Info
🌱 來自: Huppert’s Notes
Diseases of the Vasculature🚧 施工中
Diseases of the Vasculature
Hypertensive emergency
• Definitions: Elevated SBP with end-organ damage
• Etiology: See etiologies for hypertension in General Medicine Chapter 10; in particular consider medication noncompliance, stimulant use (e.g., cocaine, methamphetamines), hyperaldosteronism, pheochromocytoma, Cushing’s, pre eclampsia, vasculitis, renal artery stenosis
• Symptoms: CNS symptoms (e.g., mental status changes, visual changes, papilledema, encephalopathy), renal injury (e.g., hematuria, AKI), cardiac injury (e.g., ACS, ADHF), pulmonary edema
• Treatment: Reduce mean arterial pressure (MAP) by 25% in 1–2 hours (then slower after). IV medications: Nitroprusside or nicardipine gtt
Aortic dissection
• Definitions:
- Type A: Dissection of the ascending aorta
- Type B: Dissection of the descending aorta
• Etiology: Risk factors: Hypertension (most common), stimulant use (e.g., cocaine, methamphetamines), connective tissue disease, bicuspid aortic valve
• Clinical presentation: 1) Abrupt onset tearing pain in the chest or back; 2) Pulse and/or BP asymmetry in each arm or between the arms and the legs
• Diagnosis: CT Angiogram. On CXR, see widened mediastinum. Sometimes need TEE to confirm the diagnosis.
• Treatment:
- Type A: Emergent surgery, in meantime medical management
- Type B: Medical management: IV BB to lower HR, then IV nitroprusside to lower BP (goal SBP 100–120 mmHg within 20 minutes)
Abdominal aortic aneurysm (AAA)
• Etiology: Atherosclerosis, hypertension, smoking, syphilis, connective tissue disorders
• Clinical: Pulsatile abdominal mass (rarely detect clinically); instead usually diagnosed on screening imaging or incidentally on abdominal imaging obtained for another purpose
• Screening: Ultrasound: One-time screening ultrasound indicated in men age 65–75 yr who have ever smoked. Insufficient evidence for screening ultrasounds in women
• Treatment: Open vs. endovascular repair
- Repair if 1) AAA >5.5 cm in men or AAA >5 cm in women; 2) Rapid rate of expansion, >0.5 cm in 6 months or >1 cm in 1 yr; 3) Symptoms due to the AAA
- Rupture: Triad of 1) Abdominal pain; 2) Hypotension; 3) Palpable pulsatile abdominal mass Treatment: Open repair
Peripheral artery disease (PAD)
• Etiology: Abnormal narrowing of the arteries, most commonly affecting the legs. Risk factors = atherosclerotic risk factors. Common vessels affected include the superficial femoral artery, popliteal artery (causes calf pain), aortoiliac artery (causes butt/hip pain)
• Clinical presentation: Claudication, leg pain at rest (especially at night, hanging foot over the bed often relieves the pain). Signs: Diminished pulses, less hair over legs/feet, ulcers
• Diagnosis: Ankle-brachial index (ABI): ABI <1.0 is diagnostic of PAD. Claudication typically develops if ABI <0.7 and rest pain if <0.4. If vessel calcification is present (ABI >1.4) then non-interpretable and get toe-brachial index
• Treatment: Smoking cessation, exercise, aspirin, (phosphodiesterase-3 inhibitor (e.g., cilostazol, contraindicated in heart failure). Percutaneous intervention (e.g., balloon angioplasty, stenting), surgery (i.e., bypass grafting).
Acute arterial occlusion
• Etiology: Native arterial thrombosis, arterial (or paradoxical) embolism, arterial injury
• Clinical: Six Ps: Pain (acute), Pallor, Poikilothermic (cold), Paralysis, Paresthesia, Pulselessness
• Diagnosis: CTA to determine the site of occlusion
• Treatment: Immediate IV heparin gtt and vascular procedure/surgery; Use anticoagulation with caution for suspected cholesterol emboli