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The Big Heart Disease Lie

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Vascular S.tiii^efy;

Carotid stenosis: the classic presentation is a transient ischemic attack (TIA), especially amaurosis fugax, which is characterized by sudden-onset and transient unilateral blindness, some times described as a "shade pulled over one eye." Patients may have a carotid bruit, if a bruit is heard or the patient has a TIA, ultrasound of the carotid arteries should be done to determine the degree of stenosis.

a If stenosis is greater than 70% and the patient has had a TIA/amaurosis fugax or a small, nond.isabli.ng stroke, carotid endarterectomy (CPA) should be performed. Patients should not undergo CPA after a stroke that leaves them severely disabled, nor should they undergo CM during a TIA or stroke in evolution. CPA is an elective, not emergent, procedure.

b If stenosis is less than 70%, whether the patien t has symptoms or not, do not do CPA. Treat with daily aspirin instead.

® If the patient has greater than 70% stenosis, with or without symptoms, CPA provides the best long-term prognosis. If the patient is asymptomatic, you have to weigh the risk- benefit ratio more carefully.

a Carotid stenosis is a generalized marker for atherosclerosis. Virtually all patients have significant coronary artery disease; perioperative myocardial infarction is the most common cause of death in patients undergoing vascular surgery Make sure to evaluate risk factors for atherosclerosis (cholesterol, hypertension, smoking, diabetes mellitus).

Abdominal aortic aneurysm (AAA): look for a pulsatile abdominal mass that may cause ab dominal pain. If pain is present, suspect possible rupture of AAA, although even an unruptured AAA may cause some pain. CT scan usually is used for initial evaluation. If the AAA is smaller than 5 cm, follow it with serial ultrasound to make sure that it is not enlarging. If the AAA is larger than 5 cm (or you are told that it is rapidly enlarging), surgical correction should be done.

® A pulsatile abdominal mass plus hypotension -- emergent laparotomy (means ruptured AAA, which has a mortality rate of roughly 90%).

s A dissecting AAA, if not ruptured, can be treated conservatively with antihypertensive medications, although an elective repair should be considered if the patient is in good health.

leriche's syndrome: claudication in the buttocks, buttock atrophy and impotence in men; a classic marker for aortoiliac occlusive disease. Patients usually need an aor to iliac bypass graft.

Claudication: pain the the lower extremity (usually) brought on by exercise and relieved by rest. Claudication is an indicator of severe atherosclerotic disease. Associated physical findings include cyanosis (with dependent rubor), atrophic changes (thickened nails, loss of hair, shiny skin), decreased temperature, and decreased (or absent) distal pulses.The best treatment is conservative: cessation of smoking, exercise, and control cholesterol, diabetes me.ll.itus, and hypertension. Beta blockers may worsen claudication (due to beta-2 receptor blockade) and should be avoided.

sa If the patient progresses to rest pain in the forefoot, which generally occurs at night and is relieved by hanging the foot over the edge of the bed, or cannot continue current: lifestyle or work obligations, consider revascularization procedure.

h Severe pain in the foot that: has a sudden onset without previous history, trauma, or any associated chronic physical findings is generally more serious, and may represent an embolus (look for atrial fibrillation) or compartment syndrome (commonly occurs after revascularization procedures). m Claudication and peripheral vascular disease are generalized markers for atherosclerosis. Check patients for other atherosclerosis risk factors.

Mesenteric ischemia: the classic patient has a long history of postprandial abdominal pain, which causes a fear of food and thus leads to extensive weight loss. This diagnosis is difficult because, like all atherosclerotic disease, it presents in patients over 40, who may have other dis orders that cause the problem (e.g., peptic ulcer disease, pancreatic cancer, stomach cancer). Look for a history of extensive atherosclerosis (previous myocardial infarctions, cerebrovascular accidents, known coronary artery disease, or peripheral vascular disease with several risk factors), possible abdominal bruit, and a lack of jaundice (which would steer you toward pancreatic cancer). Usually CT scan of the abdomen is negative and should make you more suspi cious of ischemia. Patients should be treated surgically with revascularization because of the risks of bowel infarction and malnutrition.

Note: After a penetrating trauma in ait extremity (or iatrogenic catheter damage), an arteriove nous fistula may result. Look for bruits over the area or a palpable pulsatile mass (aneurysm). Such fistulas can be left alone if they are small; otherwise, surgical correction is needed.

Venous insufficiency: generally refers to the lower extremities. Patients may have a history of deep vein thrombosis; swelling in the extremity with pain, fatigability, and heaviness, which are relieved by elevating the extremity; and/or varicose veins. Skin pigmentation may increase around the ankles with possible skin breakdown and ulceration. Initial treatment is conservative: elastic compression stockings, elevation with minimal standing, and treatment of any ulcers with cleaning, wet to dry dressings, and antibiotics (if cellulitis is present). Patients with varicose veins, localized leg pain with cord- like induration, reddish discoloration, and mild fever have superficial thrombophlebitis (not deep vein thrombosis), which rarely leads to pulmonary embolism. Patients do not need anticoagulation. Treatment is often thrombectomy under local anesthesia; medical treatment (NSAIDs) is used if pain is mild or the patient does not want surgery. Pain generally subsides in a few days on its own.

Subclavian steal syndrome: usually due to left subclavian artery obstruction proximal to the vertebral artery. To get blood to an exercising arm, blood is "stolen" from the vertebrobasilar system; it flows backward into the distal subclavian artery instead of forward into the brainstem. As a result, the patient develops central nervous- system symptoms (syncope, vertigo, confusion, ataxia, dysarthria) and upper extremity claudication. Treat with surgical bypass.

Cervical rib: may compromise subclavian vessel blood flow. Patients may develop upper extremity paresthesias, weakness, and cold temperature (arterial compromise) or edema/venous distention (venous compromise) without CNS symptoms. Treat with rib resection.

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