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« on: February 17, 2009, 05:15:18 pm »

Peripheral Artery Disease



Approximately 1.5 million people live in 17,000 nursing homes within the United States. Ninety percent are 65 years or older and 24 percent are 85 years or older. It is estimated that by 2030, more than 8 million seniors will reside in nursing homes or long-term care facilities. Reports show that with the advance in years comes an increase in sedentary lifestyles. This decline in mobility combined with a decrease in circulation gives rise to circulatory problems such as stroke, heart attacks and peripheral vascular disease, also known as peripheral artery disease (PAD).

Physical activity is undoubtedly an important health benefit. Research shows that physical activity can reduce the risk of certain chronic diseases, relieve symptoms of depression, help maintain independent living, and enhance the overall quality of life. Data from the National Center for Health Statistics show the most common types of exercise among older Americans were light to moderate activities such as walking, gardening, and stretching. More than 21 percent of the older population reported that they would like to be doing more while 63.9 percent felt they were doing enough and 2.3 percent thought they were doing too much.1

ஐﻬ WHAT IS PAD?

PAD occurs because of a decrease in oxygen-rich blood flow to the blood vessels or arteries that supply the legs. This decrease in circulation is usually caused by a narrowing or blockage in the blood vessels.1 As you know, arteries are blood vessels that carry blood away from the heart to the rest of the body, always under a great deal of pressure. The artery wall has three layers: the intima, the media and the adventitia. The intima consists of epithelial cells and is the innermost layer, which is closest to where blood flows through the artery. The media is the middle layer, consisting of elastic connective tissue and smooth muscle tissue, which are surrounded by a network of collagenous, elastic fibers. The outermost layer of the arterial wall consists of fibrous connective tissue.

Arterial walls lose some of their elasticity and vasomotor tone with normal aging. It is now thought that vascular aging may occur at different rates and to varying degrees in different individuals and among races and societies. The artery has difficulty complying with the changes in the body's needs and therefore cannot meet the demand. Increased peripheral vascular resistance elevates blood pressure along with an increase in vasopressor, which increases systolic and diastolic pressures. 2

Atherosclerosis is a major contributor to PAD. Atherosclerosis comes from the Greek words athero meaning paste and sclerosis meaning hardness. This hardening and narrowing of the arteries builds up plaque in the walls of the artery. Plaque is the deposit of fats, cholesterol and other substances. This plaque formation can reduce the blood flow through an artery or completely block it.

ஐﻬ WHO IS AT RISK?

Promoting a healthy endothelium, the inner lining of your blood vessels, may be the key to maintaining strong blood vessels and preventing atherosclerosis and other circulatory problems. Identifying the risk factors is the first step in tackling PAD.

• Cigarette smokers: May be diagnosed with PAD 10 years earlier than non-smokers.

• Obesity: Diets high in saturated fats and cholesterol increase the risk of cardiovascular problems.

• Diabetes mellitus: People with type 2 diabetes have 3-4 times the normal risk for PAD. They also tend to develop PAD at earlier ages and to have more severe cases.

• Hypertension: High blood pressure almost doubles the chances of developing PAD.

• Pulse pressure greater than 70 mm Hg: The difference between the systolic (top) number of the blood pressure and diastolic (bottom) number is called the pulse pressure. Normal range is between 30 and 50 mm Hg. The higher the number, the greater the damage or stiffening of blood vessels.

• Hypercholesterolemia: The risk of PAD is increased by at least 10 percent with every 10 mg/dl increase in total cholesterol levels. These patients also tend to have lower high-density lipoprotein (HDL, or good cholesterol) and high triglyceride levels.

• Elevated C-reactive protein levels: These elevated levels are indicators of persistent inflammation in the arteries, which is now known to cause significant damage in blood vessels. This inflammatory damage is associated with PAD.

• Physical inactivity: Decreased exercise can exacerbate chronic diseases, increase the risk of osteoporosis and increase the risk of cardiovascular events. 3

ஐﻬ SIGNS & SYMPTOMS

A client may have no symptoms at all or may report a cramping pain, tiredness in the legs, thighs, calves or hip muscles while exercising, walking or climbing stairs. This pain is referred to as an intermittent claudication and usually occurs with exercise but goes away with rest. The pain occurs because of the lack of blood flow to the extremity.4 The muscles need more blood flow when they are being used. If the blood supply does not meet the demand, the patient has pain. Calf muscles may become withered and reddish in color when in a dependent position but pale when elevated. The skin will have an absence of hair, and may appear smooth and shiny while the nails become hardened and brittle. In advanced PAD, black, painful ulcers may develop; they do not bleed.

ஐﻬ DIAGNOSTIC STUDIES


When diagnosing PAD, healthcare providers can use several methods.

• Ankle-brachial index (ABI): Compares blood pressure in the feet to that in the arms to determine how well blood is flowing in the artery.

• Doppler and ultrasound imaging: Noninvasive test done to evaluate blood flow in the major veins and arteries.

• Magnetic resonance angiography: Allows the visualization of blood flowing through the cerebral vessels.4

ஐﻬ TREATMENT MODALITIES

There are two primary goals in the treatment plan of PAD. The first goal is to manage the pain of intermittent claudication, improve functioning and prevent progression of the disease that could lead to gangrene or amputation. The second is to reduce the risk of cardiovascular events such as heart attack and stroke. To meet these goals, the provider screens the patient for risk factors, particularly diabetes mellitus, as people with type 2 diabetes have 3-4 times the risk for PAD, heart disease and severe complications in the legs and feet.

Since cigarette smoking may be directly responsible for about 20 percent of all deaths from heart disease, advise patients to stop smoking.

A heart-healthy diet is recommended to maintain appropriate levels of cholesterol and lipids as well as maintain normal blood pressure and weight. Good hydration is important. Some providers may approve a glass of red wine every other day, which is believed to actually help circulation. Patients are normally steered away from alternative or natural remedies because these products are generally not regulated.

Regular exercises like walking or swimming are highly recommended. The exercise plan should include a fair amount of intensity, an established length of time and a frequency of about 3-4 times per week. Weight-bearing exercises are better at building strength and muscle mass and have lifelong benefits for the cardiovascular system.2

Another modality of treatment is the intermittent pneumatic compression device. This cuff-like apparatus encloses the lower leg and exerts pressure in waves to stimulate the natural increase in blood flow during walking.

Medications also may be used in the treatment of PAD to help manage leg pain and improve overall functioning. Aspirin, Plavix (clopidogrel), or Pletal® (cilostazol) are examples of anti-platelet agents given to prevent blood clots and to open blood vessels. Thrombolytics or clot-busters such as Activase® (alteplase) and Retavase® (reteplase) are agents given to break up existing clots. Mevacor®, Pravachol® and Zocor® are statins prescribed to aggressively treat high cholesterol levels. New studies have showed statins also to be beneficial in improving symptoms of intermittent claudication and reducing the risk of heart attack and stroke. Angiotensin converting enzyme (ACE) inhibitors like Capoten (captopril), Vasotec® (enalapril), Accupril® (quinapril) and Lotensin® (benazepril) prevent the conversion of angiotensin I to angiotensin II, a very potent vasoconstrictor. Its action also reduces peripheral vascular resistance and therefore lowers the blood pressure.5

Surgical procedures open obstructed blood vessels by using angioplasty or performing bypass grafts. In a percutaneous transluminal angioplasty, the obstructed blood vessels are opened. The vascular surgeon inserts a wire through the artery in the groin and passes it to the obstructed area. Once in place, a deflated balloon is passed over the wire to the obstruction, then inflated to open the artery.6 This procedure only requires local anesthetic and the patient can usually return to normal activity in 24-48 hours.

When performing a surgical bypass graft, the surgeon uses a natural vein taken from a different location in the leg or one made by synthetic material and re-routes the flow of blood around the obstructed area.2

ஐﻬ THE NURSE'S ROLE
Nursing care should consist of assessing the peripheral vascular system. The nurse will assess:

Pain: Location, characteristics, duration, intensity rated on a scale of 0-10.

Pulse: rate, rhythm and quality. If the nurse is unable to palpate the pedal pulse a Doppler should be obtained to verify circulation is present.

Pallor or cyanosis: Does the skin feel warm, cool or clammy?

Paresthesia and paralysis: Look for signs of edema, which may be unilateral or bilateral, pitting or non-pitting.

Blood pressure: Calculate the pulse pressure after measuring the blood pressure.7

A nursing diagnosis for a client with peripheral vascular disease may include any of the following:

• Altered peripheral tissue perfusion

• Pain related to decrease arterial flow

• Altered nutrition

• Immobility

• Knowledge deficit
« Last Edit: February 18, 2009, 03:58:35 pm by Adminஐﻬ » Logged


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« Reply #1 on: March 17, 2009, 11:05:13 am »

Study Questions Screening for Leg Vessel Blockages
Current guidelines may be set too high to catch disabling peripheral artery disease, experts say

 March 17, 2009

Some people considered normal under current screening guidelines for peripheral artery disease (PAD) may be at high risk for loss of mobility, according to a U.S. study.
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Peripheral arterial disease, which involves narrowed vessels in the lower extremities, can sometimes lead to severe obstructions, known as critical limb ischemia (CLI), a condition in which decreased blood flow causes pain and skin ulcers.

The new study found that people with borderline or low-normal ankle brachial index (ABI) -- the ratio of systolic blood pressure at the ankle compared to that in the arm -- have a twofold to threefold increased risk of physical disability. These ankle blood pressure readings are a common means of diagnosing PAD.

Currently, an ABI value of 0.91 or greater is considered normal. But this study of 666 people found that people with ABI values between 0.90 and 1.09 had higher rates of mobility loss than those with an ABI value of between 1.10 and 1.30, and were more likely to progress to an ABI of less than 0.90 over five years than those with an ABI of 1.10 and above.

The findings are in the March 24 issue of the Journal of the American College of Cardiology.

"This study confirms that patients with ... an ABI value below 0.90 experience significant and progressive loss of function and mobility," study author Dr. Mary McDermott, professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago, said in an American College of Cardiology news release. "But even those with borderline or low normal ABI also appear to be at significantly greater risk of functional declines, including losing the ability to walk up a flight of stairs or walk a quarter of a mile without assistance, compared to people who have no evidence of PAD based on ABI values between 1.10 and 1.30."

She said the findings add to a growing body of evidence that ABI values between 0.90 and 1.09 are clinically significant. Previous studies have found that borderline and low normal ABI values are associated with increased risk of cardiovascular problems and early signs of atherosclerosis.

"This study shows that people we have not previously labeled as having significant PAD, those with borderline ABI values, are at high risk for disease progression and decline in function over time. Given these and other data, the 'normal' value of 0.91 or greater needs to be revisited, perhaps even raised to 1.10," said Dr. Heather Gornik, medical director of the Non-Invasive Vascular Laboratory at the Cleveland Clinic, who wrote an accompanying editorial.

More information

The American Heart Association has more about peripheral artery disease.http://www.americanheart.org/presenter.jhtml?identifier=4692
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« Reply #2 on: August 22, 2009, 01:06:28 am »

Peripheral Arterial Disease (PAD)

If you are 40 or older, have pain in your legs when you walk that goes away when you stop, and have been diagnosed with peripheral arterial disease or poor blood flow in your legs, you may qualify for this study.

The research site is in Pinellas Park, Fla.

More information

Please see http://www.clinicalconnection.com/clinical_trials/condition/peripheral_arterial_disease.aspx.
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« Reply #3 on: October 27, 2009, 12:09:13 am »


Leg Artery Disease Often Goes Undetected

Many middle-aged adults may be walking around with a dangerous health problem and not even know it.

The condition called peripheral artery disease, or PAD, occurs when arteries in the legs become narrowed or clogged with fatty deposits, reducing blood flow to the legs. PAD affects about 8 million Americans.

PAD is as serious as heart disease, Dr. Ross Tsuyuki of the University of Alberta in Edmonton noted in a telephone interview with Reuters Health, "but, in general, it is under-recognized by the public and by our health care system."In 10 pharmacies in Central and Northern Alberta, Tsuyuki and colleagues had five pharmacy students screen 362 adults over age 50 for PAD. The screening procedure, which is fairly simple, compares the blood pressure in the leg to that of the arm.Seventeen people who were screened -- about 5 percent -- had PAD. And, importantly, Tsuyuki said, 80 percent of the people found to have PAD were previously unaware they had the dangerous condition.
"PAD is a very strong risk factor for poor outcome, including heart disease, stroke and lower limb amputation," Tsuyuki said.

"We informed them of what we found and followed up with them and most of them had gone to see their family physician for treatment," Tsuyuki said, which may include aspirin or other anti-blooding clotting therapies and aggressive cholesterol-lowering treatments.

While the US Preventive Services Task Force currently does not recommend routine screening for PAD, Tsuyuki thinks it is worthwhile to screen people at high risk for PAD. "That would include people who already have heart disease and people who've suffered a stroke. They would be the highest priority," he told Reuters Health."The second highest priority," he added, "would be people middle-aged and beyond who are at high risk for heart disease and stroke, such as people with high blood pressure, diabetes and high cholesterol."
The researcher reported his team's findings over the weekend at the 2009 Canadian Cardiovascular Congress, co-hosted by the Heart and Stroke Foundation and the Canadian Cardiovascular Society.

In a statement from the meeting, Heart and Stroke Foundation spokesperson Dr. Beth Abramson said: "People don't recognize that leg cramps while walking may be due to circulation problems that put them at risk for heart disease and stroke."

While PAD may have no symptoms, there often are some warning signs, such as leg pain during exercise, open leg sores that don't heal, feeling of coldness or numbness in one or both legs, pain in the toes at night.

Current or ex-smokers are at increased risk for PAD as are people with diabetes, high blood pressure, high cholesterol and heart disease.


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« Reply #4 on: June 25, 2010, 09:06:02 am »

To Predict Atherosclerosis, Follow The Disturbed Blood Flow



June 24, 2010-A new animal model of atherosclerosis has allowed researchers to identify a host of genes turned on or off during the initial stages of the process, before a plaque appears in the affected blood vessel.

The results were published June 15 in Blood, the journal of the American Society of Hematology.

The model is the first to definitively show that disturbances in the patterns of blood flow in an artery determine where atherosclerosis will later appear, says senior author Hanjoong Jo, PhD, Ada Lee and Pete Correll professor in the Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University.

The first author of the paper is Chih-Wen Ni, a graduate student in biomedical engineering.

Atherosclerosis describes a process where the arterial walls thicken and harden, because of a gradual build-up of white blood cells, lipids and cholesterol. This process can lead to plaque formation, and eventually to heart attacks and strokes.

Jo says his team's results could provide insight into how aerobic exercise, known to provide protection against atherosclerosis, improves the patterns of blood flow and encourages protective genes to turn on in blood vessels.

Scientists have previously observed that atherosclerosis occurs preferentially in branched or curved regions of arteries, because of the "disturbed flow" branches and curves create. Constant, regular flow of blood appears to promote healthy blood vessels, while low or erratic flow can lead to disease.

The standard laboratory model of atherosclerosis has scientists feeding a high-fat diet to mice with mutations in a gene (ApoE) involved in removing fat and cholesterol from the blood. Even then, atherosclerosis usually takes a few months to develop. In these models, clogs in a mouse's arteries tend to appear in certain places, such as the aortic arch, but flow patterns are set up at birth and thus are poor gauges of cause and effect, Jo says.

"We have developed a model where we disturb blood flow in the carotid artery by partial ligation, and atherosclerosis appears within two weeks," he says. "This rapid progression allows us to demonstrate cause and effect, and to examine the landmark events at the beginning of the process."

Jo says that endothelial cells, which form the inner lining of blood vessels, are equipped with sensors that detect changes in fluid flow.

"Disturbed flow is what causes the endothelial cells to become inflamed," he says.

The inflammation resulting from "bad flow" conditions in a stretch of artery causes white blood cells to accumulate there, followed by buildup of cholesterol and lipids and plaque formation.

Just 48 hours after blood flow in the carotid arteries was disturbed, Ni and colleagues dissected the carotid arteries from the mice and used genome-wide microarray technology to identify hundreds of genes that were turned on or off in the endothelial cells.

In past experiments, scientists grew endothelial cells in dishes to probe how different patterns of fluid flow affected their patterns of genes. However, growing cells in dishes alters them enough that many of the genes Jo's team found have not been identified before in this context.

For example, the team showed that the gene LMO4 – not previously known to be involved in atherosclerosis -- is turned on in their mouse model and also in human coronary arteries. Scientists studying breast cancer think LMO4 is involved in tumor migration and invasion, making an interesting parallel between atherosclerosis and cancer, Jo says.

He says his laboratory is now probing which of the newly identified genes are most important in atherosclerosis and searching for ways to manipulate them with drugs or genetic techniques, with an eye towards possible diagnostic and pharmaceutical applications.



The research was supported by the National Heart, Lung and Blood Institute, the Ada Lee and Pete Correll Professorship at Emory and Georgia Tech, and the World Class University project at Ewha Womans University in South Korea.

References:

C.W. Ni, H. Qiu, A. Rezvan, K. Kwon, D. Nam, D.J. Son, J.E. Visvader and H. Jo. Discovery of novel mechanosensitive genes in vivo using mouse carotid artery endothelium exposed to disturbed flow. Blood First Edition (June 15, 2010)

D. Nam, C.W. Ni, A. Rezvan, J. Suo, K. Budzyn, A. Llanos, D. Harrison, D. Giddens and H. Jo. Partial carotid ligation is a model of acutely induced disturbed flow, leading to rapid endothelial dysfunction and atherosclerosis Am J Physiol Heart Circ Physiol 297: H1535-H1543, 2009.
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« Reply #5 on: October 20, 2010, 02:31:57 pm »

Body's Bacteria Affect Atherosclerosis
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Gothenburg , Sweden, Oct. 18, 2010-New findings suggesting that bacteria in the mouth and/or intestine can affect the the outcome pathogenesis of atherosclerosis and lead to new treatment strategies, reveals research from the University of Gothenburg, Sweden.

The results are to be published in the distinguished journal Proceedings of the National Academy of Sciences, PNAS.

"The causes of atherosclerosis have recently become clearer, but we know less about why the plaque in the arteries ruptures and contributes to clot formation," says Fredrik Bäckhed, researcher at the Sahlgrenska Academy's Department of Molecular and Clinical Medicine.

Inflammation increases the risk of the plaque rupture in the arteries, but the underlying mechanisms for inflammation are not clear. Our bodies are home to ten times more bacteria than cells, and research in recent years has shown that our gut flora is altered in obesity , which over time may lead to cardiovascular disease. Poor dental health and periodontitis have also been linked to atherosclerosis, which would indicate that the bacteria in the mouth or gut could affect the condition.

"We tested the hypothesis that bacteria from the mouth and/or the gut could end up in the atherosclerotic plaque and thus contribute to the development of cardiovascular disease."

The researchers initially found that the number of bacteria in the plaque correlated with the number of white blood cells, a measure of inflammation. Next they used modern sequencing methods to determine the composition of the bacteria in the mouth, gut and arterial plaque of 15 patients, and in the mouth and gut of 15 healthy control subjects. They found that several bacteria were found in the atherosclerotic plaques and, primarily, the mouth, but also the gut, of the same patient and that the bacteria Pseudomonas luteola and Chlamydia pneumoniae were present in all atherosclerotic plaques. These results would suggest that the bacteria can enter the body from the mouth and gut and end up min the plaque where they ultimately may contribute toinflammation and rupture of the plaque. The researchers also found that some of the bacteria in the mouth and gut correlated with biomarkers associated with cardiovascular disease.

"Finding the same bacteria in atherosclerotic plaque as in the mouth and gut of the same individual paves the way for new diagnosis and treatment strategies that work on the body's bacteria," says Bäckhed. "However, our findings must be backed up by larger studies, and a direct causal relationship established between the bacteria identified and atherosclerosis."



ATHEROSCLEROSIS

Atherosclerosis-related conditions cause 40??% of deaths in Sweden each year. Atherosclerosis occurs when cholesterol is stored in the body's blood vessels and forms plaque. This makes them narrower, which – to varying degrees – risks stopping the blood from flowing, which can cause conditions such as angina, heart attacks and strokes.
 

Contact: Fredrik Bäckhed
Fredrik.Backhed@wlab.gu.se
46-313-427-833
University of Gothenburg
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« Reply #6 on: February 08, 2011, 10:22:54 am »

Peripheral Artery Disease Harder on Women

Feb. 07, 2011

Women with PAD lose ability to walk short distances and climb stairs sooner than men


CHICAGO --- Small calf muscles may be a feminine trait, but for women with peripheral artery disease (PAD) they're a major disadvantage. Researchers at Northwestern Medicine point to the smaller calf muscles of women as a gender difference that may cause women with PAD to experience problems walking and climbing stairs sooner and faster than men with the disease.

The study was published in the February 2011 issue of the Journal of the American College of Cardiology.

Peripheral artery disease affects eight million men and women in the United States. The disease causes blockages in leg arteries, and patients with PAD are at an increased risk of having a heart attack or stroke, said Mary McDermott, M.D., professor of medicine and of preventive medicine at Northwestern University Feinberg School of Medicine and physician at Northwestern Memorial Hospital.

McDermott and a team of researchers observed 380 men and women with PAD for four years, measuring their calf muscle characteristics and leg strength every year. Oxygen is needed to fuel calf muscles, and blockages in leg arteries prevent oxygen from reaching the calf muscles of people with PAD.

The researchers also tracked whether or not the patients could walk for six minutes without stopping and climb up and down a flight of stairs without assistance every year.

"After four years, women with PAD were more likely to become unable to walk for six minutes continuously and more likely to develop a mobility disability compared to men with the disease," said McDermott, lead author of the study. "When we took into account that the women had less calf muscle than men at the beginning of the study, that seemed to explain at least some of the gender difference."

Interestingly, men in this study experienced a greater loss of calf muscle annually than the women. But the men had more lower extremity muscle reserve than the women. That may have protected men against the more rapid functional decline women experienced.

"We know that supervised treadmill exercise can prevent decline, so it's especially important for women with PAD to get the diagnosis and engage in walking exercise to try and protect against decline," McDermott said.

Contact: Erin White
ewhite@northwestern.edu
847-491-4888
Northwestern University
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