Clinical Atherosclerosis

Question 1

If you have SYMPTOMATIC peripheral arterial disease (PAD), is there a good chance you have a flow limiting coronary artery disease, or more?

Answer 1

YES

Question 2

If you have DIAGNOSED peripheral arterial disease (PAD), do you have an 8x increase in cardiac mortality?

Answer 2

YES

Question 3

Where is most PAD?

Answer 3

lower extremities

Question 4

Where is the most common atherosclerotic narrowing in a NON-DIABETIC pt?

Answer 4

mid-thigh (superficial femoral artery)

Question 5

Where is the most common atherosclerotic narrowing in a DIABETIC pt?

Answer 5

the popliteal trifurcation (anterior tibial, posterior tibial, and peroneal; fibular)

Question 6

What are the symptoms of peripheral arterial disease (PAD)?

Answer 6

intermittent claudication= cramping pain in the leg (calf muscle) is induced by exercise, typically caused by obstruction of the arteries. This occurs due to the cells undergoing anaerobic respiration, generating lactic acid. Therefore, the more you walk, the more it hurts.
As the disease progresses, shorter distances/less exercise will induce the pain.

Question 7

Do many pts tolerate intermittent claudication (leg cramping)?

Answer 7

YES until it makes their lives stink!

Question 8

In your work up what should you always ask if the patient complains of leg cramping (intermittent claudication?

Answer 8

When you walk do your legs hurt? How far do you go? What does the pain feel like? Does it go anywhere from there?
Aka you work it up just like you would for angina pectoris to see if it is from the heart.

Question 9

Will foot pain also accompany leg pain in DIABETICS with PAD?

Answer 9

YES often

Question 10

Is atherosclerosis a metastatic process?

Answer 10

YES

Question 11

How do we quantitate PAD?

Answer 11

with an ankle-brachial index (ABI). When it is 0.90 or less you have PAD. It should always be greater than 1 in a healthy patient.

Question 12

What is the most common access site for an angiogram?

Answer 12

common femoral (off the external iliac)

Question 13

What ultrasound exam is performed first to locate the disease exactly?

Answer 13

Arterial duplex scan

Question 14

What important skeletal muscles does the internal iliac supply, and why is this important?

Answer 14

ipsilateral gluteus maximus and upper thigh. So if this is diseased, you will get pain in the butt and upper thigh.

Question 15

Why is PAD of the internal iliac commonly misdiagnosed?

Answer 15

L1-2 radiculopathy (disease of nerve root) goes right through this band and is written off after x-ray as arthritis.

Question 16

What is the end artery of the internal iliac in a male, and why is this important?

Answer 16

pudendal artery (supplies genitalia). So if this is diseased, you will lose loss of erectile function (ED).

Question 17

What are the 2 reasons for erectile dysfunction?

Answer 17

1. vascular (75%)= if proximal you can significantly improve with a stent (angioplasty). Small vascular (mainly diabetics) respond well to PDE5 inhibitor medications (Levitra, Cialis, Viagra) because most of these receptors are found in the penis and lungs.
2. supratentorial (25%)= stress, depressed…

Question 18

What happens when you take a PDE5 inhibitor?

Answer 18

it explodes nitric oxide (NO) in the penis and lungs, causing vasodilation (inflow is improved) and relaxes smooth muscle, improving erectile function.

Question 19

Do female pts take PDE5 inhibitos?

Answer 19

YES for treatment of pulmonary hypertension, because there are many PDE5 receptors in the pulmonary arteries.

Question 20

What should be a part of every differential in your review of symptoms for GU for male pts?

Answer 20

ED

Question 21

Do urologists have a quantitative measurement for someone who comes in with internal iliac disease?

Answer 21

YES. penile-brachial index (PBI); cuff that goes on the penis. If it is 0.6 or less, you have internal iliac disease and a vascular etiology for your ED.

Question 22

How does the ankle-brachial index (ABI) work?

Answer 22

measure the systolic pressure of the brachial artery, and the systolic pressure of the 3 ankle arteries with doppler.

Question 23

Why do very small changes in vessel radii have larger pressures?

Answer 23

due to Bernoulli’s perfusion principle: systolic pressure= r^4 . So pressures in the ankle should always be higher than in the arm (w/o PAD). This is why it should always be greater than 1 for healthy individuals.

Question 24

What is the number 1 risk factor for PAD?

Answer 24

smoking

Question 25

Will you have micro-ischemia before pain sensation?

Answer 25

YES

Question 26

Does ischemia cause vasodilation?

Answer 26

YES and this is why the pressures will drop in the ankle compared to the brachial artery in those with PAD. It is a compensatory mechanism.

Question 27

What is the other compensatory mechanism for ischemia besides vasodilation?

Answer 27

collateral circulation

Question 28

What will smoking just 1 cigarette do to those with PAD?

Answer 28

spasm off collateral circulation that you’ve built up for compensation, and vasodilate less for 6-8 hours. Plus you increase platelet activity, clotting off these tiny arteries :(

Question 29

What kind of studies do we do now first if you have symptoms of PAD?

Answer 29

MPI (myocardial perfusion study). You get this before balloon/stent or surgery of leg. In most cases, active coronary disease is found, that has not yet expressed itself (many are diabetics). These patients don’t get chest pain, but instead get dyspnea with exertion (aka their anginal equivalent).

Question 30

Why do diabetic patients develop silent ischemia?

Answer 30

because they have neuropathy of their pericardium (where most pain receptors of the heart are found), and don’t feel the pain of ischemia that non-diabetics would feel.

Question 31

What is the formula for ABI?

Answer 31

ANKLE systolic pressure/ BRACHIAL systolic pressure

Question 32

What is the most common atherosclerotic vessel of the upper extremity?

Answer 32

left subclavian artery off of the aorta. This means that as this gets tighter and tighter, your left brachial pressure will get lower and lower.

Question 33

What is vertebrobasilar steal syndrome?

Answer 33

the resistance in the left arm drops below the posterior circulatory resistance of the brain, so instead of the blood flowing up to the brain, it reverses and comes back toward the arm. This is a cause of syncope in the elderly that docs rarely look for, but you should!

Question 34

What is the the other cause of vascular syncope other than vertebrobasilar steal syndrome?

Answer 34

carotid sinus hypersensitivity

Question 35

***Dr. Arnold’s pearl for us: What are the 2 things you should always check for first when a patient comes in with syncope?

Answer 35

1. vertebrobasilar steal syndrome

2. carotid sinus hypersensitivy

Question 36

***What is an example of how to do an ABI?

test question

Answer 36

RA= 100 mm H, LA= 90 mm Hg
RL= dorsalis pedis=110, posterior tibial= 100, peroneal= 90
LL= DP= 60, PT= 70, P= 50
*Use highest of arm pressures for both denominators.
*Use highest of each ankle pressure for the numerator.

Right ABI= 110/100 = 1.1
Left ABI= 70/100 = 0.7
If the patient complains of his/her left leg hurting, this confirms his symptoms and thus PAD.

Question 37

What 3 sounds should you listen for using the doppler in the ankle arteries?

Answer 37

triphasic, biphasic, or monophasic sounds :(

Question 38

**What ABI values must we know?

Question 39

What is the first physical sign of PAD flow limitation?

Answer 39

loss of toe and foot hair (definite demarcation of hairy foot and shiny skin).