Week 10- PAD Flashcards

Question

imaging in atherosclerosis

Answer 1

* Ultrasound of the abdomen to screen for an abdominal aneurysm (ASCVD, elderly) * Doppler device – measure ankle-brachial index (normal 1.0 to 1.40) (PAD – as a marker for ASCVD in other beds (coronary artery disease [CAD], cerebrovascular disease, among others) * Sonography of the carotids (Coronary artery stenosis, a carotid bruit) * Electrocardiogram (ECG), stress ECG * Electron beam computed tomography (EBCT) (to confirm ASCVD, determines calcium score, interpreted according to age, establishes plaque burden) * Angiography - primary method for imaging atherosclerotic lesions in the coronary circulation, invasive procedure, reserve for high-risk patients or those with symptomatology; Not a screening test. * Computed Tomography (CT) angiography – in ASCVD used to detect the presence of low-attenuated plaques and in predicting future acute coronary events. noninvasive assessment * Cardiovascular Magnetic Resonance Imaging (cardiac MRI) - costly

Answer 2

1. occlusion of vessel 2. disruption of plaque 3. emboli 4. aneurysm 5. peripheral vascular disease a. claudication

Answer 3

Hemorrhage within plaque or rupture or ulceration of plaque (with exposure of the thrombogenic components) can result in thrombus formation.

Answer 4

Plaque can break free and be carried in the blood stream farther down the vessel.

Answer 5

Atherosclerosis begins as an intimal process, but over time the thickened intima puts pressure on and causes atrophy of the media, often resulting in an aneurysm (i.e., dilation or saccular outpouching of the vessel). - can lead to rupture of the vessel and resultant hemorrhage

Answer 6

1. Claudication, which is characterized by ache or cramping in the extremities with exertion that is relieved by standing still. Patients also have cool extremities, diminished distal pulses, and shiny, hairless skin. Patients with severe peripheral vascular disease have pain at rest. Ischemic ulcerations are a common cause of morbidity. 2. Cause: Atherosclerosis of vessels of the lower extremities.

Answer 7

can present as coronary artery disease (CAD), cerebrovascular disease (CVA), transient ischemic attack (TIA), peripheral artery disease (PAD), abdominal aneurysms, renal artery stenosis, mesenteric artery ischemia

Answer 8

may be very good with management of risk factors such as LDL- cholesterol with statin therapy, BP, diabetes, smoking cessation, exercising regularly, and adhering to a prudent diet * Worse with full-blown, end-organ disease such as heart failure, ischemic stroke with paralysis and impaired cognition and gangrene necessitating amputation and rupture of an abdominal aneurysm * Pre-existing ASCVD has been shown to predict recurrent CV events – in patients with acute coronary syndromes (ACS) found that the rate of subsequent CV events over 8–17 months was 7.5%–19.9%

Answer 9

* Educate patients on regular exercise, discontinue smoking, maintain a healthy body weight, eat a healthy diet and use medications used to lower lipids when indicated * Evidence shows these can significantly reduce the risk of adverse cardiac events and stroke

Answer 10

* Treat risk factors such as elevated LDL-C, blood pressure, diabetes, obesity * Medications: statins, antihypertensives (ACEs, ARBs, diuretics, beta-blockers, CCB, vasodilators), diabetes therapies, thrombolysis therapies * Exercise and healthy diet low in saturated and trans fats, reduce salt intake, increase monounsaturated fats, fatty fish, fruits, vegetables, maintain healthy body weight * Stop smoking * Revascularization procedures: angioplasty, bypass, etc.

Answer 11

narrowing of arteries other than heart or brain risks: old, smoking, hypertension, hyperlipidemia, diabetic, metabolic syndrome mechanism: atherosclerosis causes: pain, ulceration, gangrene

Answer 12

an overarching term that encompasses vascular diseases that result from circulatory dysfunction caused by damage to arteries or veins * may affect any blood vessel outside of the heart including arteries, veins and lymphatic vessels

Answer 13

peripheral artery disease (PAD), chronic venous insufficiency (CVI), and deep vein thrombosis (DVT)

Answer 14

primarily driven by progressive atherosclerotic disease resulting in the reduction of major organ blood flow and end-organ ischemia

Answer 15

lower extremity occlusive disease

Answer 16

is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion of the major arteries distal to the aortic arch

Answer 17

* can involve both the upper and lower extremities * typically affects the abdominal aorta, iliac arteries, lower limbs to the level of the tibial arteries at the foot, and occasionally the upper extremities i.e. in carotid artery stenosis

Answer 18

arterial stenosis, reduced blood flow, and claudication

Answer 19

*American Heart Association estimates 8 to 12 million Americans have PAD-prevalence of 3%to 10% * Study: 29% in those aged >70, and between ages of 50-69 with a history of smoking or diabetes * Increased to nearly 50% in those >85 yoa

Answer 20

15% to 20% in those >70 yoa

Answer 21

-older, male, African American, low SES * Age: prevalence increases with age with up to 20% of people older than 75 years * Sex: male gender is risk factor * Race/ethnicity: non-Hispanic black race (African Americans to have an odds ratio of2.12) * Socioeconomic: * lower poverty-income ratios (PIR) have an early 2-fold increase in the risk of PAD compared to higher PIR * lower educational level to be significantly associated with PAD

Answer 22

over 50 yrs old obesity family member with heart disease smoking or tobacco products diabetes, high cholesterol, high blood pressure coronary artery disease (CAD)

Answer 23

* Advanced age, male gender, and positive family history * Prior history of coronary artery disease, sedentary lifestyle * Cigarette smoking history * Study: >80% of patients with PAD were current or former smokers * Increases odds for PVD by 1.4 for every 10 cigarettes smoked/ day and by 2.6 in patients with diabetes * Cardiovascular mortality rates of current smokers with PAD are more than double that of those with PAD who have never smoked * Diabetes mellitus * Smoking and diabetes are associated with the highest relative risk for developing lower- extremity PAD * Hypertension * Hyperlipidemia * Patients with other vascular disease have a high prevalence of PAD (19% in patients with ischemic heart disease and 26% in patients with stroke) * Low High-density lipoprotein (HDL) cholesterol (<1.04mmol/L[40mg/dL] in men and< 1.29 mmol/L [50 mg/dL] in women * Chronic kidney disease/ renal insufficiency (eGFR<60mL/minute/1.73m2) * *NHANES:Most significant risk factors- hyperlipidemia, hypertension, diabetes mellitus, chronic kidney disease, and smoking; * Odds of having PAD increase with each additional risk factor, from a 1.5-fold increase with one risk factor to a 10-fold increased risk with three or more risk factors * In one series from the Netherlands, the likelihood of a patient having PVD (as defined by an ankle-brachial index [ABI] of less than 0.9) was increased by: * being male (odds ratio[OR]1.6) * being older than 60 years (OR4.1) * having hypercholesterolemia (OR1.9) * having a history of ischemic heart disease (OR3.5), cerebrovascular disease (OR3.6), diabetes mellitus (OR 2.5), or intermittent claudication (OR 5.6) * smoking(OR1.6)

Answer 24

Classic/intermittent claudication= defined as fatigue, muscle discomfort, cramping, or pain of vascular origin in the lower limbs (primarily in the calves and buttocks) that is consistently induced by exercise (i.e. after walking a fixed distance) and is consistently relieved by rest within 10 minutes * Occurs in only 10-30% of patients with PAD * Approximately 42% area symptomatic (no leg pain) * Others have a typical (non-classical) symptoms of leg pain(47%) * Symptoms may include exertional pain that does not stop the individual from walking, does not involve the calves, or does not resolve within 10 minutes of rest --> potentially related to comorbid musculoskeletal or neuropathic conditions --> The presence of classic claudication has an LR+ 3.30 --> The absence of classic claudication has an LR− 0.89 * History-include an estimate of the walking distance

Answer 25

fatigue or pain in lower limbs induced by exercise and relieved by rest (in PVD/PAD)

Answer 26

*Additional non-classical symptoms * Leg pains or sensations * Skin, hair, nail changes * Nonhealing wounds/ulcers * Edema

Answer 27

-leg pain or cramping while walking -leg numbness or weakness -sores on toes, feet or legs that won't heal -coldness on the lower leg or foot -changes in the colour of legs, texture or temperature -slow toenail growth

Answer 28

-swelling in the feet, legs, or ankles -presence of spider veins or varicose veins -tired feeling in the legs -difficulty standing for very long -burning, numbness, or tingling in the thighs or calves -itchy, dry skin on the legs

Answer 29

to diagnose intermittent claudication; 6 questions and pain diagram; LR+ 11 i.e. do you get pain in legs while you walk? what happens if you stand still (pain goes away in 10 mins)? where do you get the pain (calf, thigh, butt)? etc

Answer 30

Vitals– Blood pressure * Inspection/Palpation: *Gait: Impaired walking function/ Intermittent claudication --> ischemic rest pain * Observe skin on lower extremities: * Non healing lower extremity wound * Arterial ulcerations -well-demarcated, “punched-out” lesions * feet inspection for ulcers between the toes (“kissing ulcers”) and ulcers related to ill-fitting footwear * Lower extremity gangrene * Observe skin perfusion: * Pallor on leg elevation or dependent rubor followed by pallor or blanching of the extremity with elevation * Inspection/Palpation: * Skin temperature: Cool skin * Nails: Dystrophic nail changes * Capillary refill: Abnormal capillary refill time * Hair: Hair loss on toes and distal ankles, shiny skin, and muscle atrophy * Pulses (grade): Diminished lower extremity pulses * Abdominal palpation: abdominal aortic aneurysm * Auscultation: vascular bruits–aortic, carotid, femoral, iliac and popliteal

Answer 31

diminished or absent pedal pulses, presence of femoral artery bruit, abnormal skin color, and cool skin – however their absence does not preclude PVD

Answer 32

vascular bruit, cool skin, bad nails, abnormal capillary refill, hair loss, diminished lower limb pulses, pallor skin, ulcer, gangrene

Answer 33

-cool skin, foot ulcer -iliac, femoral or popliteal bruit -abnormal femoral pulse -abnormal posterior tibial pulse -abnormal dorsalis pedis pulse

Answer 34

DP and PT pulses absent LR+=44.6 posterior tibial pulse dorsalis pedis pulse

Answer 35

for screening and diagnosing PVD/PAD in the primary care or hospital setting * inexpensive and reproducible method for assessing lower extremity hemodynamics * test on one or both extremities * requires a blood pressure cuff and a Doppler device with a probe for detecting arterial pulses * calculate the ratio of the highest systolic pressure in each leg (obtained at the dorsalis pedis and posterior tibial recurrent arteries using a Doppler probe), to the higher of the right or left arm brachial artery pressures

Answer 36

less than 0.9

Answer 37

AB will not exclude proximal aneurysms or arterial disease distal to the ankle

Answer 38

overall mortality, cardiovascular mortality, and major coronary events in each Framingham Risk Score category

Answer 39

- 65 yrs old + -50-64 yrs with risk factors for atherosclerosis (hypertension, diabetes, hyperlipidemia, history of smoking) or family history of PAD - younger than 50 plus diabetes and one additional risk factor for atherosclerosis -individuals with known atherosclerotic disease in another vascular bed (i.e. abdominal aorta, carotid, coronary, mesenteric, renal, or subclavian)

Answer 40

insufficient evidence if asymptomatic patients due to lack of evidence that screening improves outcomes such as cardiovascular morbidity or mortality

Answer 41

guidelines - recommends patients at increased risk of PAD should be assessed for exertional leg symptoms, ischemic rest pain, and nonhealing wounds

Answer 42

ABI screening for patients with history or examination findings suggestive of PAD * Patients at increased risk of PAD, but without suggestive history or examination findings, resting ABI testing is considered reasonable * Guideline does not recommend ABI screening in patients who are not at increased risk of PAD

Answer 43

recommends ABI screening in all patients with diabetes who are older than 50 years * Normal results --> repeat screening every five years * Patients with diabetes <50years --> screen if risk factors present (e.g., smoking, hypertension, hyperlipidemia, duration of diabetes more than 10 years)

Answer 44

10-20% * Combining the results of ABI screening with Framingham risk scores can improve 10-year cardiovascular risk prediction and alter risk factor modification goals in some patients * However USPSTF found inadequate evidence to assess balance of benefits and harms of ABI in risk assessment of CVD in asymptomatic adults to prevent CVD events

Answer 45

develops through gradual ischemic conditioning which promotes the development of collateral vessels that maintain limb perfusion

Answer 46

most significant for development of CLI are diabetes, renal failure, heart failure, and prior stroke

Answer 47

Increased risk for limb loss --> CLI also referred to as chronic limb-threatening ischemia (CLTI)

Answer 48

chronic (more than two weeks) ischemic rest pain, ischemic wounds or tissue loss, or gangrene in one or both legs * Nocturnal/ischemic rest pain - symptoms worsen at night when the patient is supine * Patients awakened by burning pain, cramping, coldness, numbness or pain in the forefoot or toes * Symptoms relieved by hanging the limb over the side of the bed, triggering dependent rubor of the foot * *Requires urgent referral to a vascular surgeon

Answer 49

urgent referral to vascular surgeous

Answer 50

DDx: Diabetic neuropathic pain – a common comorbidity * * neuropathy is experienced as pins and needles along the entire sole of the foot

Answer 51

* Mortality rate - 25% in patients with CLI

Answer 52

abrupt interruption of arterial blood flow to an extremity

Answer 53

cold, painful, and pale extremity with diminished or absent pulses, motor weakness, and sensory impairment

Answer 54

* Acute disruption of arterial flow threatens limb integrity unless prompt revascularization is undertaken * *A medical emergency – evaluation by a vascular subspecialist on an emergency basis

Answer 55

1. CHF, superimposed on chronic arterial disease 2. deep venous thrombosis, acute 3. acute spinal cord compression

Answer 56

* complete blood count with platelet count * electrolytes * fasting glucose or A1C * fasting lipid profile * kidney function tests * serum creatinine * urinalysis for glucosuria and proteinuria *although elevated homocysteine, C-reactive protein, and lipoprotein A levels are risk factors for PVD, there are no outcomes studies to demonstrate that lowering these levels leads to clinical benefit for patients with PVD

Answer 57

Duplex ultrasonography (DUS)/Doppler ultrasonography Magnetic resonance angiography (MRA) or computed tomography angiography (CTA) Digital subtraction angiography (DSA) and catheter-based angiography Transcutaneous oximetry ECG

Answer 58

safe and cost-effective method of determining PAD location, stenosis severity, and length of stenosis or occlusion * Sensitivity and specificity depend on presence of calcium in the arterial wall, location or depth of the vessel, and the presence of multiple occlusions at different locations * Doppler ultrasonography - used in routine follow-up post-procedure for surveillance of patency, can assist in decision-making when further intervention is contemplated

Answer 59

excellent high-quality vascular imaging, useful for determining candidacy for bypass surgery versus angioplasty MRA - identify small runoff vessels that sometimes may not be seen with digital subtraction angiography (DSA)

Answer 60

for determining lesion localization, best used when invasive or surgical intervention (endovascular revascularization) may be indicated * Catheter-based angiography the gold standard for diagnosing PAD

Answer 61

a rapid method of assessing perfusion in patients with ulcers

Answer 62

may reveal the presence of an arrhythmia which may be the cause of an embolic event

Answer 63

Catheter-based angiography

Answer 64

musculoskeletal -arthritis -chronic compartment syndrome -medial tibial stress syndrome -muscle strain -symptomatic baker cyst neurologic -nerve entrapment -nerve root compression -peripheral neuropathy -spinal stenosis vascular -deep venous thrombosis -popliteal artery entrapment -vasculitis -venous insufficiency

Answer 65

* Compression of the spinal nerves or nerve roots, especially in the lumbar vertebrae * Caused by the narrowing of the central canal, the lateral recess, or neural foramen * most commonly is caused by degenerative osteoarthritis of the spine or spondylosis * also disc protrusion or bulging (i.e.,caused by progressive disc degeneration with aging or trauma), loss of disc height, facet joint arthropathy, osteophyte formation, or ligamentum flavum hypertrophy

Answer 66

obesity or family history of spinal stenosis

Answer 67

Combination of low back pain, leg pain, numbness and motor weakness that starts or intensifies on standing or walking and is eased by sitting or lying down

Answer 68

combination of low back pain, leg pain, numbness/parasthesia and motor weakness that starts or intensifies with ambulation (i.e. pseudoclaudication) * * Radiating leg pain may be down entire leg, bilaterally/asymmetrically * Difficulty walking and gait disturbances * Lumbar extension increases, and flexion decreases pain * Pain worse:walking, standing, or upright exercises * Pain better: sitting or forward flexion at the waist (squatting, leaning forward), or lying down

Answer 69

focal weakness, absent deep tendon reflexes, or sensory loss

Answer 70

categorized as mild, moderate, or severe, based on the extent of leg pain and pain- related disability * Severe symptoms - exercise intolerance, greatly restricted walking capacity, may have bladder dysfunction (i.e., urinary incontinence) * Maybe asymptomatic when inactive

Answer 71

* Lumbar extension increases, and flexion decreases pain * Pain worse:walking, standing, or upright exercises * Pain better: sitting or forward flexion at the waist (squatting, leaning forward), or lying down

Answer 72

elderly adults

Answer 73

cauda equina syndrome

Answer 74

* Conservative treatment-pain-relieving agents for mild symptoms * Decompressive surgery - to remove the bone and ligaments around the stenosis for severe symptoms * Varies – for moderate symptoms

Answer 75

Can lead to chronic pain and muscle weakness, may interfere with activities of daily living and result in progressive disability

Answer 76

Venous thromboembolism (VTE) is a blood clotting condition and includes deep-venous thrombosis (DVT) and pulmonary embolism (PE) * ~1/3 of patients present with PE * ~2/3 of patients present with DVT

Answer 77

Venous Thromboembolism after MI and stroke

Answer 78

Causes cardiovascular death, chronic disability, and emotional distress

Answer 79

* Annual incidence of VTE is one or two per 1,000 persons * Overall mortality rate is between 60,000 and 100,000 annually * One-half of patients with DVT will have long-term complications, including post-thrombotic syndrome and venous ulcers * PE is more often fatal, has a higher recurrence rate, and is associated with more serious long-term complications * One-third of patients with VTE will have a recurrence within 10 years

Answer 80

DVT: blood clot forms in deep vein, most often leg -->symptoms: pain, swelling, redness in the area, dilation of the surface veins, skin warm to touch PE: clot blocks blood supply to part of the lung AND part of blood clot breaks off and travels to lungs -->symptoms: SOB, chest pain, rapid HR, coughing blood, lightheaded

Answer 81

1. hyper coagulability (blood) 2. circulatory stasis (flow) 3. vascular damage (vessel)

Answer 82

I.e. thrombophlebitis cellulitits atherosclerosis from physical trauma or micro trauma to vessel

Answer 83

i.e. varicose veins, atrial fibrillation, venous obstruction from low heart rate low BP or congenital abnormalities

Answer 84

I.e. pregnancy, infection, IBD, autoimmune, malignancy from estrogen therapy, inflammation,, dehydration

Answer 85

Vascular obstruction leading to dead space ventilation, right-to-left shunting, and decreased cardiac output

Answer 86

* *Dyspnea * Pleuritic chest pain * Tachypnea * Cough * Syncope * Less common: tachycardia, hemoptysis, hypoxia, hypotension, fever, cyanosis, shock (alone or in combination) * May have concomitant signs/symptoms of DVT

Answer 87

Classic clinical presentation: swelling, pain, warmth, and redness in the involved extremity * May be asymptomatic * Individual symptoms are neither sensitive nor specific for DVT

Answer 88

trauma, infection, peripheral artery disease, and other venous diseases * DVT can coexist with any of these disease processes

Answer 89

SLIDE 64 i.e. alterative diagnosis less likely that PE, clinical signs and symptoms of DVT = give higher score for pretest probability

Answer 90

i.e. add a point if have active cancer, paralysis of lower extremities, bed ridden = all increase pre test probability

Answer 91

* Massive (high-risk) PE - 5–10% of patients, systemic arterial hypotension and extensive thrombosis affecting at least half of the pulmonary vasculature * Dyspnea, syncope, hypotension, and cyanosis * May present in cardiogenic shock and can die from multisystem organ failure * Submassive (intermediate-risk) PE - 20–25% of patients, RV dysfunction despite normal systemic arterial pressure - high risk of clinical deterioration * Low-risk PE - 65–75% of patients, have an excellent prognosis

Answer 92

usually begins in the calf and can propagate proximally to the popliteal, femoral, and iliac veins

Answer 93

often precipitated by placement of pacemakers, internal cardiac defibrillators, or indwelling central venous catheters

Answer 94

lower leg DVT is 10x more common

Answer 95

usually presents with erythema, tenderness, and a “palpable cord.” Patients are at risk for extension of the superficial vein thrombosis to the deep-venous system.

Answer 96

Study of 210 patients with PAD and an average age of 65 years, the prevalence of abdominal aortic aneurysm was 9.0%, rising to 15.8% in patients older than 75 years * The prevalence of abdominal aortic aneurysm in the general population is only 4% to 7.6%

Answer 97

majority of AAA remains asymptomatic until which time rupture or less commonly rapid expansion occurs leading to severe and unrelenting abdominal pain radiating to the back or a pulsatile abdominal mass

Answer 98

ultrasonography for abdominal aortic aneurysm is reasonable in patients with symptomatic PAD

Answer 99

rate of disease progression to rest pain (severe ischemic pain due to insufficient arterial inflow), critical limb ischemia (gangrene, ulceration, or tissue loss), and subsequent amputation is low—on the order of 10% over 10 years or 2.5% annually

Answer 100

* 70-80% have stable claudication * 10-20% have worsening claudication with rate of disease progression to rest pain (severe ischemic pain due to insufficient arterial inflow) * 1-2% may progress to acute or critical limb ischemia (gangrene, ulceration, or tissue loss) and subsequent amputation

Answer 101

* Ischemia/Gangrene * Amputation * Infection * Ulceration * Coronary artery disease and myocardial infarction * Stroke * Blood clots * Erectile Dysfunction * Depression

Answer 102

* Repeat ABI testing with any changes in functional status, order further testing, or refer the patient to a vascular subspecialist * ABI < 0.9 associated with a two-fourfold relative risk increase for cardiovascular events and all-cause mortality * Systematic review: ABI measured at baseline and tracked coronary heart disease, stroke, and all-cause mortality in patients who had not had a previous myocardial infarction or stroke * a low ABI was 92.7% specific for predicting incident coronary heart disease * At five years, 20% of patients with PAD had a nonfatal myocardial infarction, and 15% to 30% died; three-fourths of these were cardiovascular deaths

Answer 103

higher mortality rate * Study: 1,592 patients (men and women) from Scotland who were followed prospectively for five years with PVD * all-cause mortality rate of 3.8%/year for patients with PVD and claudication and 6.1%/year for patients with PVD and no symptoms, compared to 2.0%/year in the control group * No data to demonstrate that early identification of patients with PVD is beneficial in terms of mortality or morbidity reduction

Answer 104

risk factors: renal dysfunction, heart failure, age>65, hypercholestemia, etc... increase risk of mortality

Answer 105

statin and either aspirin or cilostazol

Answer 106

* Surgical revascularization should be considered in patients with lifestyle-limiting claudication symptoms that do not respond to exercise and pharmacologic treatment * Emergent consultation for arterial reconstruction is indicated in patients with critical limb ischemia

Answer 107

* Healthcare team: family doctor, nurses and pharmacists, vascular specialist/surgeon, endocrinologist interventional radiologist * Ensure that the patient is not on any medications that can lead to vasoconstriction * Educate about basic foot hygiene and wear protective shoe wear * Educate on signs of vascular disease and seek assistance if any changes occur

Answer 108

* Changes in lifestyle can significantly decrease the rate of progression of the disease and improve the quality of life * Primary prevention of PVD - encourage smoking cessation, maintain a healthy weight and control blood sugars, exercise, control blood pressure and cholesterol * *Smoking is the most significant modifiable risk factor * Exercise has been shown to increase walking time of patients with claudication by 150% * Aspirin reduces risk of serious vascular events - with doses of 75-150 mg being as effective as higher doses * Treat hypercholesterolemia with appropriate dietary modification and lipid- lowering agents, as needed. * Pursue aggressive blood pressure reduction