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Diagnostic Test
Measures
Radiograph
Indications
Acute aortic syndromes
Chest pain
Intramural hematoma
Aortic trauma
Aortic aneurysm
Test Interpretation
Other
Result
Parameters
Intramural
Not great at detailing vessel damage
Widen mediastinum
Hematoma
Aortic arch segment is
Aortic Trauma
too wide
Aortic Aneurysm
Wide aorta
Aortic dissection
Computed
Tomography Scan
Computer-processed
x-rays produce
tomographic images
of specific areas in an
object
Aortic trauma
Annuloaortic ectasia
Mycotic aneurysm
Intramural hematoma
( aortic rupture)
Type B Dissection
Intramural
Hematoma
Crescent-moon shape in
the aorta
Aortic Rupture
Aortic Trauma
Outcropping pocket
on aorta
Aoritis
Aortic aneurysm
Takayasu arteritis
Ascending Aortic
Aneurysm
Descending Aortic
Aneurysm
Abdominal Aortic
Aneurysm
Aneurysm
Rupture
Annuloaortic
Ectasia
Takaysu Arteritis
Ambulatory
Blood Pressure
Monitoring
Holter Monitor
Ambulatory electrocardiography
monitoring
Borderline HTN
Refractory HTN
Episodic HTN
Hypotensive symptoms
from medications
Arrhythmias
> 4 cm
> 3.5 cm
> 3.0 cm
Blood surrounding and
outside of aorta
Dilated annulus
Dilated valsalva
Wall thickening
Narrowing of aorta
Advantages
Multiple readings
R/O white coat syndrome
No placebo effect
Disadvantages
Cost
Disruption of daily activities
Lack of long-term studies
Only useful if patients actually
experience palpitations while the
holter monitor is worn
Diagnostic Methods
Diagnostic Test
Measures
Event Monitor
Ambulatory electrocardiography
monitoring that stores specific
symptomatic episodes
Ankle Brachial
Index
Excerise Doppler
Stress Test
Indications
Episodic palpitations
Result
Test Interpretation
Parameters
Other
Can be activated by patient when
symptoms arise
Syncope
Noncompressible
Normal
Mild-To-Moderate
> 50 years old with
PAD
smoking and/or diabetes
Severe PAD
Non-healing wounds
> 1.30
0.91 - 1.30
0.41 - 0.90
0.00 - 0.40
Claudication
Pseudoclaudication
PVD
Clinical Medicine
Condition / Disease
Cause
Atrial
Tachycardia
Arrhythmias caused
by increased atrial
pulse rates
Bradycardia
Sinus Arrhythmia
Multifocal Atrial
Tachycardia
Different clusters of
cells outside the SA
node take control of
heart rate
Atrial Fibrillation
Rapid, disorganized
electrical signals
causes the atria to
quiver
Test
Laboratory
Result
EKG
Wolff-ParkinsonWhite Syndrome
No cardiovascular symptoms
Palpitations
Chest pain
EKG
Pulse rate
Rhythm
P Wave
Rhythm
Rate
Irregular
LOW
Variable
1:1
Irregular
100 bpm
P Wave
3 Morphologies
Rate
P-P
P-R
R-R
Rate
st
1 Degree
Atrioventricular Block
Fainting
Rate
Delta Wave
Delta Wave
Present
CHF
P Wave
Echo
Holter
Rhythm
P Wave
Supraventricular tachycardic
rhythm that occurs due to the Very brief episodes that are typically only captured
by a holter monitor
formation of a reentry circuit next
to the AV node
Slowed conduction
through the normal
conduction pathway
Class IA/IC
Antiarrhythmics
Class III
Antiarrhtyhmics
Medications
Palpitations
Shortness of breath
P Wave
Pacemaker Indications
HR < 40 bpm WITH symptoms
Pause > 3.0 seconds (while awake)
Symptomatic bradycardia from
required drug therapy
Symptomatic chrontropic
incompetence
Common in young patients
Variable
Atrial HR
Irregularly
irregular
Random and
chaotic
A-fib
A-fib
Atrial HR
150 bpm
(ventricular HR w/
2:1 a-flutter)
Regular
Saw-tooth
Distroted
(2:1 a-flutter)
Near or hidden
in QRS
Retrograde
after QRS
140 - 200 bpm
Absent
Rhythm
Artial HR
Cardioversion (hemodynamically
unstable or stable)
Rate control atttempt (borderline or
hemodynamically stable)
Anti-coagulation
(hemodynamically stable)
Dizziness
Cardioversion
Syncope
Ischemia
Electrolyte
abnormalities
Other
AV Nodal Blockers
Ablation
QRS
Atrioventricular
Node Reentry
Tachycardia
Medications
Rate
Atrial Flutter
Treatment
Triggers
Ischemia
Warfarin
Alcohol
Beta Blockers Thyroid disease
Calcium Channel Lung disesae
Blockers
Caffeine
Digoxin
Cold drinks
Anti-Arrhythmics
Adenosine
Anti-Arrhythmics
Adenosine
Beta Blockers
Calcium Channel
Blockers
AV node blockers should be avoided
in a-fib and a-flutter with a history
of WPW
200 ms
PR Interval
No therapy required
Constant
Clinical Medicine
Condition / Disease
Cause
2nd Degree
Atrioventricular Block
Type I (Wenckebach)
Progressively lengthening
conduction between the atria
and ventricles continues until a
beat is dropped
2nd Degree
Atrioventricular Block
Type II (Mobitz)
Conduction between
3rd Degree
the atria and
Atrioventricular
ventricles is
Block (Complete) completely severed
Ventricular
Tachycardia
Torsades de
Pointes
Ventricular
Fibrillation
Potentially lethal
accelerated
ventricular rate
Life-threatening polymorphic
ventricular tachycardia
Quivering ventricles produce
no net blood flow through
the heart
Aortic Stenosis
Any of a set of
diseases that cause
valvular dysfunction
Narrowing or
obstruction to
forward flow while
the aortic valve is
open
Laboratory
Result
Rhythm
Regularly irregular
PR Interval
Progessively
lengthing
Resets after
failed beat
Usually asymptomatic
Light-headedness
Dizziness
Syncope
Regular
Rhythm
PR Interval
Age
Ischemia
Post-Surgery
Congenital
Electrolytes
Digoxin toxicity
Rates
P Waves
P-P
Q-Q
Rhythm
QRS
P Waves
Can be asymptomatic
Chest pain
Dizziness
Syncope
Valvular Heart
Disease
Test
Axis
Rhythm
P Waves
QRS
Q-T
Rhythm
Rate
QRS
P Waves
Dropped
ventricular beats
Constant
Treatment
Medications
Pacemaker
Atrial and
ventricular rates
completely
independent
Pacemaker
Independent of
QRS
Constant
Constant
Cardioversion
Regular
(hemodynamically unstable)
Anti-arrhythmic therapy
Wide
Treat underlying disease
Hidden
ICD (if EF 35%)
After QRS
Ablation
Unusual
Irregular
Absent
Cardioversion
Polymorphic
Prolonged
Irregular
Cardioversion
Unknown
Chaotic
Treat underlying problem
Absent
Can be lethal
Anti-Arrhythmics
Lethal
IV Magnesium
Lethal
Systolic Murmurs
Aortic and pulmonic stenosis
Mitral and tricuspid regurgitation
Diastolic Murmurs
Mitral and tricuspid stenosis
Aortic and pulmonic regurgitation
Regurgitant lesions
Hypertrophy
(stenotic disease)
Dilatation
(regurgitant disease)
Angina
Shortness of breath
EKG
CHF
Orthopnea
S4 murmur
LVH
Cardiomegaly
CXR
Syncope or presyncope
symptoms
Symptomatic
Exerciseinduced
HR < 40
Pause > 3 sec
Stenosis
Asymptomatic with
murmur
Other
Common in athletes, elderly,
ischemic patients, or patients taking
beta blockers, calcium channel
blockers, or anti-arrhythmics.
Echo
Cath
Post-stenotic
dilation
Abnormal valvular
morphology
Aortic ballon valvotomy
(high risk of complications and disease
recurrence)
Assess
Septal defects
Tetralogy of Fallot
Septal coarctation
Normal
Area = 3.0 - 4.0 cm2
Mild
Area > 1.5 cm2
Pressure gradient < 25 mm Hg
Moderate
Area > 1.0 cm - 1.5 cm2
Pressure gradient = 25 - 40 mm Hg
Severe
Area < 1.0 cm2
Pressure gradient > 40 mm Hg
No beneficial medical therapy
Clinical Medicine
Condition / Disease
Acute Aortic
Regurgitation
Chronic Aortic
Regurgitation
Mitral Stenosis
Cause
Sudden onset of
backflow from the aortic
valve
Slowly progressing
leakage of the aortic
valve
Narrowing or
obstruction to
forward flow while
the mitral valve is
open
Acute Mitral
Regurgitation
Sudden onset of
backflow from the
mitral valve
Chronic Mitral
Regurgitation
Slowly progressing
leakage of the mitral
valve
Mitral Valve
Prolapse
Tricuspid Valve
Stenosis
Laboratory
Result
EKG
No LVH
Prosthetic valve
dysfunction
Aortic dissection
Test
S3 gallop murmur
Quincke's pulse
(nail bed)
Fatigue
Water-hammer (or
Corrigan's) pulse
Musset's sign
(head bob)
Dyspnea
Orthopnea
Hemoptysis
Peripheral edema
Palpitaiton / a-fib
Pulmonary venous
congestion
Embolic events
LA Pressure
Cardiac output
Pulmonary HTN
High-pitched, opening
Loud, palpable S1
snap after S2
Low-pitched, diastolic
Accentuated P2 and
rumble near apex
RV heave
New systolic murmur
Prior acute MI
Bacterial endocarditis Papillary muscle rupture
or dysfunction
Chordae rupture
Acute pulmonary
Abscess / necrosis
edema
Cardiogenic shock
Holosystoic murmur
JVD
at apex
Soft S1
Visible, palpable LV
Laterally displaced
heave at apex
apical impulse
S3 murmur
CHF
Asymptomatic
Fatigue
Atypical chest pain
Palpitations
Sympathetic
Anxiety disorders
hyperactivity
Postural orthostasis
Mid-systolic click MR murmur
Symptoms of right
Edema
atrium pressures
Weakness
Ascites
Fatigue
Hepato-splenomegaly
JVD
Diastolic murmur at sternal border that increases
with inspiration
Treatment
Medications
Other
Medications
Nitroprusside
Surgery
LVH
EKG / CXR
LV enlargment
Echo
Assess
Cath
Echo
Pressure
gradient
Aortic Valve
Replacement
Cath
Symptoms of
heart failure
Acute AI with
hemodynamic
compromise
LVEF < 55%
Echo
Cath
Echo
Assess MR
severity
Hydralazine +
nitrates
Diuretics
Nitrates
A-fib
Mitral valve replacement (combined
stenosis and regurgitation)
EKG
ARBs
Pulmonary HTN
Directly measure
pressures
LVH
Left atrial
enlargement
Hyperdynamic,
dilated LV
Abnormal valve
morphology
Doppler study
Assess MR
severity
ACE Inhibitors
Balloon valvuloplasty
Medications
Endocarditis prophylaxis
Beta Blockers
Diuretics
Acute MR
Chronic MR with
LV function
Surgery Criteria
Chronic MR with
end-systolic left
ventricular
diameter > 4.0 cm
Reassurance of patient
SBE prophylaxis
Medications
Surgery (when there is severe MR)
Causes
Fibrosis or thickening of leaflets
Commissural fusion
Chordae fusion and shortening
Orifice size
Normal
Valve area = 4.0 - 6.0 cm2
Pressure gradient = 0 mm Hg
Mild
Valve area > 2.0 cm2
Pressure gradient < 8 mm Hg
Moderate
Valve area = 1.0 - 2.0 cm2
Pressure gradient = 8 - 12 mm Hg
Severe
Valve area < 1.0 cm2
Pressure Gradient > 12 mm Hg
Repair surgery is favored over
replacement.
ACE Inhibitors
Digoxin
Antibiotics
Beta Blockers
Aspirin
>
Uncommon in adults
Ballon valvuloplasty
Surgical valve replacement (pressure
gradient > 5 mm Hg)
Clinical Medicine
Condition / Disease
Cause
Tricuspid
Regurgitation
Backflow of the
tricuspid valve
Symptoms of right
C-V waves in
ventricular failure
jugular veins
Pulsatile liver
Hepatojugular reflux
Holosystolic murmur at left sternal border that
increases with inspiration
Pulmonary HTN
A-fib (possible)
Pulmonic Stenosis
Narrowing or obstruction
of blood flow through the
pulmonic valve
Pulmonic
Insufficiency
Rheumatic Fever
Exertional dyspnea
Pre-syncope Sx
Cyanosis
JVP with prominent A
wave
Laboratory
Result
S4 murmur
Systemic immune
response to Group A
-hemolytic Strep
infections of the
pharynx
Other
Diuretics
Digoxin
Echo
Splitting of S2
Right ventricular
hypertrophy
Systolic doming
of PV
Transpulmonic
gradient
Balloon valvotomy
Salicyclates
Bedrest if significant cardiac disease is
present
Valvular regurgitation
or stenosis
Transient bacteremias
Microbal invasion of
the endocardium
Medications
Hyperdynamic RV with
Fairly asymptomatic
Failure of the pulmonic valve due
palpable heave
to the dilation of the valve ring Low-pitched diamond-shaped diastolic murmur in
the 3rd and 4th intercostal spaces
from pulmonary hypertension or
Treatment
Usually only treat severe TR
Medications
Fatigue
Post-surgery
Medications
Symptoms appear
2 - 3 weeks after
infection
Infective
Endocarditis
Test
History of intravascular
device
Fever
Weight loss
Petechiae / rash
Osler nodes
Splinter hemorrhages
Janeway lesions
Roth spots
Steroids
Heart failure management
Blood Culture
Positive
CBC
Anemia
Leukocytosis
ESR
UA
Proteinuria
Rheumatoid
Factor
Antibody
Echo
Positive
Prolonged IV antibiotics
Failure to clear
infection
Fungal organism
Surgical Valve
Replacement
Criteria
Severe, refractory
CHF
Intramyocardial
abscess
Recurrent embolic
events
Oscillating
vegetations
Abscesses
Unstable
Valvular
prosthetic devices
regurgitation
Predisposing heart
NO ANTICOAGULATION THERAPY
condition
Antibiotics
Clinical Medicine
Condition / Disease
Cause
Test
Laboratory
Result
Asymptomatic
(usually found on a routine exam)
Pulmonary congestion
Dilated
Cardiomyopathy
Enlargement of the
ventricles
Fatigue / Weakness
Dyspnea
Chest pain
CXR
Blood Tests
Right-sided heart failure
(late symptom)
Apex displaced
S3 (once symptomatic)
Cath
BP
Interventricular
conduction delays
Anterior
precordial Q
waves
Cardiomyopathy
Electrolytes
Thyroid Fx
ESR / ANA
Ferritin
HIV
Systolic murmur
MRI
Cardiac rehabilitation
Exclude pericardial
diseases
Assess cardiac and
pulmonary
Transplant evaluation
pressures
Assess
Peripartum
Cardiomyopathy
Pregnancy causes
cardiomyopathy
slightly pre-partum or
post-partum
Pregnancy or
post-partum
Typical cardiomyopathic
symptoms
Alcohol
Cardiomyopathy
Cardiomyopathy due to
prolonged consumption of
alcohol (> 10 years)
History of alcohol
Typical cardiomyopathic
symptoms
Alcohol cessation
Dynamic pressure
gradient
Hypertrophic
Cardiomyopathy
Portion of the
myocardium is
hypertrophied with
no apparent cause
Other
Most common form of
cardiomyopathy.
Assess
Echo
Enlarged PMI
Medications
Sinus tachycardia
EKG
Exercise intolerance
Treatment
Diastolic dysfunction
Ischemia
Mitral regurgitation
Asymptomatic
Dyspnea
Angina
Fatigue
Syncope
Harsh, crescendo
systolic murmur
EKG
LVH
ST-T changes
Gaint T wave
inversion
Prominent Q
waves in
precordium
LVH
ASH 1.5x thickness
of post. wall
Echo
Outflow tract
narrowing
Beta Blockers
Risk Factors
Age > 30
African-American
Multiparous
Twin pregnancy
History of HTN
Preeclampsia / eclampsia
Reversible
Mechanisms
Direct toxic effect on myocytes
Nutritional deficiencies
Toxic additives in EtOH product
Manage symptoms
Medications
Beta Blockers
Treat tachyarrhythmias
Pacemaker
aICD
Surgery
Calcium Channel
Blockers
Dynamic gradient
Restrictive
Cardiomyopathy
Cardiomyopathy in which
the cardiac walls are rigid
Systolic thrill
S4 Murmur
Abnormal diastolic
function
Sarcoidosis
Glycogen storage
diseases
Cath
Evaluate
Transplant
Rarest of all cardiomyopathies
Clinical Medicine
Condition / Disease
Cause
Myocarditis
Inflammation of the
myocytes, intersitium,
vasculature, and/or
pericardium
Arrhythmias
Tachycardia
Fever
Chest pain
Chest pain
Dyspnea
Laboratory
Result
ST / T wave
EKG
abnormalities
Left ventricle
Echo
dysfunction
Coxsackie
Hepatitis
Serology
HIV
T. cruzi
Stool
Viral Cultures
Throat
Pericardial fluid
Endocardial
Biopsy
Confirmatory
Endocardial
MRI
Serial EKGs are
really helpful
Diffuse ST
elevation
Test
EKG
Acute Pericarditis
Acute inflammation of
the pericardium
Symptoms of underlying
Pericardial friction rub
disease
Recurrent symptoms
Fever
Cardiac
Enyzmes
Echo
Hemorrhagic Pericarditis
Purulent
Pericarditis
Post-Infarction Pericarditis
Dressler's
Syndrome
Neoplastic
Pericarditis
ST segments
return to baseline
Treatment
Medications
Treat infections
Pericardiocentesis to confirm or
exclude purulent pericarditis
NSAIDs
Admission
TW inversion
Reversion of TW
Pain relief
inversion
PR segment
Antibiotic treatment
depression
Positive
(sometimes)
IV anticoagulant therapy (use caution)
Effusion
(sometimes)
Coricosteroids
Colchicine
S. aureus
Blood Cultures
S. pneumoniae
Friction rub
Pain
History of infarction
Malaise
Fever
Pericardial discomfort
Pericardial effusion
Lung
Breast
Leukemia
Source of Tumors
Hodkins and nonHodgkins lymphoma
Metastatic melanoma
Often asymptomatic during life
Aspirin
Leukocytosis
CBC
Other
Etiologies
Infections (most common)
Allergic reactions
Drugs
Inflammatory diseases
Toxins
Mechanisms
Invasion of the myocardium
Myocardial toxin
Immune-mediated
Aspirin
Routes of Infection
Hematogenous
Contiguous spread
Endocarditis
Post-operative
Avoid NSAIDs and corticosteroids
Avoid NSAIDs and corticosteroids if
< 4 weeks since MI
ESR
Mechanisms
Extension / attachment
Nodular tumor deposits
Diffuse pericardial infiltration
Local infiltration
Clinical Medicine
Condition / Disease
Cause
Test
Laboratory
Result
Hypotension
Beck's Triad
Systemic venous
pressures
Small quiet heart
Cardiac
Tamponade
Fluid accumulates in
the pericardium
JVP
Tachypnea
Friction rub
Tachycardia
EKG
CXR
Early echo if
Treatment
Medications
Other
Acute pericarditis
or effusion signs
Electrical
alternanas
No changes
Pericardial
effusion
Volume resuscitation
Diastolic collapse
Pericardiocentesis
of the RV and RA
Pulsus paradoxus
RA pressures
Cath
Diminished heart sounds
RV and LV
diastolic pressures Pericardial window
Pulsus paradoxus
Pulsus paradoxus
Constrictive
Pericarditis
Thick, fibrotic
pericardium restricts
diastolic filling
Aneurysm
Pseudoaneurysm
Abdominal Aortic
Aneurysm
Localized dilation of
the abdominal aorta
exceeding the normal
diamater by more
than 50%
Describers
Stroke volume
Cardiac output
Systemic congestion
Non-palpable impulse
Pulsus paradoxus
Location
Size
Morphological
appearance
Origin
EKG
Low voltage
CXR
Calcification
Effusion
Echo
Cath
Etiologies
Idiopathic
TB
Connective tissues diseases
Post-operatively
Uremia
Post-purulent pericarditis
Pericardial stripping
Hepatic vein
plethora
Assess
Risk Factors
Asymptomatic
Mild pain
Severe pain
(when ruptured)
Hypotension
(when ruptured)
Tobacco abuse
Age
HTN
Hyperlipidemia
Atherosclerosis
Family history
5 cm or 6 cm
> 1 cm growth / year
Family history
Uncontrolled HTN
Smoking
5.5 cm
95% Sensitivity
4.5 - 5.0 cm
Abdominal
Ultrasound
100% Specificity
Endovascular
Repair Criteria
Patient preference
Cost
Risk patients
with appropriate
anatomy
Pre-op study
CT Scan
Tobacco cessation
Indeterminate
ultrasound
Aortography
Rapid expansion
Saccular Aneurysm
Outpocket from a vessel
Fusiform Aneurysm
Expansion of a section of a blood
vessel
Ruptured Aneurysm
Erupted aneurysm (usually saccular
aneurysm)
Infrarenal AAAs = 90% of AAAs
Suprarenal AAAs = 10% of AAAs
80% of contained rupture goes into
the left retroperitoneum
Free rupture into the peritoneal
cavity is a lethal event.
Underestimates
diameter
Risk Factor
Modification
Aggressive HTN
therapy
Lipid medications
Open repair
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Clinical Medicine
Condition / Disease
Cause
Thoracic Aortic
Aneurysm
Ballooning of the
upper aspect of the
aorta
Ascending
Thoracic
Aneurysm
Aneurysm in the
ascending aorta
Localized dilation of
the aortic arch or
descending aorta
Aortic Dissection
Spontaneous intimal
tear in the aorta
creates a false lumen
between the tunica
media and adventitia
Thromboembolism
Renal infarct
SVC syndrome
Tracheal deviation
Cough
Hemoptysis
Dysphagia
Etiologies
Etiologies
Test
Hoarseness
CXR
Laboratory
Result
Widened
mediastinum
Enlarged aortic
knob
Tracheal
displacement
Differentiate from
anterior
mediastinal mass
Echo
CT / MRI
Severe hypotension
(when ruptured)
Coronary
Angiography
Assess
Most sensitive
diagnostic test
If surgery is
required
Treatment
Surgery (TEVAR)
Criteria
Medications
5.5 cm
ascending aorta
5.0 cm bicuspid
valve or Marfan's
Syndrome
4.5 cm aortic
valve replacement
6.0 cm
descending aorta
Other
Extent I
Distal left subclavian artery
above renal arteries
Extent II
Distal left subclavian artery
aortic bifurcation
Extent III
6th intercostal space aortic
bifurication
Extent IV
Diaphgram aortic bifurcation
Extent V
6th intercostal space above renal
arteries
Extension of ascending
or descending
aneurysms
Hx of trauma or
deceleration injury
Atherosclerosis
Hypertension
Vasculitis
Congenital cardiac
disease
Hereditary connective
tissue disease
Trauma
(+) Cocaine
Tachycardia
Tachypenia
Neurological deficits
Shock
Hypotension (later)
JVD
Pulsus paradoxus
CHF
CXR
TEE
EKG
CT
MRA / MRI
Widened
Type A
mediastinum
Rupture
Widened aortic
Limb or visceral
silhouette
ischemia
Left-sided pleural
Saccular
effusion
morphology
Surgical Repair
Pericardial
Ongoing pain
(TEVAR) Criteria
effusion
Uncontrolled
hypertension
98% sensitive
Marfan's
99% specific
syndrome
LVH
Non-specific or
Aortic
inferior
insufficiency
abnormalities
Type B
Medical Therapy
Helpful when
Chronic
Criteria
acute
Asymptomatic
Aggressive BP control
Follow up
Debakey Classification
I - Ascending and descending
aorta
II - Ascending aorta only
III - Descending aorta only
Stanford Classifcation
A - Any involvement of ascending
aorta
B - No involving ascending aorta
Clinical Medicine
Condition / Disease
Cause
Peripheral
Arterial Disease
Systemic
atherosclerosis distal
to the aortic arch
Acute Arterial
Occlusion
Giant Cell
Arteritis
Inflammatory disease of
blood vessels typically
involving the medium and
large vessels in the head
Raynaud's
Phenomenon
Chronic Venous
Insufficiency
Varicose Veins
Superficial
Thrombophlebitis
Localized thrombosis
due to sluggish blood
flow
Laboratory
Treatment
Medications
Result
Smoking
PAD
Smoking cessation
Risk Factor
Diabetes
(< 0.9)
Intermittent
Modification
HTN
Exercise
Risk Factors
claudication
Hyperlipidemia
Ankle /
Sedentary lifestyle
(< 0.7)
Antiplatelet therapy
Brachial Index
Obesity
Rest pain
Ischemic rest pain
(< 0.4)
Intermittent claudication
(frequently nocturnal)
Impending tissue
(muscular pain in the
necrosis
Ischemic ulcers
Percutaneous revascularization
lower extremities)
Tissue necrosis
(< 0.1)
Diminished peripheral
Femoral bruits
Reduced blood
pulses
Cool skin
Angiography
flow through
Surgery
Abdnormal skin color
Poor hair growth
peripheral arteries
Sexual dysfunction
Revascularization
Pain
Pulselessness
Pallor
Paresthesia
Intra-arterial thrombolytic therapy
IV Heparin
Paralysis
Poikilothermia
Surgical thromboembolectomy
A-fib
Valvular disease
Ischemic disease
Surgical bypass
ESR
Headache
Scalp tenderness
Prevention of blindness
CRP
Prednisone
Blood Work
IL-6
Visual symptoms
Jaw claudication
Mild anemia
Thrombocytosis
Anti-inflammatory therapy
Blindness (opthalmic
Throat pain
Aspirin
Temporal
Diagnostic
artery occlusion)
Artery Biopsy
Lifestyle changes (gloves or warmer
Calcium Channel
Digital ischemia
Pallor
climate)
Blockers
Sympathectomy
Nitrates
Cyanosis Rubor
Subsequent vasodilation
Treat underlying condition
Leg elevation
History of DVT
Hx of leg trauma
Compression stockings
Medical therapy
Brawney skin
Edema
Exercise
pigmentation
NSAIDs
Leg massage
Venostasis ulcerations Puritic, dull discomfort
Weight loss
Vein Stripping
Varicose veins
Heavy, achy, tired legs
Endovenous laser ablation
Spider veins
Compression stockings
Asymptomatic
Dull, aching leg
Leg elevation
Endovenous ablation
Mild skin browning
Mild edema
Sclerotherapy
Visible dilated, tortous veins
Great saphenous vein stripping
Signs and Symptoms
Inflammation
Induration
Linear erythema
Tenderness
Fever
(septic phlebitis)
Chills
(septic phlebitis)
Test
NSAIDs
Other
Pain Location Related to Vessel
Buttock / Hip - Aortoiliac disease
Thigh - Common femoral artery
Upper Calf - Superficial femoral
artery
Lower Calf - Popliteal artery
Foot - Tibial / peroneal artery
Etiologies
Genetics
Standing
Pregnancy
DVT
Trauma
Obesity
Sedentary lifestyle
Thrombophlebitis rare occurs due to
varicose veins
Aspirin
Antibiotics
Clinical Medicine
Condition / Disease
Deep Venous
Thrombosis
Cause
Thromboembolus
involving deep veins
of lower extremities
or pelvis
Edema
Painful ambulation
Fever
Tachycardia
Homan's sign
Age
Cancer
Prior VTE
Laboratory
Result
NEGATIVE
D-Dimer
(helpful)
LE Doppler /
Diagnostic
Ultrasound
Treatment
Test
VQ Scan or
Spiral CT
Thrombolytic therapy
If pulmonary
emboli suspected
DVT evidence
(3 points)
PE diagnosis
(3 points)
HR > 100 bpm
(1.5 points)
Medications
Heparin
Embolectomy
Immobilization /
Wells Criteria Surgery < 4 weeks
(1.5 points)
for PE
Obesity
Heart Failure
Paralysis
Hypercoaguable state
Warfarin
Previous DVT / PE
(1.5 points)
Cancer
(1 point)
Hemoptysis
(1 point)
Other
80% deep veins of calf
20% femoral or iliac vein
Etiologies
Virchow's Triad
Preciptators
Hypercoarguable syndromes
Complications
Pulmonary embolism
Varicose veins
Chronic venous insufficiency
Ischemic limb
> 6 Wells score = highly likely
< 2 Wells score = highly unlikely
DVT Prevention with Surgery
Risk - < 40 yo + no additional
risk factors
Med. risk - < 40 yo + risk factor
40 - 60 yo
Risk - > 60 yo
40 - 60 yo + risk factors
Risk - > 40 yo + risk factors
Hip / knee arthroplasty
Major spinal trauma
Pharmacology
Drug
Generic Examples /
Brand Name
procanamide
Class IA
quinidine
Mechanism of Action
Indications
Pharmacokinetics
E: Hepatic or renal
Modulation of Na channels
to inhibit phase 0
Atrial tachyarrhythmias
depolarization
disopyramide
K+ channel blocker
lidocaine
Modulation of Na+
channels to inhibit
phase 0 depolarization
Contraindications
Adverse Effects
Heart failure
Blood dyscrasias
GI effects
Heart failure
Hypoglycemia
QT interval
Least used antiarrhythmic
drugs
CNS effects
Seizures
Aggravation of underlying conduction
disturbance
GI effects
Psychosis
Blurred vision
Dizziness
GI effects
Aggravation of heart failure
Aggravation of underlying conduction
disturbances
Fatigue
Bradycardia
Exercise intolerance
Erectile dysfunction
Pulmonary disorder exacerbation
Ventricular
tachyarrhythmias
E: Hepatic
Class IB
mexiletime
flecainide
Class IC
propafenone
Class II
Class III
Class IV
Procainamide
Quinidine
Disopyramide
Ventricular arrhythmias
E: Hepatic or renal
Ventricular
tachyarrhythmias
K+ channel blocker
Phase IV inhibitor
Atrial tachyarrhythmias
Ventricular
tachyarrhythmias
Sympathetic nervous
system inhibitor
Rate control
Polymorphic sustained
VT
E: Variable
Beta Blockers
dofetilide
ibutilide
sotalol
amiodarone
dronedarone
Calcium Channel
Blockers
Procan
Quinidex
Norpace
E: Hepatic or renal
Ventricular
tachyarrhythmias
E: Hepatic
Rate control
A-fib / A-flutter
Monomorphic or
polymorphic sustained
VT
Atrial arrhythmias
M: Hepatic
Hemodynamically stable
E: Renal
VT
WPW
M: Hepatic
E: Renal
K+ channel blocker
Lidocaine
Xylocaine
Sustained ventricular
tachycardia
Pulseless VT / V-fib
A: IV
t: Up to 12 hours in
cirrhosis and CHF
Monitoring / Other
QT interval
Bradycardia
Complex, multi-organ effects
Nonsustained polymorphic VT
GI effects
AV block
Bradycardia
Heart failure exacerbation
Hypotension
Drug-induced lupus
Agranulocytosis
Torsades
Ventricular arrhythmias
Aggravation of heart failure
GI effects
Cinchonism
Hypotension
Torsades
Ventricular arrhythmias
Hemolytic anemia
Digoxin concentration
(when prescribed together)
GI effects
Anticholinergic symptoms
Heart failure
Aggravation of underlying conduction
abnormalities
Ventricular arrhythmias
Tosades
Confusion
Tremors
Paresthesias
Seizures
No adequate studies in
management of a-fib or aflutter
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
Indications
Pharmacokinetics
Mexiletine
Mexitil
Modulation of Na
channels to inhibit
phase 0
depolarization
Flecainide
Tambocor
Rythmol
Modulation of Na+
channels to inhibit
phase 0 depolarization
Propafenone
Dofetilide
Sotalol
Tikosyn
Betapace
K channel blocker
that prolongs the AP
palteau,
repolarization, and
refactory period
Ventricular arrhythmias
Maintenance of sinus
rhythm in patients with
a-fib / a-flutter
Pharmacologic
cardioversion of a-fib
Maintenance of sinus
rhythm
Maintenance of sinus
E: Hepatic
rhythm in patients with Potent (-) inotropic agent
a-fib / a-flutter
Maintenance of sinus
rhythm
Pharmacologic
cardioversion of a-fib
Pharmacologic
cardioversion of
symptomatic
a-fib / a-flutter
Maintenance of sinus
rhythm in patients with
a-fib / a-flutter
E: Renal
Maintenance of sinus
rhythm
Chemical cardioversion
Monomorphic or
polymorphic
sustained VT
A-fib
Adrenergic inhibitor
Monomorphic or
polymorphic sustained
VT
Maintenance of sinus
rhythm
V-fib
Pulseless VT
Cordarone
Pacerone
Prolongs AP and
refractory period
D: tissue
accumulation
t: than amiodarone
Ibutilide
Systolic dysfunction
Maltaq
Derivative of
amiodarone
Corvet
Adverse Effects
Proarrhythmias
Dofetilide concentrations
QT prolongation
(with phenothiazines or
erythromycin)
Monitoring / Other
CNS effects
Psychosis
GI effects
Aggravation of underlying conduction
abnormalities or ventricular
arrhythmias
Blood dyscrasias (rare)
EKG changes
Ventricular arrhythmias
GI effects
Blurred vision
GI effects
Aggravation of CHF
Ventricular arrhythmias
Cimetidine
Ketoconazole
Verapamil
Trimethoprim
Prochlorperazine
Megestrol
CrCl < 20 mL/min
AV node conduction
and sinus node function
Amiodarone
Dronedarone
Contraindications
A: oral bioavailability
M: Hepatic
t: 8 - 15 hours
QT prolongation
Pulmonary fibrosis (3 - 10%)
Hypothyroidism (20%)
Hyperthyroidism (5 - 10%)
Optic neuritis (1%)
Photophobia (75 - 90%)
Hepatic transaminases (5 - 20%)
Digoxin concentrations
INR (with warfarin)
Phenytoin toxicity
Proarrhythmic effects
(with sotalol)
GI disorders
Severe liver injury
Pulmonary toxicity
QT prolongation
(with erythromycin)
Bradycardia (with blockers)
Dematological disorders
10% serum creatinine
Digoxin concentrations
EKG
QT interval
Renal function
Electrolytes
Concomitant medications
3-day hospitalization to initiate
Baseline QTc < 440 msec
EKG
QTc
Electrolytes
Renal function
EKG
QT interval
Liver function
Pulmonary function
Thyroid function
Ophthalmic exam
Concomitant medications
EKG
QT interval
Electrolytes
Concomitant medications
Liver / renal function
Contains a lot less iodine than
amiodarone
A: IV
Maintenance of sinus
rhythm in patients with
a-fib / a-flutter
Pharmacologic
conversion of a-fib
Antiarrhythmics
Type
1A
1B
1C
Generic Name
disopyramide
lidocaine
flecainide
propafenone
amiodarone
dronedarone
sotalol
dofetilide
ibutilide
digoxin
adenosine
Brand Name
Norpace
Xylocaine
Tambocor
Rythmol
Cordarone
Pacerone
Maltaq
Betapace
Tikosyn
Corvet
Lanoxin
Adenocard