABIs performed to assess:
    Asx PAD or mild to mod claudication
  157. ABIs helpful to predict:
    CLI (Critical Limb Ischemia) & amputation; wound healing; or to screen/ monitor
  158. Acute arterial occlusion: Clinical features
    Pain; Pulseless; Pallor; Paresthesia; Paralysis; Poikilothermia
  159. Acute art occlusion: Etiologies:
    Embolism; Thrombus in situ
  160. Acute art occlusion: some d/t embolism: from:
    heart, aorta, large arteries
  161. Acute art occlusion: Thrombus in situ: d/t:
    atherosclerotic plaque, trauma, hypercoagulable dz
  162. Acute art occlusion: Clinical Findings
    Valvular dz or valvular prosthesis Ischemic dz (post MI/ plaque rupture); Paradoxical emboli from DVT of leg rarely produce emboli
  163. Acute art occlusion: 80-90% of arterial emboli arise from:
    the heart
  164. Acute art occlusion: A-fib prevalence
    present in 60-70% (thrombus forms in left atrial appendage)
  165. Acute Arterial Occlusion Tx
    Revascularization; IV heparin; Intra-arterial thrombolytic therapy; Surgical thromboembolectomy; Surgical bypass
  166. Venous Dz
    Varicose V; Chronic Venous Insuff; Superficial Thrombophlebitis; DVT
  167. Dilated, tortuous alterations of the saphenous v. & tributaries (lie immed under skin in the Les)
    Varicose Veins
  168. Varicose V. pathology related to:
    venous valve incompetence & subsequent venous reflux from increased pressure
  169. Varicose V. Clinical Findings
    Asymptomatic to dull, aching pain or discomfort of legs usu worse after prolonged standing
  170. Emboli from heart: destinations
    50%-60% to LEs, 20% to cerebrovasc; 10-20% to UEs/ renal/ mesenteric circ
  171. Varicose v: Increased frequency after:
    pregnancy
  172. Varicose Veins: DDx
    Secondary VV d/t: chronic venous insufficiency of deep vein; Retroperitoneal venous obstruction; Arteriovenous fistula; congenital venous malformation
  173. Varicose: complications
    Thrombophlebitis
  174. Sluggish blood flow in varicose v. => local thrombosis =
    Thrombophlebitis
  175. Thrombophlebitis: predisposing conditions =
    pregnancy, local trauma, long periods sitting
  176. Thrombophlebitis rarely:
    ascends in trunk of Gr saphenous v. & leads to thrombosis of femoral vein
  177. Varicose V. Tx:
    Graduated compression stockings (TED); Elevate legs; endovenous ablation (radiofrequency vs laser); sclerotherapy; greater saphenous vein stripping (older)
  178. Chronic V. Insuff: Pathophys:
    Functionally inadequate v. valves in LEs d/t bad leaflets (do not coapt)
  179. Chronic V. Insuff: valve damage poss d/t:
    post-thrombotic syndrome (scarred/thick) or dilatation of vein & unable to coapt
  180. Chronic V. Insuff: Clinical Findings
    Hx DVT/ leg trauma; EDEMA (below knees); brawney skin pigmentation & venostasis ulcer (above ankles); pruritic, dull discomfort(esp w/ long standing)
  181. Chronic V. Insuff: DDx
    LE edema d/t: CHF; chronic renal dz; decomp liver dz; Lymphedema (usually unilateral); Autoimmune; PAD
  182. Chronic V. Insuff: Tx
    Grad compression stockings; avoid long stand/ sit; elevate legs; last: pneumatic leg compressions
  183. Inflammation, induration, erythema & tenderness along a superficial vein =
    Superficial Thrombophlebitis
  184. Superficial Thrombophlebitis usu involves what vein:
    long saphenous v.
  185. Superficial Thrombophlebitis: spont occur in pt with:
    PG, blunt trauma, IV infusion, thromboangitis obliterans, abd ca;
  186. Superficial Thrombophlebitis : assoc with DVT how often:
    20% of cases
  187. Superficial Thrombophlebitis: Clinical Findings
    linear erythema, induration, & dull tenderness along affected vein
  188. Superficial Thrombophlebitis: Fever & chills suggest:
    septic phlebitis (IV line)
  189. Superficial Thrombophlebitis: Circular lesion more consistent with:
    cellulitis
  190. Superficial Thrombophlebitis: prevention:
    Avoid prolonged standing
  191. Superficial Thrombophlebitis: Tx
    local heat & elevation, bed rest, NSAIDs; Sx usually resolve in 7- 10 days
  192. Superficial Thrombophlebitis: Tx: if progressive recurrence =
    Ligation surgery
  193. Superficial Thrombophlebitis: Tx if extension into deep venous system =
    Anticoagulation
  194. Superficial Thrombophlebitis: Prognosis
    usually benign & brief (Varicose v. etiology: recurrent)
  195. Septic thrombophebitis mortality =
    20% (usu Staph (Antibx & vein excision)
  196. Phlebitis of saphenous vein rarely:
    extends to deep veins (potential for PE)
  197. Thromboembolus of deep veins of LEs (deep saphenous) or pelvis =
    DVT
  198. DVT: 80% develops in:
    deep veins of the calf
  199. DVT: 20% develops in:
    femoral or iliac vein
  200. Virchow’s Triad:
    Stasis, Vascular Injury, Hypercoaguable State
  201. DVT: Precipitators:
    Long bedrest/ immobility (surg), long air travel, malignancy, nephrotic syndrome
  202. DVT Clinical Findings
    50% Asx; dull aching pain in calf/leg, worse with ambulation; edema in affected limb, palpable cord, low grade temp, tachycardia; Homan sign 50% of time
  203. Wells Criteria: Clinical evidence for DVT =
    3 points
  204. Wells Criteria: PE the No. 1 dx =
    3 points
  205. Wells Criteria: HR > 100 bpm =
    1.5 points
  206. Wells Criteria: Immobilization/Surgery in past 4 wk =
    1.5 points
  207. Wells Criteria: Previous DVT/PE =
    1.5 points
  208. Wells Criteria: Cancer =
    1 point
  209. Wells Criteria: Hemoptysis =
    1 point
  210. Wells Criteria: Score of <2:
    makes dx highly unlikely
  211. Wells Criteria: Score of > 6:
    highly likely
  212. DVT Evaluation
    D-dimer; LE Doppler/ US; if PE suspected, VQ scan versus spiral CT; hypercoaguable w/u if no identifiable predisposing event
  213. D-dimer results:
    negative result is helpful; pos results non-specific
  214. DVT Tx
    Hep (vs LMWH) & concomitant warfarin loading; warfarin; Thrombolytic tx; embolectomy; IVC filter
  215. warfarin tx for DVT
    (INR 2.0 – 2.5); idiopathic 6 mos 1st event; non-idiopathic or recurrent event: consider indefinite tx
  216. DVT complications
    PE; ischemic limb; varicose v.; chronic venous insufficiency
  217. DVT Prevention in Surg pts: Low risk:
    Minor surg in pt < 40 yrs w/ no additional risk factors
  218. DVT Prevention in Surg pts: mod risk:
    Minor surg in pt < 40yrs w/ an additional risk factor or surg in pt 40-60 years of age
  219. DVT Prevention in Surg pts: High risk:
    Surgery in pt > 60 years or in pt 40-60 with risk factors
  220. DVT Prevention in Surg pts: Highest Risk:
    Surg in pt > 40 yrs w/ multiple risk factors or hip/knee arthroplasty or major trauma spinal cord injury
  221. DVT: Risk factors:
    age, cancer, prior VTE, obesity, heart failure, paralysis, hypercoaguable state
  222. DVT Prophylaxis in Surg pts: Low risk:
    Early ambulation, pneumatic stockings
  223. DVT Prophylaxis in Surg pts: Mod risk:
    SubQ unfract hep or LMWH +/- pneumatic compression
  224. DVT Prophylaxis in Surg pts: High risk:
    SubQ LMWH
  225. DVT Prevention in medical pts
    No formal risk assessment; pneumatic compression stockings for low risk pts; unfract hep or LMWH for other pts w/ systemic illness limiting mobility esp w/ other risk factors

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