Six weeks! So you have met the six-week mark, so congratulations on the hard work that you've put in. Hopefully you found some really great value in where you're at and then look forward to the next six weeks at which then you'll have completed the 12-week course. Congratulations and great job on the hard work. Today we're going to talk about peripheral vascular disease, so kind of give you some pearls in addition to your readings this week. So some statistics because it's actually quite prevalent. So for patients or folks less than 70, there's a 2.5 percent incidence in women and 5 percent in men, but it goes up significantly over that. When you start to get a greater than 70, it's now 29 percent or it's also quite a bit higher in patients that are also diabetic. But it's about 10 percent overall prevalence in the general population if you can take in consideration all ages. Now this is an important one. More than 50% of patients with cardiovascular disease also have peripheral arterial disease. That's a big deal, meaning that if you're in a cardiovascular practice, a number of patients that are coming into your practice every day have this and may not be diagnosed or managed. So I think this is really key when you talk about taking shoes and socks off and checking pulses as part of your cardiovascular exam. This is why. Smoking alone confers risk greater than having history of coronary artery disease. So if you've got a patient that has a smoking history and is certainly continuing to smoke, that is a big risk factor for peripheral vascular disease. And then 40 percent is asymptomatic. And so again, all those patients walking into your clinic and only 10 percent is really considered those typical symptoms that we think of as claudication. All right, so risk factors age over 70, males more than females, and especially males that are African-American or Hispanic. And for females, African-Americans and then smokers have higher risk. Age greater than 50 if you're diabetic and if you have more than one, one or more actually, coronary artery disease risk factor increases your risk for PAD. Age 50 to 69 with a history of smoking greater than a 10-pack year history and diabetes is a significant risk. And then again, I mentioned this already, but smoking is the most significant factor. All patients with peripheral vascular slash peripheral arterial disease need to be counseled to stop. This is more than your medicines or any interventions. This is the one thing that is going to decrease the progression or maybe even stop the progression of their disease. Signs and symptoms. So heaviness, ache, numbness in an extremity. And they may describe one of these. They may describe all three of these. Cramping in the leg, thigh, calves, or feet. Some of this is associated with activity. We talk about claudication where if they're active and they get that that cramping with walking and then they have to stop and then the cramping goes away. That would be consistent with claudication. A weak or absent pulse in those extremities. Unexplained sores on the extremities or poor healing. Now there is venous disease that can cause venous stasis ulcers. So not all sores on the extremities are from poor circulation or poor from peripheral arterial disease, but certainly it needs to be evaluated if you've got some some sores that are non-healing. Collar changes in the limbs, paleness, cyanosis. Poor nail growth, changes in hair distribution. So you may notice in some of your patients that they've got their thighs are quite hairy but as you work your way down their calves you'll see that hair begin to kind of decrease and even go away. In fact some patients it's very interesting you'll see these males that have very shiny skin and no hair in those lower extremities and that really is significant for possible PAD. And then the last one is temperature variation. Again if they are very severe peripheral arterial disease they may very well have a cooler limb on that side. Your differential diagnosis would be a deep vein thrombosis or a DVT. Phlebitis, so inflammation of the veins. Myalgia that you might get with an influenza. Again that's going to be self-limited versus a fibromyalgia or other types of myalgic type pain. Musculoskeletal disorders and peripheral neuropathy can cause similar symptoms such as osteoarthritis or restless leg syndrome as well as spinal canal stenosis. So the interesting thing about spinal canal stenosis is their pain's a little bit different. Pain with erect position, so when they're sitting straight up or standing straight up they have relief with the sitting or the lying down. Some people describe these are the the folks that you'll see or the picture where they're when they go to the grocery store and they get a cart and they can lean over the cart they can do much better job of walking and have less back pain than if they're trying to stand straight up. So that's oftentimes a good sign that it's a spinal canal issue versus a actual claudication or peripheral arterial disease type issue. Testing. So ABI or ankle brachial index is the cornerstone of vascular evaluation from a very baseline perspective. These can be done in a regular physician office. You may even have them offered in your office. Sometimes they're done in a vascular lab but they don't require a lot of equipment. They require a Doppler ultrasound along with a measurement tool and then in order to bill for them you have to have waveforms that are printed and are part of the chart. But the way these are set up is that you're literally just comparing the brachial blood pressure to the ankle blood pressure and we typically do these at the posterior tibialis and the dorsalis pedis pulse areas in the lower extremity. So you'll have two readings for each side and then you compare that to the right you know right brachial so right arm to right lower extremity left arm to left lower extremity. So it can be you know a little bit time-consuming but if you're working with a tech who does a lot of these they can do them in eight to ten minutes at the most. But the concept here is that you are comparing. So if they're equal the results would be a 1.0. If they're not equal and the lower extremity is less than the upper extremity then the results would be less than one. So the textbook suggests that anything greater than 0.9 is normal but check your normal values in for the the resource that you use. Mild obstruction would be a 0.71 to 0.89 moderate 0.41 to 0.7 and severe 0 to 0.40. Zero means there is no pulse there is no Doppler pulse and therefore there's no you're not able to measure blood pressure in that area. So significant peripheral arterial disease when you get to that less than 0.4. What that means is it's you move on to do more studies to really find out where that blockage is and how severe that blockage is. So management you know there's several things. There's medical options certainly antiplatelet therapy, lipid lowering agents through the use of statins. You want to secondary prevent them so managing hypertension, managing hyperlipidemia, getting them to stop smoking. Those are all very important interventions and then some patients go on to require interventions such as an angioplasty or a stent and others end up with a surgical intervention. So again the differences have to do with the severity, the patient's risk for surgery and sometimes just the preferred approach. So that brings us to the end of peripheral vascular disease or peripheral arterial disease. We're happy to answer any questions that you have after you've read through the curriculum. Please feel free to reach out to that MedAxiom Academy instructor if you have any questions. Thank you.

peripheral vascular disease

prevalence

risk factors

symptoms

management options