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What is it?

An abdominal aortic aneurysm (AAA) is a permanent local dilatation or bulge in the aorta greater than 1.5 times its normal diameter.

The aorta is the largest vessel carrying blood from the heart to the rest of the body. The aorta leaves the heart and descends through the chest and abdomen until it splits into two arteries to supply the legs.

The aorta is an elastic structure which is capable of loosing its elasticity as it gets further away from the heart. Therefore the most common site for an aneurysm is in the abdomen. Most aneurysms have a spindle shape, but the size, shape, and extent varies in patients.

When there is a weakening in the walls of the aorta, the high pressures within the vessel cause a bulge or sac. Further weakening of this sac and enlargement can lead to a rupture of this major blood vessel causing severe bleeding. A ruptured aneurysm requires emergency management.

Blood tends to collect within these sacs which may lead to clot (thrombus) formation. If this dislodges from the sac, it can travel to other areas of the body and obstruct circulation to a particular area.

AAA

What are the causes?

Abdominal aortic aneurysm is a degenerative process of the aorta that is often attributed to atherosclerosis; however, the exact cause remains unknown.

Other causes of an abdominal aortic aneurysm include:

  • Congenital causes: born with a genetic predisposition to a weakness in the artery walls
  • Family History: AAA may have a tendency to run in families
  • Inflammatory causes: arteritis (inflammation of the arteries)
  • Infective causes: syphilis or fungal infections
  • Trauma

What are the risk factors?

Risk factors of AAA share many of the same risk factors of atherosclerosis including:

  • Sex: men are more commonly affected than women
  • Age: ages 60-65 and increasing age
  • Race: Caucasians have a higher risk than African Americans
  • Smoking
  • Family history of AAA
  • High blood pressure (hypertension)
  • High cholesterol
  • Diabetes

Who needs to be screened?

Screening is done with an abdominal ultrasound used to view images of the aorta to detect any abnormalities.

Screening is recommended for the following groups of people:

  • Men between the ages of 65 to75 with a history of smoking
  • Men aged 60 and older with family history of AAA
  • Both men and women with risk factors of AAA

Screening reduces the incidence of emergency repair and significantly reduced the mortality rate.

What are the symptoms?

Most abdominal aortic aneurysms are small and have no symptoms. Most people are unaware of it and are often discovered as an incidental finding during work-ups for other problems.

Symptoms are produced as aneurysms grow. The most common symptom of an abdominal aortic aneurysm is pain that may be felt in the abdomen, back, or groin.

A sudden and very severe abdominal, back, or groin pain may indicate a rupture of the aneurysm. A ruptured aneurysm requires emergency management.

How is it diagnosed?

Diagnosis is based around 3 parameters. These parameters include: Patient History, Physical Examination, and Imaging tests.

Patient History:

  • Symptoms of pain in the abdomen, back, or groin
  • Symptoms of claudication (pain while walking) in both of the legs may indicate an occlusion in the abdominal aorta
  • A patient may complain of a swelling located in the abdomen

Physical Examination:

  • During a physial examination, your vitals will be taken. Vitals include your pulse, blood pressure, and temperature. High blood pressure is an indication for further work up.Maj. (Dr.) David Rice, a pulmonary and critical care physician at Wilford Hall Medical Center, Lackland Air Force Base, Texas, listens to a patient's heart beat during an exam Aug. 4 in the pulmonary clinic. (U.S. Air Force photo/Senior Airman Josie Kemp)

  • An aneurysm may be felt in the abdomen as a small soft pulsating mass around the navel.
  • Peripheral pulses will also be checked to determine if an associated aneurysm or occlusive disease is present.
  • A stethoscope is placed over the abdomen to listen for a whooshing sound called a bruit.

Imaging tests

Imaging tests are performed to determine the size, location, and extent of an aneurysm. This also helps assess the risk of rupture and management.

  • Abdominal Ultrasound- is a simple, non-invasive office procedure used to view images of the abdominal aorta.
  • Magnetic Resonance Angiography (MRA) – this is a test similar to an MRI, which involves a contrast dye to be injected into a vein, while pictures are taken of the aorta.MRA-5

 

 

  • Computerized Tomographic (CT) Angiography: this test also involves the injection of a dye into the vein while pictures of the aorta are taken.
  • Angiography: This is an invasive test done in a hospital setting, involving the insertion of a thin catheter into the groin which is then advanced up to the aorta. A contrast dye is given to view the aorta and seen under x-ray guidance. This shows the location and extent of an aneurysm.

How is it treated?

Treatment includes preventing the progression of growth and preventing complications.

Treatment involves three separate parameters including: lifestyle changes, medications, and procedures.

Lifestyle changes

These lifestyle changes help maintain a normal blood pressure and also lower the risk of progression of growth of an aneurysm.

  • First line of treatment is to reduce the risk factors by diet changes, exercise, and weight management.
  • Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas.
  • Lower your salt intake
  • Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food.
  • Maintain a healthy weight with a BMI below 25
  • No smoking
  • Be more physically active
  • Relax and reduce stress

Medications:

Medications are used to prevent the progression and complications plus close monitoring. This does not treat an aneurysm.

Some medications used are:

  • Beta Blockers- to lower the blood pressure within the vessels.
  • Cholesterol lowering medications– these reduce cholesterol levels in patients with atherosclerosis.
  • Aspirin – prevents platelets from clumping together. This reduces the chances of a blood clot from forming and narrowing or obstructing the arteries. This is not appropriate for all patients including patients with bleeding disorders or those already taking a blood thinner.

Procedures:

Aneurysm repair is the primary treatment for symptomatic aneurysms and with a  high risk of rupture.

The goal of surgical management is to treat the aneurysm before it ruptures.

Two types of surgical procedures may be done for a large abdominal aneurysm.

These involve:

  • Open surgery
  • Endovascular repair

Open surgery- is a definitive treatment for symptomatic and high risk patients. This operation is done under general anesthesia and can last 4-6 hours. The abdomen is opened and a section of the aorta is removed. This section is replaced with a graft and the graft is covered by the artery wall and sutured into place.

Following this, normal blood flow is ensured. All surgeries carry a risk, although this holds a definitive treatment for aneurysm repair.

Anterior view of abdominal aorta showing graft in place before closure of open AAA repair SOURCE: 12B11614 MOD: Added outline, shadows references: Dr. Crew described this, also based on 11B1842


Endovascular repair- is a less invasive procedure which involves the placement of a stent within the abdominal aorta. A catheter is inserted into the groin through a small incision and advanced up to the aorta. A contrast dye is given to view the aorta and seen under x-ray guidance. A metal stent is positioned in the aorta which acts as a scaffolding for the artery.

Although this is less invasive, this is not a definitive treatment.

Who is not eligible?

The following people may be contraindicated for an open surgical repair of an abdominal aortic aneurysm:

  • Severe COPD
  • Severe heart disease
  • Active infection
  • Severe co-morbidities including cancer or other end-stage diseases

What are the risks of surgery vs. the risk of rupturing?

The risk of rupture of a small (<4 cm) aneurysm is less compared to a large (>6 cm) aneurysm. A small aneurysm if asymptomatic must be closely monitored every 6 months. The risk of rupture also depends on the rate of growth of the aneurysm.

The average rate of growth of an aneurysm is about 0.3-0.4cm per year. A large aneurysm has an increase risk of rupture and grows faster in smokers.

The decision of surgical intervention depends on the associated risks as well as the surgical risks.

Most small, asymptomatic, aneurysms do not require surgical intervention and only need monitoring every 6 months. Whereas patients who have an asymptomatic aneurysm close to 5.5 cm along with a rapid growth, are advised for repair.

Factors that need to be considered include:

  • The size and rate of growth of the aneurysm
  • Symptoms
  • Multiple aneurysms present
  • Surgical risk

What are the complications?

Complications of AAA include:

  • Inflammation
  • Infection
  • Aorto-venous fistula- an abnormal connection between the aorta and a vein
  • Aortoenteric fistula- an abnormal connection between the aorta and bowel
  • Thromboembolism- dislodged clot with the potential to obstruct or narrow a vessel

*Rupture of an abdominal aortic aneurysm is a true medical emergency and can cause the following:

  • Excruciating pain
  • Severe hemorrhage (bleeding)
  • Low blood pressure
  • Shock
  • Death

What is the prognosis?

Most abdominal aortic aneurysms grow slowly. If the aneurysm is slow growing, the prognosis is good.

Increasing size on an aneurysm increases the chance of rupture. The prognosis is good for patients who undergo aneurysm repair.

However, a ruptured abdominal aortic aneurysm holds a bad prognosis. Less than 80% of patients survive a ruptured aneurysm of such a major vessel.

How can I prevent this?

Risk factor modification slows the rate of progression as well as prevents complications.

Some ways to prevent these risk factors include:

  • NO Smoking
  • Controlling high blood pressure, cholesterol, and diabetes
  • Eating a healthy diet
  • Keeping physically active regularly with the right kind of exercise
  • Maintain a healthy weight with a BMI <25
  • Reduce stress!

 

FOOD ITEM

GI

FOOD ITEM

GI

White bread

71

Broad beans

79

Golden Grahams

71

Jelly beans

80

Millet

71

Pretzels

81

Watermelon

72

Rice Krispies

82

White rolls

73

Potato, microwaved

82

Puffed wheat

74

Cornflakes

83

Corn chips

74

Potato, instant

83

Chips

75

Potato, baked

85

Waffles

76

Rice pasta, brown

92

Doughnut

76

Baguette

95

Wafer biscuits

77

Parsnips

97

Rice cakes

77

Dates

103

Weetabix

77

What is it?

Aortic dissection is a condition in which a tear develops in the inner layer of the aorta.aorta-layers

The aorta is the largest and main blood vessel branching off the heart. Blood flows through this tear into the middle layer of the aorta, causing the inner and middle layer to separate or dissect.

This weakening in the wall of the aorta is prone to rupture which is often fatal.

What are the causes?

The most common cause of aortic dissection is due to chronic or long standing hypertension (high blood pressure).

Chronic hypertension causes stress in the aortic vessel wall making it more susceptible to tearing.

Other causes include:

  • Bicuspid aortic valve
  • Marfan’s syndrome – connective tissue disease
  • Cystic medial necrosis – connective tissue disease
  • Ehlers- Danlos syndrome – collagen synthesis defect
  • Turner syndrome – chromosomal abnormality
  • Coarctation of the aorta – narrowing of the aorta
  • Syphilis – infection
  • Arteritis – inflammation of artery
  • Pregnancy – III trimester
  • Cocaine abuse
  • Traumatic injury to the chest – motor vehicle accidents in which the chest hits the steering wheel

How does it occur?

Deterioration of the inner layer of the aorta is said to be a prerequisite in the development of non-traumatic aortic dissection. Following deterioration, tearing of the inner layer or aortic intima may occur.

Blood passes into the middle layer or aortic media through the tear, separating the intima from the media and dissects the blood vessel.

The dissection can spread both proximal (before) and distal (after) to the tear, involving major branching vessels of the aorta and aortic valve and filling blood around the heart.

Spread of this nature is responsible for many of the symptoms including ischemia (decrease in blood supply) to vital organs, aortic regurgitation, and cardiac tamponade.

Who is at risk?

Those at potential risk of developing aortic dissection include:

  • Sex: men are at higher risk compared to woman
  • Age: ages between 60s and 70s
  • Uncontrolled hypertension
  • Atherosclerosis
  • Pre-existing aortic aneurysm
  • Bicuspid aortic valve
  • Aortic coarctation
  • Turner’s syndrome
  • Marfan syndrome
  • Loeys-Dietz syndrome

What are the symptoms?

Symptoms if aortic dissection includes:

    • Sudden severe chest pain in chest or upper back, described as tearing, ripping, or shearing

 

  • Loss of consciousnessChestPain
  • Shortness of breath
  • Profuse sweating
  • Sudden difficulty in speech, vision, or paralysis of half of the body
  • Confusion or disorientation
  • Weak pulse compared to other arm
  • Dizziness
  • Nausea and vomiting

What are the types?

Aortic dissection is classified by the site of dissection.

The most widely used classification is the Stanford system which classifies dissection into two types.

Type A – dissections involving the ascending aorta, regardless of the site of teartype_a_vs_b

Type B – all other dissections

What are the complications?

Complications of aortic dissection include:

  • Death due to massive internal bleeding
  • Organ damage
  • Insufficient circulation past the area of dissection
  • Thrombosis
  • Heart attack
  • Stroke
  • Cardiac tamponade
  • Aortic regurgitation

How is it diagnosed?

The diagnosis of aortic dissection is based on three parameters including patient history, physical examination, and tests.

1. Patient history

 

  • Sudden severe tearing or ripping pain in the chest or back
  • Disorientation or confusion
  • Profuse sweating

2. Physical Examination

 

  • Delay in pulse between arms and legs
  • Hypertension or hypotension
  • Blood pressure difference between right and left arms
  • Auscultation over the chest may reveal a “blowing” murmur
  • New stroke symptoms and signs like decreased sensation or movement

3. Tests

 

  • Chest X-ray: reveals widening of the mediastinum                   X-ray of an aneurysm

xrayAAA

  • Transesophageal echocardiogram (TEE) – a test that uses high pitched sounds to produce images of the heart by passing a probe down the esophagus to view the heart
  • Computerized tomography (CT) scan: injection of a contrast dye is used to  visualize the aorta
  • Magnetic resonance angiogram (MRA) – uses magnetic fields to form images of the body

 

How is it treated?

Aortic dissections are treated according to the type of dissection presented.

Type A

Type A aortic dissections are considered surgical emergencies. This is the more common and dangerous type of dissection. Surgery is preferred in this type of dissection.aorta_dissection_repair

During the surgical procedure, surgeons remove as much of the dissected aorta as possible and make a blockade so blood does not enter into the aortic wall any longer.

The aorta is then reconstructed with a synthetic tube using a graft.

Some patients may have their aortic valve replaced at the same time if a leaky valve is present.

 

Type B

Type B aortic dissections may be treated medically unless the patient demonstrates progressive dissection with ischemia (decreased blood supply) or continued bleeding into the lung or abdominal space.

Medical treatment is used to reduce symptoms and prevent progression of the disease.

Medications include beta blockers (i.e. esmolol; labetalol; metoprolol) to reduce the action of adrenaline on the heart and blood vessels, vasodilators (i.e. sodium nitroprusside) to reduce the heart rate and blood pressure and nitrates (i.e. nitroglycerin) to dilate the blood vessels to decrease blood pressure.

Surgical repair is curative and is similar to the surgical procedure for Type A.

Sometimes a small wire mesh stent is inserted which acts as a scaffolding for the aorta.

What is the prognosis?

Aortic dissection is life threatening. The condition can be managed with surgery if it is done before the aorta ruptures. Less than half of the patients with ruptured aorta survive.

For Type A aortic dissection, the mortality rate remains high, with up to 30% deaths after surgery.

For Type B, when treated medically, the mortality rate is less with a death rate of 10%.

In both types, the ten year survival rate is more than 60%.

How can I prevent this?

The most important way to prevent aortic dissection is to control your blood pressure.

Prevention is enforced in patients who are at risk of dissection.

Some ways to reduce your risk is by:

  • Controlling blood pressure, diabetes, and cholesterol
  • No smoking
  • Maintain a healthy weight with a BMI <25
  • Wear a seat belt
  • Continue taking the medications prescribed to you
  • Any chest pain should not be ignored and medical care should be given immediately by emergency medical services and calling 9-1-1

What is it?

Aortic stenosis is a condition in which the aortic valve narrows and prevents the valve from completely opening. This restricts blood flow out of the aorta and heart. Restriction of blood flow exiting the aorta diminishes the body’s potential to receive the maximum amount of oxygen rich blood.
Over time the pressure increases in the left ventricle forcing the left ventricular wall to work harder and eventually become thicker and weaker. Weakening of the heart muscle can lead to the development of symptoms including weakness and fatigue.TAVR_Poster.indd

 

What are the causes?

Narrowing of the aortic valve may be caused by the following:

  • Congenital heart defects: unicuspid or bicuspid aortic valve
  • Calcification
  • Rheumatic fever- a condition that may develop after strep throat with valvular disease developing 5-10 years after rheumatic fever occurs
  • Type II hyperlipoproteinemia

Rare causes include:

  • Fabry’s disease
  • Systemic lupus erythematosis (SLE)
  • Paget disease
  • Alkaptonuria

How does a normal heart work?

The heart consists of four chambers. The top two chambers (atria) receive blood while the bottom two chambers (ventricles) pump blood out.

Deoxygenated venous blood returns to the right atrium of the heart. Blood flows from the right atrium to the right ventricle by the opening of the tricuspid valve. Blood is prevented from going backwards into the atrium by the closure of the tricuspid valve. The right ventricle then contracts and pumps blood out through the pulmonary valve into the pulmonary artery. The pulmonary valve is closed and the blood is sent to the lungs where it picks up oxygen.

Oxygenated blood returns from the lungs by the pulmonary veins and enters the left atrium. From the left atrium, blood enters the left ventricle by the opening of the mitral valve. Blood is prevented from flowing back into the left atrium by the closure of the mitral valve. Blood is then pumped out the left ventricle to the aorta by the opening of the aortic valve. Blood is prevented from flowing back into the left ventricle by the closure of the aortic valve. From the aorta, oxygenated blood is pumped out to the entire body.

 

normal view anterior cross section view of the heart SOURCE: from 89171_1

What happens in aortic stenosis?

The aortic valve consists of three leaflets (cusps) which connect to the aorta by a ring called the annulus. Heart valves only open in one direction. Once all of the blood has emptied out of the left ventricle, the aortic valve tightly closes to ensure no backflow of blood.

In aortic stenosis, the leaflets become thickened or calcified preventing the valve to completely open. The thickening of the leaflets make the valve opening narrowed. The ejection of blood from the left stenosisflowventricle struggles to get through the narrowed opening. The complete emptying of oxygenated blood from the left ventricle is limited, increasing pressure in the ventricle and eventually thickens the wall of the left ventricle.

The limiting of blood flow into the aorta results in symptoms of breathlessness, dizziness, and loss of consciousness.

What are the risk factors?

Aortic stenosis is not considered a preventable disease, yet some risk factors include:

  • Congenital abnormalities: bicuspid aortic valve (born with two aortic leaflets)
  • Age: increasing age along with calcium deposits on valves
  • History of rheumatic fever: causes leaflets to thicken, stiffen, or fuse
  • Hypertension (high blood pressure)
  • Hypercholesterolemia (high cholesterol)
  • Diabetes (high glucose)

What are the symptoms?

Patients with aortic stenosis may have no symptoms at all.

Aortic stenosis ranges from mild to severe. Symptoms typically develop in severe aortic stenosis.

Symptoms include:

  • Shortness of breath with activity
  • Angina (chest pain)
  • Fainting, weakness, or dizziness
  • Fatigue
  • Palpitations (sensation of feeling a rapid heart beat)

How is it classified?

Aortic stenosis is classified as:

  • Mild- valve area 1.1-1.9cm2 and/or mean transvalvular gradient <30 mmHg
  • Moderate- valve area 0.8- 1.1cm2 and/or mean transvalvular gradient 30-50 mmHg
  • Severe- valve area <0.7 – cm2 and/or mean transvalvular gradient >50 mmHg

 Normal valve area: 3.0- 4.0cm2 with no transvalvular gradient

What are the complications?

Complications of aortic stenosis include:

  • Angina
  • Syncope
  • Left ventricular hypertrophy
  • Heart failure
  • Arrhythmias
  • Endocarditis
  • Cardiac arrest

Call your doctor immediately if you have any of the following:

  • Chest pain or shortness of breath
  • Weakness in the muscles of your face, arms, or legs
  • Difficulty in speaking
  • Rapid or bounding heartbeat
  • Fainting or dizziness

How is it diagnosed?

Aortic stenosis is usually diagnosed during a routine visit with your physician.

Diagnosis is based around three parameters including patient history, physical examination, and tests.

1. Patient history

Patients may complain of symptoms in severe aortic stenosis.

Symptoms of:

  • Angina
  • Dizziness
  • Syncope
  • Loss of breath

2. Physical examination

During a routine physical examination, your health care provider will notice the following:

  • Faint pulse may be felt
  • Changes in the quality of pulse in the neck
  • During auscultation a murmur may be heard

3. Tests

The following tests may be performed:

  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This test may be used to detect left ventricular hypertrophy (thickening) which may occur due to aortic stenosis.
  • Chest X-ray- a simple test performed in our office showing the size and shape of the heart to determine whether the left ventricle is enlarged. Also reveals the presence of fluid in the lungs which may occur due to aortic stenosis.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves.
  • Cardiac catheterization- a hospital procedure used to diagnose the type and severity of your heart condition. A thin tube (catheter) is inserted into an artery in your arm or groin to reach the heart. A contrast dye will be given to view the arteries and seen under x-ray guidance. This allows the physician to see any abnormalities in the arteries including blockage that may coexist with aortic stenosis.

How is it treated?

Lifestyle changes are implemented in patients diagnosed with aortic stenosis to stop the progression of the disease.

Treatment of aortic stenosis is primarily done with surgical intervention, although medications can be used to relieve symptoms of aortic stenosis.

Lifestyle modifications

Lifestyle modifications help reduce the work load on the heart.

Lifestyle modifications include:

  • Maintain a healthy weight with a BMI <25
  • Limit salt intake
  • Maintain cholesterol, sugar, and blood pressure
  • Exercise for at least 30 minutes a day 5 days a week
  • Stay physically active
  • Do not smoke!

Medications

Medications are used to reduce symptoms and control heart rhythm disturbances associated with aortic stenosis.

Medications may be used to lower blood pressure or cholesterol.

  • Cholesterol lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low density lipoprotein (LDL- your Lousy cholesterol) and keep your high density lipoprotein (HDL- your Healthy cholesterol) High.
  • Beta blockers- this lowers the heart rate and decreases blood pressure.
  • Diuretics- these are sometimes referred to as ‘water pills’ which helps excrete excess water.
  • Antibiotics- people who had rheumatic fever in the past may require long-term treatment with penicillin.

Surgical Procedures

Surgical valve repair or valve replacement is preferred in patients who develop symptoms; even if symptoms are not bad, surgery is still recommended.

Aortic valve replacement offers substantial improvement of symptoms and life expectancy. The only effective treatment for severe aortic stenosis is aortic valve replacement.

Therapies to repair or replace the aortic valve include:

  • Balloon valvuloplasty- in a hospital setting, the physician inserts a thin tube (catheter) tipped with a balloon into an artery in the leg or arm to reach the heart. The catheter is positioned into the narrowed aortic valve and the balloon-tipped catheter is inflated. The balloon pushes the aortic valve open and stretches the valve opening, improving blood flow. Balloon valvuloplasty may relieve aortic valve stenosis and symptoms, although re-stenosis of the valve is common.
  • Aortic valve replacement- is the primary treatment for severe aortic stenosis. The entire aortic valve will be replaced by a surgeon. A mechanical (metal) or tissue valve (organic) may be used to replace the stenotic valve. A mechanical valve requires life-long anticoagulation therapy such as warfarin (Coumadin) to prevent blood clot formation. Tissue valves usually come from a pig or cow. Blood does not clot easily on tissue valves so patients may only need Coumadin or aspirin for only a short time. Tissue valves may wear out faster than mechanical valves and may need to be replaced sooner.

artificialValveAorta

  • Transcatheter aortic valve implantation (TAVI) – this is a less invasive approach for aortic valve replacement with a prosthetic valve. The approach can be transfemoral (femoral artery in leg) or transapical (apex of heart). TAVI approach is reserved for patients who are at an increased risk of complication from aortic valve surgery.

What is the prognosis?

Without treatment, an individual with aortic stenosis with symptoms or complications may do poorly.

Aortic stenosis can be cured with surgery although there is a risk for arrhythmias (irregular heart rhythm) which may cause sudden death. There is also a risk that the new valve will stop working and may need to be replaced.

How can I prevent this?

Aortic stenosis itself often can not be prevented, although some of the complications may be prevented.

  • Prevent rheumatic fever: See a physician when you have a sore throat. Treating strep infections promptly with antibiotics can prevent rheumatic fever that causes aortic stenosis.
  • Reduce risk factors of coronary artery disease: Lower blood pressure, obesity, high cholesterol, and sugar. It is a good idea to maintain a healthy weight with a BMI below 25.
  • Practice good oral hygiene: gum infections may also cause inflammation of the heart tissue called endocarditis.

What is deep venous thrombosis?
Deep venous thrombosis (DVT) affects mainly the veins in the lower leg and the thigh. It involves the formation of a clot (thrombus) in the larger veins of the area. This thrombus may interfere with circulation of the area, and it may break off and travel through the blood stream (embolize). The embolus thus created can lodge in the brain, lungs, heart, or other area, causing severe damage to that organ.

Risks include prolonged sitting, bedrest, or immobilization; recent surgery or trauma, especially hip surgery, gynecological surgery, heart surgery, or fractures; childbirth within the last 6 months; obesity; and the use of medications such as estrogen and birth control pills. Risks also include a history of polycythemia vera, malignant tumor, changes in the levels of blood clotting factors making the blood more likely to clot, disseminated intravascular coagulation (DIC), and dysfibrinogenia.

Deep venous thrombosis occurs in approximately 2 out of 1,000 people. The condition is most commonly seen in adults over age 60.

Prevention:
Anticoagulants may be prescribed as a preventive measure for high-risk people. Minimize immobility of the legs.

Symptoms:

    • leg pain in only one leg
    • leg tenderness in only one leg
    • swelling of only one leg
    • increased warmth of one leg
    • changes in skin color of one leg, redness or bluish
    • joint pain

Signs and Tests:
An examination may reveal a red, swollen, tender area of the leg. The Homans sign is positive, there is sharp pain when the foot is flexed upward.
The presence of deep venous thrombosis may be seen on:

    • venography of the legs
    • extremity arteriography
    • blood flow studies
    • Doppler ultrasound exam of an extremity
    • plethysmography of the legs

Treatment:
The clot itself usually will resolve through the natural healing processes. Treatment is also aimed at relieving symptoms and preventing the clot from traveling to the lungs, heart, brain, or other areas. Treatment usually requires hospitalization, at least initially.

Anticoagulants or antiplatelet medications are prescribed to prevent further clotting. Analgesics may be needed to control pain. Thrombolytics (clot dissolving medications) are rarely needed.

Bedrest may be recommended until the symptoms are relieved. The leg may be elevated to reduce swelling. Avoid prolonged sitting. Warm, moist heat to the area may help relieve pain.

After returning home, the patient may continue oral anticoagulants or antiplatelet medications for a prolonged period of time. Warm compresses may also be continued. Continue to avoid prolonged sitting or standing in one position.

Expectations:
Most DVT’s disappear without difficulty. Complications may be life threatening.
Complications:

    • pulmonary embolus
    • stroke (rare)
    • embolus in other organs (rare)

It is recommended that you call your health care provider if symptoms suggestive of DVT occur. With proper attention and care, a person with DVT can still live a long and productive life.

Enhanced External Counterpulsation (EECP)

 

What is EECP?

EECP is a non-invasive, FDA approved, outpatient therapy for patients having coronary artery disease with persistent symptoms of angina or heart failure who have already had the standard treatments for revascularization or those who are not eligible for surgical intervention.

EECP stimulates the formation of collaterals to help create a natural bypass around narrowed or blocked arteries to improve coronary perfusion.

This increases the amount of oxygen-rich blood to the heart and reduces the symptoms of chest pain, shortness of breath, and fatigue.

Who needs EECP?

  • Patients with coronary artery disease who do not require surgical intervention.
  • A patient with chronic angina and medical therapy alone does not provide satisfactory relief.
  • Patients who have already undergone one or more invasive procedures who have persistent chest pain.
  • Patients who are seeking to lower the requirements for medications.

What are the benefits of EECP?

  • Lowers the requirement of medications.
  • Decrease the onset and frequency of chest pain.
  • Enhance the quality of life and the ability to return to daily activities.

 

How does EECP work?

EECP affects the dynamics of cardiovascular blood flow. A series of inflatable cuffs sequenced from the calves, thighs, and hips rapidly inflate and deflate.

The timing of the inflation will be during the exact resting phase of each of your heartbeats. This timed compression in the lower extremities pushes the arterial blood backward into the aorta and increases the coronary perfusion pressure causing stress in the coronary arteries facilitating the development of collaterals.

EECP also increases the venous return during the sequential compression of the lower extremities with a “milking” effect at the same time as the arteries, which further increases cardiac output.

Since collaterals take time to develop, EECP is given for about 1 hour a day, for 7 weeks, with a total of 35 sessions. 80% of patients usually notice improvement of symptoms with this therapy.

Patients may be ordered a nuclear stress test after the course of therapy is complete to confirm the improvement of coronary blood flow.

Can anybody with chest pain try this?

Patients who do not qualify for EECP include patients with:

  • Uncontrolled congestive heart failure
  • Uncontrolled arrhythmia
  • Severe pulmonary or systemic hypertension
  • Mild to moderate aortic insufficiency
  • Significant coagulopathy- patients on heparin or warfarin
  • Severe peripheral vascular disease
  • Thrombophlebitis- Inflammation in the veins due to a clot

 

What are the risks of EECP?

EECP is a non-invasive procedure and risks are very low. Although risks are rare, patients may feel discomfort or minor pain in their legs or back.

Other effects may include bruising, blistering, or skin abrasions from the inflatable cuffs.

What is it?

Pulmonary hypertension is an increase in blood pressure within the arteries of the lungs and the right side of the heart.

When the blood vessels of the lungs become narrowed, pressure builds up in these arteries, therefore called pulmonary hypertension (high blood pressure).

When the heart begins to work harder, over time the right side of the heart becomes enlarged leading to right heart failure or cor pulmonale.

 

 

What are the causes?

Pulmonary hypertension may be caused by the following:

  • Autoimmune diseases i.e. scleroderma, rheumatoid arthritis, collagen vascular disease
  • Familial
  • Congenital heart defects
  • Pulmonary embolism
  • Congestive heart failure
  • Heart valve disease
  • Hepatic cirrhosis/ portal disease
  • Infection i.e. HIV
  • Chronic hypoxia i.e COPD, pulmonary fibrosis, interstitial lung disease, obstructive sleep apnea, chronic exposure to high altitudes
  • Medications i.e. diet pills
  • Idiopathic (unknown)

 

 

What are the risk factors?

The risk factors for pulmonary hypertension include:

  • Age: older patients are more likely to have secondary hypertension, such as pulmonary hypertension
  • Sex: more common in women than men
  • Family history: genetic inheritance
  • Weight: overweight persons are at higher risk of developing pulmonary hypertension
  • Other diseases: heart, lung, or liver disease
  • Other conditions: HIV infection, blood clots, sickle cell disease
  • Drugs i.e. cocaine or diet pills
  • Those who live at high altitudes

 

 

What are the symptoms?

Symptoms of pulmonary hypertension include:

  • Shortness of breath or light-headedness during activity
  • Fast heart rate (palpitations)
  • Swelling of the ankles or legs
  • Cyanosis (bluish discoloration of the skin)
  • Dizziness or syncope
  • Fatigue or weakness
  • Chest pain
  • Upper right quadrant abdominal pain

 

 

How is it classified?

Pulmonary hypertension can be classified into:

  • Idiopathic Pulmonary Hypertension (IPH)

Unknown cause of high blood pressure in the lungs; Uncommon

  • Secondary Pulmonary Hypertension

High pulmonary pressure due to other medical problems; Common

Causes include:

  • Pulmonary Embolism
  • COPD
  • Pulmonary fibrosis
  • Connective tissue disorders
  • Congenital heart defects
  • Sickle cell anemia
  • AIDS
  • Cirrhosis
  • High altitude
  • Drugs including cocaine, diet pills

 

 

What are the complications?

Pulmonary hypertension can lead to complications including:

  • Cor pulmonale (right heart failure)- The right ventricle has to work harder therefore it becomes thickened and enlarged. Eventually the right side of the heart gives out leading to right heart failure.
  • Pulmonary embolism- dislodgement of a blood clot to the lung
  • Arrhythmia
  • Hemoptysis- coughing up of blood

 

Call your doctor immediately if you have any of the following:

Call your doctor if you develop symptoms such as:

  • Shortness of breath during physical activity
  • Fatigue
  • Chest pain
  • Or other symptoms

 

 

How is it diagnosed?

Pulmonary hypertension is diagnosed in three different parameters including patient history, physical examination, and tests.

 

 

Patient history

Patients may complain of symptoms in severe pulmonary hypertension. Including symptoms of:

  • Shortness of breath
  • Angina (chest pain)
  • Fatigue/ tiredness
  • Upper right quadrant abdominal pain
  • Palpitations (racing heart beat)

 

Physical examination

During a routine physical examination, your health care provider will notice the following:

  • Cyanosis- bluish discoloration of the skin and lips
  • Weak pulse may be felt
  • Distended neck veins
  • During auscultation, a murmur may be heard

 

Tests

The following tests may be performed:

  • Blood tests – complete blood counts, liver function tests, PT/INR.
  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This test may be used to detect whether your heart’s rhythm is steady or irregular. Right ventricle enlargement can also be detected.
  • Chest X-ray- a simple test performed in our office showing the size and shape of the heart to determine whether the right ventricle is enlarged.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves. This test can estimate the pressure in the pulmonary arteries.
  • Right heart catheterization- a hospital procedure used to measure the pressure in the pulmonary arteries. A thin tube (catheter) is inserted into an artery in your arm or groin to reach the right side of the heart to the pulmonary arteries.
  • Chest Computed Tomography (CT) – shows pictures of the heart, lungs, and blood vessels.
  •  Magnetic Resonance Imaging (MRI) – shows how the right ventricle of the heart is working as well as the blood flow to the lungs.
  • Pulmonary Function Tests (PTFs) – are used to measure the amount, rate, and quality of air you can breathe in and out. This helps to determine any lung disease that may be causing pulmonary hypertension.

 

How is it treated?

The treatment of pulmonary hypertension is aimed at early recognition, controlling symptoms, treatment of the underlying disease, and the prevention of more lung damage.

Treatment depends on what type of pulmonary hypertension is present and the severity.

 

Lifestyle modification:

  • Rest
  • No smoking
  • Exercise: Ask your physician which exercise routine is best for you. Exercise for at least 30 minutes a day, 5 days a week. This can improve symptoms of shortness of breath and fatigue
  • Avoid pregnancy and birth control pills
  • Avoid traveling at high altitudes
  • Control weight: maintain a healthy weight with a BMI less than 25. Extra weight makes the heart work harder. By reducing your weight you can reduce the strain on your heart.
  • Nutrition: Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas
  • Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food
  • Reduce stress

 

 

Medications:

  • Prostacydinces
  • Vasodilators: Vasodilators dilate the blood vessels. Epoprostenol (Flolan) is the most commonly prescribed vasodilator for pulmonary hypertension. Another medication that can be prescribed is Iloprost (Ventavis), which can be inhaled and taken directly to the lungs.
  • Endothelin receptor antagonist: These medications reverse the effect of endothelin (vasoconstrictor) which makes vessels narrower. Bosentan (Tracleer) helps to improve energy and symptoms.
  • Sildenafil (Viagra) and Tadalafil (Cialis): These medications are used to treat pulmonary hypertension by opening up the blood vessels in the lungs to allow more blood flow.
  • Calcium channel blockers: Calcium channel blockers may be given in high dosage to help relax the muscles surrounding the arteries and cause the vessels to open. This increases blood flow to the lungs and lowers blood pressure. Calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem), and nifedipine (Adalat, Procardia)
  • Ambrisenten (Lentairis): helps dilate the blood vessels
  • Anticoagulants: help prevent clot formation
  • Diuretics: these are sometimes referred to as ‘water pills’ that is used for patients with leg swelling or fluid in the lungs. This helps excrete excess water in the body
  • Oxygen: breathing in pure oxygen can help treat pulmonary hypertension

 

 

Surgical Procedures:

Surgery is required if medications are unable to control your pulmonary hypertension.

  • Atrial septostomy: an opening is created between the left and right atriums of the heart to relieve the pressure from the right side of the heart.
  • Lung transplant: is a surgery to replace a diseased lung with a healthy lung from a donor. This is reserved for patients with severe lung disease causing pulmonary hypertension.
  • Heart-lung transplant: both the heart and lung are replaced with healthy organs from a donor.

 


What is the prognosis?

 

The long term outlook for pulmonary hypertension is poor, yet new treatments may lead to better results.

Death can result in patients with associated heart failure.

Pregnancy is not encouraged for patients with this condition.

What is it?

Renal artery stenosis is the narrowing of one or both of the arteries that carry blood to the kidneys.

This may cause high blood pressure and reduced kidney function.

What are the causes?

The most common cause of renal artery stenosis is atherosclerosis due to the formation of fatty plaques on the inner lining of the arteries.

  • Fibromuscular dysplasia (narrowing due to thickening of internal wall of blood vessel) tends to run in families and is seen more in women below the age of 50. This usually involves the distal portion of the renal artery.
  • Inflammation of the arteries known as arteritis may cause narrowing.

 

 

How does it occur?

A blockage of 50-70% of the renal artery is considered significant. As a result of decreased blood flow to the kidneys, the kidney cells falsely presume that blood flow throughout the entire body is reduced.

As a normal defense mechanism, the kidney activates a hormonal system known as the renin-angiotensin system. This response expands blood volume and elevates blood pressure throughout the entire body.

 

 

What are the risk factors?

Renal artery stenosis shares the same risk factors as atherosclerosis.

These risk factors include:

  • Men have a higher incidence compared to women
  • Increasing age
  • Family history of cardiovascular disease
  • Smoking
  • Excessive alcohol intake
  • Diabetes
  • High blood pressure
  • Chronic Inflammation: i.e. viral infections
  • Increased cholesterol levels
  • Compression from a mass

 

 

What are the symptoms?

Renal artery stenosis is generally not associated with any specific symptoms. Most patients commonly present with high blood pressure (hypertension).

Renal artery stenosis may be suspected in patients:

  • Above the age of 50 or below the age of 30 with high blood pressure
  • Who have had the need for more than 5 medications including a diuretic to control blood pressure
  • Whose previously controlled blood pressure becomes uncontrollable
  • With aortic or extensive peripheral vascular disease
  • With worsening renal function
  • With asymmetrical kidney sizes
  • With flash pulmonary edema

 

 

What are the complications?

Complications of renal artery stenosis include:

  • Aortic Aneurysm
  • Heart attack
  • Congestive heart failure
  • Kidney failure
  • Stroke

 

 

How is it diagnosed?

Diagnosis is based around 3 parameters. These parameters include: Patient History, Physical Examination, and Testing.

  • Patient History:

Renal stenosis may run in the family, so you might be asked about your family medical history.

History of any risk factors including diabetes, smoking, or increased cholesterol levels.

History of heart disease or peripheral vascular disease.

Severe headaches, nausea, vomiting, confusion, or blurring of vision may show symptoms of severe hypertension.

  • Physical Examination:

During a physical examination, your vitals will be taken. Vitals include taking your pulse, blood pressure, and temperature. Blood pressure may be taken more than once.

A stethoscope will be placed over the side of the abdomen, to auscultate for a whooshing sound called a bruit. This may indicate the presence of renal artery stenosis.

  • Testing

 

 

Laboratory investigations:

 

  • Blood Analysis- this includes a complete blood count (CBC), electrolytes, renal function tests (urea and creatinine).
  • Urine Analysis- to search for the presence of any blood in the urine.

 

 

Imaging Studies:

 

  • Renal Ultrasound or Doppler- is a simple office procedure done to screen renal artery stenosis in high risk patients. The advantage of this test is that it is able to measure the size of a narrowing and measure the blood flow through the vessel.
  • Renal Angiography- is the definitive diagnosis of renal artery stenosis. This is an invasive test done in a hospital setting, involving the insertion of a thin catheter into the groin, which passes through the aorta, then is advanced to the renal arteries. A contrast dye is given to view the arteries which are seen under x-ray guidance. This shows the exact number, location, and size of blockages. The advantage of an angiography is if a significant blockage is discovered, angioplasty or stenting may be done at the same time.
  • Magnetic Resonance Angiography (MRA) – this is a test similar to an MRI, which involves a contrast dye to be injected into a vein, while pictures are taken of the renal arteries.
  • Computed Tomographic (CT) Angiography: this test also involves the injection of a dye into the vein while pictures of the renal arteries are taken.

 

 

How is it treated?

The goal of treatment is to prevent the progression of renal artery stenosis, treating high blood pressure, and relieve blockages within the renal arteries.

Treatment involves 3 separate parameters including: lifestyle changes, medications, and procedures.

Life style changes

 

  • First line of treatment is to reduce the risk factors by diet changes, exercise, and weight management.
  • Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas.
  • Lower your salt intake
  • Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food.
  • Maintain a healthy weight with a BMI below 25
  • No smoking
  • Limit alcohol to one glass a day if you chose to drink
  • Be more physically active
  • Relax and reduce stress

 

 

Medications:

Renal artery stenosis is associated with high blood pressure. The first and safest approach to treatment is with medication.

Medications used to treat high blood pressure include:

  • Angiotensin Converting Enzyme (ACE) Inhibitors: lower blood pressure by preventing some of your natural chemicals to be made, promoting relaxation of the blood vessels and dilatation.
  • Angiotensin II Receptor Blockers (ARBs): block the action of the natural chemicals that narrow blood vessels.
  • Diuretics: sometimes referred to as “water pills”. These reduce sodium and water which lower blood volume.

These drugs may cause worsening of renal function. Medications and renal function will need to be closely monitored.

  • Calcium Channel Blockers: helps to relax the muscles surrounding the arteries, increasing blood flow, and lowering blood pressure.
  • Cholesterol-lowering medications– these reduce cholesterol levels in those with conditions with atherosclerosis.

 

 

Procedure:

Intervention is required in arterial narrowing of 50-70%, uncontrolled blood pressure with medication, and worsening renal function. Interventions done to treat renal artery stenosis include:

  • Renal Angioplasty and stenting: Renal artery stenting is the preferred method of treatment of renal artery stenosis. A bare metal stent is placed inside the renal artery to restore the blood flow. Once normal blood flow is restored, the kidney stops producing hormones that cause hypertension. The re-narrowing rate following renal artery stenting is 20%. Many patients are able to decrease their blood pressure medication usage or even stop them completely after this procedure.
  • Endarterectomy: is a procedure in which a catheter is used to scrape the inner lining of an artery. That material which is blocking the artery is extracted by the use of a catheter.
  • Renal Artery Bypass: The area of blockage in a renal artery is bypassed by attaching a vessel used from another area, to a site proximal of the blockage and attaching the other end to an area beyond the blockage.

How can I prevent this?

Healthy lifestyle habits can prevent renal artery stenosis from developing. Taking action in leading a healthy lifestyle can help keep your arteries strong, elastic, and free of plaque build-up to ensure maximum blood flow.

These healthy habits include:

  • NO Smoking
  • Limiting alcohol consumption
  • Controlling high blood pressure, cholesterol, and diabetes
  • Eating a healthy diet
  • Keeping physically active with the right kind of exercise
  • Maintain a healthy weight with a BMI <25
  • Get an annual flu shot
  • Reduce stress!

What is it?

T wave alternans refers to a noninvasive diagnostic test to help identify patients who are at risk of life threatening heart rhythm disturbances that can lead to cardiac death.

This test refers to a beat to beat variability in the timing or shape of T waves on the surface electrocardiogram (ECG) which is not visible to the human eye. Therefore high resolution sensors are used to detect subtle changes in the ECG.

Sudden cardiac death is the nation’s number one cause of death. Most people who suffer a cardiac arrest have an underlying, pre-identifiable, electrical disorder that puts them at risk. A good way to identify this is through the measurement of TWA, a beat-to-beat alternation of a patients ECG.

 

Who needs it?

Patients who need a TWA are those who are at risk of sudden cardiac death (SCD). Sudden cardiac death occurs in patients who have abnormal heart rhythms or arrhythmias.

Risk of SCD typically focuses on the presence of a few factors:

  • Reduced left ventricular ejection fraction (blood squeezed out from left heart chamber)
  • Left ventricular dysfunction
  • Ischemic cardiomyopathy
  • Left ventricular hypertrophy
  • Aortic stenosis

Reduced left ventricular ejection fraction is currently the primary determinate of Implantable Cardioverter Defibrillators (ICD’s), however; reduced ventricular ejection fraction lacks sensitivity.

TWA is a tool to help clarify the overall risk of arrhythmias, especially in patients who have known risks, but who fall into this ‘gray area’ in ICD eligibility.

 

How is it done?

TWA is performed during a treadmill stress test. The standard stress test can only identify the presence of clogged arteries, while the TWA test will identify subtle changes in electrical disturbances.

For TWA to be detected and measured at this microscopic level, the patient’s heart rate must be raised, usually by means of exercise on a treadmill.

This test is painless, noninvasive, and done on an outpatient basis.

Prior to the test, sensors are attached to the patient’s chest.


The patient begins to walk on the treadmill.

Once the patient’s heart rate reaches 90 beats per minute, the TWA test will begin.

After 2.5 minutes, the test is complete.

What is it?

A stroke is a medical emergency causing neurological injury to the brain due to ischemia or hemorrhage. Ischemia to the brain means a portion of the brain is not receiving blood and oxygen. Hemorrhage means there is bleeding in the brain due to a ruptured blood vessel.

A stroke is due to a cardiovascular cause, yet causes neurological disorders. A stroke is a medical emergency.

 

What are the types?

The two types of stroke include:

  • Ischemic stroke- more common (80%)
    • Blockage of blood supply to an area of the brain
  • Hemorrhagic stroke – less common (20%)
    • Bleeding into the brain from a burst bleed vessel

 

How does it occur?

A stroke occurs when blood flow to the brain stops for more than a few seconds depriving the brain of oxygen. Without oxygen for an extended period of time, permanent brain damage can occur.

Ischemic stroke may occur due to blocked or clogged arteries. A blocked artery can be due to a blood clot. A blood clot may form in an already narrowed artery (thrombotic stroke). A clot may also dislodge from another site of the body and travel to the brain (embolic stroke). Clogged arteries are due to a collection of fat, cholesterol, calcium and other substances in the interior wall of an artery.

A hemorrhagic stroke occurs in weak vessels which can rupture causing blood to leak into the brain. (i.e. aneurysm)

 

 

What are the risk factors?

A number of risk factors are present for stroke.

These factors include:

  • High blood pressure* (number one risk factor)
  • Increasing age (>55)
  • Family history of stroke
  • Race (African Americans are at a higher risk)
  • Diabetes
  • High cholesterol
  • Atrial fibrillation
  • Peripheral vascular disease
  • Oral contraceptives (birth control pills)

Precipitating factors:

  • Obesity
  • Heavy drinking
  • Eating high amounts of cholesterol or salt
  • Substance or drug abuse

 

 

What are the symptoms?

Stroke symptoms depend on what part of the brain has suffered from the lack of blood supply. Some people may be asymptomatic and may never know they have had a stroke.

Symptoms usually occur suddenly without any warning and can even occur while you are sleeping.

Symptoms are typically more severe when the stroke first happens, but can get worse.

Hemorrhagic stroke symptoms (bleeding within the brain) typically appear with a sudden and severe headache that can happen when lying down or while sleeping. The headache can get worse while straining, coughing, or with change of position.

Other symptoms of stroke include:

  • Change in alertness
  • Change in hearing
  • Change in taste
  • Change in the perception of touch, pain, pressure, and/or temperature
  • Difficulty in swallowing, speaking, reading, writing
  • Vision disturbances
  • Loss of coordination
  • Muscle weakness in face, arm, leg (usually on one side)
  • Tingling or numbness on one side of the body
  • Difficulty in walking
  • Loss of balance
  • Clumsiness
  • Confusion/ loss of memory
  • Change in mood, personality, or emotional changes

 

 

What are the complications?

A number of complications may occur with stroke. A stroke can cause temporary or permanent disabilities, depending on how long the brain has suffered without oxygen and which part of the brain was affected.

Common complications include the following:

  • Loss of movement or feeling in one or more parts of the body
  • Loss of mobility
  • Blood clots
  • Difficulty eating and drinking, which increases the chance of pneumonia and malnutrition
  • Difficulty in speech
  • Seizures
  • Urinary tract infection
  • Bleeding in the digestive system
  • Heart attack or heart failure
  • Cardiac arrhythmia
  • Bed sores
  • Falls
  • Dementia or thinking difficulties
  • Change in behavior
  • Death

 

 

How is a stroke diagnosed?

  • F – Facial Drooping
  • A – Arm Weakness
  • S – Speech Difficulty
  • T – Time to call 911

Anyone who has signs or symptoms of stroke needs immediate medical attention in an emergency department or hospital.

Several tests may be used to determine your risk of stroke including:

  • History & Physical Examination: Your doctor will ask you or a family member what symptoms you have been having, when they started, what you were doing when they began and if these symptoms are still present. Your doctor may ask you what medications you take and whether you have experienced any head injuries. You will be asked about your personal and family history of heart disease, TIA or stroke.

Your doctor will check your blood pressure and listen to your heart sounds and for any swooshing (bruit) sound over your carotid arteries in your neck, which may indicate atherosclerosis. An eye examination may be done using an ophthalmoscope to look for cholesterol crystals of clots in the back of your eyes.

  • Blood Tests: Important tests will be ordered to see how fast your blood clots along will blood sugar levels, presence of infection, and other critical elements of blood.
  • Computerized Tomography (CT) scan: Brain imaging is a key role in determining the presence of stroke and confirm the type of stroke. A CT scan uses a series of x-rays to create detailed images of your brain and the surrounding blood vessels of the head and neck.

A CT scan can reveal brain hemorrhage, tumors, strokes, and other conditions.

Doctors may inject a dye into your blood vessels to view your blood vessels for more detail known as a CT angiography.

  • Magnetic Resonance Imaging (MRI): Uses radio waves and magnets to create a detailed image of your brain.
  • Carotid Ultrasound: A noninvasive test using sound waves are used to determine fatty deposits (plaques) and quality of blood flow in your carotid arteries.
  • Angiogram: Your doctor inserts a thin flexible tube (catheter) through a small incision in the groin and advanced up to the carotid arteries under x-ray guidance with the use of a dye to visualize the arteries.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves.
  • Loop Recorder: for cryptogenic stroke or TIA; this is a device that is implanted into the chest which detects irregular heart rhythms (i.e. atrial fibrillations).

 

How is it treated?

A stroke is a medical emergency. Immediate treatment can save lives and reduce disability.

Call 911 or seek urgent medical care at the first sign of a stroke.

 

Ischemic Stroke

The goal of treatment in ischemic stroke is to restore blood flow to the affected area of the brain as quickly as possible.

Medicines used for the early treatment of stroke are used to break down clots (i.e. aspirin, anticoagulants, etc).

Results are best seen within the first 3 hours of symptoms.

  • Mechanical removal of the clot can be done with the insertion of a catheter into an artery of the brain and removing the clot.
  • Some patients benefit from an injection into the vein of tissue plasminogen activator (TPA) which dissolves the blood clot causing a stroke. TPA can also be administered directly into the brain with the use of a catheter threaded into an artery of the brain where the stroke is occurring.
  • Carotid Endarterectomy: is a procedure where a surgeon removes the fatty plaque from the carotid arteries in the neck that lead to the brain. This decreases the risk of having stroke again.
  • Angioplasty and stent: Angioplasty is the stretching of an artery with a balloon to widen it, followed by stent placement. The physician inserts a long, thin tube (catheter) into the narrowed part of your artery. A wire with a deflated balloon is passed through the catheter to the narrow area. The balloon is then inflated, compressing the plaque against the artery walls so it no longer restricts blood flow. Following this a stent may be placed to prevent restenosis.

 

Hemorrhagic stroke

The treatment of a hemorrhagic stroke depends on the cause of bleeding (i.e. high blood pressure, use of anticoagulant medications, head trauma, blood vessel malformation).

  • The initial treatment is to first determine the cause of bleeding
  • Control the blood pressure
  • Stopping any medication that could increase bleeding. (If stroke is due to hemorrhage (bleeding), clot-breaking drugs (thrombolytics) can cause more bleeding)
  • Transfusion of clotting factors may be given to stop ongoing bleeding
  • Measuring and controlling the pressure within the brain

Surgical blood vessel repair may be needed in cases of aneurysms or arteriovenous malformation (AVM) rupture.

Surgical options include:

  • Surgical clipping: The surgeon places a clamp at the base of the aneurysm and stops blood flow to it.
  • Coiling (endovascular embolization): The surgeon guides a detachable coil into the aneurysm and fills the aneurysm with the coil. This blocks blood flow into the aneurysm and causes the blood to clot.
  • Surgical AVM removal: The surgeon removes the AVM if possible, to eliminate the risk of rupture and lower the risk of a hemorrhagic stroke.
  • Decompressive craniotomy: When a patient’s life is threatened due to the high pressure effects of a clot in the brain, the physician may open the skull and/or remove the blood.

Once the bleeding within the brain stops, treatment usually involves bed rest and supportive medical care.

 

 

What is the prognosis?

The outlook depends on:

  • The type of stroke
  • How much brain tissue is damaged
  • What body functions have been affected
  • How quickly you get treated

Some patients may recover completely or some may remain with permanent loss of function.

Over half of the patients are able to function and live at home. Others may not be able to care for themselves.

If treatment with clot dissolving drugs is successful, the symptoms of stroke may go away. However, patients who do not receive treatment soon enough may not get the same results.

Patients who have ischemic stroke (due to blood clot) have a better chance of surviving than those with hemorrhagic stroke (bleeding).

Risk of a second stroke is highest during the weeks or months after the initial stroke.

 

How can I prevent this?

Know your stroke risk factors. Identifying your risk factors makes prevention of stroke easier.

Follow your doctor’s recommendations and adopt a healthy lifestyle.

Some lifestyle recommendations include:

  • Controlling high blood pressure
  • Lowering the amount of cholesterol and saturated fat in your diet
  • No smoking
  • Control diabetes (high sugar levels)
  • Maintain a healthy body weight with a BMI <25
  • Eat a diet rich in fruits and vegetables
  • Exercise regularly
  • Drink alcohol in moderation, if at all
  • Treat obstructive sleep apnea, if present
  • Reduce stress

*Ask your doctor about taking low dose aspirin!

Taking a small dose of aspirin thins the blood and helps prevent blood from clotting.

Cardioversion

What is it?

Cardioversion is a procedure used to treat abnormal and rapid heart rhythms known as cardiac arrhythmias. Cardioversion is most commonly used for atrial fibrillation.

Cardioversion delivers an electrical ‘shock’ to the heart to restore the heart to its normal rate and rhythm.

The energy delivered can be given in one of two ways. The electrical energy can be delivered externally with the use of electrodes attached to the chest, or directly to the heart with the use of paddles to the heart during open heart surgery.

An alternative mode of delivery is by the use of a permanent implantable device known as an implantable cardioverter defibrillator (ICD).

 

How does a normal heart beat?

Heart muscle cells are activated by electrical impulses that cause them to contract regularly and in sync. This contraction produces a heartbeat, allowing blood to be pumped out to the entire body.

Electrical impulses originate from specialized cells called the sinoatrial (SA) node, which is the hearts natural pacemaker. The SA node is located in the upper right chamber of the heart, the right atrium.  From the SA node, the impulse spreads across the upper chambers of the heart to reach the atrial ventricular (AV) node located between the atria and lower ventricles. After leaving the AV node, impulses spread across the pumping chambers of the heart, the ventricles. As impulses are spread along the heart, the cardiac muscle cells are stimulated to contract, producing a heartbeat.

 

 

What is an arrhythmia?

During a rapid cardiac arrhythmia, an abnormal electrical mechanism overrides the action of the sinoatrial node. Some arrhythmias start in the atria, while others are produced by the ventricles.

Sometimes, cardiac tissue can form an electrical loop or short-circuit. If the hearts electrical energy goes through this loop, it will cycle over and over again, repeating itself indefinitely causing a re-entrant loop. Each loop through this cycle causes the heart to contract.

Arrhythmias occurring by a re-entrant loop are usually regular, organized, and can be treated with cardioversion. Atrial flutter and ventricular tachycardia are examples of organized arrhythmias. Rapid, disorganized, chaotic arrhythmias include atrial fibrillation.

Cardioversion involves a high energy shock to the heart muscle which activates all of the cardiac muscle and conduction tissue simultaneously. This interrupts and breaks the re-entrant loop ceasing the arrhythmia, triggering the sinoatrial node to fire again and restoring a normal heart rhythm.

 

 

What to do before the procedure?

Prior to a cardioversion, if not already on anticoagulation therapy, your physician will determine your risk of blood clot formation and choose an anticoagulant medicine (i.e. Coumadin) to prevent the risk of stroke or heart attack.

Arrive at least one hour before your procedure to allow for prep time.

Make arrangements to have someone drive you to and from the clinic. You will not be permitted to drive after the procedure.

 

What happens during the procedure?

An external cardioversion is common and is performed in a specially equipped procedure room in our office.

The patient’s heart rate and rhythm, blood pressure, breathing rate, and oxygen levels are monitored.

An I.V. medication is given to sedate the patient to avoid any pain for when the shock is given. Patients will be asleep during the cardioversion and most will not recall the procedure.

Two pads will be applied to the skin. One pad will be placed near the breast bone and the second pad on the back, under the left shoulder blade.

After the patient is sedated, the doctor will deliver the shock given through these pads.

The cardioversion itself only takes a few seconds.

The patient usually wakes up within 5 to 10 minutes.

 

 

What happens after the procedure?

The patient will be monitored for at least one hour after the procedure.

You may also be required to wear a Holter monitor for 24 hours to monitor the electrical activity of the heart after the procedure.

 

What are the benefits?

The benefits of cardioversion include:

  • The return of normal heart rhythm
  • Improvement of the heart’s ability to effectively pump blood
  • Decrease symptoms including palpitations, chest pain, light headedness, difficulty breathing etc.
  • Decrease the risk of clot formation in the heart

 

What are the complications?

Several complications can occur with cardioversion. These include:

  • Provocation of other arrhythmias or heart block
  • Embolus
  • Myocardial necrosis
  • Skin burns

What is it?

Peripheral vascular disease is a disease of the arteries of the circulatory system due to atherosclerosis. Atherosclerosis is a gradual build-up of fat in the arterial walls depriving the limbs of the oxygenated blood flow it needs.

Atherosclerosis is not confined to one artery but may involve other areas as well.

Most commonly peripheral vascular disease is seen in the legs and is noticed by intermittent pain while walking.

Similarly, when atherosclerosis affects the heart it is called coronary artery disease.

 

What causes peripheral vascular disease?

At a young age, fat can start to deposit within the blood vessel walls. Fat builds up over the years that can cause injury to the blood vessel walls. Not only fat, but a number of other substances in blood like inflammatory cells, cellular waste products, proteins, and calcium begin sticking to the inside of vessel wall. All of these substances collectively form what is called Plaque. The formation of plaque is known as atherosclerosis.

Many of the plaque deposits have a soft inner center and hard exterior. If the hard outer surface breaks or tears, the soft inner center will become exposed to our body’s platelets. The platelets will come to the area of breakage and form a clot around the plaque. This causes the artery to narrow even more. A clot may dislodge and permit blood flow again, but the dislodging of a clot can also be dangerous, as it can cause a blockage further downstream.

The reduced blood flow deprives the tissues of oxygen and nutrients. There is more of a demand for oxygen during activities such as walking, climbing stairs, or exercise. During these times, symptoms usually occur.

 

Although atherosclerosis is the most common, other causes of peripheral vascular disease include:

  • Congenital: some individuals develop structural defects in the blood vessels at birth.
  • Autoimmune: people with autoimmune conditions can develop inflammation of the blood vessels known as vasculitis.
  • Thrombosis: a blood clot can narrow or obstruct a blood vessel.
  • Diabetes: can cause damage to the blood vessels which can make them more likely to be weakened or narrowed.
  • Infective: certain infections like syphilis can cause inflammation and scarring leaving a blood vessel weak or narrow.
  • Trauma

 

What are the risk factors?

 

  • Genetic: Inherited tendency within the family
  • Age: increasing age, above 50 years
  • Sex: Men are slightly more at risk than women
  • Family history of peripheral vascular disease, heart disease, or stroke
  • Smoking
  • Diabetes
  • Obesity (BMI > 30)
  • High blood pressure
  • High cholesterol
  • Sedentary lifestyle
  • Coronary artery disease
  • High levels of homocysteine

 

What are the symptoms?

Many people with peripheral vascular disease have mild or no symptoms.

The first symptom is claudication. This is a pain or cramping in the calf while walking or during exercise. Pain usually subsides at rest, unless the blockage is severe and will also appear at rest.

Other symptoms include:

  • Pain or cramping in the hip or thigh during walking or climbing up stairs
  • Tingling or numbness in the legs
  • Feet that feel cold
  • Slow healing of cuts or sores on the feet and legs
  • Pale, shiny, or bluish skin
  • Brittle and slow growing nails
  • Loss of hair over the limbs
  • Absent or weak pulse in the legs or feet
  • Erectile dysfunction

 

These symptoms are NOT a normal part of aging.

Do not be afraid to speak up and let Dr. Jamnadas or Dr. Kelly know of any symptoms you are having.

 

What are the complications?

If left untreated, peripheral vascular disease can develop:

  • Permanent tingling, numbness, or weakness in the legs or feet
  • Permanent burning or aching pain which can lead to an excruciating pain
  • Leg or foot ulcers
  • Gangrene – death of a part of the body due to lack of blood supply. Treatment will be amputation of the affected part.
  • Stroke and heart attack- people with peripheral vascular disease are at higher risk of heart attack and stroke
  • Renal artery disease or stenosis- blocking the blood flow to the kidneys.

 

 

How is it diagnosed?

Dr. Jamnadas will know if you have peripheral vascular disease by:

  • Discussing with you about your symptoms, risk factors, medical and family history.
  • On physical examination- weak or absent peripheral pulses along with other signs of peripheral vascular disease will be looked for.
  • Blood tests– measuring your lipid profile and glucose levels in case diabetic.

By performing tests including:

  • Ankle Brachial Index (ABI) – this is a non-invasive test measuring the ratio of blood pressure in the ankle to your arm. If the value is lower than expected, this may indicate a vascular problem. You may be required to walk on a treadmill and have readings taken before and after exercise.
  • Ultrasound Doppler Test– helps to evaluate the blood flow through a vessel and identify the site of blocked or narrowed arteries.
  • Angiogram– allows Dr. Jamnadas or Dr. Kelly to locate the exact anatomical site of blockage by injecting a dye within the arteries, which is visualized on x-ray showing the amount of blood flow to an area, and the number, size, and location of any blockages.

 

How is it treated?

It is very important to reduce any risk factors in order to manage the symptoms and progression of peripheral vascular disease.

 

Lifestyle changes

  • Quit smoking!!
  • Limit alcohol intake if you chose to drink
  • Lower blood sugar levels
  • Maintain a normal blood pressure and cholesterol
  • Eat a well-balanced diet
  • Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas.
  • Lower your salt intake
  • Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food.
  • Exercise regularly for 30 minutes at least 3-4 times a week and be more physically active
  • Maintain a healthy weight with a BMI below 25
  • If you have diabetes, practice proper foot care and prevent injury to the foot. Avoid walking barefoot and wear proper shoes. Maintain toenails and skin care. Be sure to inspect the soles of your feet regularly.

 

Medical treatment

  • Cholesterol-lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low-density lipoprotein (LDL- your Lousy cholesterol) and keep your high-density lipoprotein (HDL- your Healthy cholesterol) High
  • High blood pressure medications– such as Beta blockers that slow your heart rate and reduce blood pressure which decreases the oxygen demand of the heart
  • Antiplatelet medication- such as aspirin or Plavix which prevents platelets clumping together. This thins the blood and reduces the chances of a blood clot narrowing or obstructing the arteries. This is not appropriate for all patients including patients with bleeding disorders or already taking a blood thinner.
  • Controlling of blood sugar
  • Cilostazol (Pletal) – used for claudication and pain relief by increasing the blood supply to the limbs by dilating blood vessels and preventing clots.
  • Pentoxifylline (Trental) – this is an alternative medication which is less effective than Cilostazol but has fewer side effects of headache and diarrhea.

 

Supplements

Food and supplements rich in omega 3 fatty acids help reduce inflammation throughout the body, lower blood pressure, and the risk of heart attack.

  • Fish and Fish Oil- are high in omega 3 fatty acids, especially in fish like salmon, herring, and tuna. Fish oil supplements are also high in omega 3 fatty acids.
  • Flax and flaxseed oil- contain omega 3 fatty acids and fiber
  • Greensoul- is a natural supplement that helps to maintain a healthy cholesterol level, supports the body’s immunity, and the ability to fight free radicals.
  • Coenzyme Q10- helps maintain a healthy cholesterol level, boosts immunity, and energy.
  • Perfusion SR- helps enhance blood flow, maintain a normal blood pressure, and enhance the elasticity of large arteries.

 

Procedures to restore blood flow

  • Angioplasty and stent placement: this is a procedure considered as non-surgical because it is done by Dr. Jamnadas or Dr. Kelly, who accesses the artery by inserting a long, thin tube (catheter) into the narrowed part of your artery while being visualized under x-ray.  A wire with a deflated balloon is passed through the catheter to the narrow area. The balloon is then inflated, compressing the plaque against the artery wall and widening it, so it no longer restricts blood flow.

Blocked arteries in the renal, iliac, and legs can easily be treated with stenting or arthrectomy.

Unlike stenting done in the coronary arteries, only bare metal stents are used in the peripheries.

Bare metal stents act as a scaffolding to keep an artery open but suffer a 30% re-stenosis rate. This is due to a process called intimal hyperplasia which is attributed to a keloid. A keloid is an overgrowth of the inner lining of the blood vessel that covers over the stent. However, this reparative process lasts no more than 6 months. After 6 months, if an artery has not re-narrowed at the site of the stent, it is unlikely to re-narrow.

If symptoms were to reoccur, it would be due to New blockages at another site within the arteries.

  • Atherectomy: is a procedure where a catheter is used to scrape the inner lining of an artery. That material which is blocking the artery is extracted and then taken out of the artery using the catheter. The procedure is Best suited for blocked arteries in the legs. Laser Arthrectomy has been used in the legs also, but Dr. Jamnadas does not favor it at this time due to the high re-stenosis rate.

**Patients will need to improve risk factor modifications to prevent New blockage formation.

  • Bypass Surgery: is performed by removing a portion of a small blood vessel and sewing or ‘grafting’ one end of the bypass proximal to the area of blockage and the other end beyond the area of blockage, therefore bypassing the affected area.

 

thigh bypass
leg bypass
Bypassing artery in the thigh
Bypassing artery in the leg

 

If your disease is very severe and these procedures are not recommended for you, your foot or leg may need to be removed (amputated). This is usually necessary if you have very little to no blood flow leading to death of the tissues which can cause risk of a life-threatening infection.

Amputation is a last resort, but if peripheral vascular disease is not controlled, it is a possible result.

 

How can I prevent this?

 

  • Do not smoke!
  • Maintain a healthy weight with a BMI <25
  • Maintain a normal blood pressure, cholesterol and sugar levels
  • Eat nutritious, low fat foods and avoid foods high in cholesterol
  • Exercise regularly for 30 minutes at least 3-4 times a week

What is it?

Venous insufficiency is a condition which affects the veins of the legs. In healthy veins, blood is pumped from the legs up to the heart. Blood is pumped upwards due to a series of valves within the veins directing blood flow from the superficial veins to the deep veins leading back to the heart.  Contraction of the calf muscles also aid in pumping the blood flow back up to the heart.

When the valves within the veins are damaged or not working properly, blood flows backwards resulting in a pooling of blood in the legs. Pooling of blood in the legs increases the pressure in the veins leading to venous hypertension. This increase in pressure can cause mild symptoms of leg heaviness and aching or in chronic cases may progress to severe symptoms.


What are the symptoms?

Symptoms of venous insufficiency include:

  • Dull aching, heaviness, or cramping in the legs
  • Pain relieved with leg elevation and aggravated while standing
  • Edema (swelling of the legs)
  • Skin discoloration
  • Prominent veins (varicose veins)
  • Skin ulcers
  • Itching, tingling, burning, or throbbing sensation in the legs or feet
  • Leg weakness

 

What are the causes?

Several causes may lead to venous insufficiency including:

  • Congenital- born with weak vein walls or abnormal valves
  • Deep vein thrombosis (DVT) – blocks the blood flow through a vein. This increases pressure in the vein and may lead to permanent vein or valvular damage.
  • Superficial Phlebitis- infection of the superficial vein in the legs can cause damage to the veins and valves.
  • Direct leg injury to the veins or valves
  • Increase in body weight (i.e. pregnancy, obesity) – increases pressure in the veins
  • Weakness in the leg muscles- standing or sitting for long periods of time without walking can decrease the draining of blood from the legs, resulting in increase pressure and pooling of blood.
  • Structural compression from other structures in the pelvis.
  • Chronic fibrotic changes within the veins

 

What are the risk factors?

Those at risk of developing venous insufficiency include:

  • Family history of venous insufficiency
  • Sex: women are more prone than men
  • Increasing age
  • Varicose veins
  • History of deep vein thrombosis
  • Obesity
  • Pregnancy
  • Prolonged sitting or standing
  • Muscle weakness
  • Trauma to the legs
  • Cancer

 

What are the complications?

If venous insufficiency is left untreated, complications may arise due to the high pressure within the vein and reduced clearance of metabolites from the legs.

Complications include:

  • Pain
  • Infection
  • Swelling of the legs
  • Non-healing venous skin ulcers
  • Recurrent cellulitis
  • Stasis dermatitis
  • Thrombophlebitis

 

How is it diagnosed?

Venous insufficiency is diagnosed based around 3 parameters.

These parameters include: Patient History, Physical Examination, and Testing.

 

A. Patient History:

Symptoms give a strong clue in diagnosing venous insufficiency.

Typical symptoms include:

  • Swelling, throbbing, cramping, heaviness, and burning in the legs
  • Development of leg pain after standing or sitting for long periods of time
  • Pain that is relieved by elevating the legs
  • Warmth aggravates symptoms while cold relieves them

 

B. Physical Examination:

The appearance of the leg gives an idea of whether venous insufficiency is present.

Skin discoloration, swelling, stasis dermatitis, cellulitis, and dilated veins may be noticed in the legs.

Venous skin ulcers if present are typically located over the inner aspect of the ankle, but can also be present over the leg.

A manual maneuver known as The Trendenlenburg test may help in distinguishing insufficiency due to valvular damage. This is done by elevating the leg to empty the veins and applying pressure to block the junction where reflux is occurring from the deep to superficial veins. While maintaining this blocking, the patient is asked to stand. If the lower portion of the vein remains empty or slowly fills, the occlusion is removed. If this is followed by rapid filling, the junction has been correctly identified. If filling occurs with the occlusion, this may indicate a valvular problem in the deep veins.

 

C. Tests

Laboratory investigations:

Blood analysis: Elevated platelets levels increase the susceptibility to clot formation.

Diagnostic Studies:

  • Venous Reflux Study: this is a non-invasive test carried out in our clinic used to detect the presence of venous insufficiency
  • Venous Doppler: is a non-invasive test done in our clinic showing the direction of blood flow and detects thrombus (clot) formation
  • Magnetic Resonance Venography (MRV): is an imaging study used to provide a detailed picture of the deep and superficial veins of the legs using radio waves within a strong magnetic field
  • Direct Contrast Venography: is an invasive test used to detect venous and nonvascular causes of leg pain and edema
  • Intravenous Ultrasound (IVUS): A catheter is placed into the veins in the pelvis and an ultrasound image is taken from inside the vein. This gives an accurate assessment of whether there are any obstructions to blood flow.

 

How is it treated?
The goal in treatment is to reduce symptoms and correct the underlying problem.

 

Conservative treatment:

  • Weight loss: Losing weight can boost the blood flow in your legs.
  • Leg Elevation: Legs are elevated just above the level of your heart for about 30 minutes and should be done three to four times a day. Elevation improves the drainage of blood and metabolites from the lower extremities. This helps relieve symptoms in patients with mild venous insufficiencies.
  • Exercise: Foot and leg exercises help to improve symptoms. Movement helps prevent stasis of blood and also helps the calf muscles pump blood up towards the heart.

 

  • Graduated Compression: this is the cornerstone of treatment.


Compression stockings can be used in all patients with venous insufficiency and is available in our clinic.  Compression stockings apply a greater amount of pressure toward the ankle while pressure tapers as it goes up the leg. Compression stockings prevent pooling of blood and help to improve blood flow from the lower extremities.


Compression bandages are used for patients with severe symptoms including severe leg swelling or ulcers. Ulcers must have a dressing on before the application of a compression bandage. Application should be done by trained personnel. The bandage must stay dry and covered while bathing. If the bandage becomes wet, the bandage should be removed due to development of potential infection. The bandage may be changed once to twice a week.

Procedures:

The goal of these procedures is to improve the venous circulation by correcting insufficiencies by removing the reflux pathways.

  • Sclerotherapy: is a chemical ablation done by injecting a sclerosing agent into the vein, causing the vein to collapse.
  • Thermal Ablation: is a minimally invasive technique using intense thermal energy to irreversibly destroy an incompetent or diseased vein.  This procedure is carried out in our clinic.

  • Vein ligation or Stripping: is a surgical procedure done to remove veins requiring the use of incisions. Ligation and stripping are becoming outdated due to ablation techniques.
  • Venous Stenting: is a procedure similar to stents in other blood vessels, where a wire is guided through a narrowed portion of a blood vessel, after which a balloon is used to open the vein up to its original size. finally, a metal stent is placed, to act as scaffolding, keeping the vessels open.

 

How can I prevent this?

  • Lose weight
  • Avoid prolonged standing or sitting
  • Be more physically active by walking or running to promote the calf pumping function
  • Elevate your legs to improve circulation
  • Correct the underlying problem to prevent progression
  • Change your sitting or standing position regularly
  • Protect your legs from injury

What is it?

Venous ablation is a minimally invasive technique using intense thermal energy to irreversibly destroy an incompetent or diseased vein.

A catheter with heat is inserted into the targeted vein and closes off the vein. The vein is closed off, but not removed.

Who needs it?

Venous ablation is indicated in patients with symptoms of venous disease with reflux.

  • Dilated, engorged, or tortuous veins (varicose veins)
  • Skin discoloration
  • Burning or itching sensation in the legs or feet or around the veins
  • Swelling in the legs, ankles, or feet (edema)
  • Heavy feeling or weakness of the legs
  • Cramping or throbbing in the lower legs
  • Skin ulcers
  • Leg pain, especially after sitting or standing for a long period of time
  • Spider veins

A venous Doppler ultrasound is used to confirm the presence of venous obstruction, reflux, valvular incompetence, or clot formation.

 

 

Who does not qualify as a candidate?

Patients who do not qualify for venous ablation include patients with:

  • Thrombus (blood clots) in the affected vein
  • Infection in the vein (phlebitis)
  • A combination of infection and clot known as thromboembolism
  • Pregnancy

 
Why do I need it?

The goal of venous ablation is to treat and reduce the symptoms and signs of venous disease.

Venous ablation is also useful in preventing the risk of complications from venous disease (blood clot formation).

 

How to prepare for the procedure:

 

Before the procedure:

This procedure is done here in our clinic. Arrive at the clinic at the time of your appointment.

You may eat and drink before and after the procedure. This procedure is not effecting by eating.

This procedure does not require any alteration in medications, so take your morning medications as prescribed.

Arrange for someone to drive you home after the procedure. You may not be permitted to drive immediately after the procedure.

The procedure lasts about 1-2 hours.

 

During the procedure:

The procedure will be carried out in our clinic in our procedure room.

During the procedure you will lay on a table positioned on your back.

Under ultrasound guidance, the exact location of the vein will be determined.

A guide wire is inserted through a small opening in the skin into the targeted vein.

Once the guide wire is in, an introducer sheath is passed over the guide wire. The guide wire can then be removed. Under ultrasound guidance, the catheter is passed through the sheath and is advanced up the vein until it reaches 2cms below a junction called the saphenofemoral junction.

Under sterile precautions, a local anesthetic along with sodium bicarbonate will be injected into the tissue along the length of the vein to ensure that you do not feel any heat from the catheter. This compresses the vein from two sides and also separates the vein from other structures including nerves.

After the catheter is in place, the tip of this will send out a radiofrequency which is converted into heat that reaches 120oC. When the catheter is slowly withdrawn, the heat causes the vein to collapse and close off. Once the vein is closed off, blood is re-routed into other healthy veins.

 

 

After the procedure:

While you are on the table, an ultrasound will be done over the ablated vessel to confirm that the vessel is collapsed as well as an absence of blood flow in that vein.

Following the procedure, a bandage will be placed over the insertion site. A compression bandage will be wrapped around the entire length of the leg and should be worn for 2-3 days.

A compression bandage is important because it helps prevent bruising and tenderness as well as reduces the risk of blood clot formation and dislodgment. A compression stocking is required to be worn for up to 4 weeks.

You are encouraged to walk for at least 30 minutes a day after the procedure to prevent deep vein thrombosis.

Avoid heavy or strenuous exercise for a few days.

Avoid prolonged sitting or standing.

Wear compression stockings for up to 2 weeks.

An ultrasound follow up is required 3 days after the procedure to rule out any deep vein thrombosis (clot formation).

After 4 weeks of the procedure, an ultrasound follow up is required to ensure the complete closure of the vein and no reflux.

 

What are the possible risks and complications?

Venous ablation is generally a safe procedure, but with any surgical procedure it carries a risk.

If they occur are usually minor and temporary.

Complications include:

  • Bruising
  • Pain
  • Infection
  • Skin burn
  • Blood clot formation
  • Perforation of vessel
  • Nerve irritation or damage

 

 

What are the benefits?

The benefits of venous ablation include:

  • Relief of symptoms
  • Outpatient procedure
  • Well tolerated procedure
  • High success rate
  • Less invasive, less pain, tenderness, and few complications compared to surgical venous procedures
  • Does not require general anesthesia
  • Quick healing time
  • Can return to normal daily activities within 1-2 days
  • Good cosmetic results
  • Greater efficacy compared to venous surgical procedures with a positive prognosis of 10 years

What is it?

Syncope is defined as a brief loss of consciousness with an inability to maintain postural tone that is followed by a rapid and complete recovery.

Syncope is common and about one-third of the population experiences a syncopal episode in their life. Syncope may be an alarming sign in some people who have a serious underlying medical condition. In a younger age group, more than 75% of cases are not associated with an underlying medical problem.

 

What are the symptoms?

Syncope is often preceded by symptoms of ‘faintness’ including:

  • Lightheadedness or dizziness
  • Blurring of vision
  • Heaviness in the lower limbs and swaying
  • Loss of consciousness
  • Drowsiness
  • Pale skin
  • Sweating
  • Nausea

 

What are the causes?

A number of causes can lead to syncope. To remain conscious, oxygen-rich blood must supply the brain without delay. A delay of blood to the brain for even 3-5 seconds can result in syncope.

Consciousness is regained after falling or lying down because blood returns to the brain once gravity is removed. A number of medical conditions can cause syncope.

The most common causes include:

 
A. Vasovagal Syncope

This is the most common type of syncope. This is triggered by a number of conditions including physical or emotional stress, fear (i.e. sight of blood), dehydration, bleeding, pain, anemia, fever, or fasting.

These conditions or ‘triggers’ stimulate a nerve to slow the heart rate and dilate the blood vessels, which causes blood to pool in the legs, resulting in low blood pressure (hypotension). This leads to a decrease or delay in blood flow to the brain resulting in syncope.

Symptoms include nausea, sweating, stomach pain, hyperventilation, weakness, and confusion.

 

B. Cardiac Syncope:

Cardiac syncope can be due to arrhythmia or obstruction to cardiac outflow.

  • Alteration of the heart rate and rhythm can produce cardiac syncope. The heart rate and rhythm are controlled by the natural pacemaker of the heart known as the Sinoatrial Node.

This regulates the electrical activity of the heart which follows through a conduction pathway.

Syncope can occur due to problems at several places in this pathway.

When this is altered the condition is termed as arrhythmia.

Arrhythmias are produced by:

Bradycardia: this means the heart rate is slower than normal. A slow heart rate does not allow enough blood flow to reach the brain.

Heart Block: The transmission of impulses from the sinoatrial node are blocked. This interrupts the heart rate, making it slow and delaying blood flow to the brain.

Ventricular Tachycardia: this refers to a fast heart rate. The ventricles in the heart send out their own rapid electrical impulses, over taking the normal rhythm produced from the sinoatrial node. This causes an inadequate amount of blood flow to the brain.

Supraventricular Tachycardia: this also includes a fast heart beat, although the generation of rapid electrical impulses originates above the ventricles.

  • Obstruction to cardiac outflow may also result in a sudden loss of consciousness. The most common causes of obstruction are due to hypertrophic cardiomyopathy (exertional syncope) and aortic stenosis.

– Hypertrophic Cardiomyopathy: is a thickening of the left ventricular muscle wall. This can lead to inadequate blood flowreaching the brain.

Aortic Stenosis: is the thickening of the aortic valve in the heart leads to inadequate blood flow leaving the heart and can also lead to hypertrophic cardiomyopathy.

Other obstructive causes include mitral stenosis, pulmonary stenosis, pulmonary embolus, left atrial myxoma, and pericardial tamponade.

C. Orthostatic Syncope (Postural Syncope):

This refers to a low blood pressure after suddenly getting up from a laying position or from standing for a long period of time.

The heart rate slows and the blood vessels in the legs dilate causing a pooling of blood in the legs, leading to a lowering of blood pressure. This can decrease the blood flow to the brain and cause a syncopal episode.

The causes of orthostatic hypotension include blood or fluid loss, illnesses affecting the nervous system (i.e. diabetes, Parkinson disease), alcohol, carotid sinus hypersensitivity, and certain medications used to treat arrhythmias and lower blood pressure.

These medications include:

Angiotensin Converting Enzyme (ACE) Inhibitors
Nitrates
Beta Blockers
Quinidine
Calcium Channel Blockers
Amidarone
Diuretics
Tricyclic Antidepressants

 

D. Other Causes:

 

Other causes of syncope include low blood sugar, anemia, hyperventilation, seizures, heart attack, cardiac tumor, or pulmonary embolism.

 

Differential Diagnosis of a syncopal attack:

 

Endrocrine

Cardiovascular

Adrenal Insufficiency/Crisis
Abdominal Aortic Aneurysm
Hypoglycemia
Acute Massive Myocardial Infarction
Aortic Dissection

Metabolic

Aortic Stenosis
Hyponatremia
Asystole
Atrial Fibrillation

CNS

Brugada Syndrome
Subarachnoid Hemorrhage
Obstructive Cardiomyopathy
Heart block

Toxicity

Left Atrial Valve Thrombus or Myxoma
Antidepressant Toxicity
Long QT Syndrome
Antiarrhythmic Toxicity
Mitral Stenosis
Beta-Blocker Toxicity
Multifocal Atrial Tachycardia
Calcium Channel Blocker Toxicity
Pulmonary Embolism
Cocaine Toxicity
Pulmonary Valvular Stenosis
Tricyclic Antidepressant Toxicity
Pulmonary Hypertension
Sinus Bradycardia
Sick Sinus Syndrome
Tetralogy of Fallot
Torsade de Pointes
Tachycardia
Wolff-Parkinson-White Syndrome

 

 How is it diagnosed?

Dr. Jamnadas or Dr. Kelly will better understand your syncope based around 3 parameters.

These parameters include: Patient History, Physical Examination, and Testing.

 

A. Patient History:

 

Obtaining patient history is the most important diagnostic tool in syncope. 85% of the diagnosis comes from the history given from the patient.

  • Dr. Jamnadas or Dr. Kelly will ask of the events which occurred before, during, and after a syncopal attack.
  • You will be asked of precipitating factors such as sleep or food deprivation, if you were in a warm atmosphere, if alcohol was consumed, if u had any pain, or had strong emotional stress before the occurrence of syncope.
  • Warning signs before the attack might be discussed such as sweating or dizziness, which gives a clue towards a vasovagal syncopal attack.
  • If the event was sudden without warning signs, it is more likely to be a heart rhythm problem.
  • If the syncopal attack occurred during exertion, it is most likely an obstructive cause.
  • If the event occurred after postural changes or standing for a long period of time.
  • Details may be given from a witness present at the time of syncope and be able to estimate the duration of unconsciousness.
  • A witness may also provide history of how you were after the episode. If postevent confusion was present, it is a clue to determining whether the episode was syncope or a seizure. Postevent confusion is suggestive of a seizure.
  • You will also be asked if you have any preexisting medical conditions like heart disease or diabetes.
  • History will be taken from patients who have taken medication prior to the event, including blood pressure lowering drugs.
  • You will also be asked of any other personal and family history of cardiac disease.

 

 

B. Physical Examination:

 

  • During a physical examination, your vitals will be taken. Vitals include taking your pulse, blood pressure, and temperature. Blood pressure may be taken more than once, in the laying and sitting position.
  • Dr. Jamnadas or Dr. Kelly will listen to the sounds of your heart to determine whether any high-grade valvular defects are present. They will also listen for any carotid artery bruits, indicating a narrowing of the blood vessel supplying the brain.
  • Carotid sinus massage may be done. The carotid artery (artery in the neck) is firmly massaged while your heart rate is monitored. This can help in diagnosing a condition known as carotid sinus syncope.
  • You will also be examined for any injuries that may have been sustained secondary to syncopes such as head injury, lacerations, or fractures.

C. Testing:

A number of medical tests can help determine the cause of syncope. These tests include:

        

  Laboratory investigations:

  • Blood Analysis- this includes a CBC to reveal signs of anemia, serum glucose levels, electrolytes and renal function tests. Cardiac enzymes may be checked in patients whom cardiac origin is high.
  • Urine Analysis- to search for bacteria causing urinary tract infection, which may precipitate syncope.

      

   Diagnostic Studies:

  • Electrocardiogram (EKG) – this is a common and easy test to perform which records the electrical activity of the heart. This detects any irregular heart rhythms and may show evidence of a preexisting heart attack.
  • 24-Hour Holter monitor– records the electrical events of the heart during your normal daily activities. This helps in detecting signs of arrhythmias. It is important to accurately record your activities and symptoms so Dr. Jamnadas or Dr. Kelly can compare them to the Holter monitor findings.
  • Event monitor- If symptoms of arrhythmia are infrequent and do not occur within 24 hours, an event recorder may be ordered for you for up to 30 days.
  • Echocardiogram (ECHO) – shows images of the heart determining the size and shape of the heart, and shows whether the heart walls and pumping activity are normal or performing weakly.
  • Tilt Table Test– In this test you will be asked to lay flat on a table. The table will be tilted in various angles while your heart rate and blood pressure are monitored. This test is useful in revealing abnormal cardiovascular reflexes that produce syncope.
  • Stress test- helps access the blood flow to the heart at rest and during stress. Will detect if any areas are receiving less blood flow.

 

        Other Studies:

  • Chest x-ray– to assess the size and shape of the heart in congestive cardiac failure, infections within the lung causing pneumonia, or any fluid or mass can be seen in the lungs.
  • Computerized tomography (CT scan) – to look for signs of abdominal aortic aneurysm or aortic dissection.
  • T-wave alternans test (TWA)- detects abnormalities in electrical conduction that predicts sudden death.

 

How is it treated?

Syncope is treated depending on the underlying cause. The goal of treatment is to prevent recurrences and the progression of serious problems.

Vasovagal syncope:

Vasovagal syncope can be treated by educating the patient of the precautions to be taken as well as avoiding potential triggers to minimize the potential risk of harm.

For example:

  • If you have carotid sinus syncope, you will be instructed to not wear tight collars, to use a razor instead of electric razor, and drink plenty of fluids.
  • If you usually faint at the sign of blood, Lie Down immediately and elevate the legs once you feel any symptoms of syncope. If you are unable to lie down, sit down with your head between your knees.

 

Cardiac Syncope:

Cardiac syncope is treated with antiarrhythmic drugs or pacemaker/ ICD placement. A pacemaker is a small device that is implanted under the skin of the chest. This connects wires to the heart which transmits impulses to regulate the heart rate and rhythm.

 


Patients with life-threatening ventricular arrhythmias may need an implantable cardioverter defibrillator (ICD). This does the same as the pacemaker, but also administers an electric shock to correct the electrical problem that can prevent a person from dying.

Cardiac outflow obstruction can be treated with Beta Blockers to decrease the workload of the heart. Cardiovascular intervention procedures may be required or valvular correction surgeries.

 

Orthostatic Syncope:

Orthostatic syncope treatment also involves patient education. Certain techniques are designed to decrease the pooling of blood in the legs that allows blood pressure to drop once you stand. These techniques include the contraction of the leg muscles before and during standing. You will also be instructed to and rise slowly, in stages to stand.

Additional therapy may be given such as increasing salt in your diet, foot exercises, compression stockings for the legs, and consumption of plenty of fluids can be useful in the treatment of syncope.

It is important to Stay Hydrated.

Antihypertensive medications, especially diuretics are notorious for causing orthostatic syncope and many need adjustment.

Medications used:

  • Fludrocortisone– can be given to increase the amount of blood volume.
  • Midodrine– is a medication that can also be given to constrict the blood vessels to increase the blood volume.

 

What is the prognosis?

Vasovagal syncope and orthostatic syncope have an excellent prognosis and do not increase the risk of death.

Patients with cardiac syncope may be restricted from their daily activities.

Without treatment, the prognosis for people with cardiac conditions is usually poor and has a mortality of 25%.

 

How can I prevent this?

Patient education is very important!

Education may have a vital impact on prevention and recurrence of syncope.

Certain maneuvers can be tried which may stop or delay vasovagal syncope.

These maneuvers include:

– Crossing the legs while tensing the leg muscles, abdominal muscles, and buttock

– Clenching your fists or gripping a stress ball

– Gripping your arms while trying to pull them apart

  • Avoid standing up too quickly
  • Sit near the aisle so you can leave if you feel faint
  • Increase your salt and potassium intake
  • Drink plenty of fluids
  • Do not skip meals
  • Do not stand for a long period of time
  • Avoid alcohol and caffeine
  • Review your medications with your doctor

 

Safety Issues:

Patients who present with syncope are instructed not to drive until cleared by the doctor to do so.

This is recommended mostly for patients with no warning signs of syncope.