Varicose Veins and CVI Overview

Varicose Veins

• Blood pools in veins, causing them to become distended, tortuous, and palpable
• Caused by damaged valves and increased pressure due to gravity
• Common in people who stand for long periods, wear restrictive garments, or cross their legs
• Risk factors: age, female gender, family history, obesity, pregnancy, deep vein thrombosis (DVT), previous leg injury
• Can progress to chronic venous insufficiency (CVI)

Chronic Venous Insufficiency (CVI)

• Inadequate venous return over a long period
• Venous hypertension, circulatory stasis, and tissue hypoxia cause skin ulcerations
• Infection can occur due to poor circulation and impaired immune response
• Symptoms: edema in the lower extremities, hyperpigmentation of the skin, slow circulation (capillary refill > 3 seconds)
• Treatment: elevating legs, compression stockings, exercise, endovenous ablation, sclerotherapy, surgical ligation and stripping

Thrombus Formation in Veins

• Thrombus: a blood clot attached to a vessel wall
• Embolism: a thrombus that breaks free and travels through the bloodstream
• Deep Vein Thrombosis (DVT): a blood clot that blocks veins, typically in the lower extremities
• Virchow's Triad: the three factors that promote venous thrombosis: venous stasis, venous endothelial damage, hypercoagulability

Orthostatic (Postural) Hypotension

• A decrease in systolic and diastolic blood pressure upon standing
• Lack of normal blood pressure compensation in response to gravity
• Can be acute or chronic
• Signs and symptoms: dizziness, syncope, blurring or loss of vision
• Treatment: changing positions slowly, compression stockings, fluid intake, avoiding alcohol, increasing salt intake, eating small meals, exercise

Aneurysm

• A local dilation or outpouching of a vessel wall or cardiac chamber
• True aneurysms involve all three layers of the arterial wall
• False aneurysms are extravascular hematomas that communicate with the intravascular space
• Most common locations: thoracic or abdominal aorta, cerebrum
• Can lead to dissection or rupture
• Risk factors: genetics, smoking, diet, atherosclerosis, hypertension

Clinical Manifestations, Diagnosis, & Treatment of Aneurysms

• Clinical manifestations vary depending on location
• Diagnosis: ultrasound, CT, MRI, angiography
• Treatment:
  • If not ruptured: cessation of smoking, reduction of blood pressure and blood volume
  • If ruptured or still growing: surgical treatment

Arteriosclerosis/Atherosclerosis

• Arteriosclerosis: thickening and hardening of a vessel wall
• Atherosclerosis: a type of arteriosclerosis caused by lipid accumulation within the arterial wall, leading to plaque formation
• Leading cause of Coronary Artery Disease (CAD) and Cerebrovascular Disease
• Risk factors: smoking, hypertension, diabetes, high LDL cholesterol, low HDL cholesterol, autoimmunity
• Clinical manifestations: inadequate tissue perfusion, ischemia, infarction
• Diagnosis: history of risk factors, lipid panel, glucose reading, imaging
• Treatment: stabilizing/reversing plaques with medication, restoring blood flow if obstructed, lifestyle modifications

Peripheral Artery Disease (PAD)

• Atherosclerotic disease of arteries that perfuse the limbs, primarily the lower extremities
• Narrowed arteries reduce blood flow to the arms or legs
• Risk factors: similar to atherosclerosis, with major links to diabetes and smoking
• Clinical manifestations: leg numbness, weakness, pain when walking (claudication), no pulse or weak pulse in foot, shiny skin on legs, skin colour changes, slower toenail growth, coldness in the lower leg or foot, sores on toes, legs or feet that may lead to gangrene
• Diagnosis: history and physical focusing on atherosclerotic disease, ankle-brachial index (ABI)
• Treatment: similar to atherosclerosis, managing risk factors, medications, surgery

Myocardial Infarctions (MI)

• Infarction of the myocardium extending from the endocardium to the pericardium (full thickness)
• Causes ST elevation on ECG
• Clinical manifestations: sudden severe crushing chest pain radiating to the neck, jaw, shoulder, or left arm; back pain (more common in women), indigestion, nausea, vomiting, cool and clammy skin, increased HR and BP
• Can result in cardiac arrest due to ischemia, left ventricular dysfunction, and electrical instability
• Diagnosis: history and physical examination, ECG results, cardiac troponin elevations
• Treatment: aspirin, pain relief (nitroglycerin and morphine), oxygen, positioning in high Fowler's, telemetry monitoring, antithrombotics and anticoagulation, percutaneous coronary intervention (PCI) or thrombolytics if PCI is not available

Post Myocardial Infarction Care

• Cardiac monitoring
• Bed rest with gradual return to activities of daily living (ADLs)
• DVT prophylaxis
• Stool softeners
• Education: diet, caffeine intake, smoking cessation, exercise

Disorders of the Heart Wall

• Disorders of the pericardium: acute pericarditis, pericardial effusion
• Disorders of the myocardium: cardiomyopathy (dilated, hypertrophic, restrictive)
• Disorders of the endocardium: infective endocarditis, valve dysfunctions (stenosis and regurgitation)
• Other: heart failure (left-sided vs. right-sided), rheumatic fever and rheumatic heart disease

Acute Pericarditis

• Inflammation of the pericardium
• Most often idiopathic, but can be caused by viral infections
• Clinical manifestations: chest pain that worsens with respiratory movements or laying down, friction rub at the cardiac apex, ECG changes, new or worsening pericardial effusion
• Diagnosis: CT, US, MRI
• Treatment: anti-inflammatory drugs, colchicine, aspiration of pericardial effusion if present

Pericardial Effusion & Cardiac Tamponade

• Accumulation of fluid in the pericardial cavity
• Usually idiopathic, but can be caused by infection; ultimately indicates an underlying disorder
• Can lead to cardiac tamponade, a life-threatening condition where pressure on the heart prevents it from filling and pumping effectively
• Beck's Triad: low BP, distended jugular veins, muffled or diminished heart sounds
• Diagnosis: echocardiogram, CT
• Treatment: pericardiocentesis, pain management, potential surgery

Infective Endocarditis

• Inflammation of the endocardium
• Caused by bacteria, viruses, fungi, parasites
• Clinical manifestations: fever, new or changed cardiac murmur, petechial lesions, Osler nodes, Janeway lesions, weight loss, back pain, night sweats, heart failure
• Diagnosis: positive blood cultures, echocardiogram, C-reactive protein (CRP)
• Treatment: antibiotics

Cardiomyopathies

• Conditions that affect the heart muscle, preventing it from efficiently pumping blood
• Progresses over time
• Treatment can slow progression and improve quality of life