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Cardiovascular disease
The atherosclerosis
Definition
Fats, cholesterol and other substances deposit in and on arterial walls (between intima and media), it
lead to arterial narrow and occlusion of arteries. May occur in adult and children but, it is slowly
progressive that appear over 45 years old.
Risk factors
Non-modifiable factors
This factor can’t be controlled as:
(1) Age
Old people in high risk to develop atherosclerosis
(2) Gender
Men are more to develop atherosclerosis than women.
(3) Race
(4) Family history
If one person of family has cardiovascular disease then it is high risk to develop atherosclerosis
Modified factors
This factor can be controlled as:
(1) Major factors
Hypertension, diabetes mellitus, hyperlipidemia and smoking
(2) Minor factors
Sedentary lifestyle, bed rest, inactive for long time and obesity
Pathogenesis of atherosclerosis
How the atherosclerosis occur
(1) deposition of lower density lipoprotein (LDL) between intima and media.
(2) endothelial dysfunction, rough surface
(3) prolifation of smooth muscle in media
(4) formation of plaque on arterial wall, leading to narrow artery
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(5) thrombosis, hemorrhage and complete arterial block may occur
Sites of atherosclerosis
(1) Common occurs adjacent to arterial bifurcation (fork of arteries, at begin of branches of arteries)
(2) At the origin of major arterial branches and at sites where passes beneath.
(3) Occur in any artery in body (arteries of lower and upper limb, cerebral and carotid arteries, renal
artery)
Complications
It is problems because of untreated atherosclerosis
(1) Chronic ischemia
It is slowly progressive arterial obstruction, it will give enough time for collateral to develop
(2) Acute ischemia
It is sudden obstruction to blood flow
Ulceration of endothelium
Acute thrombosis
Hemorrhage
(3) aneurysm
It is a bulge in the arterial walls caused by a weakness in the arterial wall.
Symptoms of atherosclerosis
No symptoms in stage 1
Symptoms will start with stage 2
(1) Cramp-like pain increase by exercises and relieve by rest (intermittent claudication)
(2) This disease will progress leading to pain at rest
(3) Due to sever ischemia, it will be ulceration, gangrene and amputation
(4) Impotence
(5) If atherosclerosis present in arteries of:
Heart leading to chest pain (angina)
Brain leading to Stroke and Alzheimer's disease
Upper and lower limbs leading to Pain when walk
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General examination
(1) Normal, arteries are palpated, Assess of pulse
(2) In atherosclerosis, it will be hypertension. blood pressure should be measured
Local examination
(1) Tropic changes
Loss of skin appendages
The skin will be dry and thin
The muscle becomes wasted
The bone will be osteoporotic
Ischemic limb will be Likely coldness
(2) Color changes. Pallor, redness and cyanosis
(3) Weakness or absence of pulse
Special tests
Test for capillary circulation
Press over the tip of the toe, it will be pale, the colour will return when the pressure released In
Ischemic limb the return of colour is slow (sluggish capillary circulation)
Buerger’s angle
The patient lies supine and his legs is gradually elevated, the smaller the angle at which blanching
occurs, the more sever the ischemia is.
Harvey’s venous refilling time
With the patient supine, the limb is elevated to right angle until all veins empty. It is then brought down
to the horizontal position. Normally the veins refill in 10-15 seconds, in chronic ischaemia venous
refilling is delayed to above 30 seconds.
Clinical staging of chronic limb ischemia
Stage 1 Asymptomatic, patient don’t feel any problems
Stage 2 Intermittent claudication, pain with exercise, relieve of pain at rest
Stage 3 Pain at rest
Stage 4 Gangrene, late stage, indicate to amputation
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Investigations
(1) Laboratory investigations
Blood picture. red blood cell count, white blood cell count and platelet count.
Blood sugar
Serum creatinine
(2) Imaging
_Doppler flow study
It will show stenosis
Collateral refilling after stenosis
_Duplex
Detect area of block
_Arteriography. Provide information about:
Sit of arterial block
State of proximal arteries
Treatment of chronic ischemia
Mild to moderate claudication will treat with conservative treatment. It is non-surgical treatment, such
as physical therapy and medication
Conservative treatment will be:
(1) Mild exercises
(2) Stop smoking
(3) Improve anemia
(4) Treat all risk factors (diabetes melitus,hypertension)
(5) Care of feet
Clean the feet daily to keep it dry to avoid trauma of feet
To avoid clod injury, woolen stocks should be worn
Any infection in feet must be treated
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The patient should not apply heat
(6) Medications as aspirin, stains, calcium channel blockers
Sever claudication
Angiography should be done to detect endovascular surgery or open surgery
Indications for surgery
(1) Severe incapacitating claudication that affect the patient's work and style of life
(2) pain at rest and presence of ulcers or gangrene.
Endovascular surgery
(1) Percutaneous transluminal angioplasty (PTA).
It is a procedure that can open up a blocked blood vessel using a small, flexible plastic tube, or catheter,
with a balloon at the end of it
(2) Intravascular stents.
Open surgical techniques
(1) Thromboendarterectomy
If present multiple occlusions in arteries, in in this surgery may occur thrombosis as a complication of
surgery
(2) By-pass surgery is more performed
Indication for amputation
(1) Massive gangrene
(2) Spreading infection
(3) Sever and uncontrolled pain, in this case the patient ask for amputation

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Cardiovascular disease The atherosclerosis Definition Fats, cholesterol and other substances deposit in and on arterial walls (between intima and media), it lead to arterial narrow and occlusion of arteries. May occur in adult and children but, it is slowly progressive that appear over 45 years old. Risk factors Non-modifiable factors This factor can’t be controlled as: (1) Age Old people in high risk to develop atherosclerosis (2) Gender Men are more to develop atherosclerosis than women. (3) Race (4) Family history If one person of family has cardiovascular disease then it is high risk to develop atherosclerosis Modified factors This factor can be controlled as: (1) Major factors Hypertension, diabetes mellitus, hyperlipidemia and smoking (2) Minor factors Sedentary lifestyle, bed rest, inactive for long time and obesity Pathogenesis of atherosclerosis How the atherosclerosis occur (1) deposition of lower density lipoprotein (LDL) between intima and media. (2) endothelial dysfunction, rough surface (3) prolifation of smooth muscle in media (4) formation of plaque on arterial wall, leading to narrow artery k9 1 (5) thrombosis, hemorrhage and complete arterial block may occur Sites of atherosclerosis (1) Common occurs adjacent to arterial bifurcation (fork of arteries, at begin of branches of arteries) (2) At the origin of major arterial branches and at sites where passes beneath. (3) Occur in any artery in body (arteries of lower and upper limb, cerebral and carotid arteries, renal artery) Complications It is problems because of untreated atherosclerosis (1) Chronic ischemia It is slowly progressive arterial obstruction, it will give enough time for collateral to develop (2) Acute ischemia It is sudden obstruction to blood flow Ulceration of endothelium Acute thrombosis Hemorrhage (3) aneurysm It is a bulge in the arterial walls caused by a weakness in the arterial wall. Symptoms of atherosclerosis No symptoms in stage 1 Symptoms will start with stage 2 (1) Cramp-like pain increase by exercises and relieve by rest (intermittent claudication) (2) This disease will progress leading to pain at rest (3) Due to sever ischemia, it will be ulceration, gangrene and amputation (4) Impotence (5) If atherosclerosis present in arteries of: Heart leading to chest pain (angina) Brain leading to Stroke and Alzheimer's disease Upper and lower limbs leading to Pain when walk k9 2 General examination (1) Normal, arteries are palpated, Assess of pulse (2) In atherosclerosis, it will be hypertension. blood pressure should be measured Local examination (1) Tropic changes Loss of skin appendages The skin will be dry and thin The muscle becomes wasted The bone will be osteoporotic Ischemic limb will be Likely coldness (2) Color changes. Pallor, redness and cyanosis (3) Weakness or absence of pulse Special tests Test for capillary circulation Press over the tip of the toe, it will be pale, the colour will return when the pressure released In Ischemic limb the return of colour is slow (sluggish capillary circulation) Buerger’s angle The patient lies supine and his legs is gradually elevated, the smaller the angle at which blanching occurs, the more sever the ischemia is. Harvey’s venous refilling time With the patient supine, the limb is elevated to right angle until all veins empty. It is then brought down to the horizontal position. Normally the veins refill in 10-15 seconds, in chronic ischaemia venous refilling is delayed to above 30 seconds. Clinical staging of chronic limb ischemia Stage 1 Asymptomatic, patient don’t feel any problems Stage 2 Intermittent claudication, pain with exercise, relieve of pain at rest Stage 3 Pain at rest Stage 4 Gangrene, late stage, indicate to amputation k9 3 Investigations (1) Laboratory investigations Blood picture. red blood cell count, white blood cell count and platelet count. Blood sugar Serum creatinine (2) Imaging _Doppler flow study It will show stenosis Collateral refilling after stenosis _Duplex Detect area of block _Arteriography. Provide information about: Sit of arterial block State of proximal arteries Treatment of chronic ischemia Mild to moderate claudication will treat with conservative treatment. It is non-surgical treatment, such as physical therapy and medication Conservative treatment will be: (1) Mild exercises (2) Stop smoking (3) Improve anemia (4) Treat all risk factors (diabetes melitus,hypertension) (5) Care of feet Clean the feet daily to keep it dry to avoid trauma of feet To avoid clod injury, woolen stocks should be worn Any infection in feet must be treated k9 4 The patient should not apply heat (6) Medications as aspirin, stains, calcium channel blockers Sever claudication Angiography should be done to detect endovascular surgery or open surgery Indications for surgery (1) Severe incapacitating claudication that affect the patient's work and style of life (2) pain at rest and presence of ulcers or gangrene. • Endovascular surgery (1) Percutaneous transluminal angioplasty (PTA). It is a procedure that can open up a blocked blood vessel using a small, flexible plastic tube, or catheter, with a balloon at the end of it (2) Intravascular stents. • Open surgical techniques (1) Thromboendarterectomy If present multiple occlusions in arteries, in in this surgery may occur thrombosis as a complication of surgery (2) By-pass surgery is more performed Indication for amputation (1) Massive gangrene (2) Spreading infection (3) Sever and uncontrolled pain, in this case the patient ask for amputation k9 5 Name: Description: ...
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