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Pathophysiology > Peripheral Arterial Disease (PAD) > Flashcards

Peripheral Arterial Disease (PAD) Flashcards

1
Q

Provide a definition of Peripheral Arterial Disease (PAD)

A
  • common condition
  • build up of fatty deposits in the arteries restricts blood supply to the leg muscles
  • aka peripheral vascular disease
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2
Q

What are the symptoms of PAD?

A
  • many people have no symptoms (although they may have signs)
  • painful ache in legs when walking, usually disappears after a few minutes’ rest (intermittent claudication)
  • pain can range from mild to severe
  • both legs are often affected at the same time; pain may be worse in one leg
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3
Q

What are the signs and symptoms of PAD?

A
  • hair loss on the legs/feet
  • cyanosis
  • dependent rubor
  • numbness or weakness in the legs
  • brittle, slow growing toe nails
  • ulcers (open sores) on the feet/legs which don’t heal
  • changes in skin colour on the legs e.g. pale or blue
  • shiny skin
  • in men, erectile dysfunction
  • muscles in legs wasting
  • diminished or absent pulses
  • unremitting pain at night relieved by dangling foot out of bed or standing on a cold floor
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4
Q

What do you need to be aware of concerning PAD?

A
  • symptoms of PAD often develop slowly, over time
  • if symptoms develop quickly or suddenly worsen it could be a sign of a serious problem requiring immediate treatment
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5
Q

What are the risk factors for PAD?

A
  • atherosclerosis
  • smoking - most significant risk factor
  • type 1 & 2 diabetes
  • high blood pressure
  • high cholesterol
  • old age
  • family history
  • alcohol
  • poor diet
  • sedentary lifestyle
  • obesity
  • poor sleep
  • stress
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6
Q

When should you refer?

A
  • all patients should see GP if they experience recurring leg pain when exercising (may be mistaken for growing older, but not reason why an otherwise healthy person should experience leg pain)
  • PAD is usually diagnosed through a physical examination by the GP + ankle brachial pressure index (ABPI)
  • difference between ankle/brachial blood pressure may indicated PAD
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7
Q

Although PAD isn’t immediately life-threatening, the process of atherosclerosis that causes it can lead to which serious and potentially fatal problems?

A
  • PAD makes you more likely to develop another form of CVD
  • coronary heart disease
  • stroke
  • heart attack
  • angina
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8
Q

What is critical limb ischaemia (CLI)?

A
  • blood flow to legs becomes severely restricted
  • CLI is an extremely serious complication and requires immediate referral
  • end stage of PAD: inadequate blood supply to limb; results in non-healing ulcers and gangrene
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9
Q

What are the symptoms of CLI?

A
  • severe burning pain in the legs and feet that is continuous when resting
  • skin turning pale, shiny, smooth and dry
  • loss of muscle mass in the legs
  • the skin on the toes or lower limbs becoming cold and numb, turning red and then black and/or beginning to swell and produce foul-smelling pus, causing severe pain (gangrene)
  • wounds and ulcers (open sores) on feet and legs that don’t heal
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10
Q

What physical examination should you perform for PAD?

A
  • physically examine the legs
  • shiny skin
  • brittle toe nails
  • hair loss on the legs and feet
  • pulse in the leg being very weak or undetectable
  • leg ulcers
  • reduced skin temperature/temperature differences between legs
  • reduced sensation
  • prolonged capillary refill time > 2 secs
  • muscle atrophy
  • femoral, popliteal and foot pulses
  • CVS exam - BP, heart sounds
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11
Q

What test is widely used to diagnose PAD?

A
  • ankle brachial pressure index (ABPI)
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12
Q

How is the ABPI (ankle brachial pressure index) measuring?

A
  • blood pressure in the upper arms and ankles
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13
Q

How are measurements for ABPI (ankle brachial pressure index) read?

A
  • measurements taken with Doppler probe - uses sound waves to determine blood flow in the arteries
  • second result (ankle) / first result (arm)
  • if results < 1, then potentially PAD
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14
Q

What does the result of the ABPI (ankle brachial pressure index) mean?

A
  • if ABPI = 1, then blood pressure in both parts of body are the same, or almost the same
  • if blood pressure in ankle is lower due to reduced blood supply, ABPI would be < 1 e.g. 0.8 and below is concerning)
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15
Q

What is the equation for measuring ABPI (ankle brachial blood pressure)?

A

ABPI (leg) =

P Leg (highest systolic pressure in leg of either dorsalis pedis or posterior tibial arteries)

—————————————————————————————

P Arm (highest systolic pressure in arm of either left/right arm brachial systolic pressure)

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16
Q

What other testing is available for PAD

A
  • ultrasound scan
  • angiogram
  • contrast agent may be injected directly into the arteries of the leg and x-rays may be used to produce the images
17
Q

What treatments are available for PAD?

A
  • lifestyle changes and medication
  • exercising regularly
  • stopping smoking
  • eat a healthy diet
  • lose weight if you’re overweight/obese
  • moderate alcohol
18
Q

What referral options are available for patients?

A
  • revascularisation surgery - pain in leg severe and prevents patient from carrying out every day activities or if symptoms fail to change with lifestyle changes
  • 2 main types: angioplasty or artery bypass graft
19
Q

How would you differential diagnoses between mechanical leg pain that stops the patient from walking and PAD?

A
  • mechanical pain more likely to be aggravated with movement and persists through rest for short period of time
  • PAD would be aggravated by movement, but be alleviated by short rests
  • patient case Hx indicating family history of CVS or personal history of CVS
  • patient is a smoker, overweight, poor nutrition
  • patient’s skin would be hairless, shiny, colour (blue/pale), calmly/sweaty in PAD, none of these would be evident if MSK
  • if male ask about erectile dysfunction might indicate PAD
  • bilateral muscle wastage/numbness/tingling might indicate PAD
  • brittle nails, ulcers on legs and feet which don’t heal may indicate PAD
20
Q

What are the more serious consequences of PAD?

A
  • stroke
  • CAD
  • myocardial infarction
  • angina
21
Q

Your patient tells you they have been diagnoses with PAD and they have come to you for some advice … what might you suggest?

A
  • reduce alcohol consumption
  • gentle physical activity
  • stop smoking, if smoker
  • lose weight if overweight
  • eat healthy diet
22
Q

What are the 6 Ps for critical limb ischemia?

A
  • pain
  • pallor
  • pulseless
  • paresthesia
  • perishing cold
23
Q

What are the red flags of critical limb ischaemia?

A
  • extertional discomfort - most common in calf - relieved by rest
24
Q

What are the medical co-morbidities of PAD?

A
  • diabetes
  • hypercholeseterolemia
  • hypertension
  • chronic kidney disease
  • inflammatory conditions e.g. rheumatoid arthritis
  • atypical antipsychotic medications
25
Q

What advise and patient education can you provide for PAD?

A
  • lifestyle support and advice - smoking, alcohol, diet
  • optimise medical treatment of comorbidities e.g. diabetes
  • exercise
  • anti platelet drugs
26
Q

What tests/examinations are available for referral off CLl?

A
  • contrast MRI
  • medications e.g. atorvastatin, clopidogrel, naftidrofuryloxalate
27
Q

What differential diagnosis is there for acute limb ischaemia (acute limb ischemia - commonly miss diagnosed and not considered)?

A
  • chronic peripheral neuropathy e.g. diabetic neuropathy => pulses present, unless chronic arterial occlusive disease/vasospasm + skin temp normal
  • acute compressive peripheral neuropathy e.g. compartment syndrome = tense muscle compartments (not present in acute limb ischaemia)
  • acute DVT = pulses usually palpable, oedema does not usually occur with acute limb ischaemia
28
Q

Give some differential diagnosis of intermittent claudication

A
  • nerve root compression - sharp, lancinating pain, radiating down the leg, exacerbated by sitting, standing, walking and improved by change in position
  • hip arthritis - aching discomfort in lateral hip and thigh after exercise, not quickly relieved, may improve with not weight bearing
  • spinal stenosis - often bilateral pain and weakness affecting buttocks and posterior leg. Worse on standing, relieved by flexing the lumbar spine
  • foot + ankle arthritis - aching pain in ankle and foot arch. Influenced by activity, doesn’t resolve quickly, may be relieved by not weight-bearing
  • less common compartment syndrome, venous claudication and symptomatic Baker’s cyst
29
Q

Chronic limb-threatening ischaemia can be missed if symptoms are confused with which other foot pain causes?

A
  • plantar fasciitis
  • cellulitis
  • gout
  • arthritis
30
Q

Give some differential diagnosis of claudication

A
  • arthritis
  • chronic compartment syndrome
  • muscle strain
  • baker’s cyst
  • nerve entrapment
  • nerve root compression
  • spinal stenosis
  • DVT
  • Vasculitis

Pathophysiology (12 decks)

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