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*CLINICAL EXERCISE PHYSIOLOGY > EXAM2/CH17- PAD > Flashcards

EXAM2/CH17- PAD Flashcards

1
Q

PVD

A

peripheral vascular disease

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2
Q

where does PVD occur

A

arteries + veins

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3
Q

PAD

A

peripheral artery disease

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4
Q

where does PAD occur

A

ONLY the arteries

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5
Q

are PVD + PAD the same thing

A

no

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6
Q

peripheral artery disease (PAD)

A

blockage of the leg arteries by plaque, leading to gradual narrowing of the arteries in the lower extremities
-leads to decreased blood flow to muscles of the leg

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7
Q

PAD is the same issue seen in ____

A

CVD

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8
Q

PAD in arms is less/more severe

A

MORE SEVERE

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9
Q

what is the prevalence of PAD

A

202 million cases

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10
Q

more than ____ adults have PAD in the United States

A

8 million

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11
Q

___% to ___% of PAD patients have intermittent claudication (IC)

A

35-40%

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12
Q

___% to ___% of PAD patients experience critical limb ischemia

A

1-2%

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13
Q

individuals with PAD are at high risk of developing ____

A

CVD

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14
Q

critical limb ischemia

A

most severe PAD that occurs when not taking care of your PAD

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15
Q

common risk factors of PAD

A

-diabetes
-smoking
-hypertension
-hypercholesterolemia
-increased blood viscosity (blood thickness)

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16
Q

blood viscosity

A

blood thickness

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17
Q

PAD has the same risk factors as what

A

CVD

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18
Q

patients with PAD have an increased risk of what 2 types of diseases

A

-cardiac
-cerebrovascular

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19
Q

pathophysiology of PAD

A

(same as pathophysiology for atherogenesis in CH13)

  1. endothelial injury (chronic or excessive injury)
  2. inflammatory response (monocyte, platelet, LDL-C aggregation)
  3. endothelial dysfunction (increased wall adhesiveness, impaired vasodilation)
  4. plaque formation (lesions progress from endothelium to intima)
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20
Q

2 signs + symptoms of PAD

A

-intermittent claudication
-critical limb ischemia

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21
Q

what is the most common symptom of PAD

A

intermittent claudication
-most common symptom once the disease process reaches a certain point

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22
Q

what % people with PAD experience intermittent claudication

A

35-40%

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23
Q

what is intermittent claudication caused by

A

ischemia

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24
Q

intermittent claudication

A

-pain, cramping, aching feeling
-tends to occur with physical exertion + diminish with rest

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25
Q

what is the most common location for intermittent claudication

A

calf (gastrocnemius)
-increased gastrocnemius O2 consumption during walking but those with PAD do not have O2 delivery capacity to the lower extremity

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26
Q

if PAD is not treated where does intermittent claudication move

A

thighs/hips

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27
Q

what is intermittent claudication of the thigh + buttock region indicative of

A

PAD in the profunda femoris + internal iliac

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28
Q

critical limb ischemia

A

chronic ischemia causing more severe PAD (arterial occlusive disease) + can lead to ischemia at rest, foot ulcers, or gangrene
-wounds don’t heal

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29
Q

gangrene

A

a serious condition that occurs when tissue dies due to a lack of blood flow or a bacterial infection

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30
Q

what may critical limb ischemia ultimately lead to

A

amputation

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31
Q

what % of PAD cases experience critical limb ischemia

A

1-2%

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32
Q

if PAD is suspected, what are the invasive + noninvasive procedures that occur in the initial assessments

A

-scales (Fontaine, Rutherford)
-imaging (angiography, ultrasound)
-hemodynamic (pressure) studies

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33
Q

scales for suspected PAD

A

-Fontaine
-Rutherford

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34
Q

imaging for suspected PAD

A

-angiography
-ultrasound

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35
Q

hemodynamics

A

pressure studies

36
Q

treatment for if PAD is suspected

A

surgical interventions can be used in severe conditions

37
Q

Fontaine scale

A

1.. asymptomatic (incomplete blood vessel obstruction)
2a.. mild claudication in limb
2b.. moderate to severe claudication in limb
3.. ischemic pain at rest, mostly in feet
4.. ulceration, gangrene, or necrosis of the limb

38
Q

Fontaine scale is subjective/objective

A

100% subjective
-physician creates rating based on what the patient tells them

39
Q

Rutherford scale

A

-grade 0, category 0
* asymptomatic–no hemodynamically significant occlusive disease
* objective test: normal treadmill or reactive hyperemia test

-grade 0, category 1
* mild claudication
* objective test: completes treadmill exercise; ankle pressure after exercise > 50 mmHg but at least 20 mmHg lower than resting value

-grade 1, category 2
* moderate claudication
* objective test: between categories 1 + 3

-grade 1, category 3
* severe claudication
* objective test: cannot complete standard treatmill exercise, + ankle pressure after exercise < 50 mmHg

-grade 2, category 4
* ischemic rest pain
* objective test: resting ankle pressure < 40 mmHg, flat or barely pulsatile ankle or metatarsal pulse volume recording; toe pressure < 30 mmHg

-grade 3, category 5
* minor tissue loss–nonhealing ulcer, focal gangrene with diffuse pedal sichemia
* objective test: resting ankle pressure < 60 mmHg, ankle or metatarsal pulse volume recording flat or barely pulsatile; toe pressure < 40 mmHg

-grade 3, category 6
* major tissue loss–extending above transmetatarsal level, functional foot no longer salvageable
* objective test: same as category 5

40
Q

Rutherford scale is subjective/objective

A

subjective + objective
-SO, THIS SCALE IS MORE USEFUL

41
Q

Fontaine or Rutherford scale is more useful

A

Rutherford- has both subjective + objective criteria

42
Q

diagnostic testing for PAD- imaging (2)

A

-CT angiography
-MRI angiography

43
Q

imaging studies for PAD

A

provide anatomic detail (of plaque buildup)

44
Q

PAD imaging- CT angiography

A

-most common first-line option
-uses iodine contrast injection
-detailed image of blood vessels + tissue

45
Q

PAD imaging- MRI angiography

A

-with/without contrast
-radio frequency waves give image of vessels

46
Q

advantages of CT angiography

A

-widespread availability
-simplicity of imaging protocols
-higher spatial resolution
-rapid scanning times
-large gantry size
-ability to viasualize calcium
-ability to visualize lumen within stents
-lower cost

47
Q

CT angiography disadvantages

A

-artifact in presence of severe calcium
-exposure to ionizing radiation
-use of nephrotoxic contrast

48
Q

MRI angiography advantages

A

-absence of ionizing radiation
-no interference from calcium
-ability to obtain some information with specialized protocols without use of contrast agents

49
Q

MRI angiography disadvantages

A

-higher cost
-more complicated imaging protocols
-contraindicated in patients with ferromagnetic materials (pacemakers, orthopedic hardware, shrapnel)
-small gantry size, limiting studies for patients with claustrophobia or marked obesity
-scanning times prolonged, requiring greater degree of patient cooperation
-venous contamination in legs
-difficulty visualizing stents; artifact from previously placed stents

50
Q

diagnostic testing for PAD- hemodynamics (4)

A

-ankle-brachial index (ABI)
-toe pressure (toe-brachial index)
-segmental limb pressures
-transcutaneous oxygen pressure

51
Q

diagnosing PAD- hemodynamic studies

A

-provide FUNCTIONAL information
-uses pressure measurements

52
Q

what is the GO TO diagnostic tool for PAD

A

hemodynamics

53
Q

what is the most common diagnostic subtool of hemodynamics

A

ankle-brachial index (ABI)

54
Q

ankle-brachial index (ABI)

A

assesses pressure differences between the brachial artery + dorsalis pedis + posterior tibial arteries using BP cuffs + a Doppler probe (ultrasound)
-aka pressure difference between ankle + arm

55
Q

larger pressure difference between ankle + arm in ABI =

A

more severe PAD

56
Q

if you had PAD, pressure will be lower in the ankle/arm

A

ankle

57
Q

diagnostic testing for PAD- segmental limb pressures

A

BP cuff measures at segments of the leg
-ankle -> calf -> thigh
-looking for changes between segments

58
Q

diagnostic testing for PAD- transcutaneous oxygen pressure

A

skin sensor detects O2 delivery to tossie

59
Q

transcutaneous oxygen pressure- lower value of O2 saturation in toe means +/- PAD

A

+

60
Q

2 categories of treatment for PAD

A

-optimal medical treatment
-revascularization (surgical bypass vs. endovascular techniques)

61
Q

the 2 categories of treatment for PAD are the same as for what disease

A

acute coronary syndrome
-same medications
-same revascularizaton proecedures

62
Q

PAD treatment- optimal medical treatment

A

-minimizing risk factors (HTN, smoking, diabetes, high cholesterol)
-antiplatelet agent (aspirin or clopidogrel)
-claudication improvement (not gaurenteed to go away)

63
Q

what is the ONLY drug shown to improve intermittent claudication

A

cilostazol
-only current drug shown to improve IC walking distance (54%)
-has HORRIBLE side effects so not commonly prescribed

64
Q

what other medication helps to relieve IC

A

ACE inhibitors

65
Q

PAD treatment- revascularization

A

similar to that of heart revascularization (CH14)

66
Q

4 methods of revascularization for PAD

A

-percutaneous transluminal angioplasty
-stenting
-atherectomy
-bypass

67
Q

is it possible for claudication to persist after treatment (either medication or revascularization)?

A

YES
-claudication may persist after treatment

68
Q

what is helpful in diagnosing PAD

A

exercise testing
-can do a sign/symptom limited test for claudication + angina

69
Q

what will typically be done BEFORE + AFTER exercise testing

A

ABI

70
Q

goals of exercise testing

A

define functional limitations
-can they walk? (walking + walking FAST may be very hard for PAD patients; it encourages IC which is painful)
-do they have a prosthetic (due to amputation)?

71
Q

cardiovascular testing for PAD

A

-presence of intermittent claudication?
-at what point (time, intensity) does claudication set in?

72
Q

exercise testing protocol for PAD

e

A

treadmill (2-2-2)
-constant speed of 2 mph
-2% grade increase every 2 min (change in intensity is via change in GRADE)
-endpoint is patient’s intolerance to leg pain

73
Q

when is pre/post ABI abnormal

A

when the ankle pressure drops by 30 mmHg or more OR drops by >20% from baseline + takes >3 min to normalize

74
Q

other exercise testing- 6 min walk

A

patient self selects their speed
-useful in predicting functional capacity based on the distance that can be completed

75
Q

what % of patients with PAD are unable to complete treadmill walking for various reasons

A

16%

76
Q

other modalities for patients that cannot complete treadmill walking

A

-arm + leg ergometry
-recumbent stair stepping

77
Q

Dr. Gardner’s take away **know

A

-no 2 clinical patients are exactly alike
-start with program that is doable for patient + then progress

78
Q

Dr. Gardner’s minimum program requirements **know

A

cardiorespiratory
* 10 min per bout of exercise
* 2-3 days per week

resistance training
* 2-3 days per week

flexibility + balance
* as often as possible

79
Q

for PAD, low or high intensity training is more beneficial

A

low intensity is more beneficial

80
Q

ExRx intensity should be guided by what

A

IC symptoms
-patients must exercise below the ischemic threshold (before the pain kicks in)

81
Q

____ training is preferred

A

supervised

82
Q

in PAD patients doing ExRx, always assess for what

A

angina
-due to link to atherosclerosis

83
Q

as PAD patients exercise at higher intensities, attention should be focused on what

A

potential CVD symptoms due to high incidence of CAD

84
Q

benefits of exercise training for PAD

A

-walking distance increases
-higher ischemia threshold (distance to claudication onset increases)
-adverse CV event risks are reduced

85
Q

**PRIMARY goal of training for PAD

A

increase walking distance

86
Q

increased walking distance in PAD patients

A

-increased angiogenesis + collateral circulation, resulting in increased blood flow
-reduction in blood viscosity
-attenuation of atherosclerosis
-increased extraction of oxygen + metabolic substrates resulting from improvements in skeletal muscle oxidative metabolism
-increasd pain tolerance
-improved endothelial function

*CLINICAL EXERCISE PHYSIOLOGY (15 decks)

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