Epidemiology of primary vasculitis in Colombia and its relation with reported for latin america. Carlos D. Universidad Nacional. Nosotros calculamos el porcentaje para todos los casos que fueron informados para Colombia. Resultados : se identificaron casos de vasculitis primaria en Colombia. No existen estudios de incidencia y prevalencia.
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Understanding medical treatment in lower limb peripheral arterial disease. The management of patients with peripheral arterial disease has changed dramatically over the last ten years. Surgery, once the preferred treatment method for intermittent claudication, is not longer the treatment of choice for patients with this presentation. Medical management is now the first choice, and an improvement of claudication and quality of health can be achieved using a combination of statins, platelet aggregation inhibitors and the new inhibitor of cyclic AMP adenosin monophosfate , Cilostazol.
This review focuses on the new recommendations for clinical evaluation, diagnosis and medical treatment of patients with the disease. Vascular surgery is unique amongst surgical specialties, because it includes not only surgical treatment options but also non-invasive medical therapies for patients with peripheral arterial disease PAD. This wide spectrum of alternatives results in patients with PAD not being detected early while management options remain widely unknown to general practitioners 1.
As the life expectancy increases due to advances in medicine, vascular diseases have become increasingly frequent, creating the need to diagnose and treat PAD in early stages. The spectrum of the disease can range from asymptomatic patients which constitute the majority of patients , patients with intermittent claudication and patients with rest pain and critical ischemia.
Thus, modern medical management has proven to be superior than elective surgery and bypass reconstruction for the improvement in walking distance in patients with intermittent claudication.
PAD is a marker of early mortality due to cardiovascular events. Declining ankle brachial index is directly proportional to the risk of coronary events 9.
Multiple risk factors have been associated with these high mortality rates, such as tobacco use, advanced age, dialysis dependence and diabetes. Because of the traditional age group in which chronic limb ischemia presents, the role of the vascular surgeon is aimed at identifying patients with arterial insufficiency and differentiating it from other causes of limb pain such as degenerative arthritis, radiculopathy and other osteo -muscular diseases 11 Table 1.
Chronic limb ischemia has a spectrum of clinical manifestations that range from asymptomatic to severe critical limb ischemia. Symptoms only occur when the demand for oxygen is higher than the blood supply in the presence of stenotic lesions of peripheral arteries. In sedentary patients symptoms may therefore not be apparent initially unless a stress test is applied. There are two main classification systems: Fontaine and Rutherford, the former is widely adopted and used in most publications.
Fontaine is based on clinical symptoms and signs rather than diagnostical findings. This classification can vary, however, because a subset of patients who are initially classified in stage I, have pain only with specific forms of exercise or only induced with extreme exercise as mentioned earlier.
Careful clinical evaluation is therefore essential. Functional assessment of the degree of arterial compromise can be achieved by asking the patient to describe the nature of the symptoms, at what distance usually measured in meters they occur, if the pain subsides after walking and if it's present at rest or forces him to leave his bed at nighttime.
It is very important to ask how long the pain persists after the patient has stopped walking; typical claudicants require less than 10 minutes of rest to resume activities. Longer resting times are more closely related to other causes of pain with exercise termed pseudoclaudication such as radiculopathy and osteoarthrosis It can be very challenging for the specialist to identify other causes of leg pain, especially those caused by nerve entrapment by a herniated disc or ostephyte at the lumbar root level, as this too can cause pain on walking and standing, or at night.
A systematic review of the significance of clinical signs was published in by Khan et al The most reliable clinical sign to predict the presence of PAD was the absence or presence of palpable pulses. The likelihood of having PAD was further increased in patients with intermittent claudication, and with additional risk factors such as age, smoking, dyslipidemia and diabetes mellitus. When present, these signs were useful in predicting the presence of PAD, but their absence, especially in patients with other risk factors, were not useful to exclude PAD.
No other clinical sign was useful in lowering the risk for a patient having PAD. Capillary refill time had a very poor diagnostic accuracy in this study. The individual likelihood ratios have to be used simultaneously with the pretest probabilities e. However, when the combination of normal clinical signs and low risk factors are present, the physician can safely rule out PAD.
It is imperative to gather additional information regarding other vascular beds coronary and cerebral and other risk factors for atherosclerosis. This information is valuable for current treatment and for prevention of further complications following therapy. The ankle brachial pressure index ABPI is one of the most useful tools to evaluate the state and prognosis of patients with PAD due to its high sensitivity and specificity Other methods are available, such as duplex scanning, arteriography and CT-angiography, but the ABPI is non invasive, readily available and can be applied and interpreted by any trained person.
It has been validated in multiple clinical and epidemiological studies, proving its reliability in classifying the severity of PAD and helping physicians and vascular surgeons to make decisions on adequate management options. It is also very useful in determining the outcomes of any therapeutical approach They found a direct connection between ABPI and walking distance on a 6 minute treadmill test. With an ABPI of 0. The same effect was also observed when analyzing the amount of time spent on the treadmill which was shorter for lower ABPIs.
The method for calculating the index is the ratio of the highest ankle systolic pressure divided by the highest brachial systolic pressure in each side As a general recommendation by most vascular laboratories, the preferred method for auscultation the pulses after deflation of the pressure cuff is using a hand-held Doppler with frequencies of 8 mHz and this should be used for every measurement.
With the patient lying supine, the pressure cuff of the sphygmomanometer is placed two finger-breadths above the pulse. The cuff is inflated above the highest systolic pressure, then measured and deflated at a rate of 3mmHg per second. The pressure at which the doppler sign reappears is recorded. The systolic pressure should be measured at the brachial, pedal and posterior tibialis arteries.
Mild PAD is indicated at ratio values of 0. Rest pain starts to appear at values of 0. Careful evaluations of falsely high values is imperative, as ratios of 1. Once clinical classification is made, the next step is identifying the relevant anatomical segments where the stenotic lesions are using radiological tests. Bi-dimensional and color imaging of peripheral arteries is a very sensitive and specific diagnostic tool that can help the treating physician to understand the disease and evaluate the state of collateral blood flow.
The report of a correctly performed duplex scan of lower limb arteries should include the degree of calcification, percentage of stenosis, flow velocities distal to the stenosis and identification of post occlusive blood flow due to collateral flow amongst others Other diagnostic methods such as arteriography, magnetic resonance angiography and CT angiography are usually reserved to make decisions on interventional or surgical procedures, and not for making diagnosis of the disease, as these modalities are prone to complications related to puncture, contrast and irradiation The American Heart Association and the American College of Cardiology have issued in general recommendations for the management of modifiable risk factors in patients with vascular disease, especially for smoking, dyslipidemia, hypertension, obesity and diabetes This section will focus mainly on the effects of smoking cessation on PAD and the effects of the use of statins in these patients.
A summary of the management algorithm is depicted in figure 1. Very interestingly, the majority of patients are still unaware of the effects of smoking on PAD. Many have still the concept that smoking only causes emphysema or lung cancer. Cessation of smoking is the most important modifiable risk factor in PAD in observed studies.
Additionally smoking was associated to progression of the disease up to having rest pain Fontaine III , compared to patients who quit in a seven year period It is therefore very important to identify patients who currently smoke and offer advice and therapy to assist smoking cessation. Several therapies have been suggested by a recent guideline form the U. Public Health Service, such as the use of nicotine patches, inhalers, gum or bupropion Information on prescription and use of these medications is beyond the scope of this article.
More than 40 years ago, the association between high cholesterol levels and cardiovascular disease was established Reducing cholesterol level improves mortality risk from cardiac and vascular diseases as it was first established in the ancillary 4-S trial with simvastatin in Since then, several studies have been published of the effect of lipid lowering agents, and specifically statins, on PAD.
In two different studies published in , the effect of statins vs. The placebo had no effect whatsoever on improvement of walking distance Similarly, in the Italian study, additional to walking distance, ABPI and quality of life was measured with or without simvastatin treatment.
Patients taking 40 mg a day of simvastatin had an increase of walking distance of more than 90 meters at 6 months, an improvement of more than 0. It seems that not only are there beneficial effects of statins on cholesterol levels, but also on the functional capacity of patients with PAD and the rate of decline in functional status over time. This has been consistently demonstrated in additional trials using walking distance and quality of life as measures of the effect of statins on PAD In addition to these findings, in more recent studies including the media-intimae thickness of carotid arteries, statins may have an overall reducing effect on the thickness of plaques, a direct effect on the endothelial dysfunction in patients with PAD.
At present, there are several studies addressing this issue. Claudication pain is caused mainly due to the excessive production of lactate from anaerobic glicolysis in patients with decreased supply of oxygen in PAD. Muscles have to adapt to the chronic lack of blood, and hence oxygen supply, to improve the use of glycogen stores without producing lactate It is by means of this mechanism that a subgroup of patients, who slowly develop stenotic lesions over time, become more adept at using this limited blood supply and can be asymptomatic at the time of consultation, even in the absence of palpable distal pulses.
Initially increased collateral blood flow was thought to be the cause of this adaptation, but a study by Jansson et al, revealed the adaptations of muscles to be the principal mechanism for improving claudication More than 10 randomized controlled studies have recently proven that increasing muscle exercise increases muscle adaptation and thus improvement of symptoms. Even in patients without specific training, higher daily physical activity reduces de functional decline of walking distance and intermittent claudication One of the earliest trials by Larsen et al in already showed a beneficial effect of regular exercise on walking distance in patients with PAD A more recent randomized controlled trial published in , compared resistance training vs.
Both methods improved significantly walking distance and quality of life of patients, whilst resistance training had a better effect on overall functional performance measured by walking distance, quality of life questionnaire and step climbing ability It also states that the most beneficial protocol consists of a treadmill or walking that is of sufficient intensity to bring on the claudication followed by rest and resuming the walking for a 60 minute session, to be conducted at least 3 times a week.
Aspirin or acetylsalicylic acid is widely used for prevention of ischemic events in patients with cardiovascular disease. This study applied mostly to reduction in coronary and cerebral vascular events and no specific mention of ischemic risk reduction in PAD patients was mentioned. Several studies attempting to address this issue have been published recently.
Clopidrogel was equally safe to aspirin in regards to thrombocytopenia. Nevertheless, patients with platelet aggregation inhibitor treatment have an increased risk of bleeding and temporary suspension might be required previous to surgery or other endovascular procedures. Subsequently, several trials compared the efficacy of aspirin versus other platelet aggregation inhibitor agents such as ticlopidine and other thienopyridines , with no statistical difference on event risk reduction or complication rates At present, there are no studies to show any improvement in management with combination therapy.
This was the first study to show direct evidence of the benefit of low dose aspirin in this context and current recommendations include the use of a low dose platelet aggregation inhibitor agent, but not combination therapy. Cilostazol was approved by the FDA in for use in intermittent claudication. Cilostazol is an inhibitor of phosfodiesterase III, increasing cyclic adenosine monophosfate and subsequently vasodilation form smooth muscle cell relaxation. It also has antiplatelet effects, and potentially beneficial effects on plasma lipoprotein levels.
The exact mechanisms by which it improves claudication distance are still unknown and additional effects may explain them
Tromboflebitis de la vena superficial
Todas ellas han sido afectadas por el humo del cigarrillo. Algunas de ellas son exfumadoras y otras nunca han fumado. Casi todas tienen enfermedades y discapacidades relacionadas con el tabaquismo. Estas enfermedades y discapacidades afectaron la calidad de vida —en algunos casos en forma significativa— como en la manera en que las personas comen, se visten y hacen sus tareas cotidianas. Algunas tuvieron que dejar de hacer cosas que les encantaba hacer. Conozca a Rebecca M. Conozca a Ellie N.
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