ABSTRACT
RISK FACTORS › Atherosclerotic / Degenerative (media degeneration): HTN; smoking; COPD; family history › Congenital: Bicuspid aortic valve; Tetralogy of Fallot; CoA; VSD; Transposition of great arteries › Genetic: Marfan; Ehlers-Danlos type IV; Turner; Loeys-Dietz; Noonan; Familial thoracic aortic aneurysm syndrome › Inflammatory: Takayasu; Giant cell arteritis; Behçet; Ankylosing spondylitis; Spondyloarthropathies; SLE; Sarcoidosis › Infectious: Syphilis; Salmonella; Staphylococcus; HIV
PRESENTATION: Asymptomatic; Aortic dissection; Aortic rupture; AR; Infectious aortitis; Compressive symptoms (recurrent laryngeal nerve; trachea; esophagus; SVC syndrome); Pain (neck; jaw; back; interscapular); Embolism (thrombus or cholesterol crystals); Fistula (aortoesophageal; aortobronchial) ECHOCARDIOGRAPHY: diameter at end-diastole using the leading-edge of the anterior wall to the leading of the posterior wall CT SCAN AND MRI: measurement of outer diameter CXR: large mediastinum; prominent aortic knob; trachea deviated to the right
A SC
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INDICATIONS FOR SURGERY - ASCENDING AORTIC ANEURYSM
Degenerative ascending aortic aneurysm ≥ 55 mm
Progressing aneurysm > 5 mm / year
Symptomatic aneurysm Compressive symptoms; Pain
Ao valve or CABG surgery > 45 mm
Bicuspid aortic valve > 55 mm (or > 50 mm with family history of dissection or progression ≥ 5 mm / year) Marfan 40-50 mm (g Genetic aortic syndromes)
Marfan or Genetic Syndrome or Bicuspid aortic valve
Maximum Ao area (cm²) / Patient’s height (m) > 10
Lœys-Dietz ≥ 42 mm (TEE) or ≥ 44 mm (CT or MRI)
Turner > 25 mm/m²
SURVEILLANCE - ASCENDING AORTIC ANEURYSM
Aneurysm 35 - 44 mm
• Ensure stability with follow-up assessment 6 months after diagnosis • Stable A Imaging every 1-3 years (progression ≈ 1 - 2 mm / year)
Aneurysm 45 - 54 mm Imaging after 3-6 months (stability) then every 6-12 months
Pregnancy Imaging every 6-8 weeks (until 3 months postpartum)
Total arch replacement
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SURGICAL OPTIONS: Resection of the proximal hemi-arch; Total arch replacement; Stent with reimplantation of innominate arteries... › Elephant trunk procedure: aneurysm of the aortic arch and descending aorta; allows subsequent stenting of the descending aorta
MANAGEMENT - ANEURYSM OF THE AORTIC ARCH
Isolated aneurysm of the aortic arch > 55 mm or compressive symptoms
Surgery (if acceptable surgical risk)
Aneurysm of the aortic arch < 40 mm Imaging every 1-2 years
Aneurysm of the aortic arch > 40 mm Imaging every 6-12 months
MANAGEMENT - ANEURYSM OF THE DESCENDING THORACIC AORTA
Degenerative or traumatic aneurysm > 55 mm TEVAR (when technically feasible)
Chronic dissection + [refractory symptoms or aneurysm > 55 mm or progression of diameter > 4 mm/year]
TEVAR (open surgery when TEVAR is contraindicated)
THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR): stent deployment requires a normal aortic segment > 20 mm above and below the aneurysm (with diameter < 40 mm) and adequate vascular access › Contraindications: Severe Ao atherosclerosis (risk of atheroembolism); severe PAD (limiting femoral access) › Regular long-term surveillance following TEVAR: CTscan or MRI after 1, 6 and 12 months and then yearly (or every 2 years if stable course) › Complications: Stroke; Atheroembolism; Spinal cord ischemia; Paraplegia; MI; Ventricular arrhythmia; ARF; Transformation from type B to type A dissection; Stent fracture; Stent migration; Infection; Occlusion of arterial branches (subclavian; mesenteric; celiac trunk; renal) • Endoleak: persistence of blood flow outside of the stent lumen towards the aneurysm sac
TYPE I ENDOLEAK Reperfusion and filling of the aneurysm sac via a leak in the proximal or distal portion of the stent (requires treatment)
TYPE II ENDOLEAK Retrograde flow in the aneurysm sac via a branch artery (intercostal; lumbar; mesenteric) (observation)
TYPE III ENDOLEAK Separation of stent components (fracture; separation) (requires treatment)
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Tear of the media with bleeding inside the media and along the arterial wall
STANFORD CLASSIFICATION
Type A Involves the ascending Ao
Type B No involvement of the ascending Ao
DEBAKEY CLASSIFICATION
Type I Ascending Ao A extends at least to the aortic arch (± descending Ao)
Type II Confined to the ascending Ao
Type III Confined to the descending Ao
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G AORTIC STRESS DEGENERATION OF THE MEDIA
• Aortic aneurysm • Aortic valve disease • HTN • CoA • Recent aortic intervention • Trauma / Deceleration • Pheochromocytoma • Cocaine • Weightlifting • Penetrating ulcer • Infectious aortitis
• Degenerative / Atherosclerotic • Genetic: Marfan; Ehlers-Danlos type IV; Bicuspid aortic valve; Turner; Loeys-Dietz; Familial thoracic aortic aneurysm and dissection • Vasculitis: Takayasu; Giant cell arteritis; Behçet • Other: Pregnancy; Polycystic kidneys; Chronic corticosteroid therapy
PRESENTATION: Acute - severe - tearing pain; Retrosternal pain (type A) or back pain (type B) › Target organ ischemia: Myocardial infarction; Stroke - TIA; Spinal cord ischemia (paraplegia / paraparesis) or mesenteric or renal or lower limbs; Ischemic neuropathy › Hemorrhagic: Tamponade; Hemothorax; Hemomediastinum; Aortopulmonary or aorto-enteric or aorto-esophageal fistula › Aortic regurgitation: Mechanisms: A) Aortic root dilatation (malcoaptation); B) Dissection involving a leaflet implantation site (leaflet prolapse); C) Transvalvular prolapse of the dissection flap; D) Underlying AR (bicuspid aortic valve)
CLINICAL FEATURES: Hypotension or Normotension or Hypertension (measure BP in both arms); Absent pulses (evaluate pulses in all extremities); AR murmur; Signs of tamponade; Neurological deficits; Abdominal signs
TEE: Dissection flap separating the true lumen and the false lumen (with independent movement); two flows on either side of the dissection flap on color Doppler; thrombus in the false lumen; look for the entry site and/or exit site of the dissection; pericardial effusion; myocardial ischemia (RWMA); AR; coronary ostia
TRUE LUMEN FALSE LUMEN
Size True < False False > True
Pulsation Systolic expansion Systolic compression
Direction of flow Anterograde (systolic) Retrograde or H Anterograde systolic flow
Thrombus Rare Common
Contrast agent Rapid opacification Delayed opacification
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CXR a) Aortic shadow abnormal and enlarged b) Large mediastinum: AP CXR A > 8 cm at the carina c) Calcium sign: separation between calcification of the aortic intima and the lateral wall of the aortic knob > 10 mm d) Pleural effusion (inflammatory reaction or hemothorax) e) Deviation of the trachea towards the right (or deviation of the esophagus - NGT) f) Pulmonary edema (AR)
PREOPERATIVE CORONARY ANGIOGRAPHY: it is reasonable not to perform coronary angiography in acute aortic syndrome, which constitutes a surgical emergency (class IIa recommendation)
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POSTOPERATIVE COMPLICATIONS: Aneurysm formation (at the site of dissection or at the site of anastomosis or elsewhere); Recurrent dissection; Graft dehiscence; Pseudoaneurysm; AR; Infection; Progression of false lumen
FOLLOW-UP BY CT ANGIOGRAPHY OR MR ANGIOGRAPHY: 1-3-6-12-18-24 months; then annually › Tybe B aortic dissection: TEVAR or surgical repair if aneurysm > 55-60 mm or > 4 mm/year growth or target organ ischemia or recurrent pain
Medial tear with bleeding inside the media, but absence of communication with the aortic lumen (absence of false lumen) › Can propagate in an anterograde or retrograde fashion › May have an identical clinical presentation to that of aortic dissection
MANAGEMENT: Similar to aortic dissection (for corresponding segment) a) Ascending Ao A urgent surgery b) Descending Ao A initial medical treatment; Indication for TEVAR (or surgery) according to aortic diameter or persistent symptoms or progression or compromise of branches (with ischemia)
Penetration of the aortic wall by an atherosclerotic ulcer (± secondary intramural hematoma); descending aorta in the majority of cases
MANAGEMENT a) Ascending Ao A Surgery should be considered b) Descending Ao A Initial medical treatment; Indication for TEVAR (or surgery) according to aortic diameter or persistent symptoms or progression or deteriorating associated intramural hematoma
8.3/ ABDOMINAL AORTIC ANEURYSM (AAA) ANEURYSM: Abdominal Ao diameter > 30 mm › Predominantly occurs in the infrarenal aorta › Degeneration of the media (G metalloproteinases) › Risk factors: Smoking; Family history; Age; Male gender; COPD; dyslipidemia; HTN
ABDOMINAL ULTRASOUND: High sensitivity and specificity › Screening: Male, 65 to 74 years with history of smoking; Male ≥ 60 years with family history of AAA
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MANAGEMENT - ABDOMINAL AORTIC ANEURYSM
Indication for aneurysm repair (EVAR or open surgery)
• ≥ 55 mm or • Symptoms (pain) or • Progression > 10 mm per year (> 5 mm over 6 months) or • Infectious or inflammatory
AAA 30-39 mm Surveillance every 3 years (progression ≈ 3 mm per year)
AAA 40-44 mm Surveillance every 2 years
AAA > 45 mm Surveillance every year
EVAR: endovascular AAA repair (for infra-renal AAA); anatomical suitability A proximal aortic neck (segment between the lowest renal artery and the proximal extent of the aneurysm) > 10-15 mm of length (and < 32 mm in diameter); adequate vascular access required
★ EVAR and ★ DREAM: surgical versus endovascular AAA repair; H operative mortality with EVAR; similar long term mortality; G reintervention with EVAR SURGICAL AAA REPAIR SHOULD BE PREFERRED: anatomical criteria for EVAR not met or when regular long-term surveillance is impossible › Regular long-term surveillance following EVAR: CT angiography or MR angiography at 1 month - 6 months - then annually; look for endoleakage, stent position, stability and exclusion of the aneurysm sac, stent fracture › Late complications of surgery: para-anastomotic aneurysm; graft infection; graft-enteric fistula; imaging every 5 years
COMPLEX PLAQUE: Plaque thickness ≥ 4 mm or mobile / pedunculated debris (= thrombus) or ulceration › G embolic risk › Site: particularly in the distal aortic arch and descending aorta EMBOLISM: spontaneous or iatrogenic (post-intervention) › Thrombus (thromboembolism): thrombus forms on an unstable plaque then embolizes to a medium-to-large artery (stroke; TIA; leg ischemia; renal or splenic infarction; mesenteric ischemia) • Consider anticoagulation if complex plaque in aortic arch with stroke / TIA (class IIb) › Cholesterol crystals (atheroembolism): crystal emboli to small arterioles (“blue toe”; retinal ischemia / Hollenhorst plaques; Amaurosis fugax; TIA; Confusion; ARF; HTN; Livedo reticularis; Petechiae; Purpura; Intestinal ischemia; Pancreatitis) • Hypocomplementemia; Eosinophilia • Consider endarterectomy or stent in the presence of an identified source of embolism and recurrent atheroembolism
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SYNDROME DETAILS FOLLOW-UP MANAGEMENT
Marfan
• FBN1 mutation • Dilatation of aortic root (annulo-aortic ectasia) and ascending Ao; Type A dissection • Ghent diagnostic criteria g - Chapter 7
• TTE at diagnosis and after 6 months (stability) then every 6-12 months • Follow-up by imaging of the entire aorta following repair of the ascending Ao
• BB; Losartan • Surgery: A) > 50 mm; B) Progression > 5 mm/y; C) Family history of dissection < 50 mm; D) Significant AR • Desire for pregnancy: surgery if ≥ 40 mm
Lœys-Dietz
• Autosomal dominant • TGFBR1 or 2 mutation • Tortuosities / aneurysms / artery dissection • Hypertelorism; Cleft palate or bifid uvula • Aneurysm of the aortic root; Aortic dissection
• Imaging of the entire aorta at diagnosis and after 6 months (stability) • Annual MRI of the cerebrovascular circulation and as far as the pelvis
• Surgery if ascending Ao ≥ 42 mm (TEE; inner diameter) or ≥ 44 mm (CT or MRI; outer diameter)
EhlersDanlos Type IV
• Autosomal dominant (COL3A1) • Risk of artery rupture (including thoracic and abdominal aorta) • Risk of rupture of the uterus / intestine
• Role of prophylactic repair remains uncertain (friable tissues) • Follow-up by imaging
Turner
• 45, X • Small stature; Ovarian insufficiency • Bicuspid aortic valve (20%); CoA (10%); Ao aneurysm; Ao dissection
• Look for risk factors of aortic dissection (bicuspid aortic valve / CoA / dilatation of thoracic Ao / HTN) • In the presence of risk factors: annual TTE • Otherwise: TTE every 3-5 years
• Surgery if maximum Ao area (cm2) / patient’s height (m) > 10 • Surgery if diameter > 25 mm/m2
Nonsyndromic familial thoracic aortic aneurysm and dissection
• Non-syndromic • Autosomal dominant • Variable penetrance • Genes identified: TGFBR1 and 2; ACTA2; MYH11; MYLK; PRKG1
• Family screening: 1st degree relatives of patients with unexplained dissection or aneurysm • Genetic testing if several family members are affected
• TGFBR mutation: similar management to that of Loeys-Dietz
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Destruction of vessels (inflammation; G metalloproteinases; granulomas)
Takayasu
• Vasculitis of the aorta and its branches (stenosis and/or aneurysm) • Diagnostic criteria: < 40 years; Claudication (upper limbs or lower limbs); H Brachial pulse; Aortic or subclavian murmur; sBP Difference > 10 mmHg arms; Stenosis of the Ao or its branches (CT angiography or MR angiography) • Treatment: Prednisone 50 mg; MTX; Azathioprine; Anti-TNFalpha
Giant cell arteritis (temporal arteritis)
• Vasculitis of the aorta and its branches • Diagnostic criteria: > 50 years; de novo headache; tenderness over temporal artery (or H pulse); G ESR (> 50 mm/h); Positive biopsy • Constitutional symptoms; Claudication of the jaw; Claudication of upper limbs; Visual symptoms; PMR; Aortic aneurysm / dissection • Treatment: Prednisone 50 mg
Behçet
• Diagnostic criteria: Mouth ulcers; Genital ulcers; Uveitis or retinal vasculitis; Erythema nodosum; Pseudofolliculitis; Pathergy • Arterial involvement: destruction of the media; aneurysm ± rupture (any artery can be affected)
Ankylosing spondylitis
• HLAB27+ • Diagnostic criteria: < 40 years; Low back pain; Morning stiffness; Slow progression; Improvement with exercise • AR; Dilatation of the aortic root
Predominantly involves the aortic isthmus (deceleration injury)
BP in arms > BP in legs; radiofemoral delay; interscapular murmur
Contiguous invasion or septic embolism (endocarditis) or hematogenous spread
8.5/ PERIPHERAL ARTERY DISEASE PAD: cardiovascular risk equivalent to that of CAD › 5-year mortality: 10-15% (75% from cardiovascular causes)
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PRESENTATION: Asymptomatic; Intermittent claudication; Critical limb ischemia CLINICAL FEATURES: H pulse; murmur; pallor on elevation; G erythema of limb in dependent position; coldness; muscle atrophy; hair loss; onychodystrophy; skin fissures; ulcers; devitalization - gangrene
FONTAINE CLASSIFICATION
I Asymptomatic
II Intermittent claudication
IIa Claudication > 200 m
IIb Claudication < 200 m
III Rest pain / night pain
IV Ulcer / Gangrene
DDX: vasculitis (thromboangiitis obliterans; Takayasu; giant cell arteritis); CoA; fibromuscular dysplasia; external compression; radiotherapy; neurogenic claudication (lumbosacral radiculopathy); arthritis; myositis; venous insufficiency; popliteal artery entrapment syndrome
ABI ≤ 0.90 ABI 0.91 - 0.99 ABI 1.0 - 1.4 ABI > 1.4
Abnormal Gray zone Normal Calcified noncom-pressible artery
• Mild: 0.8-0.9 • Moderate: 0.5-0.8 • Severe: < 0.5
ABI on exercise if persistent suspicion of PAD: diagnosis of vascular claudication if ABI H by > 20-25 %
DM / CRF / Age A Use toe-brachial index (diagnostic if < 0.7)
ABI: ratio of sBP in ankle (posterior tibial artery or dorsalis pedis artery) / brachial artery INDICATION FOR ABI: suspicion of PAD in the leg with: › Suspected claudication; Poor wound healing; ≥ 50 years + [DM or Smoking]; ≥ 65 years; intermediate Framingham score
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ASA: H mortality - stroke - myocardial infarction (★ Antithrombotic Trialists’ Collaboration) › Indications a) Symptomatic patient (claudication; critical limb ischemia; history of revascularization; history of amputation) (class I recommendation) b)Asymptomatic patient with ABI ≤ 0.90 (class IIa recommendation); limited evidence › Clopidogrel as alternative treatment: superior to ASA in ★ CAPRIE; marginal benefit of ASA and Clopidogrel combination in ★ CHARISMA
SUPERVISED EXERCISE PROGRAM: 30-45 min; 3 x / week ; > 12 weeks; G exercise capacity CILOSTAZOL (100 MG PO BID): phosphodiesterase-3 inhibitor; H platelet aggregation; direct arterial vasodilator; contraindicated in the presence of heart failure; beware of drug interactions
REVASCULARIZATION: Indications A A) Symptoms refractory to medical treatment with impaired quality of life; B) Critical limb ischemia
Aortoiliac
• First-line endovascular revascularization (with stent) (TASC II type A - B - C) • Surgical revascularization: aortofemoral bypass graft with Dacron or PTFE prosthesis; femorofemoral bypass graft; axillofemoral bypass graft
Femoropopliteal
• First-line endovascular revascularization (TASC II type A - B - C) • Stenting for intermediate length (TASC type II B) • Surgical revascularization: femoropopliteal bypass graft preferably with autologous venous conduit (or PTFE prosthesis)
Infrapopliteal (below the knee)
• Revascularization in the presence of persistent critical limb ischemia despite proximal revascularization • First-line endovascular revascularization • Stenting if suboptimal result • Surgical revascularization: femorotibial or femoroperoneal bypass graft (autologous venous conduit)
› Mode of revascularization: first-line endovascular treatment in most cases; decision by multidisciplinary team according to anatomy / durability / comorbidities / local expertise / patient preference • Percutaneous revascularization: medium-and long-term patency decreased in the presence of a distal lesion / lesion > 10 cm / multiple lesions / poor distal runoff / DM / CRF
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• Surgical revascularization: preferred in the case of disseminated disease or technically difficult endovascular revascularization or TASC II type D (± type C) › Regular surveillance: for all patients post-revascularization; history - ABI - physical examination; ± Doppler US (vein graft) › Antithrombotic therapy: ASA for all patients; Clopidogrel 1 to 3 months post-stenting; consider Warfarin after bypass graft with vein graft
DEFINITION: A) Ischemic pain at rest; B) Ischemic lesion (ulcer; gangrene) › sBP at ankle: < 50 mmHg (rest pain) or < 70 mmHg (ischemic lesion)
ONE-YEAR MORTALITY: 25 % MANAGEMENT: A) Analgesia; B) Urgent revascularization if tissues are still viable (endovascular if technically feasible); C) Amputation if tissues are devitalized; D) Secondary prevention - wound care - adjusted shoes - treatment of infectious complications › ★ BASIL: revascularization by infrainguinal venous bypass graft similar to endovascular revascularization; H reintervention with bypass graft; H mortality with bypass graft in patients surviving > 2 years
MECHANISM: embolism (cardiac; Ao; peripheral arteries); thrombosis in situ; thromboembolism from a popliteal artery aneurysm (repair of aneurysm as primary prevention if > 20 mm); thrombosis of infrainguinal bypass graft; trauma; dissection; thrombophilia - hyperviscosity; phlegmasia cerulea dolens; iatrogenic (endovascular procedure; IABP; extracorporeal cardiac mechanical support)
Innominate / subclavian artery stenosis
SUBCLAVIAN STEAL SYNDROME: claudication of the arm; reversal of flow of the vertebral artery (vertigo; syncope; diplopia; dysarthria; ataxia) or of a mammary bypass graft (angina) to perfuse the arm
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8.6/ ATHEROSCLEROTIC RENOVASCULAR DISEASE H Renal perfusion A activation of renin-angiotensin-aldosterone system A peripheral vasoconstriction + salt and water retention A HTN BILATERAL RENAL ARTERY STENOSIS (OR FUNCTIONAL SOLITARY KIDNEY): G BP (renin-angiotensin-aldosterone system) with salt and water retention in the absence of compensatory sodium excretion A flash pulmonary edema CONSEQUENCES: Asymptomatic; HTN; Flash pulmonary edema - Diastolic dysfunction; Progressive deterioration of renal function (ischemic nephropathy; hypertensive nephropathy in contralateral kidney + proteinuria)
Yes
Renal artery stenosis
Screening
Diagnosis
NO
NO
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ASSESSMENT: MRI (diffusion-weighted images - DWI) or brain CT scan; noninvasive imaging of head and neck vessels (carotid Doppler; CT angiography; MR angiography); ECG; TTE; ± TEE (cryptogenic TIA; suspicion of cardioembolic TIA); Holter; ± Evaluation of intracranial arteries (CT angiography or MR angiography or angiography or transcranial Doppler) › Evaluation of hereditary thrombophilia: thrombophilia associated with venous >>> arterial thromboses; consider in the presence of cryptogenic TIA or suspected antiphospholipid syndrome (miscarriages; venous thrombosis; livedo reticularis) or personal or family history of systemic thrombosis • Look for: protein C or S or antithrombin III deficiency; Leiden factor V; prothrombin mutation G20210A; lupus anticoagulant; anticardiolipin antibody
HEMORRHAGIC STROKE (20%) ISCHEMIC STROKE (80%)
OTHER
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
LACUNAR (SMALL PENETRATING VESSELS)ATHEROTHROMBOTIC
(LARGE VESSELS)
CARDIOEMBOLIC
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ABCD² SCORE ≥ 60 years 1 point
48-hour stroke risk 0-1: 0 % 2-3: 1 % 4-5: 4 % 6-7: 8 %
BP ≥ 140/90 1 point
Dysphasia without weakness or Unilateral weakness
1 point 2 points
Diabetes 1 point
Duration 0-59 min Duration ≥ 60 min
1 point 2 points
ASSESSMENT: ECG; 24-hour monitor / Holter; TTE; TEE › Additional ambulatory electrocardiographic monitoring beyond 24-hour for subclinical AF detection if cardioembolic TIA suspected (★ EMBRACE; ★ CRYSTAL-AF)
HIGH CARDIOEMBOLIC RISK POTENTIAL CARDIOEMBOLIC RISK
• LA (LAA) or LV thrombus • AF - Flutter • Recent MI (< 1 month) • Rheumatic MS • Prosthetic valve • Severe LV dysfunction • Infective endocarditis • Noninfective endocarditis (Libman-Sacks; Antiphospholipid syndrome; Nonbacterial thrombotic endocarditis) • Myxoma - Fibroelastoma • ASD or VSD
• Complex atherosclerosis of the aorta • Aortic valve disease • Mitral annular calcification • MVP • PFO • Atrial septal aneurysm • LV aneurysm without thrombus • Spontaneous echo contrast in LA • Regional wall motion abnormality • HCM • LV noncompaction
NIH STROKE SCALE (NIHSS): QUANTIFICATION OF NEUROLOGICAL IMPAIRMENT
Level of consciousness 0 - Alert; 1 - Drowsy; 2 - Stuporous; 3 - Comatose
Orientation (2 questions) 0 - 2/2; 1 - 1/2; 2 - 0/2
Response to 2 commands 0 - 2/2; 1 - 1/2; 2 - 0/2
Gaze 0 - Normal lateral eye movements 1 - Partial gaze palsy 2 - Complete palsy
Visual fields
0 - No visual loss 1 - Partial hemianopia 2 - Complete hemianopia 3 - Bilateral hemianopia
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Facial palsy
0 - Normal 1 - Minor paralysis 2 - Partial paralysis 3 - Complete paralysis
A) Motor function - left arm B) Motor function - right arm
0 - No drift 1 - Drift in 5 s 2 - Some effort against gravity; limb falls in 10 s 3 - No effort against gravity 4 - No movement
A) Motor function - left leg B) Motor function - right leg
0 - No drift 1 - Drift in 5 s 2 - Some effort against gravity; limb falls in 10 s 3 - No effort against gravity 4 - No movement
Ataxia 0 - Absent 1 - Present in one limb 2 - Present in two limbs
Sensory 0 - Normal 1 - Mild-to-moderate sensory loss 2 - Severe to total sensory loss
Language
0 - No aphasia; normal 1 - Mild-to-moderate aphasia 2 - Severe aphasia 3 - Mute, global aphasia
Dysarthria 0 - Normal 1 - Mild-to-moderate dysarthria 2 - Severe dysarthria
Extinction and Neglect
0 - No abnormality 1 - Visual, tactile, auditory, spatial, or personal inattention or extinction (1 sensory modality) 2 - Profound hemi-inattention or extinction to more than one modality
IMMEDIATE MANAGEMENT: ABC; Cardiac monitor (> 24 h); IV line; O2 (if SaO2 < 94%); Blood glucose; NPO
EXAMINATIONS: Unenhanced brain CT scan; Blood glucose; ECG; Electrolytes; Renal function; CBC; PT-aPTT; Troponin; ± Lumbar puncture (if suspicion of SAH and in the absence of bleeding on CT scan); ± EEG (rule out seizures)
INTRAVENOUS THROMBOLYSIS: rtPA 0.9 mg/kg IV (max 90 mg) over 60 min (10% of dose as a bolus over 1 min) › ★ NINDS rtPA Stroke Study: < 3 h after onset of symptoms; improvement of neurological recovery at 3 months; similar mortality to that with placebo; cerebral hemorrhage in 6% of patients • 3 to 4.5 h of symptoms: ★ ECASS-3; improvement of neurological recovery at 3 months › Post-thrombolysis: intensive care; monitoring of neurological signs every 15-30 min for 6 h, then hourly for 24 h; Brain CT scan STAT if suspicion of intracranial hemorrhage; BP every 15-30 min for 6 h then hourly for 24 h; target BP < 180/105; repeat CT scan after 24 h
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CANDIDATES FOR INTRAVENOUS THROMBOLYSIS
< 3 h after onset of symptoms 3 to 4.5 h after onset of symptoms A) Ischemic stroke with measurable neurological deficit (not minor); B) Absence of improvement of neurological deficit; C) Caution in the presence of major neurological deficit (risk of hemorrhagic transformation); D) Absence of SAH; E) Absence of head injury or stroke < 3 months; F) Absence of myocardial infarction < 3 months (risk of myocardial rupture; relative contraindication); G) Absence of GI or urinary bleeding < 21 days; H) Absence of major surgery < 14 days; I) Absence of noncompressible arterial puncture < 7 days; J) Absence of history of intracranial hemorrhage; K) Absence of CNS neoplasm / AVM / intracranial aneurysm; L) Absence of recent intracranial or spinal surgery; M) BP < 185/110; N) Absence of active internal bleeding; O) INR < 1.7; P) DOAC: normal sensitive detection test or last dose > 48 h (with normal renal function); Q) Normal aPTT if heparin received < 48 h; R) Platelet count > 100,000 mm3; S) Blood glucose > 2.7 mmol/L; T) Absence of seizures with residual neurological impairment; U) Brain CT scan: absence of multilobar infarction (1/3 of a cerebral hemisphere)
Same criteria as for thrombolysis < 3 h of symptoms
Exclusion criteria: a) > 80 years b) Oral anticoagulants c) NIHSS > 25 d) History of stroke + DM e) Ischemic lesion > 1/3 of the middle cerebral artery territory
INTRAARTERIAL REVASCULARIZATION › ★ MR CLEAN: stroke < 6 h + proximal occlusion in the anterior cerebral circulation; 89% treated with IV tPA before randomization; intraarterial thrombolysis and/or mechanical thrombectomy versus usual care; benefit on the functional outcomes › ★ ESCAPE: stroke < 12 h + proximal intracranial occlusion in the anterior circulation; early thrombectomy associated with improved functional outcome and H mortality
MANAGEMENT OF BP › BP > 220/120 mmHg: 10-15% H BP for 24 h (Nicardipine; Labetalol) › Thrombolysis considered: target BP < 185/110 • Labetalol 10-20 mg IV x 1-2 min (can be repeated once) • Nicardipine: 5 mg/h (titrate every 5-10 min up to 15 mg/h; when target BP has been achieved A 3 mg/h infusion) › Post-thrombolysis: Labetalol 10 mg IV x 1-2 min (then every 10-20 min; max 300 mg) or Labetalol 10 mg IV then 2-8 mg/min infusion or Nicardipine (as above) › Post-stroke (long-term): target BP < 140/90 (ACE inhibitors and/or diuretics); resume antihypertensives 24 h after stroke
ASA: 325 mg in < 48 h (> 24 h in the case of thrombolysed stroke); benefit on the morbidity - mortality OTHER TREATMENTS: A) Thromboprophylaxis / sequential compression device; B) Detection of dysphagia (water swallow test); C) Target normothermia and normoxemia; D) Nutritional support; E) Insulin if blood glucose > 10.3 mmol/L (avoid hypoglycemia); F) Rehabilitation
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RISK FACTORS: g Chapter 9; Treatment of HTN (from 24 h); Smoking cessation; Treatment of dyslipidemia (★ SPARCL); Treatment of DM; Moderate alcohol intake; Regular moderate physical exercise; Healthy weight; Balanced diet; Treat OSAHS
ANTIPLATELET THERAPY: indicated in a context of noncardioembolic TIA or ischemic stroke; ASA (50 to 325 mg daily) or ASA 25 mg / Dipyridamole 200 mg bid or Clopidogrel 75 mg daily › Evidence: similar outcomes with Clopidogrel versus ASA / Dipyridamole (★ PRoFESS); no benefit of long-term combination of Clopidogrel and ASA (★ MATCH); H adverse events with ASA / Dipyridamole versus ASA (★ ESPS-2; ★ ESPRIT)
ATRIAL FIBRILLATION: Warfarin (★ EAFT) or DOAC for secondary prevention › Initiation of A/C in acute stroke: according to the severity of the stroke (risk of hemorrhagic transformation); anticoagulant therapy initiated < 14 days in ★ EAFT; wait 72 h for small stroke or 1 week for moderate stroke or 2 weeks for large stroke; no benefit of Heparin bridge › WATCHMAN: LAA occlusion device; ★ PROTECT AF (noninferior to warfarin); consider when anticoagulation is contraindicated
PFO: controversial subject; g Chapter 7 - Congenital heart disease THROMBOPHILIA: associated with venous >>> arterial thromboses; anticoagulation if concomitant DVT; Antiplatelet therapy or anticoagulation in the absence of DVT or an identifiable cause of stroke › Antiphospholipid syndrome: anticoagulation indicated
ASYMPTOMATIC CAROTID ARTERY STENOSIS: benefit of surgical revascularization in selected patients (★ ACAS and ★ ACST; studies conducted prior to the introduction of modern medical treatment); NNT = 33
ANGIOPLASTY-STENTING VERSUS ENDARTERECTOMY: comparable long-term outcomes (★ CREST; ★ SAPPHIRE) › Angioplasty-Stenting: increased risk of periprocedural stroke compared to endarterectomy (particularly in patients > 70 years) › Prefer angioplasty-stenting: anatomical / technical considerations (post-radiation; post-surgical; obesity; hostile neck; stenosis at different level); high operative risk - severe comoborbidities › Dual antiplatelet therapy: 4 weeks
REVASCULARIZATION IN THE PRESENCE OF MULTIPLE COMORBIDITIES: little evidence in favor of surgical or endovascular revascularization (NYHA III-IV; CCS III-IV; CAD ≥ 2 vessels or LMCA; LVEF ≤ 30%; recent myocardial infarction; severe lung disease; advanced CRF)
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SYMPTOMATIC (< 6 MONTHS) ASYMPTOMATIC
Carotid artery stenosis: 50-69% (angiography)
Carotid artery stenosis: 70-99% (noninvasive imaging)
Carotid artery stenosis > 70%
Endarterectomy
I; B I; A IIa; A
To be performed within 14 days of the neurological event unless contraindicated (IIa; B)
Mortality - perioperative stroke < 3%
Life expectancy > 5 years
Mortality - perioperative stroke < 6% Life expectancy > 5 years
AngioplastyStenting
Alternative to surgery: I; B Alternative to surgery: I; B IIb; B (controversial)
Mortality - perioperative stroke < 5%
MANAGEMENT: Intensive care; Neurosurgical assessment; Target normothermia; Target blood glucose < 10.3 mmol/L; Thromboprophylaxis (sequential compression device; IVC filter PRN); Phenytoin in the presence of seizures; ± Continuous EEG monitoring
ANTICOAGULATION: Discontinue anticoagulation and antiplatelet therapy for more than 1-2 weeks and subsequently reassess the indication; weigh up the thromboembolic risk against the bleeding risk (high in cortical stroke secondary to amyloid angiopathy) › Reverse Warfarin: prothrombin complex concentrate (Octaplex; Beriplex; Cofact; Proplex); complex of factors II - VII - IX - X; Target INR < 1.4 • Vitamin K: 10 mg IV (max 1 mg/min) • Fresh frozen plasma: 8 units when prothrombin complex concentrate is not available
CONTROL OF INTRACRANIAL HYPERTENSION: target cerebral perfusion pressure > 60 mmHg (MAP - ICP) and ICP < 20-25 mmHg; raise head of bed by 30°; analgesia; control of BP (target SBP < 180 mmHg and MAP < 130 mmHg, while maintaining adequate cerebral perfusion pressure); ventriculostomy (external CSF drainage); IV mannitol (target plasma osmolality: 300-310 mOsmol/kg); sedation; hyperventilation (PaCO2: 30-35 mmHg); neuromuscular blockade; surgical evacuation of hematoma; barbiturate-induced coma
8.8/ PULMONARY EMBOLISM RISK FACTORS: Age; Personal or family history of pulmonary embolism; Cancer; Trauma; Surgery; Immobilization; Pregnancy; Hormonal therapy; Oral contraceptive; Nephrotic syndrome; Chemotherapy › Thrombophilia: Homozygous factor V Leiden; Homozygous prothrombin G20210A; Protein C deficiency; Protein S deficiency; Antiphospholipid syndrome / Lupus anticoagulant
CLINICAL FEATURES: Tachypnea; Tachycardia; ± Shock; ± Cyanosis (RA L shunt via PFO); H SaO2; Low-grade fever; JVD; Left parasternal heave; G P2; TR murmur; right S3 or S4; Pleural friction rub (pulmonary infarction); signs of DVT in leg (edema; erythema; heat; pain; difference between legs)
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CXR: PA dilatation; Atelectasis; Elevation of the diaphragm; Pleural effusion › Westermark sign: Segmental oligemia secondary to proximal arterial occlusion › Hampton hump: Triangular hyperdensity adherent to the pleura secondary to pulmonary infarction (consolidation with hemorrhage)
TTE: RV dilatation (G acute afterload); RV hypokinesia; PHT (non-preconditioned RV is unable to genereate a mPAP > 40 mmHg); TR; shunt via PFO; thrombus-in-transit visible in right chambers / PA; septal curvature towards the LV; dilated and noncompliant IVC › McConnell’s sign: hypokinesis of basal / mid RV free wall (preserved apex contractility)
WELLS CRITERIA – PRETEST PROBABILITY – DEEP VEIN THROMBOSIS
Active cancer 1 point
• 0 point: low pretest probability • 1-2 points: moderate pretest probability • ≥ 3 points: high pretest probability
Paralysis or recent cast immobilization 1 point
Bedridden > 3 days or surgery < 4 weeks 1 point
Local vein tenderness 1 point
Swelling of entire leg 1 point
Difference between calves > 3 cm 1 point
Pitting edema 1 point
Superficial collateral vein 1 point
Alternative diagnosis at least as likely - 2 points
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WELLS CRITERIA – PRETEST PROBABILITY – PULMONARY EMBOLISM
Signs or symptoms of DVT 3 points
• 0-1 point: low pretest probability (10%) • 2-6 points: moderate pretest probability (30%) • ≥ 7 points: high pretest probability (65%)
Alternative diagnosis is less likely 3 points
HR > 100 bpm 1.5 points
Immobilization or surgery < 4 weeks 1.5 points
History of DVT or pulmonary embolism 1.5 points
Hemoptysis 1 point
Cancer (< 6 months or metastasis) 1 point
Ultrasensitive D-Dimer negative
D-Dimer positive
D-Dimer negative
D-Dimer positive
Initiate anticoagulation
Diagnosis excluded
Diagnosis excluded
Diagnosis excluded
Diagnosis conrmed
Diagnosis conrmed
Negative
≥ 70-6
* Interpret according to: A) Pretest probability B) Site of thrombus (main PA or lobar or segmental versus subsegmental PA)
Low to moderate pretest probability
High pretest probability
Pulmonary CT angiography* (or V/Q scan)
Leg US or V/Q scan
Pulmonary CT angiography* (or V/Q scan)
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Unfractionated heparin
• IV bolus: 80 IU/kg • IV infusion: 18 IU/kg/h (target aPTT 1.5-2.5 x control or 60-80 s)
Enoxaparin • 1 mg/kg SC bid or 1.5 mg/kg qd LMWH • Better bioavailability • More predictable effect • Avoid if GFR < 30 mL/min
Dalteparin • 100 IU/kg SC bid or 200 IU/kg qd
Tinzaparin • 175 IU/kg SC bid
Fondaparinux • < 50 kg: 5 mg SC qd • 50-100 kg: 7.5 mg SC qd • > 100 kg: 10 mg SC qd
• Indirect Xa inhibitor • Avoid if GFR < 30 mL/min
History of HIT Argatroban or Bivalirudin or Lepirudin or Danaparoid
WARFARIN: anticoagulant effect in 5 days › Initially procoagulant effect: due to H proteins C and S › Overlapping of warfarin with Heparin ≥ 5 days (and ≥ 24 h with INR ≥ 2.0)
No risk factors
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Provocated pulmonary embolism or proximal DVT (secondary to surgery; trauma; pregnancy; hormonal therapy)
Thromboembolism and active cancer
Idiopathic or recurrent pulmonary embolism (or proximal DVT)
Anticoagulation x 3 months
LMWH (★ CLOT) Continue in the presence of active cancer (warfarin as alternative)
Anticoagulation x ≥ 3 months and consider long-term treatment (according to balance between the risks of recurrence and bleeding)
IVC FILTER: Indications A A) Bleeding / Contraindication to anticoagulation; B) Recurrent pulmonary embolism despite treatment (in the presence of a proximal thrombosis) › H Pulmonary embolism recurrence rate; G DVT recurrence rate › Complications: access site complication; recurrent DVT; IVC thrombosis; IVC perforation; migration; post-thrombotic syndrome › Resume anticoagulation and remove the filter as soon as possible
INTRAVENOUS THROMBOLYSIS: H mortality in massive pulmonary embolism › Alteplase 100 mg IV x 2 h (without heparin); resume heparin without bolus at the end of thrombolysis if aPTT ≤ 80 s
CATHETER-ASSISTED THROMBUS REMOVAL › Indications: Hemodynamic instability with A A) Contraindication to thrombolysis or B) Failure of thrombolysis (rescue) • Consider surgery in the presence of mobile thrombus-in-transit in right chambers or thrombus-in-transit in PFO
LOCAL CATHETER THROMBOLYSIS FOR DVT: A) Extensive ilio-femoral thrombosis with low bleeding risk (including phlegmasia cerulea dolens); B) Progression of thrombus despite treatment; C) Extensive upper extremity DVT (subclavian and axillary veins) › Benefit: H risk of postthrombotic syndrome › Pharmacomechanical approach: local thrombolysis combined with catheter thrombectomy ± balloon venoplasty (± stent)
UPPER EXTREMITY DVT: Risk factors A central catheter; pacemaker; thoracic outlet syndrome (Paget-Schroetter disease); Cancer › Risk of complications in the case of proximal DVT (starting at axillary vein) › Risk of PE: 10 % › Anticoagulation: ≥ 3 months • It is acceptable to observe upper extremity DVT distal to the axillary vein
POSTTHROMBOTIC SYNDROME: varicosities; hyperpigmentation; ulcers › Compression stockings: 30-40 mmHg › Consider angioplasty ± stenting in the presence of iliac vein obstruction
THROMBOPROPHYLAXIS IN MEDICALLY HOSPITALIZED PATIENTS › Unfractionated heparin: 5000 IU SC bid or tid › LMWH: Enoxaparin 40 mg SC qd or Dalteparin 5000 U SC qd › Fondaparinux: 2.5 mg SC qd (useful in patients with a history of HIT) › Intermittent pneumatic compression: contraindication to anticoagulants or multiple risk factors (with anticoagulant)
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Immune form (IgG)
PATHOPHYSIOLOGY: Antibody directed against neoantigens on protein PF4 (protein released by activated platelets) › Neoantigens are exposed following binding of PF4 with heparin A IgG binds simultaneously to the heparin-PF4 complex and to platelet Fc receptors A platelet activation with release of prothrombotic molecules A platelet consumption + intense thrombin production A multiple thromboses (venous or arterial)
5-10 days post-exposure to heparin (or earlier in the case of re-exposure < 3 months)
H > 50% of platelets (compared to baseline count) or thrombosis beginning 5-10 days after the start of heparin
4 T SCORE
2 POINTS 1 POINT 0 POINT
Thrombocytopenia
> 50% decrease in platelet count and nadir ≥ 20,000/ μL and no surgery in past 3 days
• > 50% decrease in platelet count and surgery in past 3 days or • 30-50% decrease in platelet count or • Nadir 10,000-20,000/μL
• < 30% decrease in platelet count or • Nadir < 10,000/μL
“Timing” (postexposure)
Day 5 to Day 10 (or ≤ 1 day if prior heparin exposure within 30 days)
Uncertain interval (but probably between Day 5 and Day 10) or after Day 10 (or ≤ 1 day if prior heparin exposure within 30-100 days)
Decrease in platelet count ≤ Day 4 (no other heparin therapy during past 100 days)
Thrombosis
Confirmed new thrombosis; Skin necrosis at injection site; Anaphylactoid reaction to IV heparin bolus
Recurrent venous thrombosis while on anticoagulant therapy or suspected thrombosis or nonnecrotic skin lesions at injection site
None
oTher causes
No alternative cause to explain thrombocytopenia
Possible alternative cause
Probable alternative cause (recent surgery; bacteremia; chemotherapy; drugs…)
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DIAGNOSTIC WORK-UP: to be performed in the case of intermediate to high probability (4 T score) › ELISA assay of anti-PF4 antibodies (excellent NPV but low PPV) › Serotonin-release assay (platelets containing labeled serotonin placed in contact with the patient’s plasma and heparin); gold standard diagnostic test
1) Stop all forms of heparin
2) Argatroban or Bivalirudin or Fondaparinux or Danaparoid
3) Initiate Warfarin once the thrombocytopenia has resolved (with IV co-administration of a direct thrombin inhibitor; overlapping for ≥ 5 days; discontinue after achieving therapeutic INR for 2 days); anticoagulation ≥ 3 months if confirmed thrombosis › If the patient is treated with Warfarin at the time of HIT: reverse with vitamin K
PHT GROUP 1-3-4-5 PHT POSTCAPILLARY (GROUP 2)
mPAP ≥ 25 mmHg
mPAP ≥ 25 mmHg Wedge ≤ 15 mmHg
mPAP ≥ 25 mmHg and Wedge > 15 mmHg
Isolated postcapillary: dPAP - Mean Wedge < 7 mmHg and/or PVR ≤ 3 WU
With precapillary component: dPAP - Mean Wedge ≥ 7 mmHg and/or PVR > 3 WU
Group 1: Pulmonary arterial hypertension (PAH)
mPAP ≥ 25 mmHg; Wedge ≤ 15 mmHg; PVR ≥ 3 WU
• Idiopathic PAH • Heritable PAH - BMPR2; ALK1; Endoglin; SMAD9; CAV1; KCNK3 mutation - Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) • PAH secondary to drugs - toxins (Anorectics; Cocaine; Amphetamines) • PAH associated with - Collagen diseases › Scleroderma - CREST; SLE; Mixed connective tissue disease; RA; Sjögren; Dermatomyositis - HIV - Portal hypertension (Cirrhosis) › Liver transplantation contraindicated if mPAP ≥ 35 mmHg or PVR > 250 dyn x s / cm5
- Congenital heart disease (Shunt) › VSD; Patent ductus arteriosus; ASD; Anomalous pulmonary venous return; AV canal defect; Complex congenital heart disease - Schistosomiasis
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Group 1`
• Pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis - Similar presentation to that of PAH - Suspect in the presence of pulmonary edema following administration of pulmonary artery vasodilators - Characteristic changes on pulmonary HDCT (subpleural thickened septal lines; centrilobular ground-glass opacities; lymphadenopathy)
Group 2: PHT secondary to left heart disease
mPAP ≥ 25 mmHg; Wedge > 15 mmHg
• LV systolic dysfunction • LV diastolic dysfunction • Left-sided valvular heart disease • Pulmonary veins stenosis
Group 3: Pulmonary hypertension secondary to lung disease
• COPD • Interstitial lung disease • Mixed lung disease • Sleep-disordered breathing • Alveolar hypoventilation • High altitude
Group 4 • Thromboembolic pulmonary hypertension
Group 5: Uncertain mechanism
• Hematological disease: Myeloproliferative disease (Polycythemia vera; Essential thrombocytosis; CML); Splenectomy; Chronic hemolytic anemia (Sickle-cell anemia; Hereditary spherocytosis; Homozygous beta-thalassemia) • Systemic disease: Sarcoidosis; Langerhans cell histiocytosis; Lymphangioleiomyomatosis; Neurofibromatosis; Vasculitis • Metabolic disease: Glycogen storage disease; Gaucher; Thyroid disease • Other: Neoplastic obstruction; Fibrosing mediastinitis; Dialysis
Reversible causes of PHT secondary to G transpulmonary blood flow Exercise; Anemia; Pregnancy; Sepsis; Hyperthyroidism; Volume overload
CLINICAL FEATURES: Hypotension; Cold extremities; ± Cyanosis; JVD (G A wave; G V wave); left parasternal heave; Pulmonary artery palpable in left second intercostal space; G P2; Ejection click / Systolic ejection murmur at pulmonary site; Holosystolic murmur (TR; G on inspiration); PR murmur (Graham-Steel); Right S3 and/or S4; Pulsatile liver; Anasarca › Look for signs of collagen disease (sclerodactyly; arthritis; telangiectasias; Raynaud; rash) and liver disease (spider naevi; testicular atrophy; palmar erythema); look for clubbing
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CARDIAC MRI: More favorable prognostic factors A Ejection volume > 25 mL/m² or RV end-diastolic volume < 84 mL/m² or LV end-diastolic volume > 40 mL/m²
PULMONARY ASSESSMENT: CXR; PFTs; Pulmonary high-resolution CT; Arterial blood gases; V/Q scan (± CT angiography / pulmonary angiography); Nocturnal saturometry / Polysomnography › PFTs: PAH associated with mild-to-moderate H lung volumes and H DLCO (40 to 80% of predicted) › Rule out thromboembolic PHT (Group 4) in all patients by V/Q scan
RIGHT/LEFT CATHETERIZATION › Look for a shunt (oximetry run) › Wedge pressure (end of expiration) ± LVEDP; 500 mL bolus PRN to reveal diastolic dysfunction › Cardiac output: Thermodilution (in the absence of significant TR or low output state or shunt) or Fick › PVR (WU) = mPAP - Wedge / Cardiac output › Diastolic pressure gradient = dPAP - Mean Wedge › Vasoreactivity test (Idiopathic PAH; Heritable PAH; Drug-induced PAH) • Positive: absolute H of mPAP ≥ 10 mmHg (to mPAP < 40 mmHg) in the absence of H cardiac output
INHALED NO (FIRST LINE) IV EPOPROSTENOL IV ADENOSINE
10 to 20 ppm 2 - 12 ng/kg/min 50 to 350 μg/kg/min
› Hepatic venous pressure gradient = Wedged hepatic venous pressure - IVC pressure; normal value between 1-5 mmHg (≥ 10 mmHg A portal hypertension / cirrhosis) MONITORING OF FUNCTIONAL CAPACITY: WHO functional class (equivalent to NYHA); 6MWT; Stress test; Cardiopulmonary test / VO2 max
TR TR TR RV SYSTOLIC PRESSURE (SPAP) = 4 X TR VELOCITY ² + RA PRESSURE
MPAP (MAHAN) = 79 - (0.45 X PA ACCELERATION TIME)
MPAP = 4 X EARLY DIASTOLIC PR VELOCITY ² + RA PRESSURE
MPAP = 1/3 SPAP + 2/3 DPAP
PR PR
DPAP = 4 X END-DIASTOLIC PR VELOCITY ² + RA PRESSURE
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