Lecture 6

Question 1

Peripheral Arterial Disease

Answer 1

obstruction of arteries of legs

Question 2

PAD results in:

Answer 2

claudification: pain, weakness, numbness or cramping in muscles due to decreased blood flow

Question 3

PAD impact

Answer 3

PREVALENCE

• ~8-12 million people in United States
• increases with age
• lower in women
• higher for blacks vs. whites
• higher among diabetics
• –1 to 3

Question 4

Direct Medical Costs of PAD in 2001

Answer 4

$4.37 billion

Question 5

Atherosclerosis Etiology and Pathophysiology

Answer 5

-likely begins with endothelial dysfunction due to oxidative stress

Question 6

Arterial Stenosis Etiology and Pathophysiology

Answer 6

• lowers blood flow to musculature
• ischemia and low oxygenation
• –during activity

Question 7

Metabolic and Neural Effects

Answer 7

• impaired energy utilization
• impaired re-synthesis of ATP and CP
• low concentration of ATP and CP
• loss of muscle fibers
• lower metabolic efficiency of muscle
• mitochondrial damage
• damage to peripheral nerves

Question 8

Risk factors

Answer 8

• older age
• smoking
• diabetes
• dyslipidemia
• hypertension
• high C-reactive protein
• high homocysteine
• high fibrinogen
• high blood viscosity
• family history for cardiovascular diseases

Question 9

Prevention

Answer 9

• early evaluation of risk factors
• modification of risk factor profile
• –medication
• —–hypertension
• —–dyslipidemia
• -lifestyle modification
• —-smoking cessation
• —-physical activity
• —-diet

Question 10

Symptoms are progressive

Answer 10

Mild PAD may asymptomatic

Question 11

Intermittent Claudication

Answer 11

• 35-40% of PAD Patients

- progressively occurs during shorter activity bouts

Question 12

Critical Limb Ischemia

Answer 12

• presence of ischemic rest pain; foot ulcers; gangrene

- 1-2% of PAD patients

Question 13

Gangrene

Answer 13

Amputation

Question 14

Other symptoms of Arthersclerosis

Answer 14

MI, Stroke

Question 15

Common Morbidities

Answer 15

• heart disease
• cerebrovascular disease
• diabetes
• pulmonary disease

Question 16

Classification

Answer 16

Fontaine Stages

Rutherford

Question 17

Fontaine Stages

Answer 17

I. asymptomatic
IIa. mild claudication
IIb. moderate to server claudication
III. ischemic rest pain
IV. ulceration or gangrene

Question 18

Rutherford

Answer 18

0: asymptomatic
1: mild claudication
2: moderate claudication
3: severe claudication
4: ischemic rest pain
5: minor tissue loss
6: major tissue loss

Question 19

Specialists

Answer 19

primary care physician, cardiologist, vascular specialist vascular surgeon

Question 20

Components of Medical Evaluation

Answer 20

-physical exam and risk factor assessment

diagnostic tests

• blood test for risk factors
• ankle-bracial index
• exercise test
• doppler ultrasound
• reactive hperemia
• CT or MR Angiogram

Question 21

Ankle-Brachial Index

Answer 21

Ratio: SBP in ankle/SBP in arm

Question 22

Post Exercise ABI

Answer 22

May help identify severe ischemia

Question 23

Prognosis

Answer 23

• worse when intermittent claudication is present
• poor with clinical limb ischemia
• lower with low functional capacity
• high risk for cardiovascular and cererbovascular events
• –5-7% per year

Question 24

Treatment

Answer 24

LIFE-STYLE MODIFCATION
smoking cessation, diet, physical activity

MEDICATION
cholestrol, hypertension, diabetes, anti-coagulants (blood thinners), pain

REVASCULARIZATION

• bypass grafting
• angioplasty

AMPUTATION

Question 25

Exercise as Treatment

Answer 25

IMPORTANT COMPONENT OF MANAGEMENT more effective than meals -for improving walk time IMPROVES - pain free walking time and distance - ---claudication does not disappear - risk factor profile - functional capacity - quality of life

Question 26

Adaptations

Answer 26

- improved oxidative metabolism in muscles - improved walking biomechanics - --better efficency and economy - reduced blood viscosity - greater collateral circulation - better endothelial function - greater pain tolerance - higher pain-free walking distance and time - --115% in distance after 6 months increase

Question 27

Exercise Testing: Diagnostic

Answer 27

- with ABI helps identify severe ischemia in legs | - diagnosing heart problems

Question 28

Exercise Testing: Functional

Answer 28

- may be true peak GXT - should record - --time and distance prior to onset of pain - --time and distance prior to onset go max pain

Question 29

Exercise Testing: Prognostic

Answer 29

- worse prognosis with | - --low FC, early onset of claudication

Question 30

Protocols

Answer 30

- constant speed 2mph - ramping protocols common - discontinuous protocols may be used - relative indication for termination: 3+ to 4 point pain scale

Question 31

Aerobic Exercise Prescription

Answer 31

MODE - large muscle activities - --waiting most important but should included other activities - intermittent training commonly used - ---especially during initial phase FREQUENCY - intially:2-3times a week - progress daily INTENSITY moderate -40-60% VO2R or HER -until 3+ on 4 point scale DURATION - start with intermittent - --2-5 min exercise. 1-2 minute recovery - progress to longer bouts. as tolerated

Question 32

Training for Strength and Flexibility

Answer 32

-follow general guidelines