Lecture 10: Peripheral vascular disease Flashcards
An angina equivalent refers to:
1) type of medication used to treat angina
2) Diagnostic tool for angina
3) Symptoms other than chest pain indicating MI
4) risk assessment for MI
3
Which of the following diagnoses MOST LIKELY results in pulmonary fibrosis?
1) rib fx
2) cor pulmonale
3) sacroidosis
4) pleuritits
3
grenuloms can cause an immune response to cause this
A narrowing of peripheral arteries, resulting in a decrease in blood supply
* where is it most commonly found
Peripheral Arterial Disease
Result of the same atherosclerotic process for CAD, but commonly found in the LE
Symptoms appear when the atheroma becomes so enlarged that blood flow to the distal tissues in blocked
* plaque is super enlarged and causes this
KNOW: w/ PAD
* Patients are unable to produce regular increases in peripheral blood flow for exercising muscles (because when you exercise those muscles need more O2/Blood flow, but that increase in blood can’t get to the distal extremeitites because those vessels are somewhat blocked, making this increase in blood not be able to get through)
* Inadequate oxygen supply leads to ischemia and the production of lactic acid, causing pain (intermittent claduication) and shortness of breath
* Intermittent claudication leads to moderate to severe impairment in walking ability
LE/UP pain that occurs w/ exercise due to restriction in blood flow
Intermittent claudication
This inadequate O2 supply leads to ischemia and the production of lactic acid, causing this pain / shortness of breath
Condition where part of the body doesnt recieve enough blood flow?
Ischemia
How is intermittent claudication addressed?
Walking program
* walk until it comes on. rest, then walk again / repeat
Is intermittent cluadication perdictable?
Yes
“I can walk 10 minutes then the pain comes on” then rest and it goes away
What happens to a PAD patient BP w/ EX?
Patients w/ PAD may exhibit steep rises in BP during EX (I think because the arterload on the heart is increased because they’re really trying to push that blood into the LE vessels which are narrowed = an increase in resistance) (BP may be normal at rest, but this gets bad when they EX because they really need to push that blood through the narrowed vessels in LE)
Make sure you asses vital signs throughout treatment!
* Also, atherosclerosis is systemic, so if you have it in the LE leading to PAD, you proably also have CAD (atheroscleorsis in heart) meaning those vital signs really need to be assesed.
What is ankle-brachial index (ABI)?
Taking the systolic BP at the ankle, and taking it at the arm
Where should systolic BP be higher, in the ankle or in the UE?
Ankle (gravity dependent = higher BP)
If the BP is lower in the LE than UE what do we expect and why?
We suspect PAD
This is because the BP should be higher in the LE (because its gravity depdent). However, if improper blood flow is getting to the LE, those vessels won’t have as much pressure on them (less volume of blood inside pushing on the walls), meaning the vessels are blocked (aka less blood flow getting to them) which is what happens in PAD.
If ankle brachial index is less than _ we consider it abnormal
<.90 = abnormal
* so if BP is higher in UE than LE its abornomal and we expect PAD
Ankle BP / UE BP
1/2 = .5 is very abnormal (meaning the BP is half as strong in ankle as UE)
Signs of PAD in extremity (6 P’s)
Some of those signs of PAD
Results from atherosclerosis of the renal artery
Renal artery disease
NOTE: RAS is associated w/ loss of renal mass, progressing to renal insufficiency, refractory HTN, and renal failure
* increased hypertension because the kidnes arent working properly. They’re sensing a drop in BP (because their blood supply is blocked) so the start the RAS system increasing that hypertension
A permanent pathologic dilation of the aortic wall that is at least 50% greater than the expected normal disameter (>3cm in adults)
* Described in terms of location, size, morpholofic appearance, and origin
Aortic aneurysm
* basically the entire length of the torso (anywhere in the aorta)
Where is a triple A?
The abrominal aortic aneurysms (AAAs) are in the abominal portion of the aorta
* AAAs are at significant risk for rupture (usually fatal)
PT therapy implications for AAAs
Risk factors:
* >60
* immediate family hx (genetic)
NOTE: we should be assessing vital signs at REST and w/ ACTIVITY
High BP during activity may produce excessive stress on the already weakened area (Increased BF = further extensibibility of that aorta)
Tachycardia, low blood pressure, and patient complaints of sudden abdominal pain could be a sign of rupture
* Low BP because the aorta has popped and the blood is now rushing out
* Tachycardia because the heart is trying to restore that CO with decrease BF (pumps it faster)
* Sudden abdominal pain as well
NOTE: you should never palpate over tripple A
* Note, you can have a stable tripple A
* If you’re the first person to find the AAA its a medical emergency
Promote regule moderate EX in patients with small AAAs - these activities do not influence risk of rupture
* Don’t want issues w/ deconditioning
* We want low impact, nothing thats strenously working the abdominals
What is arterial occulusive disorders
* What are the 3 different kinds?
A disorder that occludes the arteries
1) Arterial thrombosis/embolism
2) Thromboangitits obliterans
3) Arteriosclerosis (specially the arterioles)
I think just know the bold and the pulses
KNOW ABI is found using the dorsalis pedis artery
S/S of arterial insufficiency
Should make sense, its a blockage of BF
What is intermittent claudication
* How does a PT treat this
its just pain
Pain, usually with walking, relieved at rest
* feels like burning or cramping
* Lack of BF
PT treats this w/ a walking program
PT management:
* Supercised EX programs are preferred
* Treadmill walking
* Exercise tolerance test and training HR first
* Progressive conditioning program (want to get to pain then stop)
* Near-maximal pain and intervals
Arterial thrombosis and emblosim
* Complication of what two things
* 6 clinical manifestations (remember artery is blocked in some form)
* Contraindications (3)? Why?
Complication of:
* Ischemia heart disease (think, CAD [atherosclerosis]) - not enough BF = death of heart muscle = MI
* Rheumatic heart disease
Clinical manifestations: - blockage of artery leads to these symptoms
* Numbness
* Coldness
* Pain
* tingling, or changes in sensations
* Skin changes (pallor or mottling)
* Weakness, and muscle spasm
Contraindications:
* Heat application
* Cold application
* Massage
* All because they thrombosis could become dislodged and become an embolism
Embolism can go to the heart or lungs
* then it becomes a pulmonary embolism if it goes to the lungs
Another name for thromboangiitis obliterans?
* What is causes this disease?
Buerger Disease
Thrombus formation and vasospasm occludes blood vessels
* the spasms occlude the blood vessels
NOTE: this is also an inflammatory disorder (part of vasculitits disease - inflammation of vascular system because it is a vasospasm that can happen it is also a inflamatory disorders)
* Happens to smokers
* Mostly in the hands
Atherosclerosis MOI
Beging w/ an injury to the endothelial lining of the artery (intimal layer) that makes the vessel permable to circulating lipoprteins
Names for it:
* Ateriosclerosis
* Chronic occulusive arterial disease
* Obliterative arteriosclerosis
* PAD
Most common arterial disease = PAD, CAD, and cerebrovascular disease
* can impact dementia because of lack of BF to certain areas and also stroke (stroke can be either an occulusion or a rupture)
Atherosclerosis is present when the vessel is narrowed _% or more
50% or more
KNOW: clinical manifestations of atherosclerosis: think narrowed artery not getting enough BF out
* Present when narrowing is 50% or more
* Intermittent claudication (pain w/ activity)
* pain (cramping or burning)
* Pallor
* Parethesias
* Paralysis
* Pulselessness
* Slient ischemia - not having a very obvious outward signs
* Skin is shiny, hairless, cracks - trophic changes due to lack of BF
Risk factors:
* Smoking
* Diabetes
* High cholesterol
* Hypertension
* Older age
* Sedentary lifestyle
* Family Hx
* Elevated inflammatory markers
* Increased homocysterione
Common clinical examins:
* Decreased ankle brachiel index - we can do this one
* Segmental limb pressures
* Pulse volume recordings
* CT
* Duplex US
* MRI
Atherosclerosis management
Risk reduction:
* if they have the s/s of this (patient has intermeditent claudication) they can be at risk for other things - attack w/ life style modifications
KNOW: Smoking cessation = most effective tool in atherosclerosis management!!
preventative skincare - we have cracks, dryness, shiny skin = we need to at least address these side effects
Drugs:
* Asprin - blood thinner
* Statins
* Antihypertensives
Ankle brachial Index:
Ankle systolic BP / UE systolic BP
we would take one BP in arm and get systolic
We use Doppler ultrasound to get the systolic BP in the ankle
What are the norms
* Normal
* borderline
* Abnormal
* Severe arterial disease
* Calcification/hardening of arteries
So we actually want the ankle BP to be higher than UE (gravity dependent = increased BP)
Responsible for the bold
Venous Disease is made up of what 3 kinds?
1) Thrombophlebitis
2) Varicose Veins
3) Chronic venous Insufficiency
This vein disorder results from inadequate muscle action, incompentent venous valves, or venous obstruction.
Venous insufficiency
Venins have a one way valve, thats how they prevent back flow
* These being incopotent often leads to varicouse veins
* Can also be due to not moving / having no muscle activation = muscle pump not working = blood not pumped back up (think paralysis would be big issue for this)
This vein disorder is chronic venous insufficiency leads to skin changes, swelling, and wounds
Venous stasis ulcers
So if that insufficieny (think backflow of those vessels) goes on for a long time it can lead to this
blood in vein pools, does not get filtered back to heart
* you basically now have a pool with no filtration system and it turns “gross”
This vein disorder includes both deep venous thrombosis (DVT) and pulmonary embolism
Venous thromboembolism
Development of a clot in a deep vein of the LE or pelvis (or less often, in the arm)
Deep vein thrombosis
When the vein is blocked entirely (C) it will pool (will cause varicose veins)
Notice when it breaks off (D) its an embolism
DVT risk factors (5)
* What percent is idiopathic
1) Immobility - it can just be someone sedentary, however, its often someone whose recovering from some surgery and hasnt moved around - or even after pregnancy or and epidural
2) Trauma
3) Lifestyle: Smoking/Hormone replacement
4) Hypercoagulation
5) Family Hx, DM, High BMI, Buerrger disease, previous DVT, >60 years older
50% = idiopathic
What perdiction model do we use for DVT’s?
Wells Criteria (tells you how at risk the pt is for a DVT)
* If you suspect a DVT she thinks we should fill this out and put it into our documentation / pt education
Physical therapy implications for venous disease:
When obtaining the patients hx, consider risk factors and signs/systeoms for venous insufficiency and venous thromboembolism (VTE)
USe the wells perdiction model for VTE for lower extremity DVT (LE DVT)
When examining the LE, be aware of medical problems that can mimic a DVT (bakers cyst or muscle injury)
* bakers can appear as swollen and mimic a DVT
* muscle injury: got epidural and LE numb and walked wrong but didnt feel it. This muscle injury seemed like the s/s of a DVT
Throughout the session, assess vital signs and monitor for s/s of PE
Wells Criteria for DVT
Pitting edema = pit that lasts a few seconds when pushing down
* Can happen if you consume to much salt
S/S of DVT: (4)
* most common site of this (2)
1) Assymptomatic at first
2) Dull, ache, tight feeling, pain in the calf
3) Swelling, tenderness, warm skin
4) Cyanotic if severe (blue)
Iliac veins/femoral veins = more common site
Interventions for VTE:
1) Mechanical compression
2) Early monitored mobility
3) anticoagulation medication
Interventions for venous insufficent and venous ulcers:
1) EX
2) Extremity elevation
3) Avoiding long periods of sitting or standing (compression socks help w/ this)
4) Compression
5) Aggressive wound management
6) Education to prevent further progression
w/ preggnancy you get varicose veins/spider veins (as well as obese)
* essentialy something is squeezing the iliac veins / vasculature = compression
Common sites for venous embolism
* because fx / trauma
* Tumors
* Not as common in UE
* IV can cause this
* Air inside veins can cause this (on lots of crime shows)
Swelling ov a vein due to inflammation, possible due to blood clot
Thrombophlebitis
* normally will see outline of vein (which is why its important to know common sites)
Normally due to a blood clot (DVT) or superficial thrombophlebitis
Which of these conditions can mimic a DVT
1) Muscle strain
2) Cellulitis
3) Muscle cramp
4) Fracture
1
Occurs when part of a thrombus in the DVT breaks loose and travels through the right side of the heart into the pulmonary artery (which goes to the lungs)
S/S? (3)
Pulmonary Embolism (PE)
S/S
1) Shortness of breath
2) Chest pain
3) Cough
NOTE: theres normally S/S of a DVT before this happens (because the breaking off of the deep vein thrombosis is what causes the embolism in the first place, then that travels to the heart)
Varicose Veins: normally starts as spider veins (more red and light, darker purple = varicose veins)
Risk factors:
* Family hx
* Pregnancy
* Menopause (because of the hormones flucuations)
* High venous pressure with heavy lifting, prolonged sitting or standing
Common symptoms
* Usually asymptomatic
* Dull, achy, heaviness, tension, or fatigue
* Cramps
* Dilated, elonged, tortuous veins
Varicose Veins: Dilated veins essentially (distended)
When you’re just standing its harder (because of gravity) for the blood to get up to your heart
* and if you’re not moving the muscle pumps in the gastroc / soleus / other muscle in LE arent helping to move that blood up to your heart so those valves eventually fail and theres a backflow of blood
Varicose veins:
Medical management:
* Compression stockings
* Elevation and periodic rest
* Vein stripping - surgical - does not always work and can cause edema
* Conservative hemodynamic correction of venous insufficiency - medical
* laser (more cosmedic)
* ablations (more cosmedic)
Chronic venous insufficiency = venous stasis / postphlebitic symdrome (think venous system is static which develops wounds)
What is it?
Inadequate venous return over a long period of time
High ambulatory venous pressures in the calf / veins which helps bring blood back to the heart
Superficial veins and capillaries dilatue due to venous HTN
Edema and hyperpigmentation are common
Treatment:
* Compression stocking
* rest, elevation
* Intermittent compression pump
What can a PE resemble
1) Influenza
2) Heart attack
3) Back Strain
4) Arrhythmia
b
Group of disorders that result in narrowing and occulsion of the lumen
Vasculitis
* can be infectious or non infectious
Multiple sites of inflammatory and destructive lesions
Polyarteritis Nodosa
Form of vasculitis that affects children and young adults
Hypersensitivity angiitis
mucocutaneous lymph node syndrome; acute febrile illness assocaited w/ systemic vasculitis. 80% affected are children younger than 4
Kawasaki
This disease happens to smokers, men younger than 40 mainly
Buerger disease
May mimic PAD
* Good differential diagnosis
This disease has intermittent episodes of small artery or arteriole constriction
* Who does it most affect
* What are these pts prone to
* how does skin progress
* Treatment
Raynaud’s disease/Phenomena (Dr King)
* arteries actually get occluded
Women > Men
prone to migrains
Skin progresses from blue –> white –> red
Tx: prevention and alleviation; patient education
* treat them how to avoid/deal w/ those extreme emotions
* Also to avoid cold weather
NOTE: happens in extreme emotions / cold weather (big reason lots of people move to flordia)
Wounds can form this / can rot off
Top 2 pix more common
