Cardiology #12 (GCA, Thrombophlebitis, DVT, Varicose Veins, Venous Insufficiency)

Question 1

What are some risk factors for giant cell (temporal) arteritis?

Answer 1

-Women > 50 years old
-Northeastern Europeans

Question 2

Symptoms of GCA

Answer 2

-Headache
-Jaw claudication with mastication
-Visual changes (monocular vision loss, amaurosis fugax, CRAO, anterior ischemic optic neuritis is MC)
-Scalp tenderness
-Temporal artery may be tender, pulseless, or normal.
-Fever, fatigue, weight loss, night sweats, malaise.

Question 3

Although GCA is primarily a clinical diagnosis, what labs can be drawn for further evidence?

Answer 3

Increase ESR and CRP. Normocytic normochromic anemia.

Question 4

What is the definitive diagnostic for GCA?

Answer 4

Temporal biopsy

Question 5

What treatment should be started for GCA once suspected. Do not delay treatment to biopsy or while waiting for biopsy results.

Answer 5

High-dose corticosteroids

Question 6

What is the MC complication of GCA

Answer 6

Blindness

Question 7

What are other options for treatment for GCA if the patient cannot take steroids?

Answer 7

Methotrexate
Azathioprine
Low dose Aspirin

Question 8

What is superficial thrombophlebitis?

Answer 8

Inflammation and/or thrombosis of a superficial vein

Question 9

Etiologies of superficial thrombophlebitis

Answer 9

-Associated with IV catheterization, pregnancy, varicose veins, venous stasis

Question 10

What is Trousseau Sign?

Answer 10

Migratory thrombophlebitis associated with malignancy (pancreatic cancer, etc.)

Question 11

Symptoms of superficial thrombophlebitis

Answer 11

Pain, tenderness, induration, edema, and erythema along the course of the vein.
May feel a palpable cord

Question 12

Although superficial thrombophlebitis is a clinical diagnosis, what can be done for further evaluation?

Answer 12

Venous Duplex US: noncompressible vein with clot and wall thickening

Question 13

MCC of superficial thrombophlebitis

Answer 13

Factor V Leiden

Question 14

Treatment for superficial thrombophlebitis

Answer 14

-Supportive is mainstay: NSAIDs, elevation, warm compresses
-Vein ligation/excision (phlebectomy)
-If septic (febrile), give IV ABX

Question 15

Most DVT’s originate in

Answer 15

the calf

Question 16

What are the risk factors (Virchow’s Triad) for a DVT?

Answer 16

-Venous stasis (immobilization or prolonged sitting)
-Hypercoagulability (Protein C or S deficiency, Factor V Leiden mutation, OCP, malignancy, pregnancy, smoking)
-Intimal Damage (trauma, infection, inflammation)

Question 17

Symptoms of a DVT

Answer 17

-Unilateral swelling and edema of the lower extremity > 3 cm (MOST SPECIFIC SIGN)
-Calf pain and tenderness
-Warm to palpation
-Homan sign: deep calf pain with foot dorsiflexion while squeezing the calf (not reliable)

Question 18

First-line imaging for a DVT

Answer 18

Venous Duplex US

Question 19

Explain a D-dimer and specificity for a DVT

Answer 19

-highly sensitive but not specific.

Negative D-dimer with low-risk for DVT can exclude DVT as diagnosis.
Positive D-dimer should be followed by ultrasound

Question 20

What is the gold standard diagnostic for DVT

Answer 20

Contrast venography

-However, it is invasive, difficult to perform, and rarely used.

Question 21

First-line treatment for patients with a DVT

Answer 21

Anticoagulation: LMWH + Warfarin, LMWH + either Dabigatran or Edoxaban, or mono therapy with Rivaroxaban or Apixaban

Question 22

When should an IVC filter be placed in a patient with DVT? 3 reasons

Answer 22

1) recurrent DVT/PE despite adequate anticoagulation
2) Stable patients in whom anticoagulation is contraindicated
3) Right ventricular dysfunction with an enlarged RV on echocardiogram

Question 22

When should an IVC filter be placed in a patient with DVT? 3 reasons

Answer 22

1) recurrent DVT/PE despite adequate anticoagulation
2) Stable patients in whom anticoagulation is contraindicated
3) Right ventricular dysfunction with an enlarged RV on echocardiogramWhen is

Question 23

When is thrombolectomy or thrombolysis considered in a patient with a DVT?

Answer 23

Massive DVT or severe cases

Question 24

If the patient has a DVT, is is their first DVT and they have a modifiable risk factor, what is the time frame in which they should stay on treatment?

Answer 24

at least 3 months -Modifiable risk factor: OCP, surgery, trauma, etc

Question 25

If the patient is pregnant and gets a DVT, what is the preferred treatment?

Answer 25

LMWH

Question 26

If the patient has malignancy, what is the medical therapy for DVT?

Answer 26

LMWH Warfarin or direct oral anticoagulants are alternatives but LMWH is the preferred method

Question 27

According to the 2016 ACCP guidelines, what is preferred over Warfarin therapy as the management of DVT/PE if the patient does not have cancer?

Answer 27

Novel oral anticoagulants (Apixaban, Dabigatran, Edoxaban, Rivaroxaban)

Question 28

What is the mechanism of action of LMWH?

Answer 28

Potentiates antithrombin III (works more on factor Xa than thrombin (Factor IIa)

Question 29

What is the antidote to LMWH?

Answer 29

Protamine Sulfate

Question 30

What is one major contraindication to use of LMWH?

Answer 30

Renal failure because LMWH is excreted by the kidneys

Question 31

Regarding the Well's Criteria for DVT, what score is associated with low probability of DVT? Moderate probability? High probability?

Answer 31

Low: -2 to 0 Moderate: 1-2 High: 3-8

Question 32

Explain what some of the points are that are given for Well's Criteria for a DVT

Answer 32

Active cancer or treatment within last 6 months : 1 point Paralysis or immobilization of lower extremity: 1 point Bedridden for more than 3 days due to surgery (within 4 weeks) : 1 point Localized tenderness along deep veins: 1 point Swelling of entire leg: 1 point Unilateral calf swelling of greater than 3 cm: 1 point Collateral superficial veins: 1 point Unilateral pitting edema: 1 point Another diagnosis more likely than DVT: -2 points

Question 33

Explain the pathophysiology of varicose veins

Answer 33

Dilation of superficial veins due to failure of the venous valves in the saphenous veins, leading to retrograde flow, venous stasis, and pooling of blood

Question 34

Risk factors for varicose veins

Answer 34

Family history Female gender Increased age Standing for long periods Obesity Increased estrogen (OCP use, pregnancy) Chronic venous insufficiency

Question 35

Symptoms of varicose veins

Answer 35

Most are asymptomatic but may present due to cosmetic issues -Dull ache or pressure sensation -Pain is worse with prolonged standing or sitting with the leg flexed. Relieved with elevation. -Dilated visible veins -Telangiectasias -Swelling, discoloration -Mild ankle edema

Question 36

Treatment for varicose veins

Answer 36

Conservative: compression stockings, leg elevation, pain control -Ablation: laser or radiofrequency -Ligation and stripping -Sclerotherapy

Question 37

When does chronic venous insufficiency occur and what is it?

Answer 37

Changes due to venous hypertension of the lower extremities as a result of venous vavular incompetency Occurs after superficial thrombophlebitis, DVT, or trauma to the leg

Question 38

Explain the pain associated with chronic venous insufficiency

Answer 38

-Worse with prolonged standing or sitting with the feet dependent -Better with ambulation and leg elevation -Burning, aching, throbbing, cramping, or "heavy leg"

Question 39

What does the skin look like on the associated leg with chronic venous insufficiency?

Answer 39

-Stasis Dermatitis: itchy eczematous rash, excoriations, brownish or dark purple hyperpigmentation of the skin -Venous stasis ulcers: at medial malleolus -Dependent pitting leg edema -Increased leg circumference -Normal pulse and temperature -Atrophie blanche: hypo pigmented areas with punctuate red dots

Question 40

Where are ulcers associated in chronic venous insufficiency?

Answer 40

Most times at the medial malleolus

Question 41

Treatment for chronic venous insufficiency

Answer 41

-Conservative: initial management. Leg elevation, compression stockings, exercise and weight management -Surgical intervention only for non-response to conservative therapy -Ulcer management: Zinc impregnated gauze, wound debridement, Aspirin

Question 42

Why give aspirin for an ulcer associated with chronic venous insufficiency?

Answer 42

It accelerates the healing process of the ulcer