Cardiovascular Flashcards

Question

What is the pathophysiology of ACS

Answer 1

Acute coronary syndrome is usually the result of a thrombus from an atherosclerotic plaque blocking a coronary artery. When a thrombus forms in a fast flowing artery its is made up mostly of platelets This is why anti-platelt medications such as aspirin, clopidogrel and ticagrelor are the mainstay of treatment

Answer 2

Unstable angina ST elevation myocardail infarction (STEMI) Non-ST elevation myocardial infarction (NSTEMI)

Answer 3

ECG -ST elevation or new LBBB - diagnoses of STEMI -No ST elevation then perform troponin blood test -- If raised troponin levels and/or other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI -- If troponin levels are normal and the ECG does not show pathological changes, the diagnosis is either unstable angina or another cause such as MSK chest pain Perform all investigation normally arranged for stable angina: -Physical exam (heart sounds, signs of heart failure, BMI) -ECG -FBC (check for anaemia -U and Es (prior to ACEi and other meds) -LFTs (prior to statins) -Lipid profile -TFTs -HbA1C and fasting glucose Plus: -Chest xray to investigate other causes of chest pain and pulmonary oedema -Echo after the event to assess the functional damage -CT coronary angiogram to assess for coronary artery disease

Answer 4

Central, constricting chest pain associated with: -Nausea and vomiting -Sweating and clamminess -Feeling of impending doom -Shortness of breath -Palpitations -Pain radiating to jaw or arms Symptoms should continue at rest for more than 20 minutes. If they settle with rest consider angina. Diabetic patients may not experience typical chest pain during an acute coronary syndrome. This is often referred to as a “silent MI”.

Answer 5

Proteins found in cardiac muscle The specific type of troponin, the normal range and diagnostic criteria vary by lab so check policy Diagnosis off ACS typically requires serial troponins. A rise in troponin is consistent with myocardial ischaemia as the proteins are released from the ischaemic muscle Troponins are non specific so a rise does not automatically mean ACS. Alternative causes may be: -chronic renal failure -sepsis -myocarditis -aortic dissection -PE

Answer 6

Patients with STEMI presenting within 12 hours of onset should be discussed urgently with local cardiac centre for either: -Primary PCI (if available within 2 hours of presentation) -Thrombolysis (if PCI not available within 2 hours) The local cardiac centre will advise about further management (such as further loading with aspirin and ticagrelor).

Answer 7

Percutaneous Coronary Intervention (PCI) involves putting a catheter into the patient’s brachial or femoral artery, feeding that up to the coronary arteries under xray guidance and injecting contrast to identify the area of blockage. This can then be treated using balloons to widen the gap or devices to remove or aspirate the blockage. Usually a stent is put in to keep the artery open.

Answer 8

Thrombolysis involves injecting a fibrinolytic medication (they break down fibrin) that rapidly dissolves clots. There is a significant risk of bleeding which can make it dangerous. Some examples of thrombolytic agents are streptokinase, alteplase and tenecteplase.

Answer 9

BATMAN B – Beta-blockers unless contraindicated A – Aspirin 300mg stat dose T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk) M – Morphine titrated to control pain A – Anticoagulant: Fondaparinux (unless high bleeding risk) N – Nitrates (e.g. GTN) to relieve coronary artery spasm Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

Answer 10

This scoring system gives a 6-month risk of death or repeat MI after having an NSTEMI: - <5% Low Risk - 5-10% Medium Risk - >10% High Risk If they are medium or high risk they are considered for early PCI (within 4 days of admission) to treat underlying coronary artery disease.

Answer 11

DREAD D – Death R – Rupture of the heart septum or papillary muscles E – “Edema” (Heart Failure) A – Arrhythmia and Aneurysm D – Dressler’s Syndrome

Answer 12

AKA post-myocardial infarction syndrome Usually occurs around 2-3 weeks after an MI Caused by a a localised immune response and causes pericarditis (inflammation of the pericardium around the heart) Less common as the management of ACS becomes more advanced Presents with pleuritic chest pain, low grade fever and a pericardial rub on auscultation. Can cause a pericardial effucion and rarely a pericardial tamponade (where the fluid constricts the heart and prevents function) A diagnosis can be made with an ECG (global ST elevation and T wave inversion), echo (pericardial effusion) and raised inflammatory markers (CRP and ESR) Manage with NSAIDs (aspirin/ibuprofen) and in more severe cases steroids (prednisolone) May need pericardiocentesis to remove fluid from around the heart

Answer 13

6 As -Aspirin (75mg OD) -Another antiplatelet (clopidogrel or ticagrelor for upto 12 months) -Atorvastatin (80mg OD) -ACE inhibitors (ramipril titrated as tolerated to 10mg daily) -Atenolol (or other beta blocker titrated as high as tolerated) -Aldosterone antagonist for those with clinical heart failure (epleretone titrated to 50mg once daily) Dual antiplatelet duration will vary following PCI procedures depending on the type of stent that was inserted due to higher risk of thrombus formation in different stents

Answer 14

Stop smoking Reduced alcohol consumption Mediterranean diet Cardiac rehabilitation (a specific exercise regime for patients post MI) Optimise treatment of other medical conditions (eg diabetes and hypertension)

Answer 15

STEMI: -ST segment elevation in leads consistent with an area of ischaemia -New left bundle branch block NSTEMI: -ST segment depression in a region -Deep T wave inversion -Pathological q waves (suggesting a deep infarct - a late sign)

Answer 16

When the left ventricle is unable to adequetely move blood through the left side of the heart and out into the body. This causes a backlog of blood that increases the amount of blood stuck in the left atrium, pulmonary veins and lungs. The vessels in these areas are engorged with blood due to the increased colume and pressure that they leak fluid and are unable to reabsorbe fluid from the surrounding tissues, causing pulmonary oedema.

Answer 17

Where the lung tissues and alveoli become full of interstitial fluid. This interferes with the normal gas exchange in the lungs, causing SOB, O2 desaturation and the other signs and symptoms

Answer 18

Iatrogenic (aggressive IV fluid in frail elderly patient with impaired left ventricular function) Sepsis Myocardial infarction Arrhythmias

Answer 19

Typically rapid onset breathlessness that is exacerbated by lying flat and improves on sitting up. Causes type 1 respiratory failure (low o2 without an increase of CO2 in the blood) SOB Looking and feeling unwell Cough (frothy white/pink sputum) Increased resp rate Reduced o2 sats Tachycardia 3rd heart sound Bilateral basal crackles (sound wet) on auscultation Hypotension in severe cases (cardiogenic shock) May also have signs and symptoms of underlying cause (chest pain, fever, palpitations) May also have right sided heart failure (raised JVP, peripheral oedema)

Answer 20

History and exam ECG (for ischaemia and arrhythmia) ABG Chest Xray Bloods: -infection markers -kidney function -BNP -troponin (if ?MI) echo

Answer 21

B-type natriuretic peptide is a hormon that is released from the heart ventricles when the cardiac muscle (myocardium) is stretched beyond the normal range. Finding a high result indicates the heart is overloaded (with blood) beyond its normal capacity to pump effectively The action of BNP is to relax the smooth muscle in blood vessels. This reduces the systemic vascular resistance making it easier for the heart to pump blood through the system. It also acts on the kidneys as a diuretic to promote the excretion of more water in the urine to reduce the circulating volume helping to improve the function of the heart. Testing for BNP is sensitive but not specific which means that when negative it is useful in ruling out hear failure, but when positive rsult can have other causes: -Tachycardia -Sepsis -PE -Renal impairment -COPD

Answer 22

Main meausure of left ventricular function The presentage of the blood in the left ventricle which is squeezed out with each ventricular contraction An ejection fraction above 50% is considered normal

Answer 23

A cardiothoracic ratio of more than 50% When the diameter of the widest part of the heart is more than half the diameter of the widest part of the lung fields

Answer 24

Fluid in the septal lines, seen on chest xray

Answer 25

Pour SOD Pour away (stop) IV fluids Sit up Oxygen (if <95%) Diuretics (IV furosemide 40mg stat) Monitor fluid balance IV opiates NIV (non-invasive ventilation) (CPAP, may escalate in intubation and ventilation) Inotropes

Answer 26

Strengthen the force of heart contractions and improve heart failure, but need close titration and monitoring, so need to send patient to the local coronary care unit/ HDU/ ICU)

Answer 27

Term used to describe high blood pressure BP >140/90 in clinic or 135/85 with ambulatory or home readings

Answer 28

Accounts for 95% of hypertension AKA primary hypertension Means the hypertension has developed on its own and does not have a secondary cause

Answer 29

ROPE Renal disease - most common, if the bp is very high or does not respond to treatment, consider renal artery stenosis Obesity Pregnancy induced hypertension/ pre-eclampsia Endocrine - most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (Conns syndrome) as this may represent 2.5% of new hypertension. Specialist investigations should be considered in patients with a potential secondary cause for their hypertension or aged under 40 years.

Answer 30

Renin:akdosterone ratio blood test

Answer 31

Ischaemic heart disease Cerebrovascular accident (stroke or haemorrhage) Hypertensive retinopathy Hypertensive nephropathy Heart failure

Answer 32

Measure BP every 5 years to screen for hypertension It should be measured more often in those on the borderline for diagnoses Measure every year in patients with type 2 diabetes

Answer 33

Patients with a clinic bp between 140/90 and 180/120 should have 24 hour ambulatory blood pressure or home readings to confirm the diagnosis, due to white coat syndrome Measure BP in both arms and if the difference is more than 15, use the reading from the arm with higher pressure

Answer 34

Stage 1: >140/90 (clinic) or >135/85 (Home) Stage 2: >160/100 (clinic) or >150/95 (home) Stage 3: >180/20 (clinic)

Answer 35

Urine albumin: creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage Bloods for HbA1c, renal function and lipids Fundus examination for hypertensive retinopathy ECG for cardiac abnormalities

Answer 36

A – ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily) ARB – Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily). Used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent. ACE inhibitors and ARBs are not used together. B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily) C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily) D – Thiazide-like diuretic (e.g. indapamide 2.5mg once daily)

Answer 37

Diagnosis Investigate for possible causes and end organ damage Advise on lifestyle modifications Medical management: - all patients with stage 2 hypertension - all patients under 80 y/o with stage 1 hypertension that also have a q risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage Step 1: -Age <55 and non black use A -Age over 55 or black of african or African-caribbean descent use C Step 2: -A and C -Alternatively A and D or C and D -If black then use ARB instead of A Step 3: -A and C and D Step 4: -A and C and D and *additional* *Additional* -if serum potassium = 4.5 mmol/l consider a potassium sparing diuretic (spironolactone) -if serum potassium <4.5mmol/l consider an alpha blocker (doxazocin) or a beta blocker (atenolol) Regularly check U and Es when using ACE inhibitors and all diuretics because: -spironolactone increases risk of hyperkalaemia -ACE inhibitors increase risk of hyperkalaemia -Thiazide diuretics can cause hypokalaemia and other electrolyte imbalances

Answer 38

A potassium sparing diuretic Blocks the action of aldosterone in the kidneys resulting in sodium excretion and potassium reabsorption Can be helpful to use when thiazide diuretics are causing hypokalaemia

Answer 39

<80 y/o: -systolic <140 -diastolic <90 >80y/o: -systolic <150 -diastolic <90

Answer 40

Caused by either impaired left ventricular contraction (systolic heart failure) or left centricular relaxation (diastolic heart failure) This impared left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart

Answer 41

Breathlessness worsened by exertion Cough (frothy white/pink sputum Orthopnoea (SOB when lying flat, relieved by sitting or standing) Paroxysmal nocturnal dyspnoea Peripheral oedema

Answer 42

Term used to describe the experience that patients have of suddenly waking at night with a severe attack of SOB and cough and maybe wheeze. Feels like they are suffocating and will sit on side of bed, or pace room or open window for air. Symptoms will improve over several minutes

Answer 43

1. fluid settling across a large surface of the lungs when lying flat which improves when stood up as fluid sinks to bases, clearing upper lungs 2. During sleep the respiratory centre in brain is less rsponsive to resp rate and effort does not increase in response to reduced O2 sats like it normally would when awake, allowing the person to develop more significant pulmonary congestion and hypoxia before waking 3. Less adrenalin circulating when sleeping, meaning the myocardium is more relaxed which worsens the cardiac output

Answer 44

Clinical presentation BNP blood test (NT-proBNP> 2000 warrants urgent referral) Echo ECG

Answer 45

Ischaemic heart disease Valvular heart disease (commonly aortic stenosis) Hypertension Arrhythmias (commonly AF)

Answer 46

ABAL ACE inhibitor (ramilpril to 10mg OD) Beta blocker (bisoprolol to 10mg OD) Aldosterone antagonist when symptoms not controlled with A and B (spironolactone or epleretone) Loop diuretics to improve symptoms (furosemide 40mg OD) An ARB can be used instead of ACE inhibitor if ACEi not tolerated (eg candesartan up to 32mg OD) Avoid ACEi in patients with valvular heart disease until seen by specialist Aldosterone antagonists are used when there is a reduced ejection fraction and symptoms are not controlled with ACEi and BB Monitor U and Es whilst on diuretics, ACEi and aldosterone antagonists as all can causes electrolyte disturbance

Answer 47

A common and potentially fatal condition It involves blood clots (thrombi) developing in the circulation Usually secondary to stagnation of blood and hypercoagulable states

Answer 48

When a thrombus develops in the venous circulation

Answer 49

Pulmonary embolism Once a thrombus has developed, it can embolise from the deep veins, through the right side of the heart and into the lungs where it becomes lodge in the pulmonary arteries. This blocks blood flow to the areas of the lungs, which is when it is called a pulmonary embolism If a patient has a hole in their heart too (eg atrial septal defect) then the blood clot can pass through to the left side of the heart and into the systemic circulation. If it travels to the brain, it can cause a large stroke

Answer 50

Immobility Recent surgery Long haul travel Pregnancy Hormone therapy with oestrogen (COCP and HRT) Malignancy Polycythaemia Systemic lupus erythematosus Thrombophilia

Answer 51

Conditions that predispose patients to develop blood clots Examples: -Antiphospholipid syndrome -Factor V Leiden -Antithrombin deficiency -Protein c or s deficiency -Hyperhomocysteinaemia -Prothrombin gene variant -Activated protein C resistance

Answer 52

Every patient admitted to hospital should be assessed for their risk of VTE. If at increased risk of VTE, they should recieve prophylaxis unless contraindicated (eg active bleeding or existing anticoagulation with warfarin or a DOAC) Prophylaxis is usually with LMWH such as enoxaparin Anti-embolic compression stockings are also used, unless contraindicated (eg if significant peripheral arterial disease)

Answer 53

Almost always unilateral; bilateral DVT is rare and bilateral symptoms are more likely due to an alternative diagnosis such as chronic venous insufficiency or heart failure. DVTs can present with: -calf or leg swelling -dilated superficial veins -tenderness to the calf (particularly over the site of the deep veins) -oedema -colour changes to the leg Examine for leg swelling: -measure the circumference of the calf 10cm below the tibial tuberosity. -more than 3cm difference between the calves is significant Always ask questions and examine with the suspicion of a potential PE as well.

Answer 54

D-dimer blood test is sensitive but not specific for VTE. It is helpful in excluding VTE where there is low suspicion It is almost always raised in DVT, but other conditions can also cause a raised d-dimer: -pneumonia -malignancy -heart failure -surgery -pregnancy

Answer 55

D-dimer Doppler ultrasound of the leg - repeat negative US after 6-9 days of a positive D-dimer and the Wells score suggest a DVT likely

Answer 56

CT pulmanry angiogram (CTPA) or ventilation-perfusion (VQ) scan. CTPA is usually preferred, unless the patient has significant kidney impairment or contrast allergy

Answer 57

Anticoagilation: - Immediately when suspected DVT or PE (even before scan if delay) - Usually treatment dose apixaban or rivaroxaban - Consider catheter-directed thrombolysis in patients with a symptomatic iliofemoral DVT and symptoms lasting less than 14 days. Which involves inserting a catheter under x-ray guidance through the venous system to apply thrombolysis directly into the clot

Answer 58

DOACs, warfarin or LMWH DOACs are oral anticoagulants that do not require monitoring. Previously called NOACs Options are: -apixaban -rivaroxaban -edoxaban -dabigataran They are suitable for most patients inclusing those with cancer Warfarin is a vitamin K antagonist. The target INR for warfarin is between 2 and 3 when treating DVTs and PEs. It is the first-line in patients with antiphospholipid syndrome (who also require initial concurrent treatment with LMWH) LMWH is the first line anticoagulant in pregnancy Continue anticoagulation for: -3 months if there is a reversible cause (then review) -Beyond 3 months if the cause is unclear, there is recurrent VTW or there is an irreversible underlying cause such as thrombophilia (often 6 months in practice) -3-6 months in active cancer (then review)

Answer 59

Devices inserted into the inferior vena cava, designed to filter the blood and catch any blood clots travelling through the venous system, towards the heart and lungs. They act as a sieve, allowing blood to flow through but stopping larger blood clots. Used in unusual cases of patients with reccurrent REs or those that are uunsuitable for anticoagulation

Answer 60

When patients have their first VTE without clear cause: -review medical history -baseline bloods -physical exam for evidence of cancer In those who have had unprovoked VTE and are due to finish their anticoagulation, test for: -antiphospholipid syndrome (check antiphospholipid antibodies) -hereditary thrombophilias (only is they have 1st degree relative also affected by a DVT or PE)

Answer 61

Refers to the narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas Usually refers to lower limbs, resulting in symptoms of claudication

Answer 62

A symptom of ischaemia in a limb, occurring during exertion and relieved by rest. Peripheral arterial presents with this. Typically a crampy, achy pain in the calf, thigh or buttock muscles, associated with muscle fatigue when walking beyond a certain intensity

Answer 63

The end-stage of peripheral arterial disease, where there is inadequate supply of blood to a limb to allow it to function normally at rest. The features are pain at rest, non-healing ulcers and gangrene. There is a significant risk of losing the limb.

Answer 64

Refers to a rapid onset of ischaemia in a limb Typically due to a thrombus, clot, blocking the arterial supply of a distal limb, similar to a thrombus blocking a coronary artery in MI

Answer 65

An inadequate oxygen supply to the tissues due to reduced blood supply

Answer 66

Death of tissue

Answer 67

The death of the tissue, specifically due to an inadequate blood supply

Answer 68

A combination of atheromas (fatty deposits in the artery walls) and sclerosis (the process of hardening and stiffening of the blood vessel walls) It affects the medium and large arteries It is caused by chronic inflammation and activation of the immune system in the artery wall Lipids are deposited in the artery wall, followed by the development of fibrous atheromatous plaques

Answer 69

Stiffening of the artery walls, leading to hypertension and strain on the heart (whilst trying to pump blood against increased resistance Stenosis, leading to reduced blood flow (eg in angina) Plaque rupture, resulting in a thrombus that can block a distal vessel and cause ischaemia (eg in acute coronary syndrome)

Answer 70

Non-modifiable: -Old age -FH -Male Modifiable: -Smoking -Alcohol consumption -Poor diet (high in sugar and trans fat and low in fruit, veg and omega 3s) -Low exercise/ sedentary lifestyle -Obesity -Poor sleep -Stress

Answer 71

Diabetes Hypertension CKD Inflammation conditions eg rheumatoid arthritis Atypical antipsychotic medications

Answer 72

Angina MI TIA Stroke Peripheral arterial disease Chronic mesenteric ischaemia

Answer 73

Pain (burning pain worse at night when leg raised as gravity does not help pull blood into the foot) Pallor Pulseless Paralysis Paraesthesia (abnormal sensation or pins and needles) Perishing cold

Answer 74

Leriche Syndrome occurs with occlusion in the distal aorta or proximal common iliac artery There is a clinical triad of: -Thigh/buttock claudication -Absent femoral pulses -Male impotence

Answer 75

Look for risk factors: -Tar staining on the fingers -Xanthoma (yellow cholesterol deposits on the skin) Look for signs of cardiovascular disease: -Missing limbs or digits after previous amputations -Midline sternotomy scar (previous CABG) -A scar on the inner calf for saphenous vein harvesting (previous CABG) -Focal weakness suggestive of previous stroke Peripheral pulses may be weak on palpation, can use hand-help doppler to accurately assess difficult pulses Signs of PAD on inspection: -Skin pallor -Cyanosis -Dependent rubor (a deep red colour when the limb is lower than the rest of the body) -Muscle wasting -Hair loss -Ulcers -Poor wound healing -Gangrene (breakdown of skin and a dark red/black change in colouration -Reduced skin temp -Reduced sensation -Prolonged cap refill -Changes during Buerger's test

Answer 76

Buerger’s test is used to assess for peripheral arterial disease in the leg. There are two parts to the test. The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees. The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go: Blue initially, as the ischaemic tissue deoxygenates the blood Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration The dark red colour is referred to as rubor.

Answer 77

Leg ulcers indicate the skin and tissues are struggling to heal due to impaired blood flow Two types: -arterial and venous

Answer 78

Caused by ischaemia secondary to an inadequate blood supply Smaller than venous Deeper than venous Well defined borders Punched out appearance Occur peripherally (eg toes) Reduced bleeding Painful

Answer 79

Caused by imparied drainage and pooling in the legs Occur after a minor injury to the legs Larger than arterial More superficial than arterial Irregular, gently sloping borders Affect the gaiter area of the leg (mid calf down to the ankle) Less painful than arterial Occur with other signs of chronic venous insufficiency (eg haemosiderin stainging and venous eczema)

Answer 80

Ankle brachial pressure index (ABPI) Duplex ultrasound (shows the speed and volume of blood flow) Angiography (CT or MRI) (using contrast to highlight the arterial claudication

Answer 81

Ankle brachial pressure index is the ratio of systolic blood pressure in the ankle (around lower calf) compared with the systolic blood pressure in the arm The readings are taken manually using a Doppler probe Results: ->1.3 can indicate calcification of the arteries, making them difficult to compress (often diabetic) -0.9-1.3 is normal -0.6-0.9 indicates mild peripheral arterial disease -0.3-0.6 indicates moderate peripheral arterial disease -Less than 0.3 indicates severe disese to critical ischaemic

Answer 82

Lifestyle changes Optimise medical treatment of comorbidities Exercise training to push near maximal claudication and pain, then rest and repeat Medical treatment: -atorvastatin 80mg -clopidogrel 75mh OD (aspirin second line) -Naftidrofuryl oxalate (5-Ht2 receptor antagonist that acts as a peripheral vasodilator) Surgical: -Endovascular angioplasty and stenting -Endarterectomy (cutting vessel open to remove athermatous plaque) -Bypass surgery (using a graft to bypass the blockage)

Answer 83

Involves inserting a catheter through the arterial system under X ray guidance At the site of the stenosis a balloon is inflated to create space in the lumen A stent is inserted to keep the artery open Lower risk treatment but might not be suitable for more extensive disease

Answer 84

Require urgent referral to the vascular team Analgesia Urgent revascularisation can be achieved by: -Endovascular angioplasty and stenting -Endarterectomy -Bypass surgery -Amputation of the limb if it is not possible to restore the blood supply

Answer 85

Require urgent referral to the oncall vascular team for assessment Management options: -Endovascular thrombolysis- inserting a catheter through the arterial system to apply thrombolysis directly into the clot -Endovascular thrombectomy- inserting a catheter through arterial system and removing the thrombus by aspiration or mechanical devices -Surgical thrombectomy- cutting open the vessel and removing the thrombus -Endarterectomy -Bypass surgery -Amputation if necessary

Answer 86

AKA Superficial thrombophlebitis Results from thrombus formation in a superficial vein, with associated inflammation in the tissue surrounding the vein

Answer 87

Saphenous vein and its tributaries of the lower limbs (60-80% of cases) Superficial veins in other areas of the body can be affected (upper limbs, neck, abdominal wall, breast, arms)

Answer 88

Thrombophlebitis that recurs at varying sites but most commonly in the leg Often associated with a serious underlying cause (eg cancer)

Answer 89

A rare condition characterised by recurrent and migratory superficial vein thrombosis, frequently in unusual sites, such as arm or chest (AKA Mondor's disease when involving chest wall veins) Most often associated with gliomas and adenocarcinomas of the GI tract (stomach, pancreas and colon), lungs, breast, ovaries and prostate Can also be seen with Behcet's and Buerger's disease

Answer 90

Often associated with prothrombotic conditions characterised by one or more of the components of Virchow triad resulting in thrombus formation Risk: -Varicose veins are most common risk factor for the lower legs -Thrombophilia -Autoimmune disease (Behcet's and Buerger's) -Previous history of it -IV injections or cannulation -Cancer -Pregnancy and up to 6 weeks post fatally -Female -Older age -Prolonged immobilisation -Oral contraceptives or HRT -Obesity

Answer 91

Vessel wall damage Venous stasis Hypercoagulability of blood

Answer 92

History: -Symptom duration and severity -Pain, tenderness, itching, reddening of the skin, hardening of surrounding tissue -Pigmentation changes -Typically develop over hours to days and resolve in days to weeks, but hardness may persist longer -Identify risk factors Exam: -Look for varicose veins and other signs of venous insufficiency -Examine standing and lying -In those with pre existing varicose veins: Tender worm like mass deep to the skin with overlying skin warm and erythematous, often with oedemaof the surrounding area without swelling of the whole limb -In those without varicose veins: often a palpable cord, sometimes nodular, associated with warmth, tenderness and erythema along the course of a non-varicose superficial vein Assess for DVT or PE Assess for complications: -Infection Suspect migratory superficial thrombophlebitis if a person has repeated thromboses developing in superficial veins at varying sites Consider differentials in atypical presentations

Answer 93

DVT Cellulitis Chronic venous insufficiency Insect bite or stings Lymphangitis Tendonitis Vasculitic conditions (eg erythema nodosum and polyarteritis nodosum)

Answer 94

Analgesia Warm compress and elevation Only give antibiotics if signs of infection Consider referral to vascular service for venous duplex scanning to guide treatment and need for further specialist intervention: -LMWH and fondaparinux to reduce risk of extension and recurrence -Fondaparinux significantly reduces risk of symptomatic venous thromboembolism and may be considered in those of increased risk of DVT or PE Compression sticking after excluding arterial insufficiency Provide written information on the condition

Answer 95

DVT or PE Infection Skin changes Varicose veins

Cardiovascular Flashcards

(119 cards)