Vascular and Ischaemic Heart Disease Flashcards by Erin Timmoney

What is Ischaemia and what does it depend on?

Impaired vascular perfusion and it depends on: speed of onset, duration and local demand

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What is infarction?

Ischaemic necrosis whereby there is a reduction of arterial blood supply or venous drainage

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What results in the corruption of haemostats?

Thrombosis

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What are the two factors involved in haemostasis?

maintained blood flow

2. Induce rapid haemostatic plug at site of vascular injury

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What is the difference between a thrombus and a blood clot?

Thrombus- in life! Has WBC, RBC, platelets, fibrin and lines of Zahn
Blood clot- not in life, no platelets and no lines of Zahn

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What are endothelial cells involved in?

Regulates inflammation, cell growth, LDL cholesterol

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Name the determinants of thrombosis

Turbulence and stasis: site and flow

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What does impaired venous drainage of the limbs result in?

DVT

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Name some acquired and genetic prothrombotic factors (hyper coagulation)

Acquired: MI, immobilisation, heparin, hyper oestrogen state
Genetic: Factor V mutation, antithrombin III, defects in fibrinolysis

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What is the morphology of Thrombi?

Occlude lumen–> coronary/femoral/cerebral–> atheroma–> firm attachment to wall–> lines of Zahn

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What are lines of Zahn?

Layers of solid serum and cells: mural thrombi in LIFE
In ventricles (heart) after MI or arrhythmia
Aortic (aneurysm): atheroma

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What are the morphology of venous thrombi?

Occlusion–> inflammation–> DVT of calf–> “cast formation of red and blue” (rhubarb and custard)

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What are the fates of thrombus?

Propigation, embolism, resolution (fibrinolysis), organisation (degranulation)

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What are the signs/symptoms of pulmonary infarcts/

Wedge shaped, firm, dysponea, chest pain, haemoptysis

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What does not cause infarcts in peripheral arterial circulation?

Venous emboli

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What is Arteriosclerosis and its main targets?

Hardening of the arterties (small-medium): aorta, coronary arteries, cerebral arteries

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What are the outcomes of Arteriosclerosis?

MI, Aortic aneurysm, Peripheral vascular disease, mesenteric artery occlusion, ischamia encephelopathy

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What is Atheroscelerosis?

A form of arteriosclerosis whereby the composition has:
A lipid core of cholesterol, stress and lipoproteins
Raised focal lesion of intima
Fibrous cap

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What is the mechanism of Atheroscelerosis?

1) Chronic endothelial injury
2) Endothelial dysfunction
3) Macrophage activation
4) Lipoprotein oxidation
5) Macrophages become foam cells, fatty streak
6) Macrophages die, oxidised lipid stuck in intima= plaque formation

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What are the complications of Atheroscelerosis?

Ulceration of atheromatous plaque and thrombosis
Haemorrhage into plaque and embolism of plaque contents
On going narrowing- critical stenosis
Aneurysm formation

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What are the three components of Virchow’s Triad and which are needed for DVT?

Hyper coagulable state, endothelial injury, statin

All three

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Name some risk factors for DVT

previous DVT, sepsis, nephrotic syndrome, trauma, vasculitis, haemolytic

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What does D Dimer testing confirm?

It does not specify DVT but if the levels are low it suggests that this is unlikely

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What is venous plethysomography?

A strain gauge is wrapped around the affected limb and inflated, draining the venous system and the refill time is measured. Can help identify a DVT alongside duplex scanning

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What happens if D dimer is positive and Ultrasound is normal?

Treat patient and repeat US

What can be used to treat DVT?

Anticoagulation with LMWH | Compression stockings which prevent the progression of oedema, thrombosis and phlebitis

What is Phlegmasia Dolens?

A life threatening extensive thrombotic occlusion which has poor arterial flow into limbs and venous gangrene

What is the treatment for Phlegmasia Dolens?

and IVC filter to prevent clot from going into the lungs, surgical decompression, only 3-4hrs to fix

What is the classifications of acute PTE?

Massive with shock of syncope, major with right ventricular dysfunction, major with normal ventricular dysfunction, minor

What are some of the classic symptoms of PTE?

SOB, collapse, pleuritic chest pain, haemoptysis, sudden death

What are some of the signs of PTE?

4th heart sound, pleural rub, signs of pleural effusion, consolidation on CXR, wheeze, tachycardia

What are the investigations for PTE and the first choice?

CTPA is first choice (poor for peripheral), ABG, CXR, VQ perfusion

What are you looking for in a echocardiogram in PTE?

Right heart strain

What is the treatment for a massive PE with shock or syncope?

Thrombolysis (streptokinase) or surgery

How many days should a patient be on heparin?

5 days

When are caval filters used?

In short term acute, high risk PE

What is endarterectomy and when is it used?

surgical procedure to remove artheromatous plaque in chronic PE

What are the differences between anti platelet, anticoagulation and thrombolytic agents/

Antiplatelet: interfere with platelet activity Anticoagulation: prevents clot formation and extension Thrombolytic agents: tPA, Strep kinase dissolves existing thrombi

What are the clotting factors in Vitamin K?

7,9,10,2

What does heparin do?

Activates antithrombin, inactivates Xa, IXa, XIa

What are the durations of therapy for PTE?

Temporary risk: 4-6 wks Idiopathic: 3-6mths second Idiopathic: lifelong with risk of bleeding

When should a patient be coagulated for life?

Inherited thrombophilic, antiphospolipid syndrome, recurrent idiopathic VTE, Thromboembolic pulmonary hypertension, recurrent idiopathic VTE

What is the definition of intermittent claudification?

Muscle ischaemia which is exacerbated through exercise

What is the most common site of peripheral vascular disease?

Between the thigh and calf

What is the liklihood of having an MI with intermittent claudification?

More likely than if they've had a previous MI

What are the non invasive investigations of lower leg ischaemia?

Exercise ABPI, Duplex Doppler probe US scanning

What are the invasive investigations of lower leg ischaemia?

Magnetic Resonance Angiography, CT Angiography, Catheter Angiography

What are the treatments of lower leg ischaemia?

Stop smoking! Cilostozol (drug), Angioplasty, surgery: Endarterectomy

Where is Endarterectomy commonly used?

Carotids

What is rest pain in critical limb ischaemia?

Toe/food ischaemia (worse on sleeping due to decreased CO) | Ulcers/gangrene- severe ischaemia and damage due to trauma or footwear, 10% of diabetics lose feet

How can critical limb ischaemia be eased?

start on morphine, worse at night, "sitting with leg out of bed", helped by walking to increase Cardiac output

What is the best outcome for amputuation?

Below the knee

What is the Killip classification?

Used in individuals with acute MI to assess them, if they have a low Fillip score, they are less likely to die within the first 30 days of their MI

What are the five factors which should be considered when assessing the liklihood of myocardial ischaemia in relation to acute coronary sydromes

1. Nature of the symptoms 2. History of Ischaemic heart disease 3. Increasing age 4. Sex 5. Number of traditional CV risk factors

What are the high risk features of ACS?

Prolonged pain (>20mins), worsening angina, pulmonary oedema and arrhythmias

What patients should be given a copy of their ECG?

Those with bundle branch block or ST segment change

Who should be treated with IV Glycoprotein IIb/IIIa receptor antagonists?

High risk patients with NSTEMI elevation ACS

What should patients with an ST elevation who ACS who do not receive repercussion therapy be treated with?

Fondaparinux

Who should be considered for beta blockade?

Patients with ACS in Killip class I in the absense of bradycardia or hypotension

What are the aspirin and clopidogrel guidelines for a patient with NSTEMI?

Lifelong aspirin and 3 months clopidogrel

What are the aspirin and clopidogrel guidelines for a patient with STEMI?

Lifelong aspirin and 4 weeks clopidogrel

What treatment should be considered on symptomatic grounds and what monitoring should be done?

Amiodarone or sotalol | Monitor the liver and thyroid function every 6 months

What are the guidelines concerning rhythm over rate control?

Control rate first: if patient is haemodynamically unstable then use electrical cardioversion. If this fails and they are still symptomatic, treat using rhythm control

Name a non vitamin K antagonist and a vitamin K antagonist

Non: rivaroxaban K: warfarin

Vascular and Ischaemic Heart Disease Flashcards

(64 cards)