In your diagnosis of peripheral arterial disease, you will start by getting an anklebrachial index, which is a blood pressure evaluation of the ankle and brachial arteries, dividing these two numbers. If the level is less than 0.9, the diagnosis is that of peripheral vascular disease. If further evaluation is further indicated, a Doppler ultrasound will help detect blood flow through the arteries in a noninvasive way. The gold standard is angiography or a dye study, used to detect specific areas of occlusion or narrowing, particularly before surgical intervention, if this is indicated. The treatment of all patients requires risk factor modification to include smoking cessation, dyslipidemia treatment, management of diabetes, exercise, management of hypertension, and improved diet. Statin drugs, aspirin, and ACE inhibitors are required to slow progression. Walking is a good form of exercise so this should be undertaken. Preventive foot inspections and foot care are also essential. Drug therapy should include aspirin or other antiplatelet drugs like dipyridamole, clopidogrel, or ticlopidine. The claudication itself can be treated with pentoxifylline or cilostazol. If these fail to help, percutaneous transluminal angioplasty is indicated using a stent to keep the vessel open or to prevent gangrene. This works best for short or just a few lesions. If the disease is extensive, then surgical interventions, like bypass grafting or revascularization is indicated. A thromboendarterectomy can be done to remove existing clots and a sympathectomy is done to remove the sympathetic nervous system’s impact on the leg vessels. An amputation is done as a last resort if there is gangrene that cannot be fixed with other surgery.
CONGESTIVE HEART FAILURE Congestive heart failure involves some type of left ventricular or right ventricular dysfunction, leading to a backup of fluid into the lungs or peripheral tissues. It is a common disease, affecting more than six million patients in the US. There are two types of heart failure, including heart failure with preserved ejection fraction and heart failure with reduced ejection fraction. Heart failure with preserved ejection fraction is called diastolic heart failure with an increase in end-diastolic pressure at rest or with exertion and an essentially normal
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