Peripheral Artery Disease and Pericardial Disease Flashcards Preview

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Flashcards in Peripheral Artery Disease and Pericardial Disease Deck (42):
1

PAD presentation example

-lower leg pain; can be bilateral; one side can hurt more than the other

-exercise-induced pain, relieved by rest (intermittent claudication)

-hanging of foot over bed = gravity helps blood flow

-High BP and heart failure = good signs of PAD

2

Is intermittent claudication necessary for PAD diagnosis?

No; only experienced by 1/3 of patients

3

PAD vs CAD treatment

PADs are not getting proper care; higher mortality than breast cancer

4

PAD physical exam

Auscultate abdomen and femoral arteries = look for bruits

Palpate for abdominal aortic aneurysm, and normal pulses

Inspect foot for ulcers, xanthomas, etc.

5

General appearance of PAD leg

Hair loss
Thickened/brittle toenails
Smooth/shiny skin
Loss of subcutaneous fat
Gangrene
Ulceration

6

Non-invasive evaluation techniques of PAD

Most commonly used initial test:
Ankle-Brachial Index
Ankle-Toe index

Further:
Ultrasonography - identifies location

7

What is the equation for ankle-brachial index

ABI = Highest ankle systolic pressure/highest brachial systolic pressure

8

What do ABI values mean

Low ABI = PAD; degree of ABI reduction correlates w/ disease severity

ABI >1.30 is also abnormal

9

Treatment of PAD

-Biggest = risk factor modification
-Exercise
-Antiplatelet therapy
-phosphodiesterase inhibitors; Cilostazole

10

Risk modification in PAD

-Smoking cessation
-Exercise
-Lower LDL = <140/90; use ACE inhibitors/beta-blockers
-Control diabetes
-Antiplatelet therapy - aspirin or clopidogrel

11

Smoking and PAD

-2-5X increased risk of PAD
-84-90% of patients w/ claudication are current or ex-smokers

12

Diabetes and PAD

-2 to 4X increase of PAD
-Significant risk reduction per 1% reduction of HgA1c

13

PAD-specific drugs

-Pentoxifylline; not very effective

-Cilostazole; phosphodiesterase inhibitor = inhibits platelets (cAMP), vasodilation (cGMP); more effective

Do not use warfarin; no benefit

14

Cilostazole; contraindications

Do not give to those w/ HF = increased mortality

15

Benefits of walking program

-formation of collaterals
-improvement of vasodilation, muscle metabolism, walking efficiency
-Much longer and more prolonged walking distances

16

General PAD treatment plan

-Aspirin or Clopidogrel
-Statin
-Walking program

17

When is revascularization indicated w/ PAD

-lifestyle-limiting symptoms
-Continued disability

18

When to consider aortic dissection?

All patients w/:
-chest, back, abdominal pain
-syncope
-perfusion deficit symptoms; CNS = depression, ischemia, etc.

19

Acute aortic dissection risk factors/assesment

-High risk condition - marfans, CT disorder, family history of aortic disease/valve disease, etc.

-High risk pain = acute onset, ripping/tearing/sharp in nature

-High risk exam = deficient pulse, low BP, focal neurologic deficit, murmurs

20

Which drug increases risk of dissection?

Cocaine

21

Aortic dissection treatment prior to surgery

-DO NOT drain/pericardiocentesis
-DO NOT increase HR

-IV metoprolol to lower HR; do not use w/ aortic insufficiency
-CCBs if can't tolerate beta blocker
-IV ACE inhibitors/vasodilators after BP is controled
-DO NOT GIVE VASODILATORS BEFORE BP/HR CONTROL - reflex tachycardia increases stress

22

Pericardial Characteristics/Anatomy

-Visceral pericardium reflects back near great vessels to become parietal pericardium

-Pericardial space = normally contains 50mL serous fluid

-Derived from mesoderm

-Phrenic nerve runs in the pericardium

23

Irritation of the phrenic nerve causes what?

Hiccups

24

Function of the pericaridum

-Maintains heart position
-Barrier to infection
-Secretes prostaglandin = coronary vascular tone
-Restrains cardiac volume

25

Pericardium compliance

Normal - minor volume changes lead to signficant complaince changes; resistant to change

Chronic volume increase - expands; more compliant

26

Acute pericarditis; etiology

-Most are idiopathic
-Viral

27

Common viruses to cause acute pericarditis

-Coxasckie B - causes myopericarditis
-HIV - africa
-Tuberculosis - africa

28

Acute pericarditis; symptoms

Sharp, pleuritic pain
-substernal, epigastric, left chest, trapezius muscle

29

Acute pericarditis; physical exam

Three component friction rub; ventricular systole, atrial systole, diastole
-at LSB with patient leaning forward

30

Acute pericarditis ECG

Dynamic;
-ST elevation
-PR depression
-Low voltage QRS
-Electrical alternans

31

Acute pericarditis CXR

Pleural effusion
CHF
Big heart

32

Acute pericarditis Echo

-not required for diagnosis

33

Acute pericarditis treatment

-NSAIDs = sufficient to treat

-NSAIDs + Colchicine = better recovery and decreased recurrence

-Steroids = rapid response; increased recurrence

-For secondary pericarditis - treat primary disorder

34

Colchicine mechanism

-anti-inflammatory
-Inhibits microtubule assembly; preferentially targets leukocytes
--inhibits intercellular granular movement and secretion

35

Acute pericarditis diagnosis

Two of the following:
-friction rup
-typical sharp chest pain
-Suggestive ECG
-New or worsening pericardial effusion

36

What is incessant pericarditis?

Pericarditis that is persistent

Pericarditis that shows symptom free intervals of less than 6 weeks and then returns

37

Treatment for incessant pericarditis?

NSAIDs + Colchicine

38

SE of Cholchicine

Major GI side effects
Hepatotoxic

39

Non-inflammatory causes of pericardial effusion

Hydropericardium - serous transudate; associated w/ CHF, hyponatremia, CKD, liver disease

-Hemopericardium - trauma, MI, myocardial rupture, dissection

40

Most common cardiac manifastation of HIV

Pericardial effusion - seen in advanced stages
-most are small, asymptomatic
-Larger effusions occur secondary to infection or neoplasm (kaposi's, etc)

41

What to do after obtaining pericardial ECG?

Catheterization tests

42

What is a feature of pericarditis?

Pulsus paradoxes - fall of >30 mmHg or more in BP w/ inspiration