Vascular Flashcards

Question

Group 1

Answer 1

Distal PA so medial hyoertrophy proliferation then fibrosis Adhesional thickening and thrombosis PLEXIFORM BODIES idiopathic 36F rare poor outcome 10% genetic BMPR2 most common / others (ALK1/endoglin/ BMPR1/SMAO9) 15% SySc PAH, other (RA SLE sj DM raynaud) — poor prognosis Drugs meth and cocaine HIV Portal HTN 5% have PAH CHD L to R shunt Schisto portal HTN Chronic haem anaemia Haemangio idio vs EIF gene. CT interstitial oedema /GGO / thick septa/ nodularity) Ix Bloods inc RHF anti dsDNA complement ANA antiSCl70 SSC yearly echo and RHC if sob CTD yearly echo PE sob 3m VQ 1 degree family PH then echo Mx Vasodilator response to inhaled NO or inhaled epo or iv epo or iv adenosine Yes if 10% or 40mmHG drop mPAP with same CO = SITBORN CRITERIA Meds high dose nifedipine or diltiazem or amlodipine SE leg oedema or hypotension 3m RHC ongoing sy and PH then 2nd agent Non responder Low risk PDE5 inhx Int add ERA antagonist + sexipleg High risk PDE5 inhx and ERA and IV Porostacyclin —> refer tx

Answer 2

LV fails Back flow PA so endothelial dysfunction Vascular remodel RV dysfunction TR Cause HFrEF HFpEF Valvular CHD Mx Underlying failure BB ACEi ald ant then entresto ICD vs crt Diuretic LVAD No evidence pulm vd CHD Balloon septotomy Rot L shunt reversed Prevent systemic blood bypassing lungs Indication syncope or pre tx or prostanoid not tolerated SE Desat

Answer 3

Chronic hypoxia so pulmonary vc and vascular remodel PA hyperplasia so mechanical stress and loss of capillaries Smoke toxin vascular remodel —— Air trapping Physiological shunt so less perfusion to hyperventilated Cause 25% Copd worse prognosis if pasp over 45 have 5year survival 10% Ild OSA Alveolar hypop in nmd Altitude Developmental ab Mx Treat disease LTOT or NIV Smoking cessation PR Diuresis Pulmonary VD if pvr more than 5 with iv TREPROSTENOL

Answer 4

Symptomatic VQ mismatch 3 months post PE and wedge less than or equal 15 Thromboembolic doesn’t dissolve and forms organised thrombi so fibrotic web obstruction so microvascular remodel, collateral supply artery and raised PVR Arteriopathic change non obstructed area 4 per 1000 PE 4% non fatal PE cause cteph Aet Abnormal clot Endothelial cell abnormality PH RF Acute previous VTE or large PE or echo phtn or cteph Chronic shunt or lines or splenectomy or thrombophilia or hypothyroid or cancer or myelop or IBD or DM Strongest risk factor splenectomy or staph ppm or non group o or VA shunt Ix sOB at 3m post ac VQ echo RHC MDT Other ix CT rings or webs/ slits/ chronic total occlusion prognosis 10% at 5y Worse non operable Mx PEA Deep hypothermia and bypass Proximal disease PAP falls in 2d and less than 10% 5% mortality BPA Distal in 4-10 sessions Se bleeding or lung injury or reperfusion injury Riocigat Enhances cGMP Inoperable cteph Pre PEA 1-2 Pdei then era vs ccb 3-4 iv prostanoid

Answer 5

Haem SCA cml pv myelof et and haemolytic disease LCH LAM NF Sarcoid Fibrosing mediastinitis Metabolic eg gauchers thyroid glycogen storage CKD Pulmonary tumour thrombotic microangiopathy

Answer 6

PDE5 inhx eg sildenafil Stops cGMP breakdown Augments NO so PA VD Increase exercise capacity Indication NYHA 2-3 in G1 + G4 SE headache flush epistaxis nasal congestion ———————————————————————————————————— ERA so reduce pro inflam mediators and reduce SM proliferation Bosentan AB blocker PO G1 Y increase exercise capacity, HD, function Ambisentan A blocker Y better lft/ symptoms / exercise G1 SE lft or headache or peripheral oedema Macentan AB blocker Y reduced mm/ increased exercise capacity/ better lft and leg swelling —————————————————————————————————— Prostanoid Increase cAMP so VD and inhibit plt aggregation and reduce proliferation G1 EpoIV or iloprost IV/neb or ineprost iv/sc Y improved survival IV tunnelled line with dose increase SE dv or headache or cough or chest pain or flush or blurred —————————————————————- Sexipleg Po prostacyclin Reduce death ————————— Riocuguat Enhance cGMP G1 and cteph Increase exercise / reduce progression / increase HD Pathway Low without com PDE5 inhx and ERA Not improving add sexipleg or riociguat Low with com then pde5 inhx or era High then combo with iv prostacyclin and refer tx

Answer 7

HIV ARV ERA or PDE5 inhx then combo Portal htn Echo pre tx Monk then combo Liver tx indication mPAP less than 35 and pvr less than 5 ASD or VSD or PDA PVR more than 5 then closure not recommended, <3 then shunt closure Once closed mono then combo then add uv prostanoid Eisenmenger Iv prostanoid and treat IDA

Answer 8

NYHA 3-4 on medical therapy Worsening RHF RAP more than 20 CI less than 2 6WT less than 350m

Answer 9

Suspected CXR D dimer based on clinical risk no role Bilateral Doppler if sysi Proximal DVT then ac LMWH and mdt re PE No DVT Cxr normal then ctpa or VQ Cxr abnormal then ctpa VQ Y low radiation breast and baby No inconclusive Kate preg or cxr abnormal CTPA Y more accurate and low fetus radiation N slightly higher breast radiation dose and x1.0003 lifetime cancer risk and not for renal failure Mx pregnancy 3m or 6 weeks post partum LMWH or UFH Anti xa in renal failure or recurrent VTE or extremes body weight Side effect HIT or bleeding Labour LMWH stop day before Regional 4 hours after stop UFH Catheter out 12h after stop UFH Thrombolysis Life threatening or arrest Systemic kr Catheter thrombectomy Bridge ecmo Risk bleeding and teratogenic

Answer 10

CR less than 15 warfarin 15-50 apix rivarox or LMWH Malignancy 3-6m then reassess LMWH esp GI cancer higher risk bleeding Antiphospholipid Warfarin Inr 2-3

Answer 11

CP SOB hours list delivery Rash dic Arrest 2 per 100,000 Risk factors CoM Placenta Praevia Polyhydromnios Instrumental Htn ICU Supportive

Answer 12

Small vessel inflammation Neutrophils then fibrinoid necrosis then vessel wall destruction then alveolar haemorrhage MPA PANCA Equal gender in 50s white Pulmonary 50% (pleurisy/ asthma/ Haemoptysis/ phaem) or Renal fsgs Bx fsgs with fubrinoid necrosis and sparse immune deposits Pred then cyclophos or ritux ——— GPA CANCA 50s white Nasal crusting or congestion or epistaxis or ulcer or saddle Subglottic stenosis Ild Renal GN or nephrotic syndrome Fever and weight loss Rash scleritis proptosis visual loss Mononeuritis Ix CANCA (negative esp if only lung) Ct nodules consolidation or pulm infiltrates retic cavities infarct pleural effusion bre — dah or OP Restrictive / reduced TLCO w raised kco Ct sinus Bal or tbb dah or neut+eo+lympth Bx respiratory small and medium necrotising vasculitis Bx Renal fs or diffuse necrotising GN Urine microscopy red cell casts Mx Local pred then cyclo then mx aza or Mtx. Relapse increased pred or severe mp then cyclo w plex Severe 70mg pred then cyclo — maint ritux then aza Life threatening iv methylpred then cyclophos w plex + dialysis —) aza Refractory infliximab or ig or MMf or leflonumide Maint 2y with pred + a aza or MMf 50% relapse risk ——- Egpa granulomatous necrotising vasculitis PANCA Middle aged male 2x Asthma /raised Eo / pulm infiltrate / sinus/ Mononeuritis and Eo on Bx Other cm or myositis or pericarditis/ GI mesenteritis/ dah/ rare renal/ skin nodules/ myalgia/ fever and WL Renal Bx fsgs Phases asthma then blood tissue Eo then systemic vasculitis CT gg /nodules/ bronchial wall thick / dah Bronch marked eosinophilia Bx extravasculad Eo, necrotising angitis, granulomata Mx Lung pred DAH MP then high dose pred Cardiac GI relapse or life threatening- iv methylpred then cyclophos No benefit Plex Maint pred and cyclophos Pg good Resp disease

Answer 13

Medium vessel vasculitis Rare lung Negative anca Association pregnancy or hepatitis b/c

Answer 14

IgG BM alveoli and nephrons 1 in a million Young men 4x Renal failure Alveolar haemorrhage Smoker Viral precedes Raised HLA DR2 in 70% Anti GBM in blood sputum and renal Bx Urine dip blood Diffuse Patchy airspace shadowing in mid and lower zones Restrictive w raised kco Bx cresenteric GN nephrons and IgG linear deposition Lung Bx alveolar haemorrhage with haemosiddherin laden macrophages High dose steroid then cyclophos Plex Dialysis If ab low and renal function refractory renal tx Pg good if treated Fatal if not treated Relapse rare

Answer 15

GPA Neg anca Headache /visual aum fugax/ UL scalp tender/ON Rare lung High esr Dx temporal artery Bx Takayasu Anca negative Frequent lung Young Asian Aorta and major branches and rarely pulmonary vessel arthritis Fever and weight loss, absent pulses Dx angiography Tx pred don’t affect mortality. Some angioplasty Generic vasculitis mx Cxr pulmonary infiltrate HRCT gg nodule dah Bal Eo Bx granulomatous necrotising polyangitis Mx Mild pred Haemorrhage mp then cyclophos Cardio or GI or life threatening then Cyclophos Mepo il5 inhibition

Answer 16

G1 Pulmonary vascular remodel Gene E1F2AK Hypoxia CT Enlarged mediastinal LN Thickened septa Central GG L heart normal echo Worse prognosis

Answer 17

Intrapulmonary shunt so raised A-a gradient Sob when sit up Insidious Clubbing Central cyanosis Ix ABG Contrast echo Mx liver tx

Answer 18

6WT BNP Echo Other RHF Syncope Vo2 max less than 35% BNP over 1500 Ra size over 26 Pericardial effusion CI less than 2 Svo2 less than 60%

Answer 19

AR Valine to glycine so affects b globulin HbSS less soluble so chronic haemolytic Tissue infarct Pneumonia Strep chlamydia HiB mycoplasma legionella rsv Acute chest crisis CX Pen v prophylaxis Asthma vo crisis VTE increased risk of Tonsils HT so risk osa PH G1 G4 G5 Mx as G1 as well as hydration and transfusion

Answer 20

Infection Fat embolism Thrombosis Pulmonary oedema Hypoxia so sickle and voc Infarction so consolidation MOF Fever sob cough Risk factor Younger Raised wcc High HiB Smoke Com Ix wcc hbss% ABG cxr septic screen echo O2 Incentive spiro Cause mx Hydration Analgesia VTE prophylaxis Tx Exchange to reduce hbss less than 20%

Answer 21

3 strata model Low No clinical signs RHF No progressive symptoms No syncope Fc 1-2 6WT more than 440 Cpet vo2 more than 15 Low bnp less than 50 RA area less than 18 and no pericardial effusion RAP less than 8, CI more than 2.5 and svo2 more than 65 Intermediate Slow progression Fc 3 6wt 165-440 Vo2 11-15 BNP 50-300 Ra 18-26 area with minimal pericardial effusion. RP 8-14/ CI 2-2.4/svo2 60-65% High RHF Rapid progression Iv functional Vo2 <11 BNP over 300 Rap over 26 area Rap over 14/ CI <2 and svo2 less than 60%

Answer 22

Ecv increased Fixed sv Fixed pvr Increased pv remodel Risk VTE 25% mortality Deliver at centre Caesarean Hospital 10d before then 2d after Mx ERA teratogenic

Answer 23

Systemic sclerosis 10% Mctd 2.5% Sle 1% Familial ph first degree relative BMPR2 gene carrier Portal hypertension pre liver tx

Answer 24

50% effusion 10% westerman sign Prominent pa is fleischners sign Hampton hump pulmonary infarction

Answer 25

12-72 hours after injury Resp failure Dic fever Dx Gurds criteria Mx supportive ICU Fluid resus Correct hypoxia

Answer 26

Indication anticoagulation Cancer DVT Multiple or proximal clots Symptoms

Answer 27

Who fc 6wt ECG ABG Bloods inc bnp

Answer 28

Based on TRV Low less than 2.8 Int 2.8-3.4 High more than 3.4

Answer 29

Inhaled NO Iv epo Inhaled ileoprost

Answer 30

Aminorex Benfluorex Desatinib Dexfenfluramine Metanelhrines Toxic rapeseed

Answer 31

Routine Immunology HIV TFT CTD

Answer 32

Low risk less than 5% Intermediate 5-20% High 20%

Answer 33

ERA Riociguat

Answer 34

Long term anticoagulation

Answer 35

Above 4 likely DVT (3) Alternative less likely than PE (3) Hr over 100 (1.5) Immobilisation more than 3 days or surgery in the last month (1.5) Previous DVT or PE (1.5) Haemoptysis (1) Malignancy with treatment in 6m (1)

Answer 36

Less than 50 More than 120

Answer 37

4x 6 weeks pp 20x

Answer 38

60s 8x higher

Answer 39

RV over LV over 1 TAPSE less than 16 Bloods increased risk Trop and bnp Lactate above 2 Elevated cr

Answer 40

CANCA Anti PR3 PANCA Anti mpo

Answer 41

Lung No renal CANCA negative

Answer 42

Associated with CTEPH Recanalisation in organised thrombus

Answer 43

FVC falls below 15ml/kg Hypercapnia Hypoxia Heralded facial weakness or bulbar dysfunction Poor prognosis Poor cough Bulbar or facial or weakness Peripheral neuropathy or ans Rapid onset Infection Fvc drops 30% 40% develop Resp and 30% of these tx itu

Answer 44

Elevated in bloodstream PAH

Answer 45

10% of PAH have PVOD Unknown aetiology Poor prognosis so for tx SOB and syncope Severe PH Pulmonary oedema on CT- thickened septa/ GGO/effusion/ enlarged PA Wedge less than 15 Single agent and refer to tx

Answer 46

Tn and bnp If ok then dc pod echo

Answer 47

Fibrin is dissolved but plasmin Heparin cofactor antithrombin iii

Answer 48

Rf Highest etoh lung disease Commonest cause CF CT 6s post contrast BAE 70-99% success 60% re bleed 30d, 6% spinal cord ischaemia Mx Txa reduces mortality Blood n resus

Answer 49

Then LHD If wedge less than 15 and low/normal CO then pre cap If wedge less than 15 and high CO consider L to R shunt

Answer 50

AD with incomplete penetrated

Vascular Flashcards

(75 cards)