kuliah vascular disorder

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Dr. Dian Samudra, SpPD

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Penyakit pembuluh darah muskular, dimanaterdapat plak diskrit yg terdiri lemakekstraselular, lemak intraselular dalam selbusa, serta matriks kolagen jaringan ikat ygdiproduksi sel otot polos pembuluh darah

Definisi :

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Diawali oleh pembentukan fatty streak(akumulasi sel busa di sub endotel) fibrous plaque (akumulasi monosit, limfosit, sel busa, sel otot polos) erosi dan ruptur plak disertaitrombosis dan perdarahan gejala klinis(infark miokard)

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Inisiasi dan progresi aterosklerosis

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Faktor Risiko :

1. Diabetes Melitus2. Tekanan darah tinggi3. Kadar kholesterol tinggi4. Tinggi lemak dalam diet5. Obesitas6. Riwayat keluarga dengan penyakit jantung7. Perokok8. Kurang aktivitas

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24.7% 29.9%

Coronary disease7.4%

Atherothrombosis is commonly found in more than one arterial bed in an individual patient*

Cerebrovasculardisease

Peripheral arterial disease (PAD)

3.8% 11.8%

19.2%

* Data from CAPRIE study (n=19,185) Coccheri S. Eur Heart J 1998; 19(suppl): P1268.

3.3%

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Penyakit akibat Aterosklerosis :

• Cerebrovasulas disease- Stroke

• Kidney disease- Atheroembolic renal disease- Renal artery occlusion

• Peripheral arterial disease ( PAD ) - Claudicatio

• DVT ( Deep Vein Trombosis )

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• Many people with diabetes and PAD do not have any symptoms

• Some people may experience mild leg pain or trouble walking and believe that it’s just sign of getting older

• Classical symptoms :– Leg pain, particularly when walking or exercise,

which disappears after a few minutes of rest– Numbness, tingling, or coldness in the lower

legs or feet– Sore or infections that heal slowly

What are the warning sign of PAD ?

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• PAD, occurs when blood vessels in the leg are narrowed or blocked by fatty deposits, platelets, fibrin, and

other substance on arterial wall

• PAD, increased risk for heart attack and stroke

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Important signs of chronic arterial insufficiency

• Limb examination (and comparison with the opposite limb) • Hair loss• Poor nail growth (brittle nails)• Dry, scaly, atrophic skin• Dependent rubor• Pallor with leg elevation after 1 minute at 60 degree

• normal color should return in 10 – 15 second• longer than 40 seconds indicated severe ischemia

• Ischemic tissue ulceration • (punched-out painful, with little bleeding) or gangrene

• Absent or diminished femoral or pedal pulses • (especially after exercising the limb)

• Arterial bruits • Additional examination by palpation and auscultation to

detect abnormal aortic aneurysm or bruit

Gey DC et al 2004 ; American Family Physician 69 : 525 - 532

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Important signs of chronic arterial insufficiency


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Differential diagnosis of intermitten claudication

Spinal stenosis(pseudoclaudication)

Prolapsed intervertebral disc

Deep vein thrombosisPeripheral neuropathies

Thromboangiitis obliterans(Buerger’s ds)

Restless legs syndrome

Arterial embolusArthritis of the hips

Vascular causesNon vascular causes


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How is PAD diagnosed ?

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Diagnosis :

1.Ankle/brachial index (ABI)

2.Arteriography

3.Cardiac stress testing

4.CT scan

5.Doppler study

6.Intravascular ultrasound (IVUS)

7.Magnetic resonance arteriography (MRA)20

ABI(Ankle Brachial Index)

ADA recommendation :–diabetes : over age of 50

have an ABI test–no-diabetes : younger

than 50 may benefit from testing if they have other PAD risk factors

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21a.Dorsalis pedis a.Tibialis posterior

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ABI(Ankle Brachial Index)

USUALLY SEVERE, MULTILEVEL OCCLUSIVE

ABI < 0.50

USUALLY ISCHEMIC REST PAIN OR TISSUE LOSS

ABI < 0.25

MILD, POSIBLY ASYMPTOMATIC

ABI > 0.80 – < 0.90

MODERATE ABI 0.50 – 0.80

ABNORMAL ABI < 0.90

INDICATED Ratio

Navarro F, The Cleveland Clinic Foundation 2002

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ABI(Ankle Brachial Index *)

severe obstruction ABI < 0.40

poorly compressible ABI > 1.30

mild obstruction ABI > 0.70 – 0.90moderate obstructionABI 0.40 – 0.69

normal ABI 0.91 – 1.30

interpretedRatio

Diabetes care 2002 ; 26 : 3333 - 3341

* The tools required to perform the ABI measurement include a hand-held 5-10 MHz

Doppler probe and a blood pressure cuff24

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• Get help to quit smoking• Aim for an A1c below 7%• Lower blood pressure < 130/80 mmHg• LDL-cholesterol < 100 mg/dl• Taking antiplatelet medicines (Aspirin)• Exercise training for Claudication• Surgical procedure (balloon angioplasty,

artery bypass graft)

How is PAD treated ?

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Risk-factor modification for the patients with PAD

• Smoking cessation• LDL-cholesterol < 100 mg/dl• A1c < 7%• Blood pressure < 130/85 mmHg• ACE-Inhibitor• Anti platelet therapy (aspirin or

clopidogrel)Stewart KJ, et al ; N Eng J Med 2002 : 24 : 1941 - 1951

27MWD = maximal walking distance; PFWD = pain-free walking distance; SF-36 = medical outcomes short form 36 questionnaire; WIQ = walkingimpairment questionnaire; A1c = hemoglobin A1c; JNC-VI = Sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; LDL = low-density lipoprotein; MRA = magnetic resonance angiography


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Segmental blood pressure measurement. A, segmental leg pressures in a normal right extremity (ABI: 115/115 = 1.00) and one with an isolated left iliac artery occlusion (ABI: 70/117 = 0.60).

Horizontal and vertical pressure gradients exist at the thigh. B, segmental leg pressures in a patient with an isolated focal right superficial femoral artery stenosis and a distal left tibial artery occlusion.

J Gen Intern Med 1992;7:91

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Pharmacotherapy for patients with Claudication

Extensive hemodynamic monitoring for risk of TTP500 mg per day orally

Ticlopidine

Correct dosing is critical; avoid in patients with heart failure; reduce dosing to 50 mg twice per day in patients taking calcium channel blockers; may cause loose stools and gastric upset

100 mg twice per day orally

Cilostazol

May have a small effect on walking ability, but insufficient data to support widespread use

1.2 g per day orally

Pentoxifylline

Fewer side effects than aspirin in the CAPRIE trial; significantly less risk for TTP than ticlopidine

75 mg per day orally

Clopidogrel

Recommended by the American College of Chest Physicians for PAD, but the FDA found insufficient evidence to approve labeling for this indication

81 to 325 mg per day orally

Aspirin

CommentsDosageDrugs

Diabetes care 2002 ; 26 : 3333 - 3341 32

Mechanism of action of ASA Membrane phospholipids

Arachidonic acid

Cyclic endoperoxidases

Prostacyclin(PGI2)

Thromboxane A2(TXA2)

Platelet aggregation& vasoconstriction

Inhibition of platelet aggregation & vasodilation

( Vascular Endothelium )(Platelets)

Inhib. by aspirin Cyclo-oxygenase(COX)-1

Phospholipase A2

kuliah vascular disorder

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