gangrene, worst case scenario especially in
a patient who is diabetic.
Clinical history. The setting of the risk
factors to be exactly as to what we talked about earlier
about the coronary arterial disease and we
will look into that in a little bit.
Non-invasive testing. This will be the
first time in which we'll not
use a EKG, obviously here, makes no sense. We are not
in the heart; we are down in the periphery.
What kind of non-invasive test, how important
is this? really important because the more
you are able to come up with non-invasive
testing and it being efficient and effective,
the better of you be it every possible way.
You will be respected by your peers and in
terms of next step of management, any question
that you get here it is. It's called ankle-brachial index
and that is the one that we will pay attention
to. There are a couple of others that you
may do as well but at least, get this one
done. Once you have understood ABI, ankle/brachial/index
in other words, you are going to measure the
pressure in the ankle, you are going to measure
the pressure in the brachial upper extremity. Are you there?
And you are going to do a ratio. When you
do that ratio, you will get a particular number
and this is what I would like you to understand.
It is too much to memorize. What I would like for you to
do is to think about what exactly is happening with
the pressures in the two extremities. And what
can you expect with the ratio. And once you
do that, you will be much better than we were.
Ladies and gentlement, we will be doing this, we have been doing this
for every single organ system from like B1 creatine
ratio to tubular fluid to plasma ratio in
nephrology, you name it. Every type of ratio
that we have done, has been the fact that it
is all about understanding, and what you can
expect normally so that you can then identify the
abnormal. Take a look at this.
So we are going to
do, either right or left and we will put both up here and
ankle A, then brachial. Do it alphabetical order. The
ankle will be on top and the brachial B will be the denominator. That
would mean ankle and then you have your brachial in your arm.
What do I mean by higher? Clinically
speaking you will measure the ankle pressure
of both of the legs, right and left and you
will take the higher one. Then you will have
the brachial. Once again you will measure
both and you will take the higher one.
On the other side, and then you will do the ratio.
Once you get the ratio, now you tell me where
do you expect there to be the higher pressure, the
ankle or the brachial? Take your time. Ankle. So, when we
do the ratio in a little bit, we are going to find where you
can have your upper normal limit of that ratio
being above 1. Now we are going into technicalities
and details, why are we doing this? Because
we are going to identify noninvasively whether
or not your patient is suffering from
peripheral arterial disease. Use common sense
now. If there is peripheral arterial disease,
am I supplying adequate amounts of blood down
to the dorsalis pedis? Of course not, so what would you
expect that pulse and the pressure to be? Decreased.
Are we clear? So let us move on. Let us confirm
this. You measure your ABI. Interpretation of it.
Abnormal, absent pedal pulses. You can feel it. Age within
20 and you find that your patient has a history
of smoking, diabetes mellitus. Let us get it
confirmed just non-invasively. You find your ABI,
ankle-brachial index to be less than 0.9 please
know that you have confirmed diagnostic of
peripheral arterial disease. This is the
one that you pay attention to first and foremost,
please. As I fill in the gaps a little bit more this will
be good information for you to keep in mind. I'll give you normal,
what that means when you have excess. Right
now let us just keep our task and our task
at hand is to confirm non-invasively peripheral
arterial disease. We are using ABI, ankle-brachial index. And so
therefore, we said and you will agree that
the ankle pressure should be higher than the
brachial. And if you find the peripheral arterial
disease that the ankle pressure is quite low,
then what can you expect that ratio to be?
Work with the concept first, a low ratio.
Once you find a low ratio, what have you done?
You confirmed PAD. What exactly is that number?
Less than 0.9. Then you memorize the number,
you do that every single time. Well the fraction excretion
of sodium, later on in nephrology. You understand
the concept first and then you memorize your
numbers, if you must. The concept will never leave you.
Here is another one. This is normal. Between
0.9 and it can go all the way up to 1.3. The
ankle pressure is a little bit higher
so therefore, this is normal, no further
testing required. What if you find your ankle
to brachial index to be greater than 1.3?
Then your next step of management is your
Doppler. And so now you start to think about
the ultrasound and such. Duplex, Doppler.
There is something else called toe pressure.
Just keep these in mind as your next step
of management if you find your ABI to be greater
than 1.3. Let us then take a look, we
confirmed PAD. Now, if it is greater than 1.3 and
you found this to be confirmed with a Doppler
waveform, then you start thinking about diabetes
mellitus and even end-stage renal disease
may have falsely elevated levels. Renal failure.
In nephrology we have talked about quite a
bit about with end stage renal disease and there
often times you find your blood pressure to
be quite high, don’t you? Why? Because you
don’t have proper GFR. And so if your GFR
dropped then you are going to build up volume,
welcome to hypertension. So, you might have
falsely elevated levels with ESRD, end-stage
renal disease. At this point, your focus should
be peripheral arterial disease and how you
could confirm that? By having a low ratio. Let's move on.
Modifiable risk factors. These are the same
ones that we saw earlier where then we talked about
atherosclerotic disease. This includes, if
you can try, to implement, smoking cessation
programmes, blood glucose levels for diabetes.
The treatment of dyslipidemia, statins, where
is the other one of the statin which is now
current day practice proven to be incredibly
effective, called proprotein convertase PC
subtilisin S, kexin 9 inhibitor and those
are your either alirocumab or evolocumab, available
now and decreases your LDL cholesterol up
to 70 percent. We have treatment of hypertension. All these are
modifiable risk factors include also antiplatelet
therapy, aspirin, have the obstructive lesions
bypassed surgically if need be, worst case
scenario, talk about that diabetic who has
peripheral arterial disease and diabetic neuropathy
and there are enough necrosis and gangrene
in which the only step of management next
is to then conduct amputation and that's just unfortunate.
Now, let us take a look at aortic dissection.