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CV > PAD > Flashcards

PAD Flashcards

1
Q

Anatomical definition of PAD

A

Anatomical: Structural atherosclerotic narrowing of any non-coronary vessel which limits blood flow to the limbs

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2
Q

Functional definition of PAD

A

Functional: Arterial narrowing causing a mismatch between organ supply and demand causing intermittent symptoms of claudication and/or tissue ischemia

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3
Q

Classifications of PAD:

A

a) Lower Extremity Disease
– Typically known as PAD
– Pain in the legs with walking or at rest (severe disease)

b) abdominal
– Aortic aneurysm
– Renal artery
– Mesenteric

c) Cerebral Vascular (Carotid)

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4
Q

Causes: Tobacco

A

– Single most important modifiable cause
– Ten-fold increase in relative risk, dose related
– Exposure to 2nd hand smoke also shown to promote changes to endothelium

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5
Q

Causes: Diabetes Mellitus

A

– Increases risk 2-4 times, due to endothelial and smooth muscle cell dysfunction
– Diabetes accounts for up to 70% of nontraumatic amputations performed
– Diabetes in combination with smoking: 30% risk of amputation in 5 years

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6
Q

Causes: Dyslipidemia

A

– Elevations of total cholesterol, LDL, and TG’s all correlated with accelerated PAD
– Correction via diet and/or medications=major improvement rates of stroke, MI

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7
Q

All Causes:

A
  1. Tobacco
  2. DM
  3. Dyslipidemia
  4. Hypertension
    – Especially, but not exclusively, related to stroke
  5. Inflammatory mediators
    – Homocysteine, fibrinogen, C-reactive protein, Lipoprotein (a), renal disease
  6. Age
  7. gender (male)-until after 85 then more women
  8. ethnicity (African Americans with higher risk)
  9. Obesity and physical inactivity
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8
Q

Prevalence of PAD

A
  1. Increases with age

2. 1/3 patients 70+ or 50-69 w/hx of DM or smoking

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9
Q

PAD Symptoms

A 
• Analogous to angina pectoris 
• Intermittent limb claudication
– Dull aching muscular discomfort induced by exercise and relieved by rest
– Often at discrete threshold of work 
• Atypical features common
– Fatigue
– Heaviness
– Dysesthesia or cold sensation 
•not nocturnal cramps or restless leg
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10
Q

Comprehensive Vascular Exam

A 
• Bilateral arm blood pressure (BP)
• Cardiac examination
• Palpation of the abdomen for aneurysmal disease
• Auscultation for bruits
• Examination of legs and feet
Pulse Examination
– Carotid
– Radial/ulnar
– Femoral
– Popliteal
– Dorsalis pedis
– Posterior tibial
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11
Q

Pulse Scale

A 
• Scale􏰁
– 0=Absent
– 1=Diminished
– 2=Normal
– 3=Bounding (aneurysm or AI)
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12
Q

Steps towards Dx of PAD

A
  1. Obtain history of walking impairment and/or limb ischemic symptoms􏰁
  2. Obtain a vascular review of symptoms􏰁
    • Leg discomfort with exertion
    • Leg pain at rest􏰂 non-healing wound􏰂 gangrene
  3. Results:
    -no leg pain
    -atypical
    -classic claudication
    -Chronic limb ischemia
    -acute limb ischemia
  4. For all of the above perform ankle-brachial index measurement
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13
Q

How to Perform ABI Exam

A
  • Performed with the patient resting in the supine position
  • All pressures are measured with an arterial Doppler and appropriately sized blood pressure cuff
  • Systolic pressures will be measured in the right and left brachial arteries followed by the right and left ankle arteries.
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14
Q

What is the ABI?

A

The ratio of the higher brachial systolic pressure and the higher ankle systolic pressure for each leg􏰁:

ABI=(ankle systolic P)/(higher brachial Psys)

≤ 0.90 is diagnostic of peripheral arterial disease

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15
Q

ABI Scale

A

1.00–1.29: Normal
0.91–0.99: Borderline, low normal
0.41–0.90: Mild-to-moderate disease
≤0.40: Severe disease
≥1.30: Noncompressible

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16
Q

Hemodynamic noninvasive tests

A
  • Resting Ankle-Brachial Index (ABI)
  • Exercise ABI
  • Pulse volume recordings
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17
Q

Pulse Volume Recordings

A

Measured all along the leg

-should be triphasic

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18
Q

Exercise ABI Testing:

A
  • Indicated when the ABI is normal or borderline but symptoms are consistent with claudication􏰂
  • An ABI fall post-exercise supports a PAD diagnosis􏰂
  • Assesses functional capacity (patient symptoms may be discordant with objective exercise capacity).
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19
Q

Color Duplex Testing

A

Significant stenosis because velocities are super high and a ton of color means a lot more turbulent blood flow

20
Q

Arterial Duplex US Testing

A

Duplex ultrasound
• diagnose anatomic location
• degree of stenosis

Duplex ultrasound of the extremities can be used to select candidates for:􏰁
(a) endovascular intervention (stent/PTA)
(b) surgical bypass
(c) to select the sites of surgical
anastomosis.

21
Q

MRA

A

MRA has virtually replaced contrast arteriography for PAD diagnosis

•Excellent arterial picture
• No ionizing radiation
• Noniodine–based intravenous contrast medium rarely causes renal insufficiency or allergic reaction
• ~10% of patients cannot utilize MRA because of􏰁
− Claustrophobia
− Pacemaker/implantable cardioverter-defibrillator
− Obesity

22
Q

CTA

A
  • Requires iodinated contrast
  • Requires ionizing radiation
  • Produces an excellent arterial picture
23
Q

Renal Artery Stenosis:

Causes?

A

Athersclerosis or Fibromuscular Dysplasia

24
Q

RAS: Atherosclerotic Etiology

A

– Increased prevalence in pts w/ CAD, CVD, PAD

– Risk factors essentially the same for each

25
Q

RAS: FMD

A

– Accounts for 40% cases
– Also seen in the carotid arteries
– Congenital arterial abnormality of fibrous, muscular and elastic components

  • Different thing altogether: connective tissue disorder
  • typically affects young women
  • Any CT disease is going to affect vasculature: FMD, Marfan’s, etc.

Beads on a string*

26
Q

Renovascular HTN

A

Caused by renal artery stenosis (kidney senses low blood flow because of the blockage)
• Thus it shoots out a lot of renin–>RAAS
• Giving them meds doesn’t do much to decrease their HTN

– Secondary to atherosclerosis – usually origin and proximal segment of renal artery

– Fibromuscular dysplasia – usually mid to distal segment of renal artery or carotid artery

– Occlusion

27
Q

AAA

A

• Def: perm localized dilation of an artery
=/> 50% normal diameter
– Dilatation >2x size of more proximal artery

  • At risk of dissection, high mortality if this occurs
  • Most often occur in infra-renal aorta
28
Q

AAA: Prevalence

A

• Abdominal: Thoracic Aneurysms
– Men 7:1
– Women 3:1

• Coexistence of other vascular dz increases incidence:
– 5% pts w/ sx CAD have AAA
– 10% pts with CVD or PAD have AAA

  • AAA affects 8% older men, 1.5% older women
  • 15,000 deaths/year in the US alone
  • Once rupture occurs, 75-90% mortality rate
29
Q

AAA Screening

A

• Prior to 1996, insufficient evidence for or against screening: now with
– Family History

30
Q

Dx of AAA

A

• Ultrasound
– Aorta, look at diameter
– Renal artery, look at diameter and velocities to estimate stenosis
• MRA
• CT scan
Goal: to adequately visualize the arteries for
measurements and velocities

31
Q

Carotid Artery Dz: Prevalence

A
  • Third leading cause of death in the US
  • 500,000 new strokes each year
  • 160,000 strokes result in death annually
  • 15-20 billion dollars per year
  • 50% of patients with a stroke will have a second stroke within 5 years if untreated
32
Q

Stroke: Causes

A 
• Only 10% of strokes preceded by TIA’s
• 15% from a cardiac source
• >33% of strokes
associated with
extracranial disease (like the carotids!)
33
Q

a) Definition of a stroke
b) ischemic
c) hemorrhagic

A
  • Sudden brain damage
  • Lack of blood flow to the brain caused by a clot or rupture of a blood vessel

b) ischemic=clot
- 85% of all strokes

c) hemorrhagic=bleed
- around brain
- into brain

34
Q

Dx of Carotid artery Dx

A
  • Physical examination: carotid bruit
  • Suspicion leads to ultrasound of carotid arteries
  • Any abnormality on ultrasound: confirm with MRA or CT
35
Q

Carotid artery Dz: Tx

A

•Lifestyle changes (no, seriously)
- must stop smoking
•Medications
•Interventions

36
Q

Two Major Goals in Treatment of PAD

A
  1. Limb outcomes

2. Cardiovascular morbidity and mortality outcomes

37
Q

Two Major Goals in Treatment of PAD:

1. Limb outcomes

A 
• Improved ability to walk
– Increase in peak walking
distance
– Improvement in quality- of-life (QoL)
• Prevention of progression to CLI and amputation
38
Q

Two Major Goals in Treatment of PAD:

Cardiovascular morbidity and mortality outcomes

A
  • Decrease in morbidity from non-fatal MI and stroke

* Decrease in cardiovascular mortality from fatal MI and stroke

39
Q

Tx to Improve CV Outcomes

A

Must treat the underlying causes!

• Smoking cessation 
• Anti-platelet therapy-aspirin
• Hyperlipidemia (lifestyle and/or medications)
-statin: 10mg & 80mg 
• Hypertension
• Keep Diabetes under good control
• Get active, lose weight
40
Q

Considerations for the Treatment of Hypertension in PAD

A
  • Blood pressure lowering is indicated to reduce the risk of stroke, MI, CHF, CRF, and death.
  • Individuals with PAD should receive hypertension treatment
41
Q

Indications for Angioplasty/Stent

A

Indications Lower Extremities:
– Persistent limiting claudication, preventing working and/or ADL
– Rest pain
– Tissue loss/non healing ulcers
• Get the Patient walking, and they will start to heal themselves!!

  • Abdominal Aorta or Renal Arteries
  • Carotid Arteries

*ADL: Activities of Daily Living

42
Q

PAD and Surgery

A

• Lower extremity arterial disease:
– Bypass (eg. Femoral to popliteal artery)
– Vein or synthetic graft used

• Abdominal Aorta
– when the risk of rupture outweighs the risk of surgery

  • Normal aorta: 3cm or less
  • Aneurysm: 3-4-5 cm
  • At 5CM: risk of rupture»»surgery

• Carotid Endarterectomy

43
Q

In regards to PAD….smoking, physical inactivity, and DM increase:

A

– Prevalence of PAD
– Presence of Asymptomatic disease
– Risk of amputation, low quality of life

44
Q

Dx modalities for PAD

A

– Doppler ultrasound to evaluate velocities
– ABI/ pulse volume recordings
– MRA, angiography

45
Q

U/S Evaluation of Degree of Stenosis

A

• 50-79% stenosis
– High systolic velocities, normal diastolic

• 80-99% stenosis
– Both systolic and diastolic velocities high

• Occlusion – signal becomes similar to external carotid signal with low diastolic velocities

46
Q

What does a carotid bruit mean?

A
  • Asymptomatic bruits do increase stroke risk (14% over 5 years) - but not always on side of bruit
  • Good indicator of significant coronary disease (50-71%)
47
Q

People risk for PAD

A
  • Age: Less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)
  • Age 50 - 69 years and history of smoking or diabetes
  • Age 70 years and older
  • Known atherosclerotic coronary, carotid, or renal artery disease

CV (11 decks)

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