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PVD
Cardiology
| Question | Answer |
|---|---|
| LE pain after long periods of standing. Dilated, tortuous, veins | Varicose veins. Tx w/ compression stockings |
| Trendelenberg test of extremities | Tests for venous insufficiency. |
| Blue extremities worse w/ cold exposure, improves w/ warming | Acrocyanosis |
| PAD location: Buttock/Hip: | Aortoiliac disease |
| PAD location: Thigh: | Common femoral artery |
| PAD location: Upper calf: | superficial femoral artery |
| PAD location: Lower calf: | popliteal artery |
| PAD location: Foot: | tibial/peroneal artery |
| PAD symptoms | Intermittent Claudication (pain w/activity, often in calf); ischemic rest pain in severe disease; foot ulcers; ED |
| PAD Clinical Findings | Diminished peripheral pulses, femoral bruits, cool skin temp, abnormal skin color, poor hair growth, ulceration, tissue necrosis; LE rubor (pallor with elevation) |
| Intermittent Claudication: contrasts with: | pseudoclaudication of spinal stenosis (normal pulses/color) |
| PAD: Diff dx | Baker Cyst; Chronic compartment syn; Arthritis; Nerve root compression; Spinal stenosis; Venous claudication |
| PAD Screen: ABI: Normal | 1.0+ (blood pressure augments distally) |
| PAD Screen: ABI: < 0.9 | dx of peripheral vascular dz |
| PAD Screen: ABI: < 0.7 | intermittent claudication |
| PAD Screen: ABI: < 0.4 | rest pain |
| PAD Screen: ABI: < 0.1 | impending tissue necrosis |
| PAD Mgmt: | Risk factor mod; SMK cessation; Walking program; antiplt tx (aspirin & clopidogrel); Pletal Trental; revascularization (Surgery vs Stenting) |
| ABIs helpful to predict: | CLI (Critical Limb Ischemia) & amputation; wound healing; or to screen/ monitor |
| Acute arterial occlusion: Etiologies: | EMBOLISM (valvular dz/prosthesis, AF, IE, MI, DM, myxoma, myocardial or proximal arterial aneurysm). Thrombus in situ (atherosclerotic plaque, trauma, hypercoagulable dz) |
| Acute arterial occlusion: Clinical Findings (5 P's): | Pain, pallor, paresthesia, pulselessness, paralysis/weakness; Poikilothermia; possibly livedo reticularis (w/arterial occlusions) and cyanosis |
| Acute arterial occlusion: 80-90% of arterial emboli arise from: | the heart |
| Acute arterial occlusion: A-fib prevalence | present in 60-70% (thrombus forms in left atrial appendage) |
| Venous Dz | Varicose V; Chronic Venous Insuff; Superficial Thrombophlebitis; DVT |
| Dilated, tortuous alterations of the saphenous v. & tributaries (lie immediately under skin in the LE) | Varicose Veins |
| Varicose veins pathology related to: | venous valve incompetence & subsequent venous reflux from increased pressure |
| Varicose veins Clinical Findings | Asymptomatic to dull, aching pain or discomfort of legs usu worse after prolonged standing |
| Varicose veins - increased frequency after: | pregnancy |
| Varicose Veins: DDx | Secondary VV d/t: chronic venous insufficiency of deep vein; Retroperitoneal venous obstruction; Arteriovenous fistula; congenital venous malformation |
| Varicose: complications | Thrombophlebitis |
| Sluggish blood flow in varicose v. => local thrombosis = | Thrombophlebitis |
| Chronic V. Insuff: Pathophys: | Functionally inadequate v. valves in LEs d/t bad leaflets (do not coapt) (poss 2/2 post-thrombotic syndrome or vein dilatation |
| Chronic V. Insuff: Tx | Grad compression stockings; avoid long stand/ sit; elevate legs; last: pneumatic leg compressions |
| Inflammation, induration, erythema & tenderness along a superficial vein = | Superficial Thrombophlebitis (usually long saphenous v.) |
| Superficial Thrombophlebitis: Clinical Findings | fever, local pain, edema, linear erythema, warmth, & dull tenderness along affected vein; induration (palpable cord) |
| Superficial Thrombophlebitis: Tx: if progressive recurrence = | Ligation surgery (if septic: PCN +/- aminoglycoside) |
| Superficial Thrombophlebitis: Tx if extension into deep venous system = | Anticoagulation |
| Paroxysmal digital ischemia from exag response of digital arterioles to cold or emotional stress (fingers, toes, ears & nose) = | Raynaud Phenomenon (may be 2/2 other dz state: scleroderma/SLE) |
| Raynaud: Excessive vasoconstriction causes: | pallor |
| Raynaud: subsequent vasodilation (after vasoconstriction) causes: | cyanosis then rubor (white to blue to red) |
| Raynaud Tx | Lifestyle changes (gloves), CCB/ nitrates for chronic vasodilation; tx underlying condition |
| Fontaine and Rutherford systems are used to classify: | severity of arterial occlusive disease |
| Thromboangiitis obliterans AKA: | Buerger dz; M SMK 20-40 yo |
| LE rubor, pallor on elevation, no hair, brittle nails, calf or LE pain w/walking short distances, relieved w/rest; claudication with rest pain (ABI < 0.4) = | Arterial insufficiency/PAD, intermittent claudication |
| Giant Cell Arteritis: clinical findings: | Unilateral temporal HA; tender scalp; jaw claudication; visual (amaurosis fugax, scotoma, diplopia), pale fundi; aortic regurg murmur |
| Giant Cell Arteritis: 50% of patients also have: | polymyalgia rheumatica |
| Sequela of Giant Cell Arteritis: | Blindness due to ophthalmic artery occlusion |
| Giant Cell Arteritis pts: higher risk of: | Thoracic aortic aneurysms (17X more frequent) |
| Most common cause of chronic lower limb occlusive disease | Atherosclerosis |
| PAD hx | Hx of intermittent claudication or rest pain |
| PAD S/S | Diminished peripheral pulses, femoral bruits, cool skin temp, abnormal skin color, poor hair growth |
| PAD Clinical Findings | Intermittent Claudication; ischemic rest pain; ulceration; tTissue necrosis |
| Intermittent Claudication: | mx pain in LE induced by exercise and relieved with rest; highly reproducible |
| Intermittent Claudication: contrasts with: | pseudoclaudication of spinal stenosis (normal pulses/color) |
| PAD Mgmt: | Risk factor mod; SMK cessation; Walking program; antiplt tx (aspirin & clopidogrel); Pletal Trental; revascularization (Surgery vs Stenting) |
| ABIs performed to assess: | Asx PAD or mild to mod claudication |
| Acute arterial occlusion: some due to embolism from: | heart, aorta, large arteries |
| Acute arterial occlusion: Thrombus in situ due to: | atherosclerotic plaque, trauma, hypercoagulable dz |
| Acute Arterial Occlusion Tx | Revascularization; IV heparin; Intra-arterial thrombolytic therapy; Surgical thromboembolectomy; Surgical bypass |
| Dilated, tortuous alterations of the saphenous v. & tributaries (lie immed under skin in the Les) | Varicose Veins |
| Varicose V. pathology related to: | venous valve incompetence & subsequent venous reflux from increased pressure |
| Varicose V. Clinical Findings | Asymptomatic to dull, aching pain or discomfort of legs usu worse after prolonged standing |
| Varicose v: Increased frequency after: | pregnancy |
| Varicose: complications | Thrombophlebitis |
| Sluggish blood flow in varicose v. => local thrombosis = | Thrombophlebitis |
| Thrombophlebitis: predisposing conditions = | pregnancy, local trauma, long periods sitting |
| Thrombophlebitis rarely: | ascends in trunk of Gr saphenous v. & leads to thrombosis of femoral vein |
| Varicose V. Tx: | Graduated compression stockings (TED); Elevate legs; endovenous ablation (radiofrequency vs laser); sclerotherapy; greater saphenous vein stripping (older) |
| Chronic V. Insuff: Pathophys: | Functionally inadequate v. valves in LEs d/t bad leaflets (do not coapt) |
| Chronic V. Insuff: valve damage poss d/t: | post-thrombotic syndrome (scarred/thick) or dilatation of vein & unable to coapt |
| Chronic V. Insuff: Clinical Findings | Hx DVT/ leg trauma; EDEMA (below knees); brawney skin pigmentation & venostasis ulcer (above ankles); pruritic, dull discomfort(esp w/ long standing) |
| Chronic V. Insuff: DDx | LE edema d/t: CHF; chronic renal dz; decomp liver dz; Lymphedema (usually unilateral); Autoimmune; PAD |
| Chronic V. Insuff: Tx | Grad compression stockings; avoid long stand/ sit; elevate legs; last: pneumatic leg compressions |
| Superficial Thrombophlebitis usu involves what vein: | long saphenous v. |
| Superficial Thrombophlebitis: spont occur in pt with: | PG, blunt trauma, IV infusion, thromboangitis obliterans, abd ca; |
| Superficial Thrombophlebitis : assoc with DVT how often: | 20% of cases |
| Superficial Thrombophlebitis: Clinical Findings | linear erythema, induration, & dull tenderness along affected vein |
| Superficial Thrombophlebitis: Fever & chills suggest: | septic phlebitis (IV line) |
| Superficial Thrombophlebitis: Circular lesion more consistent with: | cellulitis |
| Superficial Thrombophlebitis: prevention: | Avoid prolonged standing |
| Superficial Thrombophlebitis: Tx | local heat & elevation, bed rest, NSAIDs; Sx usually resolve in 7- 10 days |
| Superficial Thrombophlebitis: Tx: if progressive recurrence = | Ligation surgery |
| Superficial Thrombophlebitis: Tx if extension into deep venous system = | Anticoagulation |
| Superficial Thrombophlebitis: Prognosis | usually benign & brief (Varicose v. etiology: recurrent) |
| Septic thrombophebitis mortality = | 20% (usu Staph (Antibx & vein excision) |
| Phlebitis of saphenous vein rarely: | extends to deep veins (potential for PE) |
| HA, scalp tenderness, visual sx, jaw claudication/ throat pain = | Giant Cell Arteritis |
| Giant Cell Arteritis labs | High ESR, CRP & Interleukin-6 ; mild norm/norm anemia w/ thrombocytosis; temporal art bx is diagnostic |
| Giant Cell Arteritis Tx | prevention of blindness, Prednisone 60 mg ASAP & continue for 1-2 months before taper dosage |
| Paroxysmal digital ischemia from exagd response of digital arterioles to cold or emotional stress (fingers, toes, ears & nose) = | Raynaud Phenomenon |
| Raynaud prevalence | Primarily affects young women |
| Raynaud: Excessive vasoconstriction = | pallor |
| Raynaud: Subsequent vasodilation = | cyanosis then rubor (white to blue to red) |
| Raynaud can be: | primary or secondary to other disease states (scleroderma/SLE) |
| Giant cell arteritis DDx | PMR, Takayasu, RA, amyloid, SLE, polymyositis |
| Giant cell arteritis physiology | Immune-mediated, large arteries (MOST COMMONLY temporal arteries; also subclavian, axillary, Ao); M>F; w/polymyalgia rheum |
| Arterial occlusive dz RF | M>F; 20-30% of >70 yo; Smoking, dyslipidemia, HTN, homocysteinemia, DM, metabolic syndrome; <50 yo w/DM + 1 other RF; 50 - 69 yo with h/o smoking or DM; ≥70 yo |
| Arterial occlusive dz Pathophysiology | flow limiting stenoses occur segmentally |
| Arterial occlusive dz Sx/Sx | exertional intermittent claudication; dec periph pulses, bruits, hair loss, thin shiny skin, mx atrophy |
| Arterial occlusive dz 2 systems of classification | Fontaine and Rutherford: based on sx severity and presence of ulcer or gangrene |
| Leriche syndrome = | aortoiliac disease (arterial occlusive dz of buttock and hip) |
| Buerger test | foot pallor with elevation of leg and, in the dependent position, a dusky red flush spreading proximally from the toes |
| Arterial occlusive dz DDx | DVT, musculoskeletal d/o, peripheral neuropathy, lumbar degenerative spinal canal stenosis (not relieved w/rest) (pseudoclaudication) |
| Arterial occlusive dz: Dx studies | ABI <0.9 (nl = 0.9-1.3); duplex u/s & waveform studies (esp if false normal d/t DM or renal calcification); CTA or MRA; gold std: cath angio (only for pts getting revascularization) |
| Arterial occlusive dz Tx | RF mods: smoking, DM, HTN, HLD; surg (aorto-fem, fem-fem, fem-pop), angioplasty & stenting; cilostazol (PDE5 inhib) |
| Venous insufficiency RFs: | age, FH, ligamentous laxity (eg, hernia, flat feet), prolonged standing, inc BMI, SMK, sedentary, LE trauma, prior DVT, AV shunt, PG, high estrogen |
| Venous insufficiency Patho | reflux (incompetent venous valves), obstruction, venous pump dysfn |
| Venous insufficiency Dx studies | venous u/s; ABI; venography |
| Venous insufficiency Tx | Conservative: leg elevation, exercise, and compression therapy; derm agents; ulcer mgmt. If refractory >6 mos: ablation tx (chem, thermal, mechanical) |
| Venous insufficiency Mgmt guided by | CEAP (clinical, etiologic, anatomic, pathophysiologic) categories |
| PAD etiology: | Atherosclerosis (arteriosclerosis obliterans; most common); thromboangiitis obliterans (Buerger); trauma, arteritis; extrinsic compression |
| PAD pathophysiology: | obstruction / narrowing of lumen of peripheral arteries (most commonly in LE) -> interruption of blood flow -> high risk for CAD |
| PAD risk factors | Old age, smoking, DM, HTN, HLD, obesity; M>F |
| PAD dx studies | Arteriography (gold standard); U/S; ABIs; MRA |
| PAD mgmt: | Stop smoking; diet (low fat/chol/calorie); exercise; foot care; FD ASA; Pletal vs Trental vs Plavix; consider propionyl-L-carnitin; surgery |
| PAD: surgery | angioplasty, bypass graft, arthrectomy, stents |
| Acute arterial occlusion mgmt: | Dx (Doppler extremity; TTE; angiography). Embolism: heparin; thrombosis: antiplatelet meds (alteplase); embolectomy; tx underlying cause |
| Superficial Thrombophlebitis etiology: | Septic (SA, Klebs, Candida, CMV in HIV); malignancy; OCP & PG: hypercoag dz; Behcet dz; Buerger dz |
| Superficial Thrombophlebitis pathophysiology: | inflammation of superficial veins with thrombosus |
| Superficial Thrombophlebitis risk factors: | Immobility, obesity, older age, IV >2 days, burns, steroids, AIDS, varicose veins, post-op, PG |
| Systemic granulomatous inflammation of medium & large arteries (CRANIAL, subclavian, axillary, aorta); >60 yo, M>F; pale fundi; aortic regurg murmur ) = | giant cell arteritis |
| Giant cell arteritis has been associated with: | severe infections, high doses of Abx, chronic autoimmune disorders (RA, SLE) |
| Cold induced pain at extremities with color change as they warm up | Raynaud phenomenon |
| Volkmann contracture of forearm, peroneal nerve injury, foot drop, pain with passive flexion, all suggest: | compartment syndrome |
Created by:
Abarnard
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