Heart 6

oelomar's version from 2016-05-03 21:45


Question Answer
What are the symptoms of acute limb ischaemia?6P’s (not all may be present): Pain (absent in 20% of cases); Pallor (within a few hours becomes mottled (blotchy) cyanosis); Paraesthesia (light touch lost first then sensory modalities); Paralysis/Power loss (most important – indicates impending gangrene); Perishingly cold; Pulselessness (not reliable).
How is acute limb ischaemia managed?Management is dependent on the degree of ischaemia. Patients showing improvement may be treatable with heparin or an appropriate treatment of the underlying cause. Patients with emboli following MI or AF need long-term warfarin. An amputation may be warranted in un-reconstructable or severe ischaemia.
What link does compartment syndrome have with limb ischaemia?Compartment syndrome can occur with prolonged ischemia; requiring fasciotomy.
What are the risk factors for developing chronic lower limb ischaemia?Smoking, DM, hypercholesterolaemia, hypertension.
Patients with early-stage peripheral artery disease may complain of intermittent claudication. What is intermittent claudication?Exertional discomfort most commonly in the calf which is relieved by rest. The “claudication-distance” is reproducible: same distance to elicit pain, same location of pain, same amount of rest to relieve pain.
What is critical limb ischaemia and what are its clinical features?This is an advanced stage of peripheral artery disease. It includes ischaemic rest pain which stop a patient from sleeping, which is partially relieved by dangling the foot over the edge of the bed or standing on a cold floor. It may also include arterial insufficiency ulcers and gangrene.
What investigations can be carried out in patients with peripheral artery disease?An estimation of the anatomical level of disease may be possible with the examination of pulses. The severity of disease is indicated by ankle brachial pressure index (ABPI). Intermittent claudication is associated with an ABPI of 0.4–0.9. Values of < 0.4 are associated with critical limb ischaemia. If the arteries are heavily calcified and incompressible, i.e. in renal or diabetic disease, the ABPI will be falsely elevated. In these patients toe pressure values are more sensitive.
What would an ankle brachial pressure index of >1.2 indicate?Abnormal vessel hardening from peripheral vascular disease.
How is peripheral vascular disease managed?All patients need risk factor management. Duplex ultrasound is first-line imaging to all people for whom revascularisation is being considered. Offer angioplasty for treating suitable people with intermittent claudication. Do not offer primary stent placement for people with aorto-iliac disease (except complete occlusion) or femoro-popliteal disease. Offer bypass surgery when angioplasty has been unsuccessful or is unsuitable. Consider naftidrofuryl oxalate for patients who prefer not be considered for invasive procedures.


Question Answer
What is aortic dissection?Aortic dissection occurs when a tear in the tunica intima of the aorta causes blood to flow between the layers of the wall of the aorta, forcing the layers apart.
What is the difference between aortic dissections type A & B?Type A: involving the aortic arch and aortic valve proximal to the left subclavian artery origin. Type B: involving the descending thoracic aorta distal to the left subclavian artery origin.
What are the causes of aortic dissection?Hypertension (most common), connective tissue disease (e.g. Marfan’s, Elhers-Danlos).
What are the clinical features of an aortic dissection?Most patients present with a sudden onset of severe and central “tearing” chest pain that often radiates to the back and down the arms, mimicking MI. Hypertension is present in 75-85% of patients. There are asymmetrical blood pressures and pulses between arms.
What investigations can be undertaken in a patient with suspected aortic dissection?The mediastinum may be widened on chest x-ray, but urgent CT scan (gold standard) or transoesophageal echocardiography or MRI will confirm the diagnosis.
How are aortic dissections managed?Antihypertensive medications with IV beta-blockers and vasodilators (GTN). Type A dissections should undergo surgery (arch replacement) if fit enough, as medical management carries a high mortality (50% within 2 weeks). Type B dissections carry a better prognosis and should be initially managed medically unless they develop complications.


Question Answer
What is an aneurysm?An excessive localised swelling of the wall of an artery. An aneurysm is defined if there is a permanent dilatation of the artery to twice the normal diameter.
What is the difference between a true aneurysm and a false aneurysm?True aneurysm: involving all vessel wall layers (intima, media, adventitia). False aneurysm (also known as psuedo-aneurysm): disruption of the aortic wall or the anastomotic site between vessel and graft with containment of blood by a fibrous capsule made of surrounding tissue.
What are the risk factors for developing an aortic aneurysm?The main risk factors include being male, increasing age, hypertension, smoking, and family history of AAA.
What are the clinical features of an abdominal aortic aneurysm?75% are asymptomatic (discovered incidentally). A pulsatile, expansile abdominal mass may be felt. Rapid expansion or rupture of an AAA may cause severe pain (epigastric pain radiating to the back). A ruptured AAA causes hypotension, tachycardia, profound anaemia, and sudden death.
The NHS has a screening program for AAA. Who is eligible?Men during the year they turn 65.
What investigations can be carried out in someone with a suspected AAA?An AAA is first assessed by ultrasound (100% sensitivity). A CT scan is more accurate. CT scans are performed in all those presenting to A&E with back pain over the age of 60.
When is it recommended for an operation to carried out to manage an AAA?An operation is recommended if the aneurysm is: ≥ 5.5 cm diameter, expanding > 1 cm/year, symptomatic.

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