Peripheral Arterial Disease, DVT, and Chronic Venous Insufficiency Flashcards
what are the most significant risk factors for PAD?
if they have atherosclerosis somewhere else in the body (so if someone has had an ischemic stroke, ACS, MI, or angina), hypertension, hyperlipidemia, DM, CKD, and smoking
what happens to the risk for PAD if a person has one of the risk factors for PAD?
the risk increased 1.5 fold
what happens if a person has 3+ risk factors for PAD?
the risk for PAD increased 10 fold
what is the difference between a plaque rupture and a plaque erosion?
plaque rupture: large lipid core +thin fibrous cap; plaque erosion: scant lipid+ thick fibrous cap
how does the clinical presentation of atherosclerotic disease vary?
could be asymptomatic or symptomatic; symptomatic patients have varying symptoms based on location and based on acuity
how does chronic PAD present?
intermittent claudication: fatigue, discomfort, cramping, pain in muscles of affected limb; induced by exercise and relieved with rest
what should be noted about chronic ischemia seen in PAD?
40% of patients have no leg symptoms and 50% of patients who do have symptoms do not follow the classic pattern
how does acute arterial occlusion seen in PAD present?
medical emergency- LIMB ATTACK; 6 Ps: poikilothermia, pain, pallor, pulselessness, paralysis, paresthesias
how long can skeletal muscle tolerate ischemia for?
~4-6 hours
how do you diagnose/ screen for chronic ischemia seen in PAD?
you start with an ankle-brachial test; if it is higher than a .9 it is ok; if it is lower than a .9 it is bad and they need further testing- a definitive diagnostic procedure
what are 3 examples of definitive diagnostic procedures used to diagnose PAD?
arterial US, CT angiography, and angiography
what is an important step before any revascularization procedure?
an angiography
how do you treat PAD?
meticulous control of those risk factors like DM and HTN; exercise, drug therapy
what are some of the drug therapies used for PAD?
antiplatelet therapy: aspirin or clopidogrel; statin therapy (high intensity); antihypertensive therapy for those with HTN; meds that improve circulatory flow
what are 2 meds that improve circulatory flow?
cilostazol and pentoxifylline
which drug increases red cell deformability/ improves flow; but does not help with symptoms and is actually not recommended?
pentoxifylline
for patients who have an inadequate response to medical therapy or they just have a really significant lifestyle-limiting claudication, what is the treatment of choice?
revascularization
what are three options for revascularization?
angioplasty/ stenting, endarterectomy, and bypass grafting
what is an endarterectomy?
when you actually open the artery and remove the blockage and then patch the hole that is left
what is a complication associated with PAD?
critical limb ischemia (CLI)j
how does critical limb ischemia present?
chronic (more than 2 weeks) ischemic rest pain, ischemic wounds or tissue loss, or gangrene in one or both legs; symptoms are often relieved by hanging hanging the limb over the side of the bed
what are the annual mortality rates of patients with CLI?
~25%
what is the standard approach to screening for AAA?
abdominal duplex US in men aged 65-75 years who have ever smoked more than 100 cigs
what are considered the strong risk factors for a VTE?
major surgery, trauma, cast, or cancer
what are considered the moderate risk factors for VTE?
anticoagulant deficiencies, factor V Leiden mutation, non-O blood groups, prothrombin mutation; acquired: lifestyle, medications, medical conditions such as HF, IBD
what are considered the weak risk factors for VTE?
all other known genetic variants
what is the general idea of the pathogenesis of DVT?
hyper coagulability, changes in flow (stasis and turbulence), and endothelial dysfunction
when should risk of VTE be assessed?
in all patients on admission to hospital, and appropriate thromboprophylaxis should be prescribed
what is considered to be the principal cause of preventable death in hospitalized patients?
PE
when diagnosing a DVT, what is the first most important thing to determine?
the persons’s pretest probability
how do you determine a person’s pretest probability of having a DVT?
the Wells criteria
what is d-dimer?
fibrin degradation product
what is the initial treatment for a DVT?
5-10 days of anticoagulation; traditional: heparin; newer: some direct oral anticoagulants
what is the long term treatment for VTE?
3-6 months; traditional: warfarin; newer: DOAC (but super expensive)
besides a PE, what are the complications associated with a DVT?
they may have residual vein occlusion and post thrombotic syndrome, which in turn increases recurrence risk
what are the symptoms and signs of post-thrombotic syndrome?
leg pain, leg heaviness, vein dilation, edema, skin pigmentation, and venous ulcers
what does post thrombotic syndrome lead to?
chronic venous insufficiency
What is the common endpoint of chronic venous insufficiency?
elevated venous blood pressure
what are the symptoms of chronic venous insufficiency?
pain, leg heaviness, aching, swelling, skin dryness, tightness, itching, irritation, and muscle crmaps
what are the signs of chronic venous insufficiency?
dilated veins, leg edema, skin changes (induration and hyperpigmentation), and superficial skin ulcerations
what is the management of chronic venous insufficiency?
avoid prolonged standing, sitting; elevate legs; encourage walking; no ulcer present: compression therapy and emollients; ulcer present: infected: treat infection with antibiotics and debridement; not infected: wound management with multilayer compression bandaging
