Cardiology 4

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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
  15. Has a fairly symmetrical dilation (involves full circumference of aortic wall)
  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
  27. AAA: men over 55
  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:
  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 =
  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
  91. TAA Mgmt: Annual growth rate for 5-5.9 cm
  92. TAA Mgmt: Annual growth rate for >6 cm
  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 =
  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:
  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
  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:
  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
  174. Sluggish blood flow in varicose v. => local thrombosis =
  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:
  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 =
  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 =
  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
Card Set:
Cardiology 4
2011-07-18 20:22:36
DPAP2012 Cardiology

Cardiology flashcards made by previous students
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