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Cardiology Part 2 (aorta) (Peripheral Arterial Disease Chapter 11…

- - - - diastolic dysfunction
        
        Diastolic dysfunction arises from abnormal relaxation and poor myocardial compliance, leading to an increase in left ventricular filling pressures.
      - dynamic LVOT obstruction
        
        Dynamic LVOT obstruction, present in approximately two thirds of patients, results from septal hypertrophy and anterior displacement of the mitral valve apparatus;
      - mitral regurgitation
        
        this displacement also is associated with decreased coaptation of the valve leaflets and resultant mitral regurgitation
    - - increased contractility
        
        reduced preload
        
        reduced afterload
    - - carotid upstroke
        
        bifid bisferens (twice beating)
      - jugular venous pulse
        
        heightened a wave (infindibular hypertrophy)
    - - it increased with decreased preload/afterload
    - - LVOT obstruction is considered significant when the calculated pressure gradient is either 30 mm Hg or greater at rest, or 50 mm Hg or greater with provocation, assymetrical thickness
    - - Negative inotropes (β-blockers, nondihydropyridine calcium channel blockers [verapamil], and disopyramide) depress contractility, ICD placement in high risk feautures, alcohol ablation, surgical myomectomy
    - - first degree relatives should be screening (12-18 months) or onset at symptoms
- - - - cystic medial degeneration that leads to loss of smooth muscle cells and elastic fiber degeneration, resulting in a weakening of the aortic wall (aging, HTN.
      - risk factors
        
        aging, HTN
    - - 5.0 cm and rapid expansion
    - - BB, losartan (especially in Marfan's)
    - - annually with Echo
      - with marfan's
        
        follow-up imaging is recommended 6 months after diagnosis with annual surveillance thereafter if the aortic root is less than 4.5 cm in diameter and otherwise stable
    - - , elective thoracic aortic repair is recommended if the aortic root or ascending aorta is greater than 5.5 cm (5.5–6.0 cm for the descending aorta) or has rapid growth (>0.5 cm/year). For genetically mediated disorders (such as Marfan syndrome), a lower threshold of 5.0 cm (4.0–5.0 cm in certain patients) may be used for repair. For patients with a bicuspid aortic valve, repair is indicated if the aortic diameter is greater than 5.5 cm and is reasonable if the diameter is greater than 5.0 cm and the patient has an increased risk of dissection (family history of dissection or rapid growth).
  - - - blood passes through a tear in the aortic intima, creating a false lumen that separates layers of the aorta. Propagation of the dissection can proceed in an anterograde or retrograde fashion from the initial tear, involving side branches and causing complications such as tamponade, aortic valve insufficiency, or malperfusion syndromes
    - - An intramural hematoma may result from rupture of the vasa vasorum or “microtears” in the intima, resulting in a crescent of hematoma within the media without identifiable interruption of the intima
    - - type A dissections as originating within the ascending aorta or arch, whereas type B dissections originate distal to the left subclavian artery.
    - - medical management
        
        Intravenous β-blockers (esmolol) should be used to target a heart rate of below 60/min and BP 120 mmg. In patients requiring additional blood pressure control, a rapidly titratable antihypertensive medication, such as sodium nitroprusside, labetalol, enalaprilat, hydralazine, or nicardipine, should be given intravenously, with a goal of decreasing the mean arterial pressure to the lowest level that still allows visceral and cerebral perfusion.
      - surgical management
        
        type A dissection or hematoma, or failed medical therapy
  - - - when the minimum anteroposterior diameter of the aorta reaches 3.0 cm
    - - recommend a one-time ultrasonographic screening in men aged 65 to 75 years who are active or former smoke
    - - annually
        
        3.5-4.4 cm
      - every 6 months
        
        4.5 - 5.4
    - - 5.5 cm in diameter, increased more than 0.5 cm within 6 month interval, or for people who have symptoms. In women, 5.0 cm
- - - - calcification of the artery, result interpretable, need to do
        toe-brachial index . If less than 0.70 then diagnostic of PAD
    - - CT/MRA (galodium with Cr - nephrogenic sclerosis), MRA implanted pacemakers and cardioverter-defibrillators
      - endovascular procedures
        
        Inflow (aortoiliac artery) and outflow (infrapopliteal artery) should always be assessed before revascularization. Inflow lesions should be revascularized first followed by outflow lesions if bothersome symptoms persist.
      - main complication of thrombolysis from acute limb ischemia
        
        compartment syndrome. Symptoms and signs include severe pain, hypoesthesia, and weakness of the affected limb; myoglobinuria and increased serum creatine kinase levels often occur
  - - - phosphodiesterase inhibitor (cilastozol) - increasing walk distance