Referat Peripheral Atrial Disease

Referat Peripheral Aterial Disease(PAD)

AFRIDAYANTI (2009730065)dr. Tuti sri hastuti, Sp.Pd, mkesSTASE INTERNARSUD CIANJUR16 FEB 2014 27 APR 2014

PADMerupakan suatu kondisi adanya lesi yang menyebabkan aliran darah dalam arteri yang mensuplai darah ke ekstremitas menjadi terbatas.

Diabetic PAD

Individual at risk for lower-extremity Peripheral Aterial DiseaseAge less than 50 years, with diabetes and one other atherosclerosis risk factor (smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)Age 50 to 69 years and history of smoking or diabetesAge 70 years and olderLeg symptoms with exertion (suggestive of claudication or ischemic rest pain)Abnormal lower extremity pulse examinationKnown atherosclerotic coronary, carotid, or renal artery disease

Diagnosis and Treatment of Asymptomatic PAD and Atypical Leg PainIndividual at risk of PAD (no leg symptoms or atypical leg symptoms)Consider use of the Walking Impairment QuestionarePerfom a resting ankle-brachial index measurementABI grater than 1.30 (abnormal)ABI 0.91 to 1.30(borderline & normal)ABI less than or equal to 0.90 (abnormal)Pulse volume recording Toe-brachial index (Duplex ultrasonography*)Measure ankle-brachial index after exercise testNormal results:No Peripheral Aterial DiseaseAbnormal resultNormal post-exercise ankle-brachial index: No peripheral aterial diseaseConfirmation of PAD diagnosisEvaluate other causes of leg symptomsDecreased post-exercise ankle-brachial index

Pharmacological Risk Reduction:Antiplatelet (ACE Inhibition; class IIb, LOE C)Risk factor normalization:Immediate smoking cessationTreat hypertension : JNC-7 guidelinesTreat lipids: NCEP ATP III guidelinesTreat diabetes mellitus: HbA1C less than 7%

Clinical PresentationNoninvasive Vascular TestAsymptomatic lower extremity PADABIClaudicationABI, PVR, or segmental pressuresDuplex ultrasoundExercise test with ABI to assess functional statusPossible pseudoclaudicationExercise test with ABI Postoperative vein graft follow-upDuplex ultrasoundFemoral pseudoaneurysm; iliac or popliteal aneurysmDuplex ultrasound

Suspected aortic aneurysm; serial AAA follow-upAbdominal ultrasound, CTA, or MRACandidate for follow upDuplex ultrasound, MRA, or CTA

Typical Noninvasive Vascular Laboratory Tests for Lower ExtremityPAD Patients by Clinical PresentationAAA = Abdominal Aortic Aneurysm, ABI = Ankle-Brachial Index, CTA = Computed Tomographic AngiographyMRA = Magnetic Resonance Angiography, PAD = Peripheral Aterial Disease, PVR = Pulse Volume Recording

Diagnosis and Treatment of Critical Limb IschemiaChronic symptoms: Ischemic rest pain, gangrene, nonhealing woundIshemic etiologt must be established promptly:By examination and objective vascular studiesImplication: impending limb lossHistory and physical examination:Document lower extremity pulses ; document presence of ulcers or infectionSystemic antibiotics if skin ulceration and limb infection are presentSevere lower extremity PAD documented:ABI less than 0.4 ; flat PVR waveform; absent pedal flowABI, TBI, or duplex USAssess factors that may contribute to limb risk: diabetes, neuropathy, chronic renal failure, infectionSevere lower extremity PAD documented:ABI less than 0.4 ; flat PVR waveform; absent pedal flowNo or minimal atherosclerotic aterial occlusive diseaseConsider atheroembolism, thromboembolism, or phlegmasia cerulea dolensEvaluation of source (ECG or Holter monitor; TEE; and/or abdominal US, MRA. Or CTA); or venous duplex

Written instructions for self-surveilansOngoing vascular surveilance Revascularization possible (see treatment text, with application of thrombolytic, endovascular, and surgical therapies)Revascularization not possible:Medical theraphy; amputation (when necessary)Imaging of relevant arterial circulation (noninvasive and angiographic)Define limb arterial anatomy; assess clinical and objective severity of ischemiaPatient is a candidate for revascularizationObtain prompt vascular specialist consultation:Diagnostic testing strategy ; Creation of therapeutic intervention planPatient is not a candidate for revascularizationMedical therapy or amputation (when necessary)

Diagnosis of Acute Limb Ishemia

Figure 7. Treatment of Acute Limb IshemiaSevere PAD documented:ABI less than 0.4, flat PVR waveform, absent pedal flowImmediate anticoagulation:Unfractionted heparin or low molecular weight heparinObtain prompt vascular specialist consultation:Diagmostic testing strategyCreation of therapeutic intervention planAssess etiology:Embolic (cardiac, aortic, infrainguinal sources) - Legg bypass graft thrombosis- Popliteal cyst or entrapment - Aterial trauma- Phlegmasia cerulea dolens Progresive PAD and in situ thrombosis- Ergotism (prior claudication history)- Hypercoagulable state

16

Revascularization: Thrombolysis, endovascular, surgicalAmputationGuides to treatment:Site and extent of occlusion- Embolus versus thrombusNative artery versus bypass graft- Duration of ischemiaPatient comorbidities- Contraindications to thrombolysis or surgeryViable LimbNot immediately threatenedNo sensory lossNo muscule weakness Audible aterial and venous USSalvageable limb:Threatened marginally(reversible ischemia)Salvageable if promptly treatedMinimal (toes) or no sensory lossNo muscle weaknessInaudible (often) arterial Doppler signalsSalvageable limb:Threatened immediately(reversible ischemia)Salvageable with immediate revascularizationSensory loss more than toes, associated with rest painMild to moderate muscule weaknessInaudible (usually) aterial Doppler signalsAudible veous Doppler signalsNonviable limb:(irreversible ischemia)Major tissue loss or permanent nerve damage inevitableProfound, anesthetic sensory lossProfound paralysis (rigor)Inaudible arterial Doppler signalsInaudible venous Doppler signal

Key Elements of a Therapeutic Cladication Exercise Training Program (Lower Extremity PAD Rehabilitation)Peran klinis utamaMenetapkan diagnosis PAD menggunakan pengukuran ABI atau evaluasi laboratorium vaskuler tujuan lainnya.Tentukan klaudikasio itu adalah latihan gejala pembatas utama.Diskusikan risiko / manfaat alternatif terapi cladication , termasuk farmakologi , perkutan, dan intervensi bedah.Lakukan modifikasi risiko sistemik atherosclerosis.Lakukan treadmill stress testing.

Exercise guidelines for claudicationWarm-up and cool-down period of 5 to 10 minutes eachJenis latihanTreadmill dan jalur berjalan adalah execise yang paling efektif untuk klaudikasio.Perlawanan pelatihan telah diberikan manfaat bagi individu dengan bentuk lain dari penyakit jantung , dan penggunaannya , sebagai ditoleransi , untuk kebugaran umum melengkapi tetapi bukan pengganti untuk berjalan.IntensitasBeban kerja awal treadmill diatur ke kecepatan dan kelas yang menimbulkan gejala klaudikasio dalam waktu 3 sampai 5 menit.Pasien berjalan di beban kerja ini sampai mereka mencapai klaudikasio parah, yang kemudian diikuti dengan periode singkat berdiri atau duduk istirahat untuk memungkinkan gejala untuk menyelesaikan.LamanyaPola latihan - istirahat - latihan harus diulang sepanjang sesi latihan.Durasi awal biasanya akan mencakup 35 menit berselang berjalan dan harus ditingkatkan dengan 5 menit setiap sesi sampai 50 menit berselang berjalan dapat dicapai.FrequencyTreadmill or track walking 3 to 5 times per week

Peran pengawasan langsungSebagai pasien meningkatkan kemampuan mereka berjalan, beban kerja execise harus ditingkatkan dengan memodifikasi kelas treadmill atau kecepatan ( atau keduanya ) untuk memastikan bahwa selalu ada stimulus nyeri klaudikasio selama latihan. Sebagai pasien meningkatkan kemampuan mereka berjalan, ada kemungkinan bahwa tanda-tanda jantung dan sympoms mungkin muncul ( disritmia , angina , atau ST - segmet depresi ) .