Determine Atherosclerotic Disease + Atherosclerotic Disease Flashcards
Disease primarily of the arterial endothelium
Plaques will invade tunica intima and cause thickening and scarring of the tunica media.
Pertinent Anatomy: Atherosclerotic Disease
1) Coronary arteries
2) Lower extremities arteries: Aortoiliac segment, femoral-popliteal segment, and tibial segment.
3) Cerebral arteries
4) Carotid arteries
5) Aorta
The different sites that are most commonly affected of Atherosclerotic Disease
Endothelial dysfunction, dyslipidemia, inflammatory and immunologic factors, plaque rupture, and smoking.
As plaques form, a new layer of endothelial tissue will cover the plaque and continue to cause inflammation and narrowing of the vessel. Along with endothelial tissue inflammation, tunica media thickens, and tunica intima becomes more rigid, leading to further vessel narrowing.
Dyslipidemia and abnormal lipids play a critical role in developing this disease.
Pathophysiology: Atherosclerotic Disease
*Dyslipidemia and abnormal lipids play a critical role in the development of
Atherosclerotic Disease
1) *Hypercholesterolemia
2) *Hypertension
3) *Diabetes Mellitus
4) Male gender
5) Smoking
6) Family history
Risk factors for atherosclerotic disease
(1) *Coronary atherosclerosis leads to coronary arterial narrowing.
(2) *Number one killer in the United States.
Atherosclerotic Coronary Artery Disease (CAD)
(a) Family history
(b) Male gender
(c) Hypercholesterolemia
(d) Diabetes mellitus
(e) Hypertension
(f) Physical inactivity
(g) Abdominal obesity
(h) Cigarette smoking
Excessive alcohol
(j) Poor diet: Low in fruits and vegetables, high in fat.
(k) Metabolic Syndrome
Risk Factors:
Atherosclerotic Coronary Artery Disease (CAD)
Metabolic Syndrome:
Combination of medical disorders that, when
occurring together increase the risk of developing cardiovascular disease and diabetes
(abdominal obesity,
- triglycerides > 150 mg/dL,
- HDL < 40 mg/dL for men and < 50 mg/dL for women, fasting glucose > 110 mg/dL, and hypertension)
(a) Chest pain
(b) Left shoulder pain
(c) Indigestion
(d) Nausea/Vomiting
(e) Pale
(f) Diaphoresis
(g) New heart murmur
(h) Rales on pulmonary examination
(i) S3
(j) S4
(k) Sudden cardiac death
Symptoms/Physical Exam Findings:
Atherosclerotic Coronary Artery Disease (CAD)
(a) Lipid panel (looking for LDL, which is bad cholesterol, and HDL, which is good cholesterol).
(b) EKG
(c) Fasting glucose
(d) Troponin
*these are the same as hyperlipidemia
Labs/Studies:
Atherosclerotic Coronary Artery Disease (CAD)
LDL is
bad cholesterol
HDL is
good cholesterol
1) ***Lifestyle changes: Increase activity and exercise.
2) Low-fat diet high in fruits and vegetables.
3) MOST important SMOKING CESSATION.
4) Moderate use of alcohol.
5) Control of HTN, Diabetes, and hypercholesterolemia.
Non Pharmacological Treatment:
Atherosclerotic Coronary Artery Disease (CAD)
HMG-CoA reductase inhibitors
MOA: They work by inhibiting the rate-limiting enzyme in the formation of cholesterol.
- Atorvastatin (Lipitor) - Initial dose 10 mg before bedtime, titrate to a maximum dose of 80 mg
*NOTE: Adverse Reactions: Rhabdomyolysis
Monitoring: Need to check initial LFTs, then repeat in 3-6 months
- Aspirin (Bayer, Ecotrin, Enteric coated Aspirin) -The dose for primary prevention is *81 mg daily for > 10 years.
Pharmacological Treatment:
Atherosclerotic Coronary Artery Disease (CAD)
1) Coronary Artery Bypass Grafting (CABG)-a large clot
2) Stenting (opening the artery)
3) Primary percutaneous coronary intervention
Surgical Treatment:
Atherosclerotic Coronary Artery Disease (CAD)
(a) Number one thing is risk factor modification.
(b) If signs of Acute Myocardial Infarction need to MEDEVAC STAT.
(c) Treat underlying HTN, Diabetes, and Hypercholesterolemia.
Initial Care:
Atherosclerotic Coronary Artery Disease (CAD)
***_____________________ are occlusive atherosclerotic lesions that develop in the legs and, less commonly, the arms causing decreased perfusion of the extremities.
S/S similar to CAD
It may be diffuse but usually occur segmentally (aortoiliac segments, Femoral- Popliteal segments, and Tibial segment)
*High correlation between smokers and patients with diabetes.
Atherosclerotic Peripheral Vascular Disease (PAD)
(a) Claudication
(b) Patients with pain unrelieved by rest are at high risk for amputation.
(c) Diminished femoral, popliteal, or pedal pulses.
(d) Tissue ulceration and gangrene.
(e) Erectile dysfunction
(f) Loss of hair
(g) Thinning and cool skin
(h) Atrophy of muscles
Symptoms/Physical Exam Findings:
Atherosclerotic Peripheral Vascular Disease (PAD)
***What is cramping pain or tiredness in the thigh, calf, or foot with walking or exercise and relieved by rest?
Claudication
(a) Doppler examination with ABI
(b) ***CT Angiography and Magnetic Resonance Angiography if intervention is required. (GOLD STANDARD)
(c) Lipid panel
(d) Chemistry - to evaluate for renal dysfunction
Labs/Studies:
Atherosclerotic Peripheral Vascular Disease (PAD)
1) SMOKING Cessation
2) Risk factor reduction
3) Weight loss
4) Consistent moderate exercise
Non Pharmacological Treatment:
Atherosclerotic Peripheral Vascular Disease (PAD)
Treatment: Trial of Phosphodiesterase inhibitor:
Cilostazol
100 mg PO BID
Pharmacological Treatment: Atherosclerotic Peripheral Vascular Disease (PAD)
1) Surgical Bypass
2) Endovascular angioplasty/stenting
3) Amputation
Surgical Treatment: Atherosclerotic Peripheral Vascular Disease (PAD)
***EMERGENCY
Acute occlusion due to emboli or thrombus.
Emboli
Thrombus
50% goes to limbs 20% goes to brain
Atrial Fibrillation is the most common cause, but it can also be caused by valvular heart disease.
Claudication
Acute Arterial Occlusion of a Limb
- ________ are thrombus or plaque that breaks off and travels until the lumen becomes too small for the _______ to continue to move.
- _______ large enough to occlude proximal arteries are almost always from the heart.
Emboli
_______ is a blood clot that forms as a plaque ruptures, and platelets start to adhere and aggregate on the rupture site.
Thrombus
50% of the heart goes to the lower extremity, 20% goes to cerebrovascular circulation, and the remainder goes to the upper limb, renal, and mesenteric circulation.
Arterial Occlusion
Typical patient with a primary thrombus has a history of
Claudication
(a) **Sudden onset of extremity pain with loss or reduction of pulses is diagnostic.
(b) **Neurological deficits: Numbness or paralysis
(c) Signs of severe arterial ischemia are the six 6 Ps
Symptoms and Physical Exam Findings:
Acute Arterial Occlusion of a Limb
1) Pain
2) Pallor (or mottled with delayed capillary filling)
3) Poikilothermia (coolness)
4) *Pulselessness
5) Paresthesia
6) Paralysis
Signs of severe arterial ischemia
(a) Chemistry may show systemic acidosis.
(b) Doppler will show little or no blood flow to distal vessels.
(c) CTA/MRA should be done in the operating room to prevent delay in revascularization.
Labs/Imaging: Acute Arterial Occlusion of a Limb
Enoxaparin (Lovenox) anticoagulant
Dose: 1mg/kg SC q12 hours
Heparin Sulfate 5000-10,000 Units IV STAT
Immediate Revascularization within 3 hours. Delays increase the risk of irreversible tissue damage. Risk approaches 100% at 6 hours.
1) Surgical intervention
2) Endovascular Thrombolysis
Treatment: Acute Arterial Occlusion of a Limb
Immediate Revascularization within _______. Delays increase the risk of irreversible tissue damage. Danger approaches 100% at ______.
1) Surgical intervention
2) Endovascular Thrombolysis
Revascularize: 3 hrs
Danger: 6 hrs
(a) Give a dose of Heparin immediately 5000-10,000 Units IV STAT
(b) MEDEVAC immediately, do not delay.
Initial Care: Acute Arterial Occlusion of a Limb
