Cardiovascular Disorders 3

What are lipids?

fats that are either absorbed from food or synthesized by the liver in the form of cholesterol or triglycerides

what are lipoproteins?

hydrophilic, spherical structures that transport lipids through the body

what is dyslipidemia?

elevation of plasma cholesterol and/or triglycerides OR a low HDL cholesterol level that contributes to development of atherosclerosis

what is VLDL?

very low density lipoproteins, BAD

what is LDL?

low density lipoproteins, BAD

what is HDL?

high density lipoproteins, GOOD :)

primary dyslipedmia is ___________.

genetic

secondary dyslipidemia is ________________/

caused by lifestyle and other factors

what is hypercolesterolemia?

increase in cholesterol only

what is hypertriglyceridemia?

increases in triglycerides only

what is hyperlipidemias?

increase in both cholesterol and triglycerides

how does dyslipidemia clinically present?

the condition itself is asymptomatic, however atherosclerosis causes symptoms secondary to dyslipidemia

how are dyslipidemias diagnosed?

- risk assessment

- physical manifestations of elevated lipids

- blood work (lipid panel)

what is the most common physical manifestation of dyslipidemia?

xanthoma

how are dyslipidemias treated?

- lifestyle modifications

- medications (statins)

what is the goal of dyslipidemia treatment?

decrease the risk of developing atherosclerotic cardiovascular disease and other complications of hyperlipidemia, such as pancreatitis

what conditions are considered atherosclerotic cardiovascular disease (ASCVD)?

- ischemic heart disease

- cerebrovascular disease

- peripheral artery disease

- aortic syndromes

what are common risk factors for ASCVD?

- male gender

- +FHx

- HTN

- Hyperlipidemia

- DM

- CKD

- lifestyle factors

how is a metabolic syndrome diagnosed?

3 of the following must be present: Obesity, High tiglycerides, Low HDL, Elevated BGL, HTN

what is angina?

chest pain caused by cardiac ischemia

what are characteristics of angina?

- substernal, pressure/heavy feeling

- brought on by exertion/emotional stress

- improved with rest or nitroglycerin

- pain may radiate

where does angina pain most commonly radiate to?

the left arm and up into the jaw

what are associated symptoms with angina?

- N/V

- Diaphoresis

- dyspnea

- feeling of impending doom

what does angina equivalent mean?

symptoms other than CP that are ischemic related and serve as angina surrogates

what symptoms associated with angina equivalent?

- dyspnea

- dizziness/light-headedness

- fatigue

what is variant (Prinzmental Angina)?

pain is caused by a spasm of the coronary arteries that is usually severe and occurs at rest (cocaine users)

what two people are most commonly affected with silent ischemia?

women and people of color

what is stable/chronic ischemic heart disease (IHD)?

reversible supply/demand mismatch causing ischemia OR history of myocardial infarction (MI) OR documented coronary artery plaque

Q waves are seen with previous MI

how does stable/chronic IHD clinically present?

ASx or angina controlled by medication or revascularization

how is stable/chronic IHD diagnosed?

EKG, cardiac stress test, cardiac catheterization

how is chronic/stable IHD treated?

1. lifestyle modifications

2. lipid lowering medications (STATINS)

3. antiplatelet medication (ASPIRIN/PLAVIX)

4. Antianginal medication (sublingual nitroglyxerin + beta-blocker OR sublingual nitroglycerin + long acting nitrate)

5. Revascularization (CABG or Percutaneous coronary intervention)

what is a myocardial infarction?

presence of acute myocardial injury detected by abnormal cardiac biomarkers in the setting of evidence of acute myocardial ischemia

what are the two types of myocardial infarctions?

- ST Elevated Myocardial Infarction (STEMI)

- Non-ST Elevated Myocardial Infarction (NSTEMI)

myocardial infarction can also be called what?

acute coronary syndrome (ACS)

if chest pain is present with a myocardial infarction, how is it described?

- changing pattern of angina

- occurs at rest or with little exertion

- not relieved with rest or medication

how is a myocardial infarction diagnosed?

- high-sensitivity troponin

- EKG (differentiates STEMI or NSTEMI)

what are general treatment guidelines associated with a myocardial infarction?

- Supplemental O2

- aspirin - sublingual nitroglycerine - IV Morphine

- revascularization procedures

- management of complications

what artery does mesenteric ischemia specifically target?

the superior mesenteric and inferior mesenteric arteries supplying blood to the intestines

what causes mesenteric ischemia?

- mesenteric arterial embolism/thrombosis (75%)

- nonocclusive mesenteric ischemia d/t intestinal hypoperfusion (20%)

how does mesenteric ischemia clinically present?

ACUTE = abdominal pain out of proportion to what is found on exam

CHRONIC = post-prandial pain ("Intestinal angina")

how is mesenteric ischemia diagnosed?

CT or CT angiography

how is mesenteric ischemia treated?

- pain control

- anticoagulation

- antibiotics

- surgery

- treatment of specific disease

what causes peripheral artery disease?

atherosclerosis of arteries in the periphery

are the upper or lower extremities more commonly impacted by chronic peripheral artery disease?

lower extremities

how does chronic PAD clinically present in the lower extremities?

- ASx

- Claudication

- atypical limb pain

- chronic pain- threatening ischemia including pain at rest, gangrene, and non-healing ulcers

how is chronic PAD diagnosed?

- ankle-brachial index

- CT angiography

what scales are used to classify chronic PAD based on claudication and tissue loss?

rutherford or fontaine stages

how is Chronic PAD treated?

medical: Decrease modifiable CV disease, exercise therapy, pharmacotherapy (cilostazol)

surgical: revascularization

what is acute extremity ischemia?

sudden decrease in limb perfusion that causes a potential threat to limb viability in patients who present within 2 weeks of the acute event

what are common causes of acute extremity ischemia?

- cardiogenic/arteriogenic emboli

- dissection of an artery

- thrombosis at the site of a prexisting athrosclerotic plaque ***Most common

- trauma

- hypercoagulability

- occlusion of a previously placed bypass graft or stent

how does acute extremity ischemia clinically present?

- pain

- pallor

- poikilothermia (cool extremity)

- pulses

- paresthesia

- paralysis

how is acute extremity ischemia diagnosed?

doppler study or arteriography

what is the treatment for acute extremity ischemia?

medical: thrombolytic therapy

surgical: revascularization, amputation

what are chronic venous diseases?

wide spectrum of longstanding venous abnormalities, ranging from varicose veins to chronic venous insufficiency which develop secondary to venous hypertension and lead to impaired blood return

what is venous hypertension?

elevated venous pressure caused by any of the following: inadequate muscle pump function, incompetent venous valves, venous thrombosis, or non-thrombotic venous obstruction

chronic venous disease is classified based of what scale?

CEAP Scale

- Clinical presentation

- etiology

- anatomy

- pathophysiology

what is the associated clinical presentations of chronic venous disease?

- benign skin lesions/changes

- varicose veins

- edema

- pathological skin lesions

what anatomy is associated with teh CEAP scale for chronic venous disease?

superficial vs. deep veins

what is the pathophysiology associated with the CEAP scale for chronic venous disease?

reflux and/or obstruction

what are varicose veins?

subcutaneus veins dilated to at least 3mm in diameter when measured with the patient upright in position

how do varicose veins clinically present?

- ASx

- mild pain/heaviness

- cosmetic concern

how are varicose veins diagnosed?

clinically

what is the treatment for varicose veins?

procedural/surgical: laser therapy, sclerotherapy, surgical removal

what is chronic venous insufficiency (CVI)?

stasis of blood in the LE secondary to vein valve incompetance/obstruction

how does chronic venous insufficiency clinically present?

leg pain, edema, skin lesions (hyperpigmentation - Stasis Dermatitis) and ulcers

how is chronic venous insufficiency diagnosed?

clinically with venous duplex US, severity based on venous disability score

what is the treatment of chronic venous insufficiency?

- leg elevation

- compression therapy

- wound therapy/surgery

What is score 0 on the venous disability score?

asymptomatic

what is score 1 on the venous disability score?

symptomatic but able to carry out usual activities without compressive therapy

what is score 2 on venous disability scale?

symptomatic but able to carry out usual activities with compressive therapy

what is score 3 on venous disability score?

unable to carry out usual activities even with compressive therapy

what is peripheral vascular disease?

degree of both venous and arterial insufficiency

what is the scale used to classify impairment of vascualr disease?

american medical association impairment grading scale

what is the hallmark symptom of chronic peripheral artery disease?

claudication

what is the hallmark symptom of chronic venous disease?

swelling

what is an aneurysm?

a segmental, full-thickness dilation of a blood vessel having at least 50% increase in diameter compared with the expected normal diameter

what are the demographics associated with thoracic aortic aneurysms?

most common in men over 60

how does a thoracic aortic aneurysm clinically present?

- ASx

- Sx

- Sx due to rupture

what symptoms are associated with thoracic ascending aortic aneurysm?

severe chest pain

what symptoms are associated with a thoracic descending aortic aneurysm?

serve upper-mid back pain

how is a thoracic aortic aneurysm diagnosed?

CT/MRI angiography

how is a thoracic aortic aneurysm treated?

- ASx: BP management, statin medications, monitor size of TAA, ELECTIVE SURGERY (much better 5 year survival rate when compared to emergency surgical repair)

- Sx/Rupture: Surgical repair

what are the most significant risk factors associated with abdominal aortic aneurysms (AAA)?

- male gender

- age > 65

- tobacco usage

what is a abdominal aortic aneurysm?

abnormal dilation of the infrarenal abdominal aorta of 3+ cm

what screening should be done for abdominal aortic aneurysms?

one time US in all men ages 65-75 who ever smoked

how does an abdominal aortic aneurysm clinically present?

- ASx

- Sx: Severe abdominal pain or lumbar pain

- Sx ruptured: severe abdominal or lumbar pain, hypotension, and pulsatile abdominal mass

how is an abdominal aortic aneurysm diagnosed?

US or CT Scan

how is an abdominal aortic aneurysm treated?

- surveillance with elective repair

- Ruptured: Surgical repair

what is the prognosis of abdominal aortic aneurysms?

Misdiagnosis is common! ~50% do not make it to hospital alive, and those that do arive ~ 50% do not survive surgery

where is the most common location for peripheral aneurysms?

the popliteal artery

how does a popliteal aneurysm clinically present?

- ASx as a pulsatile popliteal mass

- Sx as acute/chronic limb ischemia or rupture

how is a popliteal aneurysm diagnosed?

US or CT Angiography

how is a popliteal artery aneurysm treated?

ASx surveillance, Sx/Rupture surgical repair

what is aortic dissection?

the abnormal, and usually abrupt, formation of a tear along the inside wall of an artery. As the tear increases size, it forms a fals channel.

aortic dissections are __________ but _______________!!!!!!!!!

uncommon; catastrophic

what is stanford type A of aortic dissections?

ascending aorta (most common)

what is stanford type B of aortic dissections?

descending aorta

how does an aortic dissection clinically present?

- sudden, tearing chest or back pain

- manifestations of lack of blood flow through the aorta (MI, Stroke, mesenteric ischemia, limb ischemia, renal failure)

how is an aortic dissection diagnosed?

CT scan

how is an aortic dissection treated?

surgical