General Medicine I Exam II

Peripheral Vascular Disease

- Includes disorders of arterial and venous blood vessels

- Classified by underlying pathology

Peripheral Vascular Disease - Types

- Arterial occlusive

- Inflammatory

- Vasomotor

- Venous

Peripheral Vascular Disease - Arterial Occlusive Disorders

- Peripheral Arterial Disease (PAD)

- Arterial Thrombosis/Embolism

- Causes Ischemic signs and symptoms

Arterial Thrombosis/Embolism

- Commonly due to atherosclerosis

- Also caused by vasomotor and clotting disorders

Ischemic Signs and Symptoms

- Pain

- Numbness

- Coldness

- Pallor

- Sensation changes

- Weakness

- Muscle spasm

Peripheral Vascular Disease - Inflammatory Disorders

- Vasculitis = inflammation

- Result in narrowing or occlusion of the blood vessel lumen or weakening of the vessel wall and formation of aneurysm

Vasculitis - Types

- Polyarteritis Nodosa

- Arteritis

- Allergic or hypersensitivity angiitis

- Kawasaki disease

- Thromboangiitis Obliterans (Buerger's Disease)

- Wegener's Granulomatosis

Peripheral Vascular Disease - Vasomotor Disorders

- Raynaud's Disease

- Complex regional pain syndrome

- Can lead to focal areas of ischemia affecting tissue and nerves -> TEMPORARY!

- Increasing activity -> increases vasoconstriction

Peripheral Vascular Disease - Venous Disorders

- Chronic Venous Insufficiency

- Venous Thromboembolism -> Thrombophlebitis

Chronic Venous Insufficiency (CVI)

- incompetence of valves allows venous blood to pool and flow backward

- Causes hypertension, obstruction of venous flow, and veins become enlarged and weak

Chronic Venous Insufficiency (CVI) - Causes

- Incompetent venous valves

- Inadequate muscle action

- Venous obstruction

*Physiological consequences of venous thromboembolism

Chronic Venous Insufficiency (CVI) - Risk Factors

- Age

- Genetics

- Obesity

- Prolonged standing

- Sedentary lifestyle

- Smoking

- Female hormones

- Pregnancy

Venous Insufficiency - Spider Veins

- Dermal veins

Venous Insufficiency - Varicose Veins

- Subcutaneous veins

- large!!

Venous Insufficiency - Swelling

- Can cause build-up of wastes which can lead to infection

Venous Insufficiency - Skin Changes

- Ex: Cellulitis

Venous Insufficiency - Hemosiderin Staining

- RBCs stuck in skin

- Redness/brownish skin

Venous Insufficiency - Chronic Leg Ulceration

- 80% of all ulcerations

- Due to waste build-up

Chronic Venous Insufficiency (CVI) Treatment

- Promote venous return

- Wound care

- medical and surgical management

**Poor prognosis for resolution of CVI

How to promote venous return in CVI?

- Rest and elevation throughout the day

- Avoid dependent position (decrease amount of standing)

- Raise foot of bed 6 inches

- compression stockings, pumps

- ROM exercise, progressive ambulation

**Caution must be taken with compression dressings and elevation due to common co-morbidities of arterial insufficiency, diabetes mellitus, and congestive heart failure

Arterial Vascular Disorder - Symptoms

- Aching or cramping that is predictable with activity and elevation

Arterial Vascular Disorder - Edema

- May or may not be present

Arterial Vascular Disorder - Muscle Mass

- Reduced

Arterial Vascular Disorder - Elevation

- Worsens symptoms

- Dependency improves symptoms

Arterial Vascular Disorder - Walking Exercise

- Aching begins at specific time/distance, goes away with rest, returns with exercise

- Intermittent claudication

Arterial Vascular Disorder - Pulses

- Decreased or absent

- Bruits may be present

Arterial Vascular Disorder - Skin

- Reduced hair

- tight, shiny skin

- thick/brittle nails

Arterial Vascular Disorder - Skin Color

- Cyanotic or pale

- Dependent rubor

Arterial Vascular Disorder - Skin Temperature

- Cool

Arterial Vascular Disorder - Ulcers

- Pale base

- Found at high-pressure sites such as heel or tip of toes

Venous Vascular Disorder - Symptoms

- Aching, burning, cramping

- Fatigue while standing

- Heaviness

- Night cramping

- Swelling

- Throbbing

Venous Vascular Disorder - Edema

- Worse at end of day

- Improves with elevation

Venous Vascular Disorder - Muscle Mass

- Unaffected

Venous Vascular Disorder - Elevation

- Lessens symptoms

Venous Vascular Disorder - Walking Exercise

- Lessens symptoms

Venous Vascular Disorder - Pulses

- Pulses still strong! but may be difficult to palpate due to edema

Venous Vascular Disorder - Skin

- Chronic cellulitis, dermatitis, ulceration

Venous Vascular Disorder - Skin Color

- Hyperpigmented

- Brown discoloration

- Often superior to medial malleolus

Venous Vascular Disorder - Skin Temperature

- May be warm with infection, phlebitis

Venous Vascular Disorder - Ulcers

- Often near medial malleolus and gaiter area of lower leg

- Irregular border

- Pink/red base

Venous Thromboembolism

- Partial or complete occlusion of a vein by a thrombus (clot) with secondary inflammation of the vein

- Ex: Deep Venous Thrombosis (DVT)

Deep Venous Thrombosis (DVT)

- Typically occur in lower extremities or pelvis

- Small percentage occur in UEs

- Can progress into pulmonary emboli -> thrombus will got to right side of heart and then into pulmonary system

*~ 50% are asymptomatic

**80% of symptomatic cases involve proximal DVT (iliac, femoral, or popliteal vein) --> usually more SEVERE b/c bigger veins (bigger clots) --> at diagnosis, more than half already have a PE

Venous Thromboembolism - Signs and Symptoms

- Pain or tenderness in the calf

- Leg or calf swelling

- Dilation of superficial veins

- Warmth

- Pitting edema

Venous Thromboembolism - Risk Factors

- Previous DVT

- Increasing age

- Active cancer/cancer treatment

- Severe infection

- Estrogen-containing oral contraceptives

- Hormonal replacement therapy

- Pregnancy or given birth < 6 wks ago

- Immobility (bed rest, flight travel, fractures)

- Surgery/anesthesia/critical care admission

- Central venous catheters

- Inherited thrombophilia

- Obesity

Padua Prediction Score

- Used to evaluate patient's risk of DVT

- Score >/= 4 indicates a high risk of DVT

Venous Thromboembolism - Prevention

- Education

- Hydration

- Activity

- Mechanical ventilation -> not first option if patient mobile

- Medical management -> decrease hypercoagulability of blood, LMWH, warfarin, greenfield filter (not common)

Wells' Clinical Prediction Rule

- Reliable and valid tool for clinical assessment for predicting the risk of DVT in the LE

- Score of 2 or more = DVT likely

- Score less than 2 = DVT unlikely

Venous Thromboembolism - Treatment Goals

- Prevent pulmonary embolism (PE)

- Limit extension of thrombus

- Limit damage to vein

- Prevent another clot

Venous Thromboembolism - Medical Management

- Anticoagulation (LMWH, DOACs)

**Will not get ride of clot, but will stop body from making more clots

Venous Thromboembolism - Surgical Interventions

- Thrombolysis

- Thrombectomy

- Embolectomy

- IVC filter

**These are only performed in unable to anticoagulate

LMWH - Time to Mobilize

- Mobilize at > 5 hrs since administration

- Ex: Lovenox, Fragmin

Fondaparinux - Time to Mobilize

- Mobilize at > 3 hours since administration

- Ex: Arixtra

UFH - Time to Mobilize

- Mobilize at > 24 hours since administration

- Ex: Heparin

DOAC - Time to Mobilize

- Mobilize at > 3 hours since administration

- Ex: Eliquis, Xarelto, Pradaxa

Pulmonary Embolism - Signs and Symptoms

- Pleuritic chest pain, diffuse chest discomfort

- Tachypnea, tachycardia

- Hemoptysis (coughing up blood)

- Anxiety, restlessness, apprehension

- Dyspnea, persistent cough

- Sudden death

Simplified Geneva Score

- Assesses clinical probability of PE

- Low probability = score 0-1

- Intermediate = score 2-4

- High = score >/= 5

Mobilization with PE

- Communicate with medical team before mobilizing

- Need to determine risk of mortality

- Low risk vs high risk dependent on clinical parameters of PE severity, hemodynamic stability, signs of R ventricular dysfunction, and elevated troponins

Cardiac Rehab Phase 1: Inpatient

- Immediately after CV accident

- Hospital stay could be 24 hour for PCI (angioplasty)

- Often less than 5 days for uncomplicated MI, CABG

- Exercise physiologist, PT

Cardiac Rehab Phase 1 - Goals

- Offset effects of bed rest

- Patient monitoring and assessment of hemodynamic responses to allow safe return to activity

- Identify impairments that influence prognosis

- Prepare patient and support system for home progression

- Recommendations for continued cardiac rehab

Cardiac Rehab Phase 1 - Frequency

- 2-4x/day, at least 1x/day

Cardiac Rehab Phase 1 - Intensity

- Patient hemodynamic and symptomatic responses, ECG findings

- RPE

Cardiac Rehab Phase 1 - Duration

- 10-15 minutes

- Begin with short bouts (3-5 minutes), use frequent rest periods (goal 2:1 exercise/rest)

- Include warm-up and cool-down exercises

Cardiac Rehab Phase 1 - Type

- Functional activities

- Large muscle group activities -> challenges CV system, alters vital signs more reasonably

**targeting small muscles can drastically increase vital signs

Cardiac Rehab Phase 1 - Progression

- INDIVIDUALIZED based on daily assessment

- Progression can include less rest breaks and/or shorter rest breaks

**Discontinue exercise if the pt shows signs of an adverse response and DOCUMENT

Cardiac Rehab Phase 1 - Documentation

- Patient position, level of assist and time

- Type of sitting and/or standing exercises

- Time period and distance ambulated, number of stairs

- Number and duration of rests

- Vital sign response to each activity

- Education provided

Cardiac Rehab Phase 2: Outpatient

- Several weeks after CV accident

- Includes SNF

- Most patients go home w/ cardiac rehab and/or PT

- Formal cardiac rehabilitation programs are multi-disciplinary and involve education, exercise, and behavior change to assist individuals with CVD to achieve optimal physical, psychological, and functional status within the limits of their disease

Cardiac Rehab Phase 2 - Goals

- Supervision and monitoring of the patient, and assisting with implementation of a safe and effective physical activity program

- Helping the patient to return to vocational and recreational activities

- Risk factor reduction

- Improve psychosocial well-being, which influences recovery from heart disease

Cardiac Rehab Phase 2 - Frequency

- At least 3x/week, ideally 5-7x/week

Cardiac Rehab Phase 2 - Intensity

- RPE 12-16

- Patient may have exercise test ~ 4-6 weeks post hospital discharge -> 40-80% HRR or 70-85% HRmax if exercise test available

Exercise Intensity if no exercise test available

- Activity should be gradually progressive in logical stepwise fashion of increasing energy costs (METs) with appropriate HR and BP monitoring ) -> typical initial MET ~ 2-4

- Titrate based on RPE, signs/symptoms, physiologic response

- Conservative prescription usually best initially

- Functional capacity evaluation (6 min walk)

Cardiac Rehab Phase 2 - Duration

- 20-60 minutes

- Begin with multiple intervals (<10 min), gradually increase (+1-2 min/day)

- Include 5-10 minute warm-up and cool-down (low intensity aerobic activities)

Cardiac Rehab Phase 2 - Type

- Large-muscle group activities: walking, cycling, functional activity, MAKE IT FUN!!

- Supplement with increase in daily lifestyle activities: gardening, walk break at work, household chores

Cardiac Rehab Phase 2 - Education

- Risk factor reduction (secondary prevention)

- Selecting appropriate exercise intensity

- Patient self-monitoring during activity

- Ability of patient to recognize adverse symptoms

Exercise Prescription and Return to Work

- Assess patient's work environment -> primary movements, muscle groups used, MET demands, environment factors, intermittent heavy work

- Include both resistance and aerobic training

- Include functional exercises -> similar to work demands

- Expose to environment similar to work conditions

Cardiac Rehab Phase 2 - Psychosocial Considerations

- Many patients experience fear, isolation, anxiety, and/or depression post cardiac event

Cardiac Rehab Phase 3: Maintenance

- Patient takes over responsibility of exercise

Cardiac Rehab Phase 3 - FITT

- 30-60 minutes

- 3-5x/wk

- Continues indefinitely

- Compliance is an issue

Considerations for Independent Exercise

- Cardiac symptoms are stable

- Appropriate response to exercise -> HR, BP, ECG

- Demonstrated knowledge of proper exercise principles and awareness of abnormal signs/symptoms

- Motivation to continue exercise without direct supervision

Benefits of Cardiac Rehab

- Risk factor reduction

- improvement in exercise tolerance and symptoms -> decreased myocardial O2 demand due to reductions in HR and BP at any given load

- Increased VO2max and functional capacity

- Improved psychosocial well-being and quality of life

- Decreased mortality

**Can't restore cardiac function, but with training a low EF can be more sustainable

Indications for Cardiac Rehab

- MI

- Stable angina

- CABG

- PTCA or other transcatheter procedure

- Stable heart failure, cardiomyopathy

- Valve disease/surgery

- Heart transplant

- PAD

- At risk for CAD -> DM, dyslipidemia, HTN, obesity

Contraindications for Cardiac Rehab

- Any heart condition that is uncontrolled/unstable = UNFIT FOR PT!!

Healing Process Post MI - Immediately

- ECG Changes

Healing Process Post MI - 12-48 Hours

- Cardiac Enzyme Changes

Healing Process Post MI - 3 days to weeks

- Removal of damaged (necrotic) myofibrils

Healing Process Post MI - 3 weeks to months

- Collagen bundles replace muscle tissue

- Scar formation

Measure for Energy Demands of a Task

- METs

Measure for myocardial Workload of a Task

- Rate Pressure Product = HR x SBP

Ways to Alter Activity Intensity

- Alter grade

- Speed

- Resistance/load

Abnormal Responses to Exercise

- Chronotropic impairment (sinus bradycardia, HR doesn't increase with increasing workload)

- ECG abnormalities -> arrhythmias, ST segment elevation/depression, chest pain

- SBP > 250 mmHg, drop > 10 mmHg from baseline, failure to increase with increasing workload

- Rise or fall of DBP > 10-15 mmHg or DBP > 115 mmHg

- Oxygen saturation below 90%

- Hyperventilation ,dyspnea, wheezing, palpitations, pallor, dizziness, fatigue, confusion

Upper Limits of Exercise Intensity (Peak Exercise HR)

- Angina or other symptoms of CV insufficiency

- Plateau or decrease in SBP

- SBP > 240 mmHg or DBP > 110 mmHg

- ECG evidence of ischemia (ST segment depression)

- Increased frequency of ventricular arrhythmias

- Ventricular arrhythmias > 6/minute

- ECG evidence of L ventricular dysfunction

- Any other ECG disturbance

- Level 3-4 dyspnea

- Any clear signs or symptoms of exertional intolerance

MaxHR Equation

MaxHR = 220 - age

HRR Equation

HRR = MaxHR - RestingHR

%HRR Equation

%HRR = %(MaxHR- RestingHR) + RestingHR

Cardiac Resistance Training Guidelines

- Can start in phase 2 of cardiac rehab, following protocol

- Minimum of 5 wks after MI including 4 wks of continuous program participation

- Minimum of 8 wks post CABG including 3 weeks of continuous program participation

- Minimum of 2 wks following PTCA (angioplasty) including continuous program participation

Cardiac Resistance Training - Frequency

- 2-3x/wk, rest day between workouts

Cardiac Resistance Training - Intensity

- 1 set of 8-10 reps for each major muscle group

- 30-50% 1-RM

- RPE = 11-13

- Large muscle groups before small muscle groups

Cardiac Resistance Training - Cautions

- Slow, controlled movements

- Exhale during exertion, inhale with return to rest position

- Avoid straining, breath holding

Cardiac Resistance Training - Progression

- Typically can progress 2-5 lbs for upper body or 5-10 lbs for lower body when 12-15 reps performed comfortably

Heart Failure and Exercise

- Patients with decompensated (uncontrolled) CHF should not begin aerobic exercise training until CHF is compensated

- Can tell if a person has uncompensated heart failure based on if patient's symptoms keep getting worse

Exercise Prescription w/ Heart Failure - Frequency

- 3-5x/week