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Images of Vascular Medicine Symposia - The CRUDEM Foundation


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Images of Vascular Medicine (French) Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.

CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.

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Images of Vascular Medicine Symposia - The CRUDEM Foundation

  1. 1. Images de Médecine Vasculaire W.M. Vosik, MD, F.A.C.P.
  2. 2. Case 1 <ul><li>A 36 year old male with recent onset of hypertension presents with a sore throat and difficulty in swallowing. What medication is he most likely on? </li></ul>
  3. 4. Uvular Angioedema <ul><li>A rare but potentially fatal complication of ACE </li></ul><ul><li>inhibitors (enalaparil,capoten,prinivil) </li></ul><ul><li>Chronic idiopathic </li></ul><ul><li>Direct thermal injury </li></ul><ul><li>NSAIDs such as aspirin </li></ul><ul><li>ARBs (losartan,valsartan) </li></ul><ul><li>C1-inhibitor deficiency </li></ul><ul><li>Miscellaneous external triggers </li></ul>
  4. 5. Case #2 The following ECG is obtained in a 50 year old lady who presents to the emergency room with shortness of breath and fatigue. Her only past medical history is of a mastectomy for breast cancer. BP is 90/60 and is inaudible with inspiration.
  5. 6. What Does This ECG Demonstrate?
  6. 8. Malignant Pericardial Effusion <ul><li>Lung cancer </li></ul><ul><li>Breast cancer </li></ul><ul><li>Esophageal cancer </li></ul><ul><li>Lymphoma </li></ul><ul><li>Leukemia </li></ul><ul><li>Malignant melanoma </li></ul>
  7. 9. Case #3 A 40 year old with a history of a heart murmur presents with a 6-week history of fever, weight loss, and intermittent chills. Of recent, he has had sudden onset of shortness of breath and appears in the emergency room. He has a grade 3/6 systolic murmur at the apex and right lower sternal border
  8. 13. ENDOCARDITIS <ul><li>Often prior history of congenital ,rheumatic or degenerative valve disease </li></ul><ul><li>IV drug abuse </li></ul><ul><li>Presenting symptoms often: FUO, embolic phenomena, CHF. Arrythmias </li></ul><ul><li>Choices and duration of treatment dependent on clinical setting and etiological agent </li></ul>
  9. 14. Case #4 A thirty year old female with palpitations and chest pain
  10. 15. MITRAL VALVE PROLAPSE <ul><li>Most common cause of mitral regurgitation </li></ul><ul><li>2-3% of U.S. population (7%have severe mitral regurgitation) </li></ul><ul><li>Often associated palpitations, chest pain </li></ul><ul><li>Can have findings of an isolated mid-systolic click/or mitral murmur </li></ul><ul><li>ECG often abnormal </li></ul>
  11. 19. Case #5 <ul><li>Thirty-four year old female 1 month postpartum. Menses resumed 1 month later She presents to the ER with severe anterior chest pain. Her physical examination is unremarkable. A stat ECG is obtained. </li></ul>
  12. 20. What are the ECG findings? Should you give her Thrombolytics?
  13. 23. Spontaneous Coronary Dissection <ul><li>Rare cause of MI </li></ul><ul><li>Younger Females </li></ul><ul><li>SCD/A.C.S. </li></ul><ul><li>Greater peripartum period (25%+) </li></ul>
  14. 24. Case #6 <ul><li>A 34 year old multigravida presents 3 months post partum with increasing s.o.b. and ankle edema. Her exam reveals a regular heart rhythm, distended neck veins, and a third heart sound. Her hemoglobin is 11.5 gm./dl. A chest ray shows an enlarged heart. ECG is normal. What is the next test to obtain? </li></ul>
  15. 26. DILATED CARDIOMYOPATHY <ul><li>Dilation and impaired contractility of the </li></ul><ul><li>ventricles </li></ul><ul><li>Presenting symptoms of cardiomyopathy </li></ul><ul><ul><ul><li>Heart failure </li></ul></ul></ul><ul><ul><ul><li>Atrial and/or ventricular arrhythmias </li></ul></ul></ul><ul><ul><ul><li>Sudden cardiac death </li></ul></ul></ul>
  16. 27. PERIPARTUM CARDIOMYOPATHY <ul><li>Rare cause of DCM </li></ul><ul><li>Unclear etiology </li></ul><ul><li>Occurs in late pregnancy or early postpartum </li></ul><ul><li>(within 5 months after delivery) </li></ul><ul><li>Absence of a determinable cause for heart </li></ul><ul><li>failure </li></ul><ul><li>Low LVEF by echocardiogram </li></ul><ul><li>Significant risk of recurrence with subsequent </li></ul><ul><li>pregnancy </li></ul>
  17. 28. ETIOLOGY - DCM <ul><li>Ischemic </li></ul><ul><li>Stress induced cardiomyopathy (Takosubo’s) </li></ul><ul><li>Infectious cardiomyopathy </li></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><li>HIV </li></ul></ul><ul><ul><li>Chaga’s disease </li></ul></ul><ul><ul><li>Lyme Disease </li></ul></ul><ul><li>Toxic Cardiomyopathy </li></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Cocaine </li></ul></ul><ul><ul><li>Medication as Adriamycin </li></ul></ul>
  18. 29. DILATED CARDIOMYOPATHY-cont. <ul><li>Genetic causes of DCM </li></ul><ul><li>Hypertrophic cardiomyopathy </li></ul><ul><li>Left ventricular noncampaction </li></ul><ul><li>Peripartum cardiomyopathy </li></ul><ul><li>Tachycardia induced cardiomyopathy </li></ul><ul><li>Systemic LE </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>End stage renal disease </li></ul><ul><li>Celiac disease </li></ul><ul><li>Autoimmune </li></ul><ul><li>Endocrine dysfunction </li></ul><ul><li>Nutritional deficiency </li></ul><ul><li>Obstructive sleep apnea </li></ul>
  19. 30. Case #7 A 65 year old female develops severe chest pain and diaphoresis when informed of her husband’s sudden cardiac death in the emergency room. She has a stat ECG:
  20. 32. Case #7- Stress-Induced (Takotsubo) Cardiomyopathy <ul><li>ST – elevation or depression in the absence of critical coronary artery disease </li></ul><ul><li>Transient left ventricular apical balloon </li></ul><ul><li>“ Broken heart” syndrome </li></ul><ul><li>Often precipitated by intense psychological stress </li></ul><ul><li>Primarily in postmenopausal women </li></ul>
  21. 34. Case #8 A 45 year old presents to the ER with severe chest pain. The following ECG is obtained, and he is taken emergently to the cath lab. Which coronary artery is occluded?
  22. 38. Case #9 A 72 year old female with a history of myocardial infarction 3 years ago presents with symptoms consistent with congestive heart failure. You order an ECG and echo.
  23. 43. <ul><li>Mechanical complications of acute myocardial infarction include all but which of the following: </li></ul><ul><li>a. Rupture of the left ventricular free wall </li></ul><ul><li>b. Mitral regurgitation </li></ul><ul><li>c. Rupture of the interventricular septum </li></ul><ul><li>d. Pseudoaneurysm </li></ul><ul><li>e. Ventricular fibrillation </li></ul><ul><li>f. Papillary muscle rupture </li></ul><ul><li>g. L.V. Aneurysm </li></ul>
  24. 46. Cardiac Pseudoaneurysms <ul><li>A “contained cardiac rupture” </li></ul><ul><li>Rare complication post MI </li></ul><ul><li>Rare post cardiac surgery </li></ul><ul><li>Rare post traumatic </li></ul>
  25. 47. Cardiac Pseudoaneurysms – Presentation <ul><li>Asymptomatic </li></ul><ul><li>CHF </li></ul><ul><li>AMI </li></ul><ul><li>C.P., syncope </li></ul><ul><li>Arrhythmia </li></ul>
  26. 51. Case 10 - A “Hot Case” <ul><li>A 22 year old male was found in a coma after a moped accident the evening before he was found.. He was involved in a late night “binge” and had not been seen for over 8 hours. </li></ul><ul><li>He was in a deep coma, with a Glasgow coma score of 4 out of 15 (3 being the worse score) and a core body temperature of 35 degrees C (95 F) </li></ul>
  27. 53. HYPOTHERMIA <ul><li>Due to cold exposure or immersion </li></ul><ul><li>Core temperature <35 degree C or 95 degree F </li></ul><ul><li>Aggravated by age, malnutrition, trauma, drugs </li></ul><ul><li>Shivering, arrythmias, and Osborn or J waves on ECG </li></ul><ul><li>Gradual rewarming and warmed crystalloids </li></ul>
  28. 54. Case #11 A 60 year old male smoker with temporary loss of vision in one eye
  29. 56. Amaurosis Fugax <ul><li>Transient loss of vision in one eye usually lasting 5-15 minutes. </li></ul><ul><li>Differential Dx: </li></ul><ul><ul><li>migraine aura </li></ul></ul><ul><ul><li>TIA </li></ul></ul><ul><ul><li>carotid emboli </li></ul></ul><ul><ul><li>atrial fibrillation </li></ul></ul><ul><ul><li>misc. </li></ul></ul>
  30. 57. Case #12 <ul><li>40 year old with a family history of sudden cardiac death. </li></ul>
  31. 60. ISOLATED LEFT VENTRICULAR NONCOMPACTION (LVNC) <ul><li>A rare disorder </li></ul><ul><li>A primary genetic cardiomyopathy </li></ul><ul><li>Prominent trabeculae with deep intertrabecular </li></ul><ul><li>recesses </li></ul><ul><li>A result from premature arrest of intrauterine </li></ul><ul><li>cardiogenesis </li></ul><ul><li>Occasionally accompanies other congenital heart </li></ul><ul><li>disorders </li></ul><ul><li>Features can overlap with IDC, HOCM </li></ul>
  32. 61. CLINICAL MANIFESTATIONS OF LVNC <ul><li>CHF </li></ul><ul><li>Atrial and ventricular arrhythmias </li></ul><ul><li>Thromboembolic events including stroke </li></ul><ul><li>Symptoms related to LVNC </li></ul><ul><ul><ul><li>Dyspnea </li></ul></ul></ul><ul><ul><ul><li>Class III or IV heart failure </li></ul></ul></ul><ul><ul><ul><li>Chest pain </li></ul></ul></ul><ul><ul><ul><li>Chronic atrial fibrillation </li></ul></ul></ul>
  33. 62. DIAGNOSIS LVNC <ul><li>Echocardiography </li></ul><ul><li>Cardiovascular MR imaging </li></ul><ul><li>Left ventriculography </li></ul><ul><li>Prognosis LVNC </li></ul><ul><ul><li>High incidence heart failure (53%) </li></ul></ul><ul><ul><li>Ventricular tachyarrhythmia (41%) </li></ul></ul><ul><ul><ul><ul><li>12% received an ICD </li></ul></ul></ul></ul><ul><ul><ul><ul><li>24% had a thromboembolic event </li></ul></ul></ul></ul><ul><ul><ul><ul><li>35% died including 6 sudden death </li></ul></ul></ul></ul><ul><ul><ul><ul><li>12% underwent heart transplantation </li></ul></ul></ul></ul>
  34. 63. Case #13 A 24 y/o female develops pulmonary edema during labor <ul><li>She has an irregular rhythm of atrial fibrillation, an opening snap, and diastolic rumble at the apex </li></ul>
  35. 64. Rheumatic Mitral Stenosis <ul><li>Isolated mitral valve stenosis more common in females </li></ul><ul><li>Often presents as an asymptomatic murmur </li></ul><ul><li>At apex- easier to hear when heart rate slow and in left lateral position </li></ul><ul><li>First symptom may coincide with onset of atrial fibrillation, or in labor, or with an embolic event </li></ul>
  36. 67. EPIDEMIOLOGY/PATHOGENESIS OF ACUTE RHEUMATIC FEVER- CONT. <ul><li>Epidemiology </li></ul><ul><ul><ul><li>Worldwide - 470,000 new cases of rheumatic fever and 233,000 deaths attributed to rheumatic fever or rheumatic heart disease each year </li></ul></ul></ul><ul><ul><ul><li>Much less common in developed countries </li></ul></ul></ul><ul><li>Developing indigenous countries </li></ul><ul><ul><ul><li>Mean incidence ARF 19/100,000 </li></ul></ul></ul><ul><li>Rheumatogenic strains? </li></ul><ul><li>Genetic susceptibility </li></ul>
  37. 68. ROLE OF THE STREPTOCOCCUS <ul><li>Outbreaks of ARF closely follow epidemics of </li></ul><ul><li>strep pharyngitis or scarlet fever </li></ul><ul><li>Adequate treatment of a documented strep </li></ul><ul><li>pharyngitis markedly reduces the incidence of </li></ul><ul><li>subsequent ARF </li></ul><ul><li>Appropriate antimicrobial prophylaxis prevents </li></ul><ul><li>recurrence of disease in patients who’ve had </li></ul><ul><li>ARF </li></ul><ul><li>Most patients with ARF have elevated antibody titers </li></ul>
  38. 69. Case #14 A 72 year old presents to the clinic with pain in his toes associated with mottling of both lower extremities.
  39. 71. Differential Diagnosis for Blue Toes <ul><li>CES </li></ul><ul><li>Critical ischemia from PVD </li></ul><ul><li>Thromboembolism </li></ul><ul><li>Vasculitis </li></ul><ul><li>Antiphosholipid antibody syndrome </li></ul><ul><li>Heparin-induced thrombocytopenia </li></ul><ul><li>Essential thrombocythemia </li></ul>
  40. 72. CES (Cholesterol Emboli Syndrome) <ul><li>Pain, tenderness in toes </li></ul><ul><li>Livedo reticularis on legs, feet , buttocks </li></ul><ul><li>May cause acute renal failure </li></ul><ul><li>Infarction, necrosis </li></ul><ul><li>Distal extremities: lower greater than upper </li></ul>
  41. 73. Case #15 A 24 year old male with an extensive family history of premature coronary artery disease presents for a general examination. He has noticed “growths” on his eyelids, elbows, and knees. What is the most likely diagnosis and what are the treatment options?
  42. 74. Xanthelasma
  43. 75. Familial Hypercholesterolemia <ul><li>High incidence of premature vascular disease esp. coronary artery disease at a young age </li></ul><ul><li>Tendon xanthomas, xanthelasma, early age arcus cornea </li></ul><ul><li>Difficult to “normalize” TC and LDL with statins alone </li></ul>
  44. 76. Case #16 An obese 45 year old diabetic presents with onset of abdominal pain extensive skin eruption
  45. 77. Eruptive Xanthomas
  46. 78. CASE #17 <ul><li>26 year old male presents for evaluation because of a strong family history of sudden death . He is tall 6’3”, is very near sighted. His exam reveals a high arch palate, a severe pectus excavatum .His cardiac exam reveals a mid-systolic click at the apex. </li></ul><ul><li>What other physical findings would you look for? </li></ul>
  47. 79. Marfan’s Syndrome <ul><li>Tall stature </li></ul><ul><li>High arch palate, chest deformities such as pectus carinatum or excavatum </li></ul><ul><li>Double-jointed </li></ul><ul><li>Long arm-length span and positive thumb-wrist overlap sign </li></ul><ul><li>Often MVP </li></ul><ul><li>SCD may be due to ruptured thoracic aortic aneurysm </li></ul>
  48. 84. Case #18 A 60 year old female presents with shortness of breath and is found to have an iron deficiency anemia. What is the differential diagnosis?
  49. 87. <ul><li>Telangiectasia on lips and tongue and occult GI bleeding from AVMs </li></ul><ul><li>Commonly presents with epistaxis </li></ul><ul><li>A cause of iron deficiency anemia </li></ul>Rendu-Osler-Weber Hereditary Hemorrghagic Telangiectasia
  50. 88. Case #19 A 70 year old with congestive heart failure is on an anti-arrhythmic agent and presents with a skin rash.
  51. 90. Case #20 A 31 year old female with headaches and BP of 230/130. She has a loud abdominal bruit.
  52. 92. Fibromuscular Dysplasia <ul><li>Young females </li></ul><ul><li>Strokes </li></ul><ul><li>Asymptomatic cervical bruits </li></ul><ul><li>TIA’s </li></ul><ul><li>Renals first, carotids second </li></ul>
  53. 93. Fibromuscular Dysplasia <ul><li>Non inflammation </li></ul><ul><li>Non atherogenic </li></ul><ul><li>Associate intracranial aneurysm </li></ul><ul><li>Malignant resistant HBP </li></ul><ul><li>Sudden development of pulmonary edema </li></ul><ul><li>Unexplained azotemia </li></ul>
  54. 94. Diagnosis of Renal Artery Disease <ul><li>Duplex ultra sonogram </li></ul><ul><li>MRA </li></ul><ul><li>CTA – 64 row </li></ul><ul><li>Renal artery angiogram </li></ul>
  55. 95. Case #21 A 65 y/o patient presents with severe hypertension, chest, and interscapular pain. The chest x-ray suggests widening of the mediastinum. An ECG is normal. What are your options?
  56. 97. Case 22-Stump the Faculty A 12 year old presents to the emergency room with a shock from his ICD. What is the diagnosis?
  57. 98. Stump the Faculty
  58. 99. Long QT Syndrome (LQTS) <ul><li>Syncope </li></ul><ul><li>SCD at young age </li></ul><ul><li>Seizures </li></ul><ul><li>SIDS </li></ul><ul><li>1/5,000 people </li></ul><ul><li>QTc > 460 msec </li></ul>
  59. 100. LQTS - Precipitants <ul><li>Exertion </li></ul><ul><li>Emotional Stress </li></ul><ul><li>Auditory signals </li></ul>
  60. 101. QT Interval Prolongation <ul><li>Congenital </li></ul><ul><li>Medications </li></ul><ul><li>Electrolyte predisposition </li></ul>
  61. 102. An interesting chest x-ray in a patient with bypass surgery 15 years ago. Case 23-Stump the Faculty
  62. 105. Case #23 <ul><li>Twenty-eight year old Jewish male with pain in his finger tips. What questions should you ask him? </li></ul>
  63. 107. Buerger’s Disease (TAO) <ul><li>Non atherosclerotic </li></ul><ul><li>Inflammation </li></ul><ul><li>Small/medium size arteries </li></ul><ul><li>Normal S.R., c-rp </li></ul><ul><li>Young males 40’s </li></ul><ul><li>Exclusion of autoimmune disease </li></ul>
  64. 108. Buerger’s Disease (TAO) – Risk Factors <ul><li>Smoking </li></ul><ul><li>Periodontal diseases </li></ul><ul><li>Male </li></ul>
  65. 109. Buerger’s Disease (TAO) – Presenting Features <ul><li>Digital ischemia </li></ul><ul><li>Leg ulcerations </li></ul><ul><li>Claudication of arms or legs </li></ul>
  66. 110. Buerger’s Disease (TAO) – Treatment <ul><li>Complete cessation of smoking </li></ul><ul><li>Remember urine nicotine or cotinine </li></ul>
  67. 111. Case #24 Stump the Faculty A 70 year old with a history of rheumatic heart disease and history of mitral valve replacement presents with shortness of breath to your office. She has a hemoglobin of 9.6 gm/ml. The following blood smear is obtained. What is the differential diagnosis?
  68. 113. Case #25 A 42 year old male presents with right sided hemiparesis and global aphasia. VS are stable. Examination of the carotids and heart are normal. ECG is normal. CT of the brain was unremarkable. What other test may be useful to obtain a diagnosis?
  69. 116. <ul><li>PFO occurs in 25 to 30 percent of normal individual </li></ul><ul><li>There is an increase incidence in patients with cryptogenic stroke at a young age </li></ul><ul><li>PFO is often associated with other cardiac anomalies such as atrial septal aneurysm and Chiari Networks </li></ul><ul><li>PFO is more common in patients with ASA </li></ul><ul><li>PFO closure may help migraine headaches </li></ul><ul><li>Decompression sickness in scuba divers can result in embolus in pts. with PFO </li></ul>PFO
  70. 117. What Antiarrthymic Agent is this Patient On?
  71. 119. Amiodarone <ul><li>Prevalence of side effects is as high as 15 percent in the first year and 50 percent with long-term therapy. Commonly known side effects include: </li></ul><ul><ul><li>Abnormal liver studies </li></ul></ul><ul><ul><li>Chronic interstitial pneumonitis </li></ul></ul><ul><ul><li>Solitary pulmonary mass </li></ul></ul><ul><ul><li>Hypo or hyperthyroidism </li></ul></ul><ul><ul><li>e. Elevation of the prothrombin time </li></ul></ul><ul><ul><li>f. “Blue man syndrome” </li></ul></ul><ul><ul><li>Digoxin level changes </li></ul></ul><ul><ul><li>Photosensitivity </li></ul></ul><ul><ul><li>Peripheral neuropathy </li></ul></ul>
  72. 120. What is the Diagnosis?
  73. 121. Case 26 - Stump the Faculty
  74. 122. Case #27 A 42 year old male from Thailand has a history of myocardial infarction treated with primary angioplasty. He presents later with recurrent chest discomfort over the past year. What is the diagnosis?