1. Pathosphysiology & Etiology
1.1. Definition: Arteries in limbs narrow or become blocked d/t decreased blood flow
1.1.1. Most common in BLE
1.1.2. Leads to Micro and MacroVasular Dysfunction
1.2. Secondary to:
1.2.1. Atherosclerosis: #1 Reason - The accumulation of plaque, fat deposits, cholesterol, et al on the inner walls of the arteries
1.2.1.1. Plaque Formation: Accumulates and narrows the arteries which leads to decreased blood flow
1.2.2. Ischemia: Decreased blood flow leads to decreased Oxygen, WBC, and Nutrients to affected limbs and organs.
1.2.3. Inflammation: Plaque and Ischemia lead to this which further damages arteries and blood flow.
1.2.4. Thrombosis: Ruptured plaque leads to thrombus that blocks the artery.
2. Signs and Symptoms
2.1. Usually Asymptomatic
2.2. Intermittent Claudication: #1 and In 20% of Patients
2.2.1. Especially from Exercise. More often in BLE. D/T decreased Blood Flow.
2.2.1.1. Pain
2.2.1.2. Cramps
2.2.1.3. Numbness
2.2.1.4. BLE: Fatigue, Weak, Stiff, Pressure, Parethesias, Cool to Touch
2.2.1.5. Sx Become Exacerbated with Elevation and Relieved when Lowered
2.2.2. Ischemia
2.2.2.1. Leads to Damage of Muscles, Nerves, Skin
2.2.2.1.1. Ulers
2.2.2.1.2. Non Healing Wounds
2.2.2.1.3. Slow Walk
2.2.2.1.4. Slow Walk
3. Risk Factors
3.1. Modifiable
3.1.1. Smoking is #1 Risk, HTN, Hypercholesterolemia, Obesity, Dislipidemia, atherosclerosis
3.2. Non Modifiable
3.2.1. Male, Non Asisan, >50 y.o., Poverty, Low Education, Prior CV Disease, Prior Amputation, Family Hx of PVD or CVD, Genetics
3.3. Diabetes Mellistus
3.3.1. Increases Risk 2-4x
3.3.2. 1/3 of DM patients have PVD
3.3.3. Longer DM Dx increases Risk
3.3.4. Increased A1C
3.3.5. Chronic hyperglycemia
3.3.6. Insulin Resistanace
3.3.7. Neuropathy and Retinopathy
3.4. Other
3.4.1. Non Dipping BP
3.4.1.1. Especially with HTN or Hemodialysis
3.4.1.2. Renal Disease
3.4.1.3. Sleep Apnea
3.4.1.4. Metabolic Syndrome
3.4.1.5. Higher in DM
3.4.2. Increased C-Reactive Protein
3.4.3. Increased Proinflammatory Cytokines
3.4.4. Increased Homocysteine Levels
3.4.5. Albumineria
4. Impact Other Body Systems and Complications
4.1. Increased Risk of CV Events by 35%
4.1.1. MI, Stroke, Coronary Artery Disease, Heart Failure
4.1.2. CVD Leading Cause of Mortality WorldWide
4.1.3. D/T: Increased platelet aggregation and coagulation, Decreased Antithrombin Level, Increased Thrombosis
4.1.3.1. DVT
4.1.4. CVD Associated with Dementia
4.2. Decreased Blood Flow to Major Organs
4.2.1. End Organ Ischemia
4.2.2. Erectile Dysfunction
4.2.3. Chronic Limb Threatening Ischemia
4.3. Skin
4.3.1. Unhealed Wounds
4.3.1.1. Foot Infx
4.3.1.1.1. Gangrene
5. Diagnosis
5.1. R/O other Possibilities
5.2. Good Assessment of Signs, Sx, and Risk Factors and Physical Exam
5.2.1. S/S of a Smoker: Yellow Fingers, One Discolored Tooth, Cough
5.2.2. Scars from Previous Wounds
5.2.3. Other Amputations
5.2.4. Ausculate Bruitt in Major Vessel
5.3. Measure Ankel-Brachial Index (ABI)
5.3.1. < or = 0.09 Confirms Dx
5.3.2. Not for pt with DM or Kidney Disease as Results Altered
5.3.3. Ankle SBP to Brachial SBP
5.4. Measure Toe-Brachial Index (TBI)
5.4.1. < or = 0.7 Confirms Dx
5.4.2. Use for DM pt
5.4.3. Toe SBP to Brachial SBP
5.5. Transcutaneous Oxygen Pressure (TcPO2)
5.5.1. Assesses Severity
5.5.2. OK for DM pt
5.6. Doppler Waveform Analysis of Ankle Arteries
5.6.1. Assesses Severity and Aterial Blood Flow Patterns
5.6.2. OK for DM pt
5.7. Imaging
5.7.1. Doppler US
5.7.1.1. High frequency soundwaves
5.7.1.2. Detect function and blockages
5.7.2. Magnetic Resonance Angiography (MRA)
5.7.2.1. Sees very small vessels
5.7.2.2. Determines if pt cadidate for Angioplasty
5.7.3. Computed Tomography Angiography (CTA)
5.7.3.1. Uses X-rays and Dye
5.7.3.2. Assesses blood flow and detects abnormalities
5.7.3.3. Determines if pt candidate for Angioplasty
6. Treatment
6.1. Lifestyle Changes #1
6.1.1. Quit Smoking
6.1.2. Exercise
6.1.2.1. 30-45 minutes 5 days/wk
6.1.3. Lose Weight
6.1.4. Diet Change
6.1.4.1. Mediterranean Diet
6.1.4.1.1. Low in: Red Meat, Saturated Fats, Dairy
6.1.4.1.2. High in: Fruits, Vegetables, Whole Grains, Beans, Nuts/Seeds, Olive Oil (Monounsaturated fats)
6.1.4.2. Japanese Diet
6.1.4.2.1. Low in: Red Meat, Saturated Fats, Dairy, SODIUM
6.1.4.2.2. High in: Fruits, Vegetables, Legumes, Soy, Omega-3, Fatty Acids, Antioxidant Rich Foods
6.1.4.3. Curcumin/Turmeric
6.1.4.3.1. Anti-inflammatory so Decreases Aortic Stiffness and Increases Endothelial Function of Carotid Artery
6.1.4.4. Low Sodium
6.1.4.4.1. Decrease: Salt, Cheese, Seafood, Takeout food, Frozen/Canned food, Processed Meats, Soups, Condiments, Chips, Popcorn
6.1.4.4.2. Lowers BP
6.2. RX
6.2.1. Chantix or Nicotine Replacement
6.2.1.1. Help quit smoking
6.2.2. Statins
6.2.2.1. Ezetimibe, Atorvastatin, Rosuvastatin, Simvastatin
6.2.3. Antihypertensives
6.2.3.1. Goal: SBP 120-130 and DBP <80
6.2.3.2. ACE Inhibitors: Lisinopril, Enalapril
6.2.3.3. ARB: Losartan, Valsartan
6.2.4. Antiplatelets
6.2.4.1. Plavix, ASA, Rivaroxaban, Cilostazol, Naftidrofuryl
6.2.5. Glucose Lowering Agents
6.2.5.1. Decreases Inflammation
6.2.5.2. Metformin
6.2.5.3. GLP-1RA
6.2.5.3.1. Not for pt with HF or CKD
6.2.5.4. SGLT2
6.2.5.4.1. OK for pt with HF or CKD
6.2.5.5. Encourage A1C <7 for DM pt
6.2.6. Diuretics
6.2.6.1. Treats edema and HTN
6.3. At Appointments: Especially for DM pt
6.3.1. Continuous Pt Education
6.3.2. Check feet
6.3.3. Check for Wounds/Ulcers
6.3.4. Check Peripheral Arteries
6.3.5. Check Pedal Pulses
6.3.6. Good Physical Exam and Intake of S/S
6.4. Referrals
6.4.1. Cardiologist #1
6.4.2. Endocrinologist
6.4.3. Diabetologist
6.4.4. Internal Medicine
6.4.5. Podiatrist
6.4.6. Dietitian/Nutritionist
6.4.7. Wound Specialist
6.4.8. Behavioral Therapy
6.4.8.1. Help quit smoking and lifestyle changes
6.4.9. Endovascular or Vascular Surgeon
6.4.9.1. For Revascularizatioin
6.4.9.1.1. Angioplasty