Arterial disorders Flashcards
Describe the pathological changes seen in Artherosclerosis
PAD is a disease that affects arteries 2mm > in diameter due to the build up of fatty deposits (arteriosclerosis), causing obstructed blood flow and thinning/weakening of walls.
This occurs as the endothelium of the artery is damaged due to irritants in the blood, such as lipids, toxins – from cigarettes or high blood pressure.
This endothelial lining therefore is broken down. The lipids stick to the damaged walls and form a thin fatty streaked layer on the walls.
WBC’s such as macrophages, migrate to the area and undergo phagocytosis, engulfing the lipids. They therefore form foam cells.
More lipids deposit on the damaged endothelial walls over time. Dead WBC’s reside in the area so the layer of fat thickens, forming a plaque which causes ischaemia.
The smooth muscle cells trigger collagen release to contain the lipid plaque, therefore preventing thrombogenic material triggering a blood clot. This acts as a fibrous cap.
This fibrous cap may eventually rupture, forming a clot which may dislodge and become a pulmonary embolism which may cause serious cardiorespiratory disorders such as heart failure.
Calcium may also deposit on the arterial wall, further weakening and hardening the arteries.
What are the clinical features of atherosclerosis?
The patient may have pain at night as there is decreased blood flow to the peripheries. This occurs due to elevated position. This may be resolved with dangling the leg.
The patient may have intermittent claudication due to ischaemia as a result of the plaques in the arteries so there is decreased tissue perfusion.
This may cause the patient to avoid exercise, and therefore undergo a cycle of deconditioning, therefore find mobilising difficult. The patient may therefore have muscular atrophy.
On observation, the patient may have pale, cool, dry and thin skin due to the ischaemia, decreasing tissue perfusion. This may also cause ulcerations in the skin as the decreased circulation reduces the healing times in the tissues.
Hypertension may occur due to the occlusion in the arteries and other predisposing factors such as poor diet, smoking, diabetes, high LDL cholesterol, family history of PVD, CVD and stroke.
Increases the risk of developing
- Arteriosclerosis
- PAD
- CAD
Intermittent claudication may cause reduced walking ability
Non-healing leg wounds/ulcers and/or gangrene.
5P’s include loss of pulse, pain, pallor, paraesthesia and paralysis.
Angina
MI
Explain how a diagnosis of Peripheral Arterial Disease might affect the selection and use of physiotherapy treatments for the lower limb
Rehab post complications:
o Cardiac rehab involvement for patients who have had an MI, CABG, Heart valve or heart failure. Include respiratory and MSK/exercise prescription- important to monitor vital signs throughout.
It is an integral part of the patients cardiological management providing exercise, education and psychosocial intervention from the acute episode and through to full recovery.
o Neurological after stroke
o Amputee due to PAD
Education
o Smoking cessation. Sign post to necessary help.
o On diet and affect on high blood pressure.
o Increase physical activity
o Advice on weight
o Diabetes management/foot care
o Health promotion throughout all age groups
Exercise prescription (see cardio notes) – Class or HEP
• Relaxation activity and teach to manage own stress. Breathing control, tai chi, relaxation techniques.
• Precaution and implication to some treatment
o Anything that need sensation e.g. ultrasounds
• Pacing and reassurance
• Using an objective measure.
The physio may not use massage as the skin will be damaged. Also there is a risk of increasing blood flow to the area which will cause oedema and swelling and increase the risk of a thrombus formation/ PE.
The physio will not want to elevate the leg as this will reduce blood flow to the area, therefore further reducing tissue perfusion to the already hypoxic tissue.
Taping – damaged skin
Cryotherapy – this will vasoconstrict the arteries, further decreasing blood flow to the area.
Therapeutic ultrasound – skin may have decreased sensation, therefore putting the damaged tissue at risk.
(diagnosis occurs through examination of the patients feet and legs, assessing the femoral/popliteal and foot pulse, using an ankle brachial pressure index and using angiography)
State the predisposing factors for Coronary Artery Disease, giving a brief explanation of how each factor increases the risk of developing the disease
- Hypertension – this can increase the adherence of monocytes to the endothelial lining of arteries = plaque. Also larger atheromas form at areas of high blood flow irregularities e.g. arterial branches.
- Hyperlipidaemia –may be genetic in origin. Pt’s with this have decreased receptors for LDL cholesterol in the smooth muscle, hepatocytes and fibroblasts. Therefore this is increases LDL cholesterol in the blood, therefore increasing the risk of developing CAD.
- Smoking – toxins in cigarette smoke that are soluble in plasma, damage the endothelial lining of the coronary artery – increasing lipid adhesion.
- Diabetes – potential hypertension as a result of hyperglycaemia.
- Lack of physical exercise – benefits are reduction in adipose tissue, lowering of blood pressure, prevents obesity, reduces the myocardial o2 demand, therefore increasing exercise capacity and lowers the workload of the heart Male over 50.
Explain how the pathological changes of Coronary Artery Disease may lead to the possible signs, symptoms and clinical features. (10)
Atherosclerosis of the coronary arteries causes subsequent thrombosis which occludes the vessels, reducing BF.
Coronary arteries dilate slightly to increase myocardial perfusion in proportion to o2 demand. In CAD, the CA have a reduced ability to dilate, therefore reducing perfusion to the myocardial tissue. This is called ischaemia.
The myocardium is unable to respire anaerobically and produce ATP for energy = reduced ability to contract = hypertrophy as demand increases = overstretched cardiac muscle = reduced recoil = reduced SV and arrythmias.
Narrowing of lumen leads to ischaemia:
- Angina - (Stable and unstable) - Chest pain, discomfort and tightness that occurs when an area of myocardium received decrease blood oxygen supply. Pain is often aggravated by increased demands on the heart which may be due to excs or due to the sympathic stimulation for other reason (e.g. stress) and this loads the heart muscles. Pain in commonly found on the left side of chest, neck, face, jaw and back and down the arm.
- Ischaemic heart disease
- Sudden occlusion of CA (e.g. thrombus or embolism) may cause myocardium or CC infarct - reduced o2 and nutrients to the mycardium - Serious chest pain with other signs of a heart attack include shortness of breath, dizziness, faintness, or nausea.
- Plaques may provide sites for thrombus = break off to form PE = angina, MI. Plaques may weaken arterial walls causing an aneurysm
Suggest how the physiotherapist may play a role in preventing Coronary Artery Disease (5)
Health promotion -
- Education on diet (thus weight, BMI, obesity) smoking cessation, conditions related to these areas - modifiable risk factors
- Exercise promotion - mobilising patients in the wards, preventing deconditioning, atrophy, venous stasis and therefore increased risk of thrombogenesis - exercise promotion (HEP or group)
- Relaxation promotion e.g. breathing exercises, tai chi, yoga
- avoiding tight clothing and compression
- maintaining skin health
- Identifying those who are more at risk of developing CAD e.g. smokers, obese, poor diet, sedentary
