Dmitriy Petrov PGY2 Morning Report - PowerPoint Presentation

Slide1

Dmitriy PetrovPGY2

Morning Report

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Case Presentation

68 y/o male with HTN, IDDM2, CAD s/p CABG, CKD stage III, 50 pack year smoking history, and AAA who presented to ED with 1 hour history of sudden onset severe upper abdominal pain with radiation to the back, pain is sharp and constant

Associated SOB, nausea, diaphoresis

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Physical Exam

Vital signs: Temp 98, BP 194/76 RUE, 176/82 LUE, HR 115, RR 24, SpO2 91% on RA

HEENT: NCAT, PERRL, neck supple, no JVD

Respiratory: CTAB, no wheeze, rales, rhonchi

Cardiovascular: RRR, normal S1, S2, no murmurs, radial pulses 2+ on right and 1+ on left

Abdominal: BS present. Soft, NT/ND. Central pulsatile mass palpated

Neuro: No focal neurological deficits

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Labs

17

14.3

205

130

96

31

3.1

21

1.72

305

Blood cx: Pending

UA: Protein 2+

AST: 25

ALT: 21

ALP: 65

Total

bili

: 1.1

Lipase: 16

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Differential Diagnosis

Aortic dissection

ACS

PE

Spontaneous Pneumothorax

Esophageal rupture

Mesenteric ischemia

Bowel obstruction or perforation

Biliary colic

Pancreatitis

PUD

Penetrating atherosclerotic ulcer of the aorta

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CXR

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CTA Chest

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Aortic Dissection

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Presentation Outline

Anatomy and pathophysiology

Common etiologies

Diagnosis

Treatment

Complications

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Introduction

Incidence 2.6 to 3.6 per 100,000Men to women ratio 3:1Average age 63Mortality 25-30%

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Anatomy of Aortic Dissection

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Pathophysiology

Tear in the aortic intima – primary eventDegeneration of aortic media or cystic medial necrosisAnterograde vs retrograde propagationCreation of false lumen

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Risk Factors

Hypertension – most important factor

In IRAD – 72% had

hx

of HTN

Crack cocaine use

Smoking and atherosclerosis

Collagen disorders (

Marfan

, Ehlers-

Danlos

)

Marfan

syndrome in 50% of those under age 40 vs 2% in older patients

Preexisting aortic aneurysm

Bicuspid aortic valve (Turner syndrome)

Aortic

coarctation

Vasculitis

Trauma

Pregnancy

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Signs and symptoms

Acute pain – present in 90% of patients

Pulse deficit and variation in systolic blood pressure

Heart murmur

Focal neurological deficits

Hypotension/syncope

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Evidence Based Medicine

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Evidence Based Medicine Continued

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Diagnosis

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Diagnosis

High pre-test probability (≥2 high risk features)

Surgical consultation and expedited imaging

TEE if unstable, CTA or MR if stable

Intermediate pre-test probability (1 high risk feature)

ECG – rule out STEMI

CXR – alternative etiology

Cardiovascular imaging if no alternative

Low pre-test probability (no high risk features)

Unexplained hypotension of mediastinal widening?

Cardiovascular imaging

D-dimer – not routinely recommended

Level below 500 ng/mL is highly predictive for excluding dissection

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Cardiovascular Imaging

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CTA Chest

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Serial Imaging

AAA serial imaging based on size

Maximum diameter 3.5cm to 4.4cm: annually

Maximum diameter 4.5cm to 5.4cm: every 6-12 months

Elective repair

>0.5cm increase in 6 months

≥5.5cm in diameter (>5cm in women)

symptomatic

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Question 1

45 y/o male presented to ED with severe substernal CP with radiation to the back 3 hours in duration, it is 10/10 in severity. He used crack cocaine 11 hours ago. He is diaphoretic. VS: BP 176/94 (RUE) 160/88 (LUE), HR 115, RR 26. Radial pulses 2+ on right and 1+ on left. Physical exam: Bibasilar crackles, sinus tachycardia, no murmurs. CXR showed pulmonary edema. EKG showed ST depressions in leads V1-V4. Troponin: 6.1, D-dimer 700.

What is the next best step in management?

Transthoracic echocardiogram

Intravenous heparin and ASA 324mg

Transesophageal echocardiogram

IV labetalol and IV morphine

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Treatment

Hemodynamically unstable

Fluid bolus (MAP ≥ 70 or

euvolemia

)

Pressors

– vasopressor (norepinephrine or phenylephrine)

Evaluate for tamponade, contained rupture, severe AR

Surgical consultation

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Treatment

Hemodynamically stable

Rate/pressure control

IV beta blockade target HR <60 (caution in acute AR)

What if BB contraindicated?

Blood pressure target <120/80

Indications for surgery:

Type A dissection

Complicated type B dissection

Persistent/recurrent pain

Uncontrolled HTN

Early expansion

Malperfusion

syndrome

Rate/pressure control and surveillance on discharge

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Evidence Based

Christoph A.

Nienaber et al. Circulation. 2009;120:2519-2528

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MKSAP Question 1

A 62-year-old woman is evaluated in the emergency department for sudden onset of severe chest, upper abdominal, and back pain of 2 hours' duration. She has not had similar symptoms previously and notes no other symptoms. Medical history is significant for hypertension. She is a current smoker with a 55-pack-year history. Her medications are amlodipine and benazepril

.

On physical examination, she is afebrile, blood pressure is 165/100 mm Hg in both arms, pulse rate is 102/min, and respiration rate is 20/min. Oxygen saturation is 98% on ambient air. Cardiac auscultation reveals an S

4

gallop but no murmurs. Pulmonary examination is normal. Pulses are symmetric and equal in all extremities. The remainder of the physical examination is unremarkable

.

Laboratory studies reveal a D-dimer level of 0.8

μg

/mL (0.8 mg/L) and a serum creatinine level of 2.4 mg/

dL

(212

μmol

/L) (baseline is <1 mg/

dL

[88.4

μmol

/L]). Initial cardiac troponin T level is 0.4 ng/mL (0.4

μg

/L).

Electrocardiogram shows left ventricular hypertrophy with repolarization abnormalities. Chest radiograph demonstrates an enlarged cardiac silhouette. A magnetic resonance angiography study demonstrates aortic dissection originating distal to the left subclavian artery extending to the

aortoiliac

bifurcation (maximum diameter 63 mm). Bilateral renal arteries arise from the false lumen

.

Treatment with analgesics, a β-blocker, and sodium nitroprusside is started

.

Which of the following is the most appropriate next step in management?

Aortic repair

Coronary angiography

Continue current medical therapy

Intravenous heparin

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MKSAP Question 2

Laboratory studies:Total cholesterol186 mg/dL (4.82 mmol/L)LDL cholesterol123 mg/dL (3.19 mmol/L)HDL cholesterol44 mg/dL (1.14 mmol/L)Triglycerides109 mg/dL (1.23 mmol/L)

A 58-year-old man is evaluated during a routine appointment. He is asymptomatic. He was diagnosed with type 2 diabetes mellitus 4 years ago and has hypertension, dyslipidemia, and obesity. His medications are enteric-coated low-dose aspirin, lisinopril, fluvastatin (20 mg/d), and metformin. His calculated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) using the Pooled Cohort Equations is 10%. On physical examination, blood pressure is 126/78 mm Hg and pulse rate is 72/min. The remainder of the examination is normal.

Which of the following is the most appropriate statin management?

Increase

fluvastatin

to 40 mg/d

Switch to atorvastatin, 40 mg/d

Switch to lovastatin, 20 mg/d

Switch to pravastatin, 20 mg/d

Switch to simvastatin, 10 mg/d

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MKSAP Question 3

A 31-year-old woman is evaluated during a follow-up examination.

Marfan

syndrome was diagnosed 6 months ago and was confirmed by significant family history and the presence of

ectopia

lentis

. She has been in good health and physically active. She does not report any chest discomfort, shortness of breath, syncope, or

presyncope

.

On

physical examination, the patient is tall and slender. Blood pressure is 100/62 mm Hg and equal in both arms. Significant findings include a high arched palate, pectus excavatum, and arachnodactyly. The jugular and carotid examinations are normal. There is a grade 1/6 blowing diastolic murmur best heard at the left sternal border. The remainder of the examination is unremarkable.

Except

for pectus excavatum, a chest radiograph is unremarkable. Transthoracic echocardiography shows enlargement of the aortic root, measuring 3.9 cm with mild aortic regurgitation, unchanged from previous imaging studies. The remainder of the echocardiographic examination is unremarkable.

How

frequently should this patient undergo surveillance imaging

?

Every 6 months

Every 12 months

Every 24 months

Every 3 to 5 years

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Summary

High index of suspicion

Do not delay imaging studies

Medical management of type B dissection

Keep in mind complications

Appropriate surveillance

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References

Randomized comparison of strategies for type B aortic dissection: the

INvestigation

of

STEnt

Grafts in Aortic Dissection (INSTEAD)

trial

UptoDate

MKSAP 17

Thanks to Jennifer Hines