Hypotension & PAD Flashcards
What is the equation for pulse pressure?
- Systole - Diastole
- ex: PP= 120-80 = 40
What is an abnormal pulse pressure? What does it indicate?
Greater than 50-60mmHg
- this is known as Wide Pulse Pressure
- often indicates Isolate Systolic Hypertension (most common in elderly)
What are the numbers for hypotension in adults?
BP less than 90/60
What are symptoms of hypotension?
- lightheadedness (pre-syncope)
- fainting (syncope)
- blurry vision
- possibly confusion
What are 3 possible causes of hypotension?
- dehydration (especially elderly)
- standing for long periods
- medications
Severe hypotension &/or shock can be indicative of what?
Multisystem organ hypoperfusion
What could cause severe hypotension/shock?
- Sudden loss of large amount of blood
- Allergic reaction (severe)
- Infection
- Myocardial infarction
Explain Orthostatic Hypotension.
greater than a 20 mmHg fall in SBP and/or 10mmHg DBP within 3 mins of going from supine to upright position
aka- postural hypotension
(most common in elderly)
= an abnormal finding
** some authors include an elevation in pulse rate as part of the criteria
What are some possible causes of orthostatic hypotension?
- medications
- prolonged bed rest
- autonomic nervous system dysfunction (decreased baroreceptor sensitivity)
- cardiovascular disorders
- anemia
What is normal HR? bradycardia? tachycardia?
Normal= 60-100bpm Bradycardia= less than 60 Tachycardia= greater than 100
What is the regular rhythm of pulse called?
Sinus
What does a normal pulse imply of the heart?
normal pacemaker function of the SA node (no variation from beat to beat- evenly spaced)
What is arrhythmia? How is it elevated?
Irregular pulse (beats are uneven) EKG test will support finding
What are the 2 types of arrhythmias and what are their subtypes?
Regularly-irregular (has a definitive pattern) - physiologic sinus arrhythmia - bigeminal pulse - trigeminal pulse Irregularly- irregular (no pattern) - atrial fibrillation
Explain physiological sinus arrhythmias.
- typical for younger fit individuals
- corresponds to breathing
- asymptomatic pulse abnormalities are usually benign
Explain bigeminal pulse.
coupled rhythm of beats in pairs
- first beat= sinus beat
- second= premature, usually ventricular beat
Explain trigeminal pulse.
coupled rhythm of beats in triplets followed bya pause
- often benign in young, healthy people
- may indicate conduction problem in elderly patients with heart disease
Combination of ______ and ______ is suggestive of a pathological arrhytmia
Palpitations & pre-syncope
If you discover that your patient has an irregularly-irregular heart beat what is your next step?
suggests atrial fibrillation
- rapid, unsynchronized contraction of heart muscle fibers
- find out if they know they have a-fib first
- requires urgent EKG evaluation if patient did not previously have known a-fib
Explain atrial fibrillation
Can lead to stroke or death
- increased risk of blood clot formation when unsynchronized atria
- it if travels to brain (embolus) = stroke
- afib causes 15% of strokes
What are the 3 types of a-fib?
Lone episode- young & healthy patients. may be due to stress, alcohol, or stimulant
Paroxysmal= a sudden attack- intermittent episodes that last minutes to hours
Chronic, sustained - requires long term anti-coagulant and rate control medication
Match the medical terms for the listed grading pulse amplitudes:
- 0 (not palpable)
- 1 (barely palpable)
- 2 (normal)
- 3 (full or increased)
0= absent 1= thready 2= strong 3= bounding
What is peripheral arterial disease and what does it indicate?
- stenosis, occlusion, or aneurysm in the limb arteries or aorta
- indicates high risk for cardiovascular morbidity or mortality
- with PAD= 6x increased risk of heart attack
Is PAD the leading cause of artherosclerosis?
Yes
- usually occlusions in the large & medium sized vessels
How does atherosclerosis start and progress?
as a fatty streak= LDL deposition in walls
- progresses with chronic inflammation
What are the modifiable risks of PAD?
Smoking & diabetes
- also includes hypertension & hyperlipidemia
What is the Non-Modifiable risk of PAD?
age over 60
sometimes also includes being African-American
What is the pathophysiology of PAD?
plaque build-up leads to narrowed arteries= decreased blood supply= poor oxygen delivery= ischemia (painful)
- especially when exercising (due to tissue demand)
PAD= oxygen supply & demand mismatch
What is the symptom of PAD?
Main symptom= INTERMITTENT CLAUDICATION = exercise induced extremity pain (due to ischemia)
most common location= calf
With PAD will the pain be distal or proximal to the occlusion?
Distal
What are the main symptom locations for an Aorta-Iliac PAD, how do you exam it, and what is the pathophysiology?
- Butt, thigh, calf, external genitalia? (often bilateral)
- Decreased or absent femoral popliteal & pedal pulses
- progressive
What are the main symptom locations for a Femoro-Popliteal PAD, how do you examine it, and what is the pathophysiology?
- often unilateral calf muscle
- decreased or absent popliteal and pedal pulses (but femoral pulses intact)
- pathophys may progress but as likely for plaque to stay localized
What is the prognosis for Intermittent claudication?
5 year outcome= 75% will have stable symptoms
6% symptom progression
7% LE bypass
4% amputation
also, 20% will have an MI or stroke
What are the PAD Exam Findings?
- Decreased pulses
- coolness to touch
- color changes
- loss of hair growth
- poor blood supply can also result in skin damage (ulcer) or tissue death (gangrene)
The lack of which 2 pulses are a powerful predictor of advanced PAD?
- dorsal pedal & posterior tibial
* * but dorsal pedal OR post tibial pulse absence can be congenital
What is normal for capillary refill time?
less than 5 seconds
Explain PAD ulcers
- common, develop rapidly
- painful
- discrete edges, punched out appearance
- often covered with crust
- most common in lower extremities
Explain critical leg ischemia
- rest pain, cool, pale extremity, gangrene
- decreased 5 year survival (less than 50%)
How do you test for PAD?
Ankle-brachial index (ABI) = SBP ankle/SBP arm
normal range 1.0-1.3
- SBP ankle should be equal to or slightly high than SBP of brachial artery
What is an abnormal ABI and what does it correlate with?
ABI less than 1.0 correlates with threshold distance
How do you confirm a PAD diagnosis?
Doppler ultrasound of arteries
Peripheral arteriogram
How do you manage PAD?
quit smoking
treat hypertension, diabetes, hyperlipidemia
- Graded ambulation (graded exercise training might be most effective!!)
Antiplatelet therapy (aspirin)
Severe= surgery
Occasionally patients with PAD can have acute arterial occlusion. what causes this?
embolism from heart
Large proximal plaque
Embolism
Trauma
Where are complete vessel occlusion from embolism more likely to occur?
sites of artherosclerotic plaques
acute Peripheral Arterial Occlusion five Ps:
Pain- acute onset, severe, at rest Pulselessness Paresthesia Paralysis Pallor- matting
What does mottled skin look like?
Violaceous netlike vascular pattern
What is an aneurysm?
Pathologic dilation of a segment of a blood vessel
What are more AAA’s caused by?
degenerative processes
- breakdown of collagen and elastic fibers alters the tensile strength of the aorta, leading to a weakened arterial wall
What population is most at risk for AAA?
Males
5-8% of patients are over 60
What are the modifiable risk factors for AAA?
Cigarette smoking
Hypertension
Atherosclerosis
What are the symptoms of AAA?
Unless the AAA is about to or has just ruptured, AAAs present with no symptoms= asymptomatic
How are AAAs detected?
Careful abdominal exam or incidental finding on imaging
What are the chances of palpating an AAA?
normally 35%,
if the aneurysm is large, can be up to 85%
What type of imaging could detect an aneurysm?
Ultrasound/Doppler: sensitivity 95%; specificity, 100%
How big is a “technical” aneurysm?
Infra-renal aorta will be greater than 3 cm in diameter
What does it mean if an aneurysm is greater than 4 cm?
Increased risk of rupture
What is the rate of rupture is the AAA is 4.0-4.9cm?
~1%
What if the aneurysm is greater than 7 cm?
This is the peak incidence of rupture, 20-25%
AAA rupture is the ____th leading cause of death in the US
13th
How often are people diagnosed with an AAA before it ruptures?
Only 1/3
What are the symptoms of impending rupture of an AAA?
Flank pain (may mimic kidney stone) LBP (may mimic herniated disc) Deep, boring ab pain Key is acute onset in an older male smoker unrelieved by changes in position "pulsatile" sensation in abdomen
What % of AAA rupture patients die even if they make it into surgery?
70-90% = early detection & treatment is key
What is the treatment for AAA?
Surgery
When do you treat AAA?
Repair AAAs that are bigger than 5.5 cm, those that have increased I’m size by 1 cm or more in 1 year, or if it’s tender
What is Raynaud’s?
Episodes of digital ischemia due to reversible arterial vasospasm, usually digital
When does Raynaud’s typically occur?
After cold exposure or emotional stress
What does Raynaud’s present like?
Discrete demarcation of color change (most often fingertips or toes)
Explain the classic tri-phasic color changes of Raynauds. How often is this seen?
Pallor, Cyanosis (blue), Rubor (red)
- 20%
What are the symptoms of Raynauds?
Having 2 of the 3 color changes
Throbbing painful sensation during the “red” (hyperemic) phase
What are the 2 types of Raynauds? Which is more severe?
Primary Raynaud’s
Secondary Raynaud’s (more severe)
What % of patients have primary vs secondary Raynauds?
50% of Raynaud’s patients in each category
Which type of Raynaud’s is usually autoimmune?
Secondary
Who are most likely to have primary Raynaud’s?
20-30 yr olds (3rd-4th decade)
More common in WOMEN
Patients who have migraines
Secondary Raynaud’s is often associated with what 2 other disorders? (there are also 3 extras that it is less associated with)
- Scleroderma - 80-90% have Raynauds
- Lupus- 20% have Raynauds
- also dermatomyositis, polymyositis, rheumatoid arthritis
What occupations are associated with secondary Raynaud’s?
Those that use of vibrating hand tools
Pianists
Keyboard operators
What is secondary Raynaud’s OCCASIONALLY associated with?
Atherosclerosis & Thoracic Outlet Syndrome
What can lead to Raynaud’s?
Frostbite
What are some severe complications of secondary Raynaud’s?
Ischemic fingertip ulcers
Can progress to gangrene if persistent spasms
How do you check for Raynaud’s?
Raynaud’s exam- should be normal, peripheral pulses should be in tact (Allen’s test??)
What is the suggested treatment for Raynaud’s?
Minimize cold exposure
Quit smoking (90% respond to conservative care)
Medication if severe
(Nifedipine- a calcium-channel blocker- can decrease frequency/severing)
