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PubMed1993

Risk of cardiac surgery in patients with peripheral vascular disease.

After reading these articles, I think the evidence is convincing that peripheral vascular disease clearly places the patient at a higher risk for coronary bypass surgery than is the case for patients without peripheral vascular disease. However, in some instances coronary bypass surgery must be performed before peripheral vascular surgery is performed. Perhaps the best way to leave it is to indicate that if there is a clear-cut indication for coronary bypass surgery it should be done independent of vascular disease elsewhere, but one must accept the fact that most reports indicate an increased morbidity and mortality. Thus, I would like to make a final point by quoting Gersh: "The protective shield of prior coronary artery bypass surgery [in patients with peripheral vascular disease] . . . has a price."

Coronary Artery Bypass↗

PubMed2005

Peripheral vascular disease and depression.

The occurrence of peripheral vascular disease (PVD) in our aging population is of great proportion affecting approximately 20% of the population, which extrapolates to 8 to 12 million Americans. PVD is a progressive disease that almost always includes one or more comorbidities that impact greatly on severity and management of the disease. The age of disease onset can vary but most commonly presents at age 65 years and older. Depressive symptoms in the same age group occur in 30% to 60% of individuals with PVD. When a disabling disease such as PVD is combined with the already deteriorating effects of the aging process, the risk of these patients developing depression is greatly increased. The depressive symptoms in this population of patients are often unrecognized by their primary physician. This article reviews the potential mechanisms of depression, the effects of the combination of depression and a chronic illness such as PVD, the importance of recognizing depressive symptoms, and the available treatment options. The characteristics of PVD, including the effects on physical and mental health, the signs and symptoms of major depressive disorder, and the available screening tools used to evaluate a patient who may have depression, will also be discussed.

Age Distribution↗

PubMedDate not supplied

Increased apoprotein B in very low density lipoproteins of patients with peripheral vascular disease.

Lipoprotein compositional studies were carried out in 20 patients with atherosclerotic peripheral vascular disease. Twelve of these patients were normolipidemic, the other eight, hypertriglyceridemic. Ten normolipidemic and 10 hypertriglyceridemic age-matched subjects were used as controls. High density lipoprotein cholesterol levels were markedly reduced in the hypertriglyceridemic subjects, both with (35.1 +/- 5.0 mg/dl) and without (36.2 +/- 11.7 mg/dl) peripheral vascular disease, as compared to the normolipidemic patients (47.0 +/- 6.3 mg/dl) and controls (48.1 +/- 10.0 mg/dl). A decreased relative content of apo C-11 in very low density lipoproteins in the hypertriglyceridemic subjects, as compared to the normolipidemics, was detected by isoelectric focusing. Hypertriglyceridemia in patients with peripheral vascular disease shows a typical Type IV lipoprotein and apoprotein profile. Apoprotein B levels in very and low density lipoproteins were determined by electroimmunodiffusion and selective precipitation with tetramethylurea (r = 0.981 between the two methods). All the patients with peripheral vascular disease showed an increased apo B content in very low density lipoproteins vascular disease showed an increased apo B content in very low density lipoproteins (VLDL) as compared to controls (apo B cholesterol in VLDL = 0.341 +/- 0.124 for peripheral vascular disease patients and 0.236 +/- 0.086 for controls, p less than 0.001). A significant correlation between VLDL cholesterol and apo b levels was detected both in peripheral vascular disease patients and in controls; however, two distinct populations could be clearly separated (slopes of the regression lines: peripheral vascular disease patients = 0.350; controls = 0.215, p less than 0.001). The data suggest a possible discriminatory power of VLDL-apo B levels in patients with peripheral vascular disease independent from other lipoprotein and lipid parameters.

Adult↗

PubMed2003

Living with peripheral vascular disease: a review of the literature.

Peripheral vascular disease is a debilitating condition that can significantly reduce a patient's quality of life. It affects mainly older people and causes severe chronic pain that can make even simple activities of daily living impossible. This paper reviews the literature on the management of PVD, with specific emphasis on the patient experience of living with the condition.

Activities of Daily Living↗

PubMed1992

Magnetic resonance imaging of peripheral vascular disease. The state of the artery.

Peripheral vascular disease is a term often used to describe the manifestation of atherosclerosis below the bifurcation of the abdominal aorta. Peripheral atherosclerosis is a major cause of morbidity in the developed countries and 2% of adults in late middle age have intermittent claudication, which is severe enough in some patients to warrant hospital admission. The disease produces problems either by reducing blood flow or by the release of emboli from ulcerated plaques. The morphology and composition of arterial segments containing atheroma is of considerable importance. Plaques of different morphology have different effects on the arterial wall, such as the potential for thrombosis and the effect of arterial spasm. The lipid content may also affect the propensity for fissuring, ulceration, and thrombosis. In addition to discrete atherotic lesions, a localized and generalized sclerosis occurs. Sclerosis, or stiffness, can be demonstrated in experimental disease in animals and in man, and regression leads to reduced stiffness. Magnetic resonance imaging promises a comprehensive assessment of peripheral atherosclerosis noninvasively and without the use of ionizing radiation. Atheroma can be imaged directly, its size can be measured, its shape can be described, its lipid content can be assessed, and its effects upon vascular hemodynamics can be studied. In addition, arterial compliance, pulse wave velocity, and the pattern of flow within the vessel can be studied. It is thus a potential tool not only for the detection of disease but also for studying its natural history, risk factors, and the effects of pharmacological or surgical interventions.

Angiography↗

PubMed1998

Peripheral vasodilators and the management of peripheral vascular disease and Raynaud's syndrome in general practice.

There is no convincing evidence that peripheral vasodilators produce any significant improvement in exercise tolerance in patients with peripheral vascular disease, and these drugs may do more harm than good. In the treatment of severe Raynaud's syndrome, however, thymoxamine, prazosin or nifedipine is recommended. A descriptive study was carried out, firstly, to determine why these drugs are prescribed in general practice, and secondly, to describe the drug choices in the treatment of both Raynaud's syndrome and peripheral vascular disease in a representative sample of 22 practices in Northern Ireland. Of those patients prescribed peripheral vasodilators 69.6% were diagnosed as peripheral vascular disease, claudication or atherosclerosis. Over three-quarters of peripheral vasodilators prescribed were repeat prescriptions. Of those with Raynaud's syndrome only half were treated appropriately, and certainty of diagnosis did not guarantee appropriate treatment. Peripheral vasodilators accounted for the majority (51.5%) of items prescribed for peripheral vascular disease. A minority of patients with peripheral vascular disease (20.3%) were prescribed aspirin, and a smaller minority (4.4%) had undergone amputation. Peripheral vasodilators were prescribed unnecessarily and inappropriately. Measures to promote evidence-based treatment of both Raynaud's syndrome and peripheral vascular disease in general practice need to be taken.

Journal Article↗

PubMed2004

[Summary of the practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners].

Peripheral vascular disease is a manifestation of atherosclerosis and may occur with or without signs or symptoms. The local prognosis is worse with signs or symptoms. The concomitant atherosclerosis in heart and brain is responsible for long-term morbidity and mortality. Absence of signs and symptoms almost excludes peripheral vascular disease, but for the diagnosis an ankle-brachial index is mandatory. This implies a protocol in general practice. Treatment of peripheral vascular disease consists of advice on cardiovascular risk factors, stopping smoking, walking exercises, and foot care. For peripheral vascular disease, anti-thrombotic medication is advised.

Fibrinolytic Agents↗

PubMed2001

Peripheral vascular disease and hypertension: a forgotten association?

Peripheral vascular disease (PVD) is associated with a high cardiovascular morbidity and mortality. Intermittent claudication is the most common symptomatic manifestation of PVD, but is also an important predictor of cardiovascular death, increasing it by three-fold, and increasing all-cause mortality by two to five-fold. Hypertension is a common and important risk factor for vascular disorders, including PVD. Of hypertensives at presentation, about 2-5% have intermittent claudication, with this prevalence increasing with age. Similarly, 35-55% of patients with PVD at presentation also have hypertension. Patients who suffer from hypertension with PVD have a greatly increased risk of myocardial infarction and stroke. Apart from the epidemiological associations, hypertension contributes to the pathogenesis of atherosclerosis, the basic underlying pathological process underlying PVD. Hypertension, in common with PVD, is associated with abnormalities of haemostasis and lipids, leading to an increased atherothrombotic state. Nevertheless, none of the large antihypertensive treatment trials have adequately addressed whether a reduction in blood pressure causes a decrease in PVD incidence. There is therefore an obvious need for such outcome studies, especially since the two conditions are commonly encountered together.

Antihypertensive Agents↗

PubMed1995

Revascularization in peripheral vascular disease: stents, atherectomies, lasers, and thrombolytics.

Peripheral vascular disease affects a significant number of individuals. Signs and symptoms may develop because of partial or total vessel occlusion due to plaque, dissection, or thrombus. Percutaneous transluminal angioplasty is effective as an independent intervention to open occluded vessels and also may be combined with other nonsurgical therapies such as stents, atherectomy, or laser treatments. Thrombolytics also are used to treat acute or chronic occlusions. The nurse's role in treating and monitoring the patient is key in minimizing complications during and after intervention.

Angioplasty↗

PubMed1998

Factors determining cardiac hypertrophy in hypertensive patients with or without peripheral vascular disease.

1. Coronary ischaemic disease and congestive heart failure are the principal causes of mortality in patients with peripheral vascular disease. Whether cardiac hypertrophy is present and even more pronounced in peripheral vascular disease than in other populations has never been explored.2.Twenty-five hypertensive patients were investigated, 11 without and 14 with peripheral vascular disease, matched for age, sex, mean arterial pressure and antihypertensive drug treatment. Cardiac mass was determined using echocardiography together with measurement of systemic blood pressure, ratio between ankle systolic pressure (ASP) and brachial systolic pressure (BSP), and standard biochemical parameters including natriuresis per 24 h.3. At the same mean arterial pressure, patients with peripheral vascular disease had a significantly higher cardiac mass (157+/-12 versus 116+/-6 g/m2; P<0.01), pulse pressure (81+/-5 versus 55+/-4 mmHg; P<0.01) and natriuresis (180+/-17 versus 144+/-6 mmol/24h; P<0. 01) than controls. Using univariate correlations, cardiac mass was positively associated with pulse pressure, mean arterial pressure and natriuresis, and negatively with the ASP/BSP ratio. On the basis of multivariate regression analysis, only natriuresis was positively correlated to cardiac mass.4. Patients with peripheral vascular disease develop a higher degree of cardiac hypertrophy in comparison with hypertensive subjects with the same level of mean arterial pressure. Sodium intake rather than mechanical factors seems to be the major modulating factor which influences the degree of cardiac hypertrophy.

Aged↗

PubMed1995

Lumbar neurolytic sympathetic blockades provide immediate and long-lasting improvement of painless walking distance and muscle metabolism in patients with severe peripheral vascular disease.

Thirty patients with angiographically proven peripheral vascular disease (PVD) and intermittent claudication were treated with percutaneous lumbar neurolytic sympathetic blockade (NSB) using 1.5 mL ethanol 95%. Claudication had been progressive in all patients during conservative treatment. Median (range) painless walking distance increased from 95 (10-200) meters (m) before to 355 (25-1003) m immediately after NSB. Further improvement was seen during the 1-year follow-up, with two exceptions: one patient lost a leg after acute arterial embolism and another patient deteriorated after 6 months. In the latter case, a second NSB improved the walking distance again. One case of transient mild neuralgia of the L3 dermatome occurred. 31P-magnetic resonance investigations of the calf muscles before, during, and after a treadmill exercise were performed in seven patients: 1 week after NSB, the postexercise recovery of phosphocreatine was accelerated in all patients compared to the pre-NSB values. The accelerated recovery suggests an improved post-ischemic metabolic situation after chemical sympathectomy.

Aged↗

PubMed1977

Teaching patients with peripheral vascular disease.

The teaching of a patient with peripheral vascular disease offers many challenges to the nurse. Although content should be understood and utilized by the patient and significant others, of primary importance is the belief that the learner is the curriculum and that his perception of self and his problems is the focus of teaching. The learning needs generally should be considered as the needs of an adult individual, who has many past experiences and an interest in the present and future. This patient may experience pain from his disease and may require the assistance and support of others. If the purpose of treatment is to improve circulation and prevent trauma and infection, then patient instruction must be recognized as a vital tool in therapy. But the nurse cognizant of the progressiveness of peripheral vascular disease must capitalized on the teachable moments--when the patient is ready and the learning is needed.

Adult↗

PubMed1979

Noninvasive radionuclide assessment of cardiac function in patients with peripheral vascular disease.

Disorders of the peripheral vascular system often are associated with heart disease which may increase operative risk. The purpose of this study was to investigate the clinical usefulness of radionuclide angiocardiography for evaluation of cardiac function in patients with vascular disorders. This simple procedure provides measurements of cardiac output, pulmonary blood volume, and left ventricular end-diastolic volume, stroke volume, and ejection fraction with no significant risk or discomfort to the patient. A total of 22 patients with vascular disorders were studied by this technique. Five patients had systemic arteriovenous malformations. The cardiac output, end-diastolic volume, and stroke volume were documented to be greater than normal in these patients before operation. In three patients studied following closure of the arteriovenous fistula, the cardiac output, left ventricular end-diastolic volume, and stroke volume decreased. Postoperative changes in left ventricular ejection fraction were variable. A group of 17 patients with atherosclerotic vascular disease underwent cardiac evaluation. In nine patients with no history of cardiac disease, the lowest ejection fraction of 0.45 occurred in a patient with a saccular thoracic aneurysm, the only patient of the 22 who died after operation. A wide variation in ejection fraction was observed in patients with a history of cardiac disease which ranged from 0.32 to 0.86. Objective documentation of cardiac function by radionuclide angiocardiography would appear to enhance the management of patients with peripheral vascular disorders.

Adult↗

PubMed2002

Areas of concern, quality of life and life satisfaction in patients with peripheral vascular disease.

OBJECTIVES: to explore the ways in which peripheral vascular disease subjectively affect patients and to relate these findings to validated measurements of quality of life (QOL) and life satisfaction. DESIGN: a cross-sectional study. SUBJECTS: eighty patients, with carotid artery stenosis (CAS), abdominal aortic aneurysm (AAA), intermittent claudication (IC) or critical limb ischaemia (CLI). METHODS: semi-structured interviews were used to explore the effect of the disease on the patients life situation. QOL was assessed by SF-36 and life satisfaction by LiSat-11. RESULTS: the SF36, LiSat-11 and our interview revealed two principal patterns: one for patients with CAS and AAA, and one for patients with IC and CLI. The interview revealed important areas affecting the vascular patient. Some of these areas: higher intellectual function, concern, sexual function, family concern and factors related to the operated areas were not covered by either the SF36 or the LiSat-11. CONCLUSIONS: for a full understanding of how peripheral vascular disease affects the individual, disease specific questions need to be added to generic QOL instruments and measurements of life satisfaction.

Adult↗

PubMed2002

Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-QI2).

BACKGROUND: Peripheral vascular disease is a manifestation of systemic atherosclerosis and is associated with an increased risk of cardiovascular morbidity and mortality. METHODS AND RESULTS: We examined clinical outcomes in 66 consecutive patients undergoing peripheral vascular interventions at our institution between January 2001 and October 2001. At hospital discharge and at 6 months, lifestyle modifications and use of evidence-based therapy was suboptimal. At 6 months, a significant proportion continued to smoke (22.7%) and only half of the patients exercised, controlled their weight, or modified their diet for lipid control. The use of antiplatelet therapy was 77.2%; of angiotensin-converting enzyme, 35.9%; of beta-blockers, 42.5%; and of statins, 50%. Twelve of the 66 patients (18.2%) had a clinical event of death, myocardial infarction, or stroke. An appropriateness algorithm for use of secondary prevention measures was created with the use of evidence-based therapy guidelines, and a composite appropriateness variable was also created. The use of evidence-based therapy was associated with a significant reduction of the composite of death, myocardial infarction, and stroke at 6 months (OR 0.02, 95% CI 0.01 to 0.44, P=0.01). CONCLUSIONS: Atherosclerosis risk factors are very prevalent in patients with peripheral vascular disease, but these patients receive less than optimal treatment after a predominantly technical vascular intervention. Effective secondary prevention with appropriate lifestyle interventions and evidence-based medical therapy needs to be strongly encouraged and implemented in these patients.

Algorithms↗

PubMed2003

The role of platelets in peripheral vascular disease.

Platelets play a major role in acute ischaemic syndromes and peripheral vascular disease. They are involved in the development and progression of atherosclerosis, native vessel and graft thrombosis. They have a central role in the development of restenosis and reocclusion after peripheral percutaneous transluminal angioplasty. Antiplatelet therapy has been shown to be beneficial in patients undergoing peripheral vascular surgery or radiological intervention. Yet current routine therapy, namely aspirin and dipyridamole are limited in their mode of action and efficacy. Recent developments in the understanding of platelet function has led to the development of new more potent drugs such as clopidogrel. Combination of drugs and more specific investigation of individual platelet function may well result in improved bypass and angioplasty patency rates. The results of proposed large randomised controlled trials on the role and safety of aspirin and clopidogrel are awaited with interest. Given the importance of platelets in peripheral vascular disease highlighted in this review, achieving an optimal safe anti-platelet effect for each patient with peripheral vascular disease should be the target of future research.

Angioplasty, Balloon↗

PubMedDate not supplied

The impact of co-morbid risk factors at the start of dialysis upon the survival of ESRD patients.

By using a computerized database, we have catalogued the presence of 29 co-morbid risk factors in 683 patients with end-stage renal disease who started dialysis from 1970 through 1989, with follow-up through 1992. The authors hypothesized that current end-stage renal disease patients have more serious co-morbid risk factors impacting upon their mortality rate. Quantitation of dialysis patient co-morbidity, as a measure of patient illness, is lacking in the general nephrology literature. Seven co-morbid risk factors have been reserved for new dialysis patients: hypertension, low albumin, cerebral vascular disease, peripheral vascular disease, pre-existing cardiac disease, abnormal EKG/old myocardial infarction, and congestive heart failure. Except for low serum albumin, the proportion of patients with the six other co-morbid risk factors has increased significantly over this 20-year period (p < 0.0001, chi-square test for hypertension, peripheral vascular disease, pre-existing cardiac disease, abnormal EKG/old myocardial infarction, and congestive heart failure, and p < 0.006 for cerebral vascular disease). In addition, the co-morbid risk factors of hypertension, low serum albumin, and pre-existing cardiac disease at the start of dialysis were strongly prognostic of survival. The Cox proportional hazards regression model identified these three risks, among other factors, that were significantly associated with a decreased survival, with risk ratios ranging from 1.40-1.66. These results support the authors' hypothesis that incoming end-stage renal disease patients, who recently start dialysis, are sicker than in the earlier years of the authors' program. If the authors' patients reflect the national end-stage renal disease population, the presence of co-morbid risk factors may, in part, explain the continuing high mortality of dialysis patients.

Adult↗

PubMed2006

Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline.

BACKGROUND AND PURPOSE: This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk. METHODS: Writing group members were nominated by the committee chair on the basis of each writer's previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statement Oversight Committee. The writers used systematic literature reviews (covering the time period since the last review published in 2001 up to January 2005), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations based on standard American Heart Association criteria. All members of the writing group had numerous opportunities to comment in writing on the recommendations and approved the final version of this document. The guideline underwent extensive peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS: Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to their potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. CONCLUSIONS: Extensive evidence is available identifying a variety of specific factors that increase the risk of a first stroke and providing strategies for reducing that risk.

Brain Ischemia↗