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Published in Aalia Khan, Ramsey Jabbour, Almas Rehman, nMRCGP Applied Knowledge Test Study Guide, 2021
Aalia Khan, Ramsey Jabbour, Almas Rehman
Peripheral vascular disease is commonly diagnosed after a patient has noticed intermittent claudication. It tends to be more common in males, smokers and diabetics. Diagnosis can be made on the history using the Edinburgh claudication questionnaire which is 91% specific and 99% sensitive, and measurement of the ankle brachial pressure index (ABPI). Investigations include serum cholesterol and possible angiography.
Wound healing and ulcers
Published in Rashmi Sarkar, Anupam Das, Sumit Sethi, Concise Dermatology, 2021
Arterial ulcers usually occur in a patient older than 45 years, who have risk factors for atherosclerosis such as diabetes mellitus, smoking, hypertension, hyperlipidemia, or obesity and a sedentary lifestyle. Patients present with intermittent claudication. Arterial ulcers are extremely painful and the pain worsens on leg elevation and improves on dependency.
Answers
Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Intermittent claudication (from the Latin claudicare, to limp) is a chronic disease caused by atherosclerosis in the peripheral vasculature and is characterised by progressive burning limb pain on exertion. Diagnosis is based on clinical evaluation, and imaging such as angiography is only indicated if medical treatment has failed or surgery is planned. Medical management involves treatment of such cardiovascular risk factors as hypertension, hyperlipidaemia, diabetes and smoking. As this is a vascular disease, it may coexist with other vascular diseases, such as ischaemic heart disease or cerebral vascular disease. Surgical treatment involves angioplasty with insertion of stents or open bypass surgery of the affected segment. Bypasses include aortobifemoral and femoral-femoral crossover. Distal disease is harder to manage with bypass, with a higher rate of graft occlusion or failure. Claudication may progress to critical ischaemia, which involves rest pain and intolerance of lying leg flat. Critical ischaemia should prompt urgent surgical referral.
The FlowOx device for the treatment of peripheral artery disease: current status and future prospects
Published in Expert Review of Medical Devices, 2021
In a recent randomized controlled trial of 72 patients with intermittent claudication, we showed that treatment with FlowOx for 1 hour twice daily for 12 weeks increased pain-free walking distance compared with sham treatment [16]. For the patients with the most symptomatic disease, there was an increase in both pain-free and maximal walking distance. This was the first double-blind, randomized sham-controlled trial to show that INP treatment increases walking capacity in patients with intermittent claudication, and the first randomized controlled trial that documented the clinical effects of FlowOx treatment. In patients with intermittent claudication, cardiovascular prevention and exercise therapy are the first-line treatment. Participation in supervised exercise therapy (SET) programs has positive effects on leg symptoms, general health, and cardiovascular risk. However, the use of SET in the management of patients with intermittent claudication is limited by low accessibility and poor compliance. A systematic review from 2016 concluded that only one third of the patients with PAD were suitable for and willing to undertake SET [17]. Hence, treatment with FlowOx might be a relevant adjunct to standard care for patients with intermittent claudication. Especially for patients with disabling claudication and a high risk of complications from endovascular or open surgical treatment, FlowOx treatment seems to be a reasonable alternative.
Echocardiographic assessment at rest and during stress in patients with intermittent claudication
Published in Scandinavian Cardiovascular Journal, 2019
Joakim Nordanstig, Odd Bech-Hanssen, Per Skoog, Lennart Jivegård
Intermittent claudication symptoms are mainly driven by a mismatch between oxygen supply and demand in the working muscle during walking exercise. However, the extent of walking impairment is not solely explained by the distribution and extent of the peripheral atherosclerotic vascular lesions, suggestive of other possible pathophysiologic mechanisms contributing to IC symptoms [25]. In theory, ischemic cardiac disease in patients with lowered ABI may also mimic IC symptoms during exercise, or at least contribute to an impairment of walking capacity beyond what the peripheral atherosclerotic burden would explain. The secondary hypothesis investigated in this study was that a subset of IC patients demonstrates impaired left ventricular function that is only evident during stress and that this may contribute to IC symptom presentation. This hypothesis could not be confirmed, as no single patient in the study demonstrated significant cardiac dysfunction during dobutamine provocation that was not also evident when examined with echocardiography at rest.
Current and emerging drug treatment strategies for peripheral arterial disease
Published in Expert Opinion on Pharmacotherapy, 2020
Hani Essa, Francesco Torella, Gregory Y. H. Lip
Prognosis in PAD can be divided into outcomes for the affected limb and outcomes for the patient generally. Overall PAD can be viewed as a proxy for global atherosclerotic disease elsewhere, including CVD and CAD. Patients with PAD have increased rates of ischemic stroke, myocardial infarction (MI), and cardiovascular death [21,22]. Within five years of diagnosis, 10–15% of patients with intermittent claudication will die from cardiovascular disease [23]. Some 60% of patients with PAD suffer from co-existent ischemic heart disease and 30% from CVD [24]. The long-term prognosis of PAD has been shown to be worse than CAD (Hazard ratio, HR: 2.4, P = 0.01) [25]. Untreated, PAD can progress to locally compromised arterial blood supply resulting in severe pain, ulcers or gangrene, and acute limb ischemia necessitating urgent revascularisation therapy to prevent limb loss [26]. The natural history of critical limb ischemia (CLI) is well documented. At 1 year, 25% of patients will be dead, 30% will have undergone amputation, and 45% will be alive with both limbs [23]. More than 60% of patients with CLI will be dead at 5 years [27]. Currently, there are no predictive formulae that allow the clinician to estimate the level of risk of an individual patient with intermittent claudication to progress to CLI or the timescale in which this is likely to occur [28]. Some patients even develop CLI as a first presenting symptom of PAD without ever having suffered intermittent claudication. Pharmacological therapy has been demonstrated to reduce the risk of asymptomatic PAD becoming symptomatic and improve overall prognosis once symptomatic.