Group E - Vascular
Is atherosclerosis only a problem in the heart?
Atherosclerosis can happen in any vascular system of the body. It occurs when the wall
of the vessels become thick and hard from a buildup of lipids and macrophages which
causes a plaque to form (Brashers, 2006).
How would he know if he has peripheral artery disease?
Peripheral artery disease can be defined as atherosclerotic disease of the arteries
that perfuse the limbs, especially the lower extremities. It is the third most important
localization of atherosclerotic disease after coronary artery disease and CVA.
Progressive growth of atherosclerotic plaques can lead to stenosis of one or more of the
arterial segments along the iliac-femoro-popliteal axis inducing the clinical
manifestations of PAD. Alterations to the coagulation patterns, fibrinolysis and platelet
function can also contribute the formation of atherosclerotic plaques and contribute to
PAD development (Novo, 2002).
Risk factors include male gender, older age, family history of PVD, smoking, diabetes
mellitus, hypertension and hyperlipidaemia. Females with diabetes, an early
menopause post hysterectomy and older than 70 have the same prevalence of disease
as do males (Hiatt, 2002).
Classification
Stage I- Patients are asymptomatic. A thorough physical exam and accurate history
may reveal cold extremities, paresthesia, vascular bruits, absent, diminished or normal
pulses or an ankle brachila pressure index (ABPI) of less than 0.9.
Stage II- Patients present with intermittent claudication (IC). IC is the most common
manifestation and is defined as pain, aching, and cramping usually of the calf that is
initiated by exercise and is relieved by rest.
Stage III- Patients have rest pain which increases at night and exercise limiting
symptoms.
Stage IV- Ulceration are visible ranging from trophic lesions to gangrene (Novo, 2002).
How would he know if he has carotid artery disease?
Atherosclerosis can develop in the carotid arteries that supply the brain with blood. The
atherosclerotic plaque of fat and cholesterol can eventually narrow the artery thereby
reducing blood flow to the brain which may lead to a stroke. There are 3 ways that
atherosclerosis can cause stroke (Heart disease: Carotid artery disease, n.d.).
1. the artery becomes very narrow
2. part of the plaque breaks off and creates a thrombus that can block smaller
arteries in the brain
3. a clot forms in a narrowed artery (Heart disease: Carotid artery disease, n.d.).
There may not be any symptoms noted with carotid artery disease. The first sign may
be a transient ischemic attack (TIA) which may lead to a stroke. Symptoms of a TIA
include:
1. Visual disturbances such as blurred vision or bilateral/unilateral loss of vision
2. Difficulty speaking or comprehending others, slurred speech
3. Weakness or parasthesia unilaterally of arms, legs, or face
4. Dizziness, confusion, impaired coordination
5. Difficulty swallowing (Heart disease: Carotid artery disease, n.d.).
Mr. H’s doctor may also be able to hear bruits, which is a rushing sound, on physical
exam by listening to the carotid arteries with a stethoscope. These are not always
heard if there is a blockage. His doctor may order tests to diagnose carotid artery
disease such as an ultrasound, angiography, or CT scan (Heart disease: Carotid artery
disease, n.d.).
End organ damage – clinical signs and symptoms
Over time, an elevated blood pressure can have a significant impact on other organs in
the body. Organs that may be affected are the brain, heart, retinas of the eyes, and
kidneys (Hypertension, 2008). Each affected organ will display its own clinical
manifestations.
CVA – drooping or loss of facial muscle tone, altered or lack of muscle tone/movement
of limbs, slurring or inability to speak or understand language (aphasia), numbness,
reduction of vibratory sensation, altered sense of smell, taste, hearing or vision,
drooping of eyelid, decreased gag or swallow reflexes, difficulty with balance, altered
respiratory and heart rates, deficits in memory, confusion, loss of consciousness
(Stroke, 2008).
Myocardial infarction – symptoms may have a gradual or sudden onset with varying
degrees of intensity. Chest pain (tightness, squeezing or pressure), pain radiating to the
left or right arm, neck or jaw, or back are possible. Pain to the epigastrium may be
mistaken for heartburn. As well, shortness of breath, pulmonary edema, diaphoresis,
weakness, nausea, vomiting, palpitations, light-headedness or loss of consciousness or
sudden death are possible (Myocardial Infarction, 2008). Lab values for CK, CK-MB
and Troponins will be elevated and ST segment changes in 12-lead ECG (ibid.).
Congestive heart failure – low output heart failure, which can occur in patients with
hypertension, may show clinical signs of impaired peripheral circulations and
vasoconstriction (initially) such as cold, pale and cyanotic extremities, decreased stroke
volume, and narrowing of pulse pressures (Quaal, 1992). Other symptoms include
fatigue, irregular pulse, edema to extremities, weight gain, nausea, shortness of breath,
bloating and increased need to urinate at night time (Hypertensive heart disease, 2008).
Hypertensive retinopathy - Hypertension can cause damage to the retina of the eye.
Signs of hypertensive retinopathy include arteriosclerotic changes where:
Arteriolar narrowing of various degrees (often bilateral):
Grade I – ¾ normal caliber
Grade II – ½ normal caliber
Grade III – 1/3 normal caliber
Grade IV – thread-like or invisible
(Hypertensive Retinopathy, 2008)
As well, vessel sclerosis, ischemic changes, hemorrhage, edema, optic disc edema
(papilledema) and although some patients may not have visual symptoms, some may
have decreased vision and headaches (ibid.).
Hypertensive nephropathy – Irreversible loss of kidney function is possible
consequence to uncontrolled hypertension. The signs and symptoms of uremia (a
number of symptoms caused by the decline of renal function and the increase of plasma
toxins), are increased urea and creatinine, decreased GFR, anorexia, nausea and
vomiting, diarrhea, weight loss, edema, pruritus and possible neurological changes
(Gray, Huether, & Forshee, 2006).
Hypertensive encephalopathy – If blood pressure remains elevated, capillary
permeability increases, allowing vascular fluid to seep into the interstitial space.
Cerebral edema ensues and cerebral dysfunction will be a result (McCance, 2006).
Signs and symptoms of encephalopathy are an altered mental state such as: loss of
cognitive ability, personality changes, lethargy, difficulty in concentrating, and
decreased level of consciousness (Encephalopathy, 2008). As well, neurological signs
may manifest as muscular twitching (myoclonus), loss of muscle tone with quick
restoration of tone (asterixis), rapid, involuntary eye movement (nystagmus), seizures,
tremor and changes n respirations (ibid.).
References
Brashers, V.L. (2006). Alterations of cardiovascular function. In K.L. McCance & S. E.
Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and
children (5th ed., p. 1081-1146.). St Louis, MO: Mosby.
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Gray, M., Huether, S. I., & Forshee, B.A. (2006). Alterations of renal and urinary tract
function. In McCance, K.L. & Huether, S.E. (Eds.) Pathophysiology: The biologic
basis for disease in adults and children (pp.1301-1335). St. Louis, MO: Elsevier
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systems. In McCance, K.L. & Huether, S.E. (Eds.) Pathophysiology: The biologic
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Novo, S. (2002). Classification, epidemiology, risk factors, and natural history of
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artery disease. Diabetes, Obesity and Metabolism, 4(2), 1-6.
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