Peripheral Vascular Disease

Peripheral vascular disease is an occlusion of the blood supply to the extremities by atherosclerotic plaques. It most commonly affect to the lower extremities.

Signs and Symptoms:

• Intermittent claudication (leg pain when walking and relieved by rest)
• Dorsal foot ulcerations may develope
• Painful, cold, and numb on foot
• Aortoiliac disease: buttock claudication and femoral pulses are absent, impotence in male
• Femoropopliteal disease: calf claudication, pulses below the femoral artery are absent
• Small vessel disease: foot pulses are absent
• Acute ischemia: caused by embolization from the heart
• Severe chronic ischemia: mucle atrophy, pallor, cyanosis, hair loss, and gangrene/necrosis

Diagnostic Procedures:

• Palpation of pulses and auscultation for bruits
• Measurement of ankle and brachial systolic BP
• Droppler ultrasound
• Arteriography and digital substraction angiography

Treatments:

• Control the underlying causes
• Eliminate tobacco
• Hygiene and foot care
• Exercise
• Aspirin, cilostazol, and thromboxane inhibitors
• Angioplasty and stenting
• Surgery (artery bypass) or amputation

Deep Venous Thrombosis

Deep venous thrombosis is a clot formation in the large veins of the extremities or pelvis. The disease can be diagnosed by doppler ultrasound.

Predisposing Factors:

• Venous statis due to immobilization
• Incompetent venous valves in the lower extremities
• CHF
• Traumatic injury to the lower extremities
• Hypercoagulable states
• Obesity
• Indwelling venous catheters

Signs and Symptoms:

• Homan's signs: tendernes on calf with passive foot dorsiflexion
• Pain, erythema and swelling unilateral lower extremities

Treatments:

• Initial anticoagulation with IV heparin or low-molecular-weight heparin, followed by PO walfarin for a total of 3-6 months
• IVC filter in patient with contraindication to anticoagulation
• Hospitalized patients: DVT prophylaxis consisting of rapid mobilization, antithromboembolic stockings, leg exercises, and SQ heparin

Aortic Dissection

Aortic dissection is a transverse tear in the intima of a vessel. The blood enters the media and creates a false lumen and hematoma that propagates longitudinally. The most common sites of origin are above the aortic valve and distal to the left subclavian artery. It occurs often in age 40-60 years of age and a greater frequency in men than in women.

Etiology:
Hypertension (most)

Signs and Symptoms:

• Sudden tearing / stabbing pain in the anterior chest in ascending dissection
• Interscapular back pain in descending dissection
• Hypertensive
• Signs of pericarditis or pericardial tamponade may be seen
• A murmur of aortic regurgitation may be heard
• Neurologic deficits may be seen

Treatments:

• If hypertensive, reduce the BP and heart rate. Do not use thrombolytics
• Surgical emergency for ascending aortic dissection
• Medical therapy for descending dissection aorta

Aortic Aneurysm

AORTIC ANEURYSM

Etiology:
Atherosclerosis (most are abdominal and more than 90% originate below the renal arteries

Risk Factors:

• Hypertension
• High cholesterol
• Other vascular disease
• Family history
• Smoking
• Age
• Gender (males > females)

Signs and Symptoms:

• Usually asymptomatic
• Pulsatile abdominal mass or abdominal bruits
• Ruptured aneurysm
• Hypotension
• Severe and tearing abdominal pain radiating to the back

Treatments:

• If asymptomatic, monitoring is appropiate for lesions less than 5 cm
• Surgical repair if lesion is more than 5.5 cm on abdominal or more than 6 cm on thoracic or if enlarges rapidly
• Emergency surgery for symptomatic or ruptured aneurysms

Mitral Valve Prolapse

MITRAL VALVE PROLAPSE

Risk Factors:
Young women (found in 7% of the population)

Signs and Symptoms:

• Benign and asymptomatic
• Murmur: late systolic murmur with mid-systolic click
• Can progress to mitral regurgitation

Treatments:
Treatments are unnecessary unless symptomatic

Mitral Regurgitation

MITRAL REGURGITATION

Risk Factors:

• Rheumatic heart disease
• Myocardial Infarction
• Infective endocarditis
• Severe mitra valve prolapse

Signs and Symptoms:

• Signs of left-sided heart failure that can progress to right-sided heart failure
• Murmur: high-pitched, holosystolic murmur at the apex that radiates to the axilla
• Laterally displaced PMI with left ventricular heave
• Atrial fibrillation
• Fatigue

Treatments:

• ACEIs
• Vasodilators
• Diuretic
• Digoxins
• Anticoagulants
• Valve repair or replacement

Mitral Stenosis

MITRAL STENOSIS

Risk Factors:
Rheumatic heart disease

Signs and Symptoms:

• Symptoms of CHF (left and right side)
• Murmur: mid-diastolic rumble with opening snap at the apex
• Atrial fibrillation
• Pulmonary rales
• Increased intensity of S1 and P2
• Right ventricular heave

Treatments:

• Avoid inotropic agents
• Beta-blocker and diuretics
• Digoxins
• Anticoagulants
• Balloon valvuloplasty

Aortic Regurgitation

AORTIC REGURGITATION

Risk Factors:

• Rheumatic heart disease
• VSS
• Infective endocarditis
• Congenital bicuspid valve
• Marfan's syndrome
• Syphilis

Signs and Symptoms:

• LVH symptoms
• Angina
• CHF
• Widened pulse pressure
• Laterally displaced PMI
• Three murmur: high-pitched (blowing diastolic murmur at the left sternal border); Austin Flint-low-pitched (mid-diastolic rumble); mid-systolic murmur at the base

Treatments:

• Aortic valve replacement
• Afterload reducers (ACEIs, vasodilators)
• Diuretics
• Digoxin

Aortic Stenosis

AORTIC STENOSIS

Risk Factors:

• Rheumatic heart disease
  
• Congenital aortic stenosis
  
• Bicuspid valve
  

Signs and Symptoms:

• Classic triad of exertional dyspnea, angina, and syncope
  
• Can develops to CHF or even death
  
• Murmur: midsystolic crescendo-decrescendo heard best at the second intercostal space radiating to the neck
  
• Pulsus parvus et tardus: weak, delayed caroid upstroke
  
• Sustained apical beat
  
• Paradoxically split S2
  

Treatments:

• Avoid afterload reducers
  
• Valve replacement
  

Cardiac Tmponade

Cardiac tamponade is an excess fluid in the pericardial sac. It compromises ventricular filling and decreases output.

Risk Factors:

• Pericarditis
• Malignancy
• SLE
• TB
• Trauma

Signs and Symptoms:

• Fatigue, dyspnea, tachycardia and tachypnea that worsen rapidly and causes shock and death
• Beek's triad (hypotension, distant heart sound, and distended neck veins)
• Narrow pulse pressure
• Pulsus paradoxus
• Kussmaul's sign (JVD on inspiration)

Treatments:

• Aggressive volume expansion with IV fluids
• Pericardiocentesis immediately
• Balloon pericardotomy
• Pericardial window

Pericarditis

Pericarditis is an inflammation of the pericardial sac. It often with an effusion and can compromise cardiac output via tamponade or constrictive pericarditis. Most commontly idiopathic.

Etiology:

• Collagen vascular disease
• Aortic dissection
• Radiation
• Drugs
• Infections
• Acute renal failure (uremia)
• Cardiac (Myocardial Infarction)
• Rheumatoid Fever
• Injury
• Neoplasms
• Dressler's syndrome

Signs and Symptoms:

• Pleuritis chest pain that worsens in the supine position and with inspiration
• Dyspnea
• Cough
• Fever
• Pericardial friction rub
• Elevated JVP
• Pulsus paradoxus

Treatments:

• Treat the underlying causes, eg. steroid/immunosuppressants for SLE, ASA/NSAIDs for viral pericarditis, dialysis for uremia
• Pericardiocentesis with continuous drainage for tamponade or large effusion

Hypertension - Urgency and Emergency

Hypertensive urgency is defined as systolic BP > 180 mmHg and diastolic BP > 130 mmHg with asymptomatic or moderately symptomatic such as headache, chest pain, and syncope.

Hypertensive emergency is defined as signs or symptoms of impending end-organ damage such as acute renal failure or hematuria, altered mental status or evidence of neurologic disease, intracranial hemorrhage, ophthalmologic problems (papilledema), unstable angina or MI, or pulmonary edema.

Malignant hypertension is defined as progressive renal failure and/or encephalopathy with papilledema.

Treatments:

1. Treatment is to decrease blood pressure slowly to prevent cerebral hypoperfusion or coronary insufficiency
2. Oral drugs: beta-blocker, clonidine, and ACEIs
3. IV agents: nitroprusside, nitroglycerin, labetalol, necardipine, or hydralazine
4. Diuretics are used if there are signs of fluid overload

Hypertension

Hypertension is defined as a systole BP > 140 mmHg and/or a diastolic BP > 90 mmHg based on three measurements, each separated by two weeks. It is classified as Stage 1 Hypertension and Stage 2 Hypertension.

Stage 1 (essential) Hypertension

It represent 95% of hypertension cases. Systolic BP 140-139 mmHg, Diastolic BP 90-99 mmHg. Risk factors: family history of hypertension or heart disease, high-sodium diet, smoking, obesity, race (African-American > Caucasians), elderly

Signs and Symptoms:

• Asymptomatic until complications develop
  
• Retinal changes
• S4 gallop
• Systolic click
• Loud S2
• If untreated will damage to the heart, brain, kidney, vasculature, and eye

Treatments:

• Lifestyle management
• Diuretics and beta-blocker
• Test for end-organ complication periodically; renal and cardiac complications

Stage 2 Hypertension

Stage 2 hypertension is due to an identifiable organic cause. Systolic BP is > 160 mmHg and diastolic BP is > 100 mmHg.

Etiologies and Treatments:
Treatments for stage 2 hypertension are treatment of underlying causes:

• Renal disease (stage 1); treatments: ACEIs
• Renal artery stenosis; treatments: angioplasty and stenting, ACEIs, and open surgery
• OCP use; treatment: discontinue OCPs
• Pheochromocytoma; treatment: surgical removal of tumor
• Conn's syndrome (hyperaldosteronism); treatment: surgical removal of tumor
• Cushing's syndrome; treatment: surgical removal of tumor
• Coarctation of the aorta; treatment: surgical repair

Myocardial Infarction (MI)

Myocardial infarction usually caused by occlusive thrombus or prolonged vasospasm in a coronary artery.

History and Physical Exams:

• Acute onset substernal chest pain that is described as pressure or tightness and radiate to the left arm, neck, or jaw
• Shortness of breath, diaphoresis, light-headedness, nausea, vomiting, anxiety, syncope
• Tachycardia, bradycardia, arrhythmias, new mitral regurgitation, hypotension, pulmonary edema, and ventricular fibrillation
• Sudden death from a lethal arrhythmia (ventricle fibrillation)
• Clinically silent MIs in elderly, diabetic, postmenopausal and postorthopic heart transplant patients

Diagnosis

• ST-segment elevation or new LBBB on ECG
• ECG changes: peaked T waves, ST-segment elevation, Q wave, T-wave inversion, ST-segment normalization, T-wave normalization
• Inferior MI : ST-segment elevation in leads II, III, and aVF
• Anterior MI : ST-segment elevation in leads V1-V4
• Lateral MI : ST-segment elevation in leads I, aVL, and V5-V6
• Serial cardiac enzymes: troponin and CK-MB.

Treatments:

1. Acute treatments is Morphine, Oxygen, Nitroglyserin sublingualy, Aspirin, and IV beta-blocker.
2. Glycoprotein
3. Heparinization, angiography and revascularization
4. Consider thrombolysis with tPA, urokinase, or streptokinase
5. PTCA
6. CABG - Coronary Artery Bypass Graft (for depressed ventricular function, unable to PTCA, stenosis of left main, and triple-vessel disease)
7. Long term treatments: ASA, beta-blocker, ACEIs, and statins
8. Dietary changes and exercises

Angina - Unstable Angina

Unstable Angina

The angina is unstable if it is new and accelerating or occurs at rest.

Treatments:

• Acute treatments is Morphine, Oxygen, Nitroglyserin sublingualy, Aspirin, and IV beta-blocker.
• Glycoprotein
• Heparinization, angiography and revascularization

Angina Pectoris

Angina pectoris is substernal chest pain due to myocardial ischemia. Angina pectoris can be distinguished from prinzmetal's (varian) angina by definition that prinzmetal's angina is caused by vasospasm of coronary vessels.

Signs and Symptoms:

• Substernal chest pain precipitated by exertion and relieved by rest or nitrates
• Pain radiates to the arms, jaw, and neck
• Shortness of breath
• Nausea or vomiting
• Light-headedness
• Diaphoresis
• Hypertension
• Tachycardia
• Apical systolic murmur or gallop

Diagnoses:

• ST segment depression or T-wave flattening on ECG
• Cardiac enzymes to rule out myocardial infarction

Treatments in Acute Case:

• Morphine
• Oxygen
• Nitroglycerin sublingually
• Aspirin
• IV beta-blocker

Treatments in Chronic Case:

• Nitrates
• Beta-blockers
• Calcium channel blockers
• ASA
• Risk factor reduction such as smoking, cholesterol, hypertension

Hypercholesterolemia

Hypercholesterolemia is defined as a total cholesterol level more than 200 mg/dL.

Risk Factors:

• Increased blood cholesterol
• Increased LDL
• Increased triglycerides
• Decreased HDL

Etiology:

• Obesity
• Diabetes Mellitus
• Alcoholism
• Hypothyroidism
• Nephrotic syndrome
• Hepatic disease
• Cushing's disease
• OCP use
• Diuretic use
• Familial hypercholesterolemia

Data Findings:

• No specific signs and symptoms for most patients
• Xanthomas - eruptive nodules in skin over tendons
• Xanthelasma - yellow fatty deposits in skin around eyes
• Lipemia retinalis - creamy of retinal vessels

How to diagnosed:

• Hypercholesterolemia is diagnosed by:
• Fasting lipid profile for patient more than 20 year and repeat ever five years
• Total serum cholesterol > 200 mg/dL on two different occation
• LDL > 130 mg/dL or HDL <>

Treatments:

• Treatments are based on risk stratification
• Diet and exercise

CHF - Diastolic Dysfunction

CHF - Diastolic Dysfunction is characterized by decreased ventricular compliance with normal contractile function. the ventricle is unable either to actively relax or to passively fill properly

Physical Examinations:

• Stable and unstable angina
• Shortness of breath
• Dyspnea on exertion
• Arrhythmias
• Myocardial infarction
• Heart failure
• Sudden death

Treatments:

• Beta-blocker
• ACEIs
• Diuretics
• Rate control drugs
• Blood pressure management

CHF - Systolic Dysfunction

CHF - Systolic Dysfunction is determined by an EF < style="font-size:130%;">Physical Examination:

• Dyspnea on exertion or at rest if severe
• Chronic cough
• Fatigue
• Lower extremity edema
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Abdominal fullness

Treatments in acute:

• Correct underlying causes such as arrhythmia, alcohol-induced failure, thyroid and valvular disease
• Diuretics
• ACEIs

Treatments in chronic:

• Beta-blocker and ACEIs together
• Daily aspirin and a statin
• Chronic diuretics
• Low-dose spironolactone
• Treatment of arrhythmias
• Limitation of dietary sodium and fluid intake
• Warfarin
• Mechanical left ventricular assist device or cardiac transplantation

Congestive Heart Failure

Congestive heart failure is the clinical condition in which the heart is unable to pump enough blood to meet the oxygen demand of the heart and other body tissues.

Risk Factors:

• CAD
• Hypertension
• Valvular heart disease
• Pericardial disease
• Cardiomopathy
• Pulmonary hypertension

Classification and Treatments:
According to the AHA/ACC the classification and treatments of CHF are:

CHF stage A

• Present of the risk factors
• No structural or functional abnormalities
• No signs and symptoms of CHF
• Treatments: managing the treatable risk factors, ACEIs

CHF stage B

• Present of structral heart disease without symptoms of CHF
• Treatments: ACEIs and beta blocker

CHF stage C

• Present of structural heart disease with prior or current symptoms of CHF (shortness of breath, fatigue, exercise intolerance)
• Treatments: diuretic, ACEIs, beta-blocker, digitalis, dietary salt restriction

CHF stage D

• Marked symptoms of CHF at rest despite maximal medical therapy
• Treatments: mechanical assist devices, heart transplant, continuous IV inotropic drugs, hospice care

Classification CHF according to New York Heart Association:

CHF Class I

• No limitation of activity
• No symptoms with normal activity

CHF Class II

• Slight limitation of activity
• Comfortable at rest or with mild exertion

CHF Class III

• Marked limitation of activity
• Comfortable only at rest

CHF Class IV

• Any physical activity causes discomfort
• Symptoms are present at rest
• Complete rest in bed or chair