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ConditionCharacteristics/EtiologySigns/SymptomsClinical ProgressionConsiderations/Red FlagsOcclusive Peripheral Arterial DiseaseChronic, occlusive arterial disease of medium and large sized veins. Result of peripheral atherosclerosis Diminished blood supply Diminished or absent pulse. Pale with elevation. Dusky Red on dependencyPrimarily Lower Extremity Early stages – intermittent claudication (pain) described as burning, searing, aching, tight, cramping. Occurs regularly with walking. Relieved with Rest. Late stages – exhibit rest pain, muscle atrophy, trophic changes (hair loss, skin, nail changes)Thromboangitits Obliterans (Buerger’s Disease) Chronic inflammatory vascular occlusive disease of small arteries and veins Paresthesias or painCyanotic cold extremity Diminished temp sensationBegins distal progresses PROXIMAL in both UE and LEFatigue, risk of ulceration, gangrene. Common in young adults (males) who smoke. Diabetic Angiopathy Inappropriate elevation of blood glucose levels and accelerated atherosclerosisNeuropathy = major complication Neurotrophic ulcers may lead to gangrene and amputation RaynaudsEpisodic spasm of small arteries and arteriolesAbnormal vasoconstrictor reflex Exacerbated by exposure to cold/emotional stressTips of fingers develop pallor, cyanosis, numbness and tingling Affects females largely Occlusive disease not usually a factor Varicose VeinsDistended, swollen superficial veins. Tortuous in appearanceMay lead to varicose ulcers Venous Thromboembolism (VTE) Formation of blood clot in deep vein that can lead to complications (including DVT, PE or post-thrombotic syndrome PTS) Tx: Compression stockings at least 30 mmHg at ankle. Intermittent pneumatic compression if not relieved with compression stockingsCan become chronic. Post-thrombotic syndrome, leads to decreased QOLBed rest NOT recommended after VTE dx after acceptable levels of rx are reached unless medical concerns Mortality – 10-30% within 1 month of diagnosisMorbidity – 1/3 experience another VTE within 10 years Deep Vein Thrombophlebitis(see Wells Criteria Below) DO NOT USE HOMANS SIGN TO EVAL PATIENTS WITH SUSPECTED DVT Clot formation and acute inflammation in a deep vein May be symptomatic early. Progressive inflammation with TTP. Dull ache, tightness/pain in calf. Swelling, warmth, redness, discoloration in LE, prominent superficial veins Usually in LE associated with forced immobilization (bed rest, lack of leg exercise), surgery, trauma, hyperactivity of blood coagulationUse graded compression stockings Medical Mgmt: Anti-coagulation therapy to prevent formation of new clots, prevent existing clots from getting larger, stabilize clot through anti-inflammatory properties (low molecular weight heparin LMWH) LMWH contraindicated in patients at high risk of bleeding – these patients are treated with unfractionated heparin (UFH) Pulmonary Embolism Can lead to RIGHT heart dysfunction/failurePresents abruptly with chest pain and dyspnea, diaphoresis, cough and apprehension. Can result in chronic thromboembolic pulmonary hypertension with reduced oxygenation and pulmonary hypertension REQUIRES EMERGENCY TREATMENTLife threatening – 20% with acute PE die almost immediately 40% die within 3 months Chronic Post-Thrombotic SyndromeCombination of clinical signs and symptoms that persists after an LE DVT, thrombosis resolution is incompletePain, intractable edema, limb heaviness, skin pigmentation changes and leg ulcersLeads to reduced QOL and impaired functional mobility Chronic Venous Stasis/Incompetence Venous valvular insufficiency from fibroelastic degeneration of valve tissue, venous dilation Grade Classification: Grade I – mild aching, minimal edema, dilated superficial veinsGrade II – Increased edema, multiple dilated veins, change in skin pigmentation Grade III – venous claudication, severe edema, cutaneous ulceration LymphadenopathyEnlargement of nodes with or without tendernessLymphedema Stages associated – progressive disease Chronic disorder with excessive accumulation of fluid due to obstruction of lymphatics or removal of lymph nodes Swelling of soft tissues in arms and legsResults from mechanical insufficiency of the lymphatic system. 1* - congenital condition with abnormal lymph node or lymph vessel formation (Hypo or Hyper Plasia) 2* - acquired, due to injury of one or more parts of the lymphatic system. Causes include:Surgery – radical mastectomy, femoro-popliteal bypass, lymph node removalTumors, trauma, infection affecting lymph vesselsRadiation therapy with fibrosis of tissues Chronic venous insufficiency In tropical and subtropical areas, filariasis (nematode worm larvae in lymph) Well Criteria for DVT: Active Cancer (Treatment ongoing, or within 6 months or palliative) +1Paralysis, paresis or rest cast immobilization of LE ORBedridden recently for 3+ days or major surgery <12 weeks+1Localized tenderness along distribution of deep venous system+1Entire leg swelling+1Calf swelling at least 3 cm larger than asymptomatic side+1Pitting edema, confined to symptomatic leg+1Previously documented DVT+1Alternative diagnosis at least as likely as DVT+1ADD UP SCOREDVT Likely if GREATER THAN OR EQUAL TO 2DVT UNLIKELY if <2Borg Scale (RPE): 6-20 scale Karvonen = % intensity (Age Predicted HR max – Resting HR) + Resting HR 7 = very, very light 13 = somewhat hard19 = very, very hard D/D: Peripheral Vascular DiseaseChronic Arterial InsufficiencyChronic Venous InsufficiencyChronic Lymphatic InsufficiencyEtiology Atherosclerosis, Thrombosis, Emboli, Inflammatory Process Thrombophlebitis, trauma, vein obstruction (clot) vein incompetencePrimary LymphedemaSecondary lymphedema Risk Factors Age > 60 Smoking Diabetes Mellitus Gender: Slightly > in Men DyslipidemiaHTNHyperhomocysteinemia Race (African American) Venous HTN Varicose VeinsInherited TraitGender: FemaleAgeIncreased BMI Sedentary Life/Prolonged sitting Ligamentous Laxity Lymphadenectomy Radiation treatment Inflammatory ArthritisObesity Signs and Symptoms: Determined by LOCATION and DEGREE of vascular involvement Pain Severe muscle ischemia/intermittent claudication WORSE with EXERCISE, Relieved with restRest pain = SEVERE involvement Muscle fatigue, cramping, numbnessParesthesia in time Minimal to moderate STEADY pain Aching pain in lower leg with prolonged standing or sitting (dependency) Superficial pain along course of vein Heaviness, tightness, aching or discomfort Location of Pain USUALLY: Calf, Lower leg, dorsum of foot MAY occur: thigh, hip or buttockMuscle compartment tendernessEDEMATOUS limbVascularDecreased or absent pulses PALLOR of forefoot on elevation DEPENDENT rubor Venous dilatation or varicosity Edema: MODERATE to SEVERE (esp after prolonged dependency) Rare complications unless severe and untreated edema Skin Changes Pale, shiny, dry skinLoss of hairNail changes COOLNESS of extremity (BLOOD IS NOT GETTING THERE) HEMOSIDERIN deposition: dark, cyanotic, thickened, brown skin Lipodermatosclerosis: fibrosing of the subcutaneous tissueMay lead to stasis dermatitis, cellulitisCutaneous fibrosisMay lead to cellulitis, lymphangitis Acute Acute Arterial obstruction: DISTAL pain, paresthetic, pale, pulseless, sudden onsetAcute thrombophlebitis (DEEP venous thrombosis, DVT): Calf pain, aching, edema, muscle tenderness, 50% asymptomatic RARELY acute, usually progressive over time except with changes in pressure to limb altering flow (repeated blood pressure measurements, airplane flights) Ulceration May develop in toes, feet, areas of traumaPale or yellow to black eschar, gangrene may developRegular in shape and may appear punched outMay develop at sides of ankles (esp. MEDIAL malleolus along the course of veins) Gangrene absentPainful, shallow, exudative and have granulation tissue in the base (THINK ABOUT IT BLOOD IS STUCK THERE SO GRANULATION MAKES SENSE) Irregular borders Unusual Absolute Contraindications for Inpatient/Outpatient Cardiac Rehab Acute MI (within 2 days) Unstable angina not previously stabilized by medical therapy Uncontrolled cardiac arrhythmias symptoms/hemodynamic compromiseAcute PE or pulmonary infarction Acute myocarditis or pericarditisAcute aortic dissection Relative Contraindications for Inpatient/Outpatient Cardiac Rehab American College of Cardiology Foundation/AHA Stages Stage A At HIGH risk for HF but w/o structural heart disease or symptoms of HFStage BSTRUCTURAL heart disease but w/o signs/symptoms of HFStage CSTRUCTURAL heart disease WITH prior/current symptoms of HFStage DREFRACTORY HF requiring specialized interventions LEFT main coronary stenosis MODERATE stenotic valvular heart diseaseElectrolyte abnormalitiesSevere arterial hypertension Tachyarrhythmias or bradyarrhythmiasHypertrophic cardiomyopathy and other forms of outflow tract obstruction Mental or physical impairment leading to inability to exercise adequately METS Activity ChartIntensityEndurance PromotingActivity1.5-2 METS Too low in energy level Standing, walking slowly (1 mph) 2-3 METSToo low in energy level, unless capacity is very lowLevel walking (2 mph), Level bicycling (5 mph) 3-4 METSYes, if continuous and target HR reachedLevel walking (3 mph), bicycling (6 mph) 4-5 METSRec activities must be continuous, (>2 minutes)Walking (3.5 mph) bicycling (8 mph) 5-6 METS YesWalking brisk pace (4 mph), bicycling (10 mph) 6-7 METSYesWalking very brisk (5 mph), bicycling (11 mph) swimming leisurely (20 yd/min) 7-8 METSYesJogging (5 mph) bicycling (12 mph) 8-9 METSYesRunning (5.5 mph), bicycling (13 mph), swimming (30 yd/min) >10 METSYesRunning 6 mph = 10 METS, 7 mph = 11.5 METS, 8 mph = 13.5 METS, 9 mph = 15 METS, 10 mph = 17 METS, swimming mod/hard = > 40 yd/min High-degree atrioventricular block Classifications of Heart Failure NY Heart Association StagesFunctions and Symptoms Class I: Mild HFNo Limits in Physical Activity (up to 6.5 METS) Comfortable at rest Ordinary activity does not cause undue fatigue, palpitation, dyspnea or anginaClass II: Slight HFSlight limitation in PA (up to 4.5 METS) Comfortable at restOrdinary PA DOES lead to fatigue, palpitation, dyspnea, angina Class III: Marked HFMARKED limitation in PA (up to 3.0 METS) Comfortable at rest Less than ordinary activity fatigue, palpitation, dyspnea, angina Class IV: Severe HFUNABLE to carry out ANY PA (1.5 METS) without discomfortSymptoms: ischemia, dyspnea, angina pain present AT REST, increasing with exercise Parasympathetic Stimulation (Cholinergic) Control Location: Medulla Oblongata (Cardio-inhibitory Center) Via Vagus Nerve (CN X)/Cardiac PlexusInnervates: SA Node, AV node, some myocardium Releases Acetylcholine (ACH) SLOWS rate and force of myocardial contraction DECREASES myocardial metabolism Causes coronary artery vasoconstriction Sympathetic Stimulation (Adrenergic) Control Location: Medulla Oblongata (Cardio-acceleratory Center) Via Cord segments T1-T4, upper thoracic to superior cervical chain gangliaInnervates SA Node, AV Node, conduction pathways and myocytesReleases epinephrine and norepinephrine INCREASES rate and force of myocardial contraction and myocardial metabolism Causes coronary artery vasodilation Skin and Peripheral Vasculature receive only POSTganglionic sympathetic innervation Causes vasoconstriction of cutaneous arteries, sympathetic inhibition must occur for vasodilation Drugs that INCREASE sympathetic function – sympathomimetics Drugs that DECREASE sympathetic function – sympatholytics Ion Concentrations Hyperkalemia – increase K DECREASED rate/force of contraction WIDENED PR Interval and QRS, TALL T waveWide QRS, flat P wave, T wave peaked Hypokalemia – decrease K flat T wave, prolonged PR and QT intervals, arrhythmias. MAY lead to ventricular fibrillationFlattens T wave (or inverts) produces a U wave Hypercalcemia – increase Ca INCREASES heart actionsWide QRS, short QT interval Hypocalcemia – decrease Ca DEPRESSES heart actions Prolongs QT interval Hypermagnesemia – increase Mg (calcium blocker) can lead to arrhythmias/cardiac arrestHypomagnesemia – decrease Mg – causes ventricular arrhythmias, coronary artery vasospasm, SUDDEN DEATH ECG Rhythms: Normal Cardiac Cycle: P wave – atrial depolarization PR interval – time required for impulse to travel from atria through conduction system to Purkinje fibersQRS wave – ventricular depolarization ST segment – beginning of ventricular repolarization T wave – ventricular repolarization QT interval – time for electrical systole Ventricular Arrhythmia: originate from ECTOPIC focus in ventricles Premature ventricular contractionsNo P waveBizarre and wide QRS, premature, followed by long compensatory pauseSERIOUS: >6 per minute, paired or in sequential runs, multifocal, very early PVC (R on T phenomena) Ventricular Tachycardia (VT): run of 3 or more PVC occurring sequentially Very rapid rate (150-200 bpm) May occur paroxysmally (abrupt onset), usually result of ischemic ventricle Wide, bizarre QRS waves, no P wavesSERIOUSLY compromised cardiac output NSVT (Non-Sustained Ventricular Tachycardia) – 3 or more consecutive beats in duration, terminate < 30 sec VT (Sustained Ventricular Tachycardia) - >30 sec in duration and/or requiring termination due to hemodynamic compromise in < 30 secVentricular Fibrillation (VF): PULSELESS, EMERGENCY situation requiring emergency medical treatment, CPR, defibrillation, Rx Chaotic ventricular activity, unable to determine rateBizarre, erratic activity without QRS complexesNo effective cardiac output. Clinical death within 4-6 minutesAtrial Arrhythmias (supraventricular): RAPID REPETITIVE firing of 1+ ectopic foci in atria (outside of sinus node) P waves abnormal (variable in shape, not identifiableRhythm irregular – chronic or paroxysmally Rate: rapid with atrial tachycardia (140-250 bpm), atrial flutter (250-300 bpm), fibrillation (>300 bpm) Cardiac output maintained if rate is controlled, may precipitate ventricular failure in abnormal heart Atrioventricular blocks: abnormal delays/failure to conduct through normal conducting system 1st, 2nd, 3rd (COMPLETE) degree AV blocks, bundle branch blocks 3rd degree life threatening, requiring rx (atropine) surgical pacemaker If ventricular rate slowed, cardiac output decreased ST Depressed with impaired coronary perfusion (ischemia/injury) Can be upsloping, horizontal or downsloping Hypothermia – Elevates ST segment SLOWS rhythm Digitalis – depresses ST segment, flat T wave (or inverts), QT short Quinidine – QT lengthens, flat T wave (or inverts) QRS lengthensBeta Blocker – decreases HR, blunts HR response to exercise Nitrates (nitroglycerin) – increases HR Antiarrhythmic agens – may prolong QRS and QT interval Outcome Measures for Cardiac/Pulmonary Dysfunction: Chronic Respiratory Questionnaire: St. George’s Respiratory Questionnaire 6 Minute Walk TestWalking Speed10 Meter Shuffle Walk TestBODE IndexKansas City Cardiomyopathy Questionnaire Inspiratory/Respiratory Muscle TrainingMinnesota Living with Heart Failure Questionnaire Walking Impairment Questionnaire ................
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