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Note: Understanding the pathophysiologic changes associated with longstanding valvular disease has a high yield (e.g., do you understand why mitral stenosis or regurgitation can cause right heart failure?). (See figures, top of next page.)

Use endocarditis prophylaxis for people with known valvular heart disease (with mitral valve prolapse, use prophylaxis only if a murmur is heard on physical exam or if the patient has history of endocarditis) or prosthetic valves. For oral surgery, use amoxicillin before and after the procedure (use erythromycin in penicillin- allergic, patients). For gastrointestinal or genitouri nary procedures, use ampicillin plus gentamicin before and amoxicillin after procedure (substitute vancomycin for penicillin-allergic patients).

Important points:

1. Remember Virchow's triad (endothelial damage, stasis, and hypercoagulable state) as a clue to the the diagnosis of deep vein thrombosis (DVT).

2. Common causes or situations in which DVT occurs: surgery (especially orthopedic, pelvic, or abdominal), neoplasms, trauma, immobilization, pregnancy, oral contraceptives, disseminated intravascular coagulation, lupus anticoagulant, and deficiency of antithrom-bin III, protein C, or protein S.

Aortic stenosis: The narrowed aortic valve results in high pressures in the I eft ventricle, which are transmitted to the left atrium and ultimately resulting in pulmonary hypertension. The left ventricle is hy-pertrophied due to the chronic pressure overload. (From James EC, Corry RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987, with permission.)

Mitral stenosis: The mitral valve orifaco is narrowed, resulting in obstruction to flow out of the atrium and an increase in pressure in the left atrium and pulmonary veins. Pulmonary hypertension develops secondarily. A = A wave, V = V wave, M = mean pressure. (From James EC, Corry RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley Si Belfus, 1987, with permission.}

Mitral stenosis: The mitral valve orifaco is narrowed, resulting in obstruction to flow out of the atrium and an increase in pressure in the left atrium and pulmonary veins. Pulmonary hypertension develops secondarily. A = A wave, V = V wave, M = mean pressure. (From James EC, Corry RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley Si Belfus, 1987, with permission.}

Aortic stenosis: The narrowed aortic valve results in high pressures in the I eft ventricle, which are transmitted to the left atrium and ultimately resulting in pulmonary hypertension. The left ventricle is hy-pertrophied due to the chronic pressure overload. (From James EC, Corry RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987, with permission.)

3. DVTs commonly present with unilateral leg swelling, pain or tenderness, and/or Homan's sign (present in 3 0%).

4. The best way to diagnose DVT is doppler ultrasound or impedance plethysmography. The gold standard is venography, but. it is invasive and usually reserved for settings in which the diagnosis is not clear.

5. Superficial thrombophlebitis (erythema, tenderness, edema, and palpable clot in a superficial vein) is not a risk: factor for pulmonary embolism (PE) and generally is considered a benign condition. Treat with NSAIDs or aspirin.

6. In patients with DVT, systemic anticoagulation is necessary. Use IV heparin, followed by gradual crossover to oral warfarin. Patients are maintained on warfarin for at least 3 months, possibly permanently if they experience more than one episode.

7. The best DVT prophylaxis for surgery is pneumatic compression boots and early ambula tion; use low-dose heparin if ambulation is not possible. Warfarin is an alternative, especially for orthopedic hip or knee surgery.

8. Pulmonary embolus follows DVT, delivery (amniotic fluid embolus), or fractures (fat emboli). Symptoms include tachypnea, dyspnea, chest pain, hemoptysis (if lung infarct), and hypotension, syncope, and death if severe. Rarely, on. a chest x-ray you may see a wedge-shaped defect due to a pulmonary infarct.

9. Left-sided heart clots (from atrial fibrillation, ventricular wall aneurysm, severe congestive heart failure, or endocarditis) that embolize cause arterial-sided infarcts (stroke and renal, GI, and extremity infarcts), no I PEs. Right-sided clots that embolize (DVTs) cause PEs, noi arterial emboli. The exception is a patent foramen ovale, in which the clot may cross over to the left side of the circulation and cause an arterial infarct .

10. UseV/Q scan to screen for PE. If positive, PE is diagnosed and treated, If indeterminate, use pulmonary angiogram (the gold standard, but invasive). If low probability or negative, it is highly unlikely that the patient: has a significant PE.

11. Treat PE with IV heparin to prevent further clots and emboli; then, gradually switch to oral warfarin, on which the patient will remain for at least 3 months. If clots recur on anticoagulation or the patient has contraindications to anticoagulation., use inferior vena cava filter (Greenfield filter).

12. Heparin causes thrombocytopenia and arterial thrombosis in some unlucky patients. Discontinue heparin immediately!

13. Heparin is followed by determination of partial thromboplastin time (FIT) (internal pathway), and warfarin is followed by prothrombin time (PT) (external pathway), whereas aspirin affects the bleeding time. In emergencies, reverse heparin with protamine, reverse warfarin with fresh frozen plasma and/or vitamin K, reverse aspirin with platelet transfusion.

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