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**Veins\ ** Vein Structure Thinner\ Less elastic walls Less muscle fiber Valves Types\ Superficial Veins\ Deep Veins\ Perforating Veins or Communicating Veins 4 **Factors that Affect Venous Blood Flow** Gravity Skeletal muscle contractions Thoracic pressure Abdominal pressure Ar...

**Veins\ ** Vein Structure Thinner\ Less elastic walls Less muscle fiber Valves Types\ Superficial Veins\ Deep Veins\ Perforating Veins or Communicating Veins 4 **Factors that Affect Venous Blood Flow** Gravity Skeletal muscle contractions Thoracic pressure Abdominal pressure Arterial flow Right atrial pressure Vein valves\ 5\ 6 **Vein Valves** Tiny bicuspid valves\ More numerous in distal leg\ Decrease proximally\ Serve as a reservoir of blood -- contain 65% blood volume Provide unidirectional flow\ 7 **Venous Thrombus vs. Venous Embolism** 8\ 9 10 11 2/23/25 1 7 8 9 10 11 **Deep Vein Thrombosis (DVT)** **DVT** **DVT Risk Factors** Age\ Travel\ Recurrent venous thromboembolism Pregnancy and Postpartum\ Malignancies\ Inherited hypercoagulable states- which are? **DVT Risk Factors** Medical Illnesses\ Acute hospitalization\ Nursing home confinement Myocardial Infarction\ Stroke\ Congestive heart failure\ Respiratory insufficiency\ Spinal cord injury\ Septic shock\ \ Nephrotic syndrome\ Major trauma\ Orthopedic procedures\ Abdominal pain\ Central venous cannulation Pacemaker insertion\ Oral Contraceptives\ Hormone Replacement Therapy (HRT) Chemotherapeutic Agents\ \ **DVT Clinical Manifestations** **DVT Clinical Manifestations** Phlegmasia alba dolens milk leg 12 13 14 15 1 2 13 14 15 **Post-Phlebitic/Post-Thrombotic Syndrome** Chronic swelling Stasis dermatitis Venous ulcers\ 16 **Arterial vs. Venous Disease** 17 **Pulmonary Embolism (PE)** Occlusion of a portion of pulmonary vascular bed Etiology\ Thrombus\ Embolus Tissue fragment\ Fat emboli\ Air bubble\ Source of clot\ Commonly from the deep veins in thigh -- why? 18 **Pulmonary Embolism (PE)** 19 **Pulmonary Embolism** 20 **Pulmonary Embolism** Prevention of venous stasis Bed exercises, frequent position changes Early ambulation\ Pneumatic calf compression Prophylactic anticoagulation: unfractionated heparin low--molecular-weight heparin Warfarin Vena cava filter\ Prevent emboli from reaching lungs Permanent or retrievable Phlegmasia alba dolens milk leg Phlegmasia cerulea dolens massive leg swelling & cyanosis 21 Prevent emboli from reaching lungs Permanent or retrievable Treatment Oxygen & hemodynamic stabilization with fluids Anticoagulation and/or fibrinolytic agent (streptokinase) Percutaneous or surgical embolectomy 21 **Think About It\...\ **A person has a pulmonary embolism. What will the nurse find upon assessment? 1.Positive PPD skin test, night sweats, weight loss 2.Productive cough, fever, pain behind the sternum\ 3.Sudden pleuritic chest pain, dyspnea, unexplained anxiety 4.Barrel chest, hyperresonant chest sounds, very little sputum 22 **Pulmonary Artery Hypertension** Resting PAP (mean) \>25 mmHg Note: Normal PAP= 5-10mmHg Several types Most common from underlying disease - respiratory disease or hypoxemia Causes\ Pulmonary artery vasoconstriction\ Elevated left ventricular pressure\ Increased blood flow through the pulmonary circulation Obliteration or obstruction of the vascular bed\ Active constriction of the vascular bed produced by hypoxemia or acidosis\ Right heart failure 23 **Pulmonary Artery Hypertension** Pathophysiologic changes Overproduction of vasoconstrictors\ Decreased production of vasodilators\ Remodeling\ Resistance to pulmonary artery blood flow, thus increasing the pressure in the pulmonary arteries 24 Resistance to pulmonary artery blood flow, thus increasing the pressure in the pulmonary arteries Workload of the right ventricle increases\ Right ventricular hypertrophy\ May be followed by failure and eventually death! 24 **Pulmonary Artery Hypertension** Clinical manifestations Masked by primary pulmonary or cardiovascular disease\ First indication: Chest x-ray showing enlarged pulmonary arteries & right heart border or an electrocardiogram that shows right ventricular hypertrophy Treatment Oxygen\ Diuretics\ Anticoagulants\ Avoidance of contributing factors air travel, decongestant medications, nonsteroidal antiinflammatory medications, pregnancy & tobacco 25 **Pulmonary Artery Hypertension** Treatment Prostacyclin analogs (iloprost)\ Endothelin receptor antagonists (bosentan, ambrisentan) Phosphodiesterase-5 inhibitors\ Lung transplantation Secondary pulmonary artery hypertension\ Treat the primary disorder\ Once pulmonary hypertension has persisted long enough for hypertrophy to develop, it is *no longer reversible* Supplemental oxygen reverses hypoxic vasoconstriction 26 **Cor Pulmonale\ ** AKA Pulmonary heart disease Right ventricular enlargement Hypertrophy\ Dilation 27 28 26 Hypertrophy Dilation\ Caused by primary or secondary pulmonary hypertension Creates chronic pressure overload in the right ventricle\ **Cor Pulmonale Think About It\...** A patient has right ventricular enlargement secondary to pulmonary hypertension. Which of the following would be the most likely diagnosis?\ 4. A.Acute bronchitis B.Pulmonary embolism\ C.Cor pulmonale\ D.Pulmonary thromboembolism **Varicose Veins** **Varicose Veins** **Varicose Vein Treatment: Radiofrequency Ablation** **Varicose Veins** Pre-procedure Post-procedure at 1 week \* **Chronic Venous Insufficiency** Inadequate venous return over a *long* period of time Results from Varicose veins Vein valve incompetence Contributes to Venous stasis ulcers **Chronic Venous Insufficiency** Swelling\ Pain\ Pigmentation Ulcers 35 27 28 29 30 31 32 33 1 2 34 34 Pigmentation Ulcers 35 **Lymphatic System** Lymphatic fluid Consists of water & small amounts of dissolved proteins Primarily albumin\ Parallels arterial & venous network Right lymphatic duct Drains lymph from right arm and right side of head, thorax Thoracic duct Receives lymph from other areas of body 36 **Lymphatic System\ **37 **Compression Stockings** Pressure\ 15 -- 20 mm Hg 20- 30mmHg 30 -- 40 mm Hg 38 **Compression Wraps** 39 **Compression Sleeve** Manage Lymphedema Provide higher pressures Expensive 40 **Compression Pump** Sequential or Intermittent Hospital or home use 41 **Pharmacologic Therapy** **Peripheral Artery Disease\ ** Peripheral artery disease is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs Caused by atherosclerosis Atheros- gruel (necrotic debris) Sclerosis- hard (fibrotic cap) Peripheral Vascular Disease https://www.youtube.com/watch?v=rTbIazck7rk) by Osmosis (https://open.osmosis.org/) is licensed under CC-BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/ 3 **Manifestations of PAD** 4 5 **Peripheral Artery Disease** Risk factors: Smoking\ Diabetes\ Hypertension\ Hyperlipidemia 6 **Peripheral Artery Disease** 7 **Peripheral Artery Disease** Intermittent Claudication Comes on with activity Relieved with rest Cramping\ Vice like Burning, tearing Sharp Shooting Rest Pain 8 9 Present at rest\ Feels better when foot is dangled- why? 2/23/25 1 10 Feels better when foot is dangled- why? 8 **Peripheral Artery Disease** 9 **Peripheral Artery Disease\ ** Any indications of prior vascular procedures? Scar Tissue Digital amputations 10 **Peripheral Artery Disease** 11 **Diagnostic Testing** 12 **Ankle Brachial Index\ ** ABI= Ankle-Branchial Index \ Ankle systolic pressure\* Brachial systolic pressure \*Use the highest pressure 13 **Ankle Brachial Index** ABI: 0.90-1.30 = Normal\ ABI: \< 0.90 = Abnormal\ ABI: \>1.30 = Non=compressible vessel 14 **Ankle Brachial Index** 15 **Diagnostic Testing** Aterial Duplex AKA Arterial Ultrasound with Duplex Ultrasound test that uses high frequency sound waves (ultrasound) and a series of blood pressure cuffs to show and measure blood flow in the arteries of the arms and legs 16 **Arterial Duplex/Ultrasound\ **Indications for Arterial Duplex studies are to screen, monitor, or diagnose:\ Abdominal aneurysm Arterial occlusion\ Blood clot such as DVT Carotid occlusive disease 17 Blood clot such as DVT Carotid occlusive disease Varicose veins\ Venous insufficiency 17 **Peripheral Arterial Disease Management** 18 **Arteriogram\ **19 **Arteriogram Imaging** 20 **Arteriogram\ ** Abdominal Arteriogram with Run-off Non-invasive procedure that takes x-ray images of the blood vessels Evaluates for aneurysm, stenosis, or occlusion Contrast medium is injected through an artery (commonly the right femoral artery) The contrast dye then flows from the abdominal aorta to the arteries of the bilateral lower extremities \ 21 **Arteriogram with Run-Off** 22 **Peripheral Artery Disease** Procedure Options Angioplasty\ Stents\ Atheroectomy Selection of procedure depends on: Short focal lesions\ Large vessels\ Stenosis vs. occlusion Single segment disease Good run off 23 **PAD- Mangement** 24 **PAD-Surgical Management** Vascular Bypass Peripheral vascular bypass (PVB) refers to the surgical revision of 23 24\ Vascular Bypass Peripheral vascular bypass (PVB) refers to the surgical revision of blood flow to restore perfusion distal to an occluded or otherwise disrupted arterial segment. PVB procedures can involve any of the arteries excluding those in the heart or the brain. These open surgical procedures are typically done by vascular surgeons, cardiologists, or interventional radiologists 25 **PAD-Management** 26 **PAD-Management** 27 **PAD- Management\ ** Arteries that may require bypass in the abdomen are: Abdominal Aorta Common Iliac External Iliac 28 **PAD-Management** Peripheral Vascular Bypass High risk surgery carrying a 5% risk of an acute coronary event Patient teachings include: Signs and symptoms of failed bypass\ Taking medication as prescribed (statin, aspirin, clopidogrel Stop smoking\ Keep blood sugars and blood pressure under control Importance of physical activity\ Weight reduction Nursing Judgement: Evaluate surgical site for s/s of infection or impaired wound healing Palpate pulses, monitor distal pulses Understand patients baseline cognitive status- evaluate for TIA or stroke if neuro status changes **Integumentary Overview** Other functions Regulates body temperature.\ Is involved in the production of vitamin D.\ Is involved in immune surveillance.\ Provides important protective functions and pleasurable sensations from touch and pressure receptors.\ Skin's microorganisms protect against pathologic bacteria. \ 4 **Layers of the Skin** 5 **Layers of the Skin: Epidermal Layers** 6 **Layers of the Skin: Epidermis** Epidermis Keratinocytes Keratin Melanocytes Melanin Vitiligo: Autoimmune-related loss of melanocytes; depigmentation of patches of skin Langerhans cells\ Present processed antigen to T cells Merkel cells\ Function as slowly adapting mechanoreceptors \ 7 **Layers of the Skin: Dermis** 8 **Layers of the Skin: Dermis** Dermis Fibroblasts\ Secrete connective tissue matrix and collagen. Mast cells 2/23/25 1 8 Secrete connective tissue matrix and collagen. Mast cells Release histamine. Macrophages Are phagocytic immune cells.\ Histiocytes: Are in loose connective tissue; phagocytize pigments and the debris of inflammation. 9 **Layers of the Skin: Subcutaneous Layer** Subcutaneous layer Fat cells or adipocytes and connective tissue Dermal collagen is continuous with the subcutaneous collagen. 10 **Layers of the Skin: Dermal Appendages** Dermal appendages Nails Hair Hair follicles Sebaceous glands Secrete sebum. Eccrine sweat glands Thermoregulate and cool the body through evaporation. Apocrine sweat glands Has very limited proven function. 11 **Layers of the Skin: Blood Supply & Innervations** 12 **Layers of the Skin: Anatomy** 13 **Think About It\...\ **Dermal appendages that are important in body temperature regulation are\ 1.Sebaceous glands. 2.eccrine sweat glands. 3.apocrine sweat glands. 4.papillary capillaries.\ 14 14 **Aging and Skin Integrity\ ** Integumentary system reflects changes from genetic and environmental factors.\ Becomes thinner, drier, wrinkled, less elastic, and demonstrates changes in pigmentation.\ Number of capillary loops shorten and decrease. Melanocytes and Langerhans cells are fewer. Sebaceous, eccrine, and apocrine glands atrophy. 15 **Aging and Skin Integrity** Other changes\ Temperature regulation is compromised.\ Pressure and touch receptors and free nerve endings decrease in number and reduce sensory perception.\ Many of the protective functions of the skin decrease. Infection increases, and wound healing is delayed. 16 **Clinical Manifestations of Skin Dysfunction** Primary lesions Macule Flat, circumscribed area that is a change in the color of the skin; measures less than 1 cm in diameter. Papule Elevated, firm, and circumscribed area; measures less than 1 cm in diameter. Patch Flat, nonpalpable, and irregular-shaped macule; measures more than 1 cm in diameter. Plaque Elevated, firm, and rough lesion with a flat top surface greater than 1 cm in diameter. \ 17 **Clinical Manifestations** **of Skin Dysfunction** Primary lesions Wheal Elevated, irregular-shaped area of cutaneous edema; is solid and 17 Wheal Elevated, irregular-shaped area of cutaneous edema; is solid and transient; diameter is varied. Nodule Elevated, firm, and circumscribed lesion; is deeper in the dermis than a papule; measures 1--2 cm in diameter. Tumor Elevated, solid lesion; may be clearly demarcated; is deeper in the dermis; measures greater than 2 cm in diameter. Vesicle Elevated, circumscribed, and superficial lesion; does not extend into the dermis; is filled with serous fluid; measures less than 1 cm in diameter. 18\ 19 **Clinical Manifestations** **of Skin Dysfunction** Primary lesions Bulla Vesicle that measures greater than 1 cm in diameter. Pustule Elevated, superficial lesion; is similar to a vesicle but filled with purulent fluid. Cyst\ Elevated, circumscribed, and encapsulated lesion; is in dermis or subcutaneous layer and filled with liquid or semisolid material. Telangiectasia Irregular red lines; are produced by capillary dilation. 20 **Clinical Manifestations of Skin Dysfunction** Secondary lesions Scale Heaped up, keratinized cells; has flaky skin and an irregular shape; can be thick or thin and dry or oily; varies in size. Lichenification Rough, thickened epidermis; is secondary to persistent rubbing, itching, or skin irritation. 21 Rough, thickened epidermis; is secondary to persistent rubbing, itching, or skin irritation. Keloid Irregular shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; is caused by excessive collagen formation during healing. \ 21 **Clinical Manifestations** **of Skin Dysfunction** Secondary lesions Scar Thin-to-thick fibrous tissue; replaces normal skin after an injury or laceration to the dermis. Excoriation\ Loss of the epidermis; is a linear, hollowed-out, and crusted area. Fissure Linear crack or break from the epidermis to the dermis; may be moist or dry. Erosion Loss of a part of the epidermis; area is depressed, moist, and glistening; follows a rupture of a vesicle or bulla. \ 22 **Clinical Manifestations** **of Skin Dysfunction** Secondary lesions Ulcer Loss of epidermis and dermis; is concave, and varies in size. Atrophy Thinning of the skin surface; and a loss of skin markings occurs. 23 **Clinical Manifestations of Skin Dysfunction** Pressure injury\ Is the result of any unrelieved pressure on the skin, causing underlying tissue damage. Shearing forces\ Friction 24 Shearing forces\ Friction\ Moisture\ Occlude capillary blood flow with resulting ischemia and necrosis Decubitus injury: Results when an individual lies or sits in one position for a long time. 24 **Clinical Manifestations of Skin Dysfunction** Pressure injury Stage I Nonblanchable erythema of intact skin Stage II Partial-thickness skin loss, involving the epidermis or dermis Stage III Full-thickness skin loss, involving damage or loss of the subcutaneous tissue Stage IV\ Full-thickness skin loss with damage to muscle, bone, or supporting structures 25 **Clinical Manifestations\ of Skin Dysfunction: Pressure Injury Progression** 26 **Clinical Manifestations of Skin Dysfunction** Pressure injury Deep-tissue pressure injury: Localized in an area of deep red, purple, or maroon discolored intact skin or a blood-filled blister caused by underlying soft tissue damage from pressure and/or shearing Unstageable: Full-thickness tissue loss with the base of the ulcer covered by slough or eschar, or both, in the wound bed Sacrum, heels, ischia, and greater trochanters: Most common sites Predicting ulcers: Braden scale\ 27 **Clinical Manifestations of Skin Dysfunction** Pressure injury 27 **of Skin Dysfunction** Pressure injury Treatments Skin assessment with repositioning and turning\ Use of pressure reduction surfaces and specialty beds Elimination of incontinence, moisture, and drainage Maintenance of nutrition, fluid balance, oxygenation\ Superficial ulcers: Covered with flat, moisture-retaining dressings that cannot wrinkle Pressure relief, debridement of dead tissue, opening of deep pockets for drainage, construction of skin flaps for large, deep ulcers. Negative pressure wound healing for advanced stages Infection: Topical and systemic agents, and pain control 28\ 29 **Clinical Manifestations** **of Skin Dysfunction** Keloids\ Elevated, rounded, and firm\ Clawlike margins that extend beyond the original site Hypertrophic scars: Elevated erythematous fibrous lesions that do not expand beyond the injury border\ Excessive collagen formation and abnormal fibroblast activity Common in darkly pigmented skin types Treatment: Intralesional corticosteroids and interferon, 5-FU, cryotherapy, radiotherapy, surgical and laser procedures, silicone gel sheeting, onion-extract preparations 30 **Clinical Manifestations\ of Skin Dysfunction: Keloid** 31 **Think About It\...\ **Which of the following is NOT a factor in keloid formation? 1.\ A.Light skin\ B.Burn trauma\ C.Foreign material in skin\ D.Poorly aligned wound tension\ 32 D.Poorly aligned wound tension 32 **Clinical Manifestations of Skin Dysfunction** Pruritus Itching Most common symptom of primary skin disorders Acute (mosquito bite) vs. chronic\ Localized or generalized or migratory\ Itch: Specific unmyelinated C-nerve fibers Scratching: Can cause skin trauma, infection, and scarring. Itch response: Can be modulated by the central nervous system (CNS)\ 33 **Clinical Manifestations** **of Skin Dysfunction** Pruritus\ Neuropathic itch: Related to any pathologic condition along an afferent pathway\ Psychogenic itch: Psychological disorders Treatment: Both topical and systemic therapies 34 **Disorders of the Skin** Inflammatory disorders Dermatitis or eczema: Most common\ Various types of dermatitis\ Generally characterized by pruritus, lesions with indistinct borders, and epidermal changes Chronic eczema: Thickened, leathery, and hyperpigmented skin from recurrent irritation and scratching 35 **Stasis Dermatitis** Usually occurs in legs Results from:\ venous stasis\ edema\ vascular trauma\ chronic venous insufficiency Clinical Manifestations chronic venous insufficiency Clinical Manifestations Erythema\ Pruritus\ Scaling\ Petechiae Pigmentation changes Ulcerations 36 **Stasis Dermatitis** Treatment Elevate legs as often as possible -- why? Avoid wearing tight clothes\ Avoid prolonged standing -- why?\ If infected: Administer antibiotics Topical creams Systemic agents\ If chronic lesions with ulceration formation: Apply moist dressings\ Use external compression garments Vein ablation surgery \ 37 **Wound Care Products** 38 **Psoriasis\ ** Chronic, relapsing, proliferative skin disorder Immune-mediated\ Scaly, thick, silvery, elevated lesions Usually on scalp, elbows, or knees\ Dermal and epidermal thickening\ 39 **Bacterial Infections** Folliculitis Infection of hair follicles\ Common cause - *Staphylococcus aureus* Furuncles 39 Furuncles\ Commonly called "boils"\ Inflammation of hair follicles\ Develop from folliculitis\ Spread through follicular wall into surrounding dermis Common cause *- Staphylococcus aureus* 40 **Bacterial Infections** Necrotizing fasciitis Rare, rapidly spreading inflammation starting in the fascia, muscles, and subcutaneous fat with subsequent necrosis of the overlying skin Treatment: Antibiotics & surgical débridement 41 **Viral Infections\ ** 8 types of herpes simplex viruses Herpes zoster Causes shingles Develops later - after chickenpox\ Virus is dormant\ Pain & paresthesia localized to affected dermatomes Vesicles erupt along a facial, cervical, or thoracic lumbar dermatome 42 43 **Scleroderma\ ** Hardening (sclerosis) of the skin\ Autoimmune disorder; associated with several antibodies Can progress to internal organs (kidney, heart, GI, lungs, etc) 50% death rate in 5 years\ Lesions have large amounts of collagen deposits with inflammation, vascular changes & capillary dilation Skin is hard, hypopigmented, taut, tightly connected to underlying tissue 44 tissue 44 **Scleroderma\ ** Lesions typically seen on face, hands, neck & upper chest Facial skin becomes very tight\ Fingers become tapered & flexed\ Nails & fingertips can be "lost" due to atrophy\ Note: may affect mouth; such that the mouth may not open completely 45 **Cold Injury\ ** Skin injury caused by exposure to extreme cold Commonly affects fingers, toes, ears, nose, cheeks Associated with "burning reaction" results from alternating cycles of vasoconstriction (pallor & pain) and vasodilation (redness & discomfort) Release of inflammatory mediators Prostaglandins\ Thromboxanes\ Bradykinin Histamine\ Can have reperfusion injury 46 **Cold Injury** Treatment\ Cover affected areas with other body surfaces & warm clothing Do not rub or massage area\ Immerse in a warm water bath (40° to 42° C \[104° to 107.6° F\]) 47 48 until frozen tissue is thawed\ Give Ibuprophen to inhibit prostaglandins\ Apply topical inhibitor of thromboxane -- aloe vera\ Administer thrombolytic therapy within 24 hrs. to reduce incidence of amputation\ Analgesics for pain\ Gentle cleansing only\ No pressure on skin during healing\ Note: should delay removal/amputation of necrotic tissue until a No pressure on skin during healing Note: should delay removal/amputation of necrotic tissue until a clear line of demarcation is established \ 47 **Cold Injury** 48 **Frost bite\ ** Classified by depth of injury -first, second, third & fourth degree; similar to ?\ Tissues freeze & form ice crystals below 28o F\ Progresses from distal to proximal\ Potentially reversible **Overview of Cardiovascular Diseases** 3 **Diseases of the Veins** Varicose veins Vein in which blood has pooled\ Distortion, leakage, increased intravascular hydrostatic pressure, and inflammation of veins\ Cause: incompetent valves, venous obstruction, muscle pump dysfunction, or combination of these. Altered ratio of prostacyclin to thromboxane A2 with potential for clotting, increased fibroblast growth factor, and increased transforming growth factor B in vein walls 4 **Diseases of the Veins** 5 **Diseases of the Veins\ ** Deep venous thrombosis (DVT) Thrombosis: clot Detached thrombus: thromboembolus; can lead to pulmonary emboli Clot in a large vein\ Obstruction of venous flow leading to increased venous pressure Factors: Virchow triad Venous stasis\ Venous intimal damage Hypercoagulable states Postthrombotic syndrome 6 **Diseases of the Veins** DVT Prevention is crucial.\ Mobilization soon after surgery, illness, injury\ Prophylactic low--molecular-weight heparin or direct thrombin inhibitors\ Tests: D-dimer and Doppler Treatment Low--molecular-weight heparin 2/23/25 1 7 7 Treatment\ Low--molecular-weight heparin\ Direct thrombin inhibitors\ Aspirin therapy\ Catheter directed thrombolytic therapy Pharmacomechanical treatment **Diseases of the Veins** Superior vena cava (SVC) syndrome Progressive occlusion of the SVC that leads to venous distention in the upper extremities and head Leading cause: nonsmall cell lung cancer, small cell lung cancer, lymphoma Clinical symptoms\ Edema\ Venous distention of face, neck, trunk, upper extremities\ Cyanosis\ Dyspnea, dysphagia, hoarseness, stridor, cough, and chest pain CNS changes\ Respiratory distress Treatment\ Radiation and chemotherapy **Diseases of the Arteries** Hypertension\ Orthostatic (postural) hypotension Aneurysm\ Thrombus formation\ Embolism\ Peripheral arterial diseases Atherosclerosis\ Peripheral artery disease Coronary artery disease Myocardial ischemia\ Acute coronary syndromes **Hypertension Hypertension** 8 9 10 11 1 2 9 10 **Hypertension** 11 **Hypertension** Risk factors Positive family history\ Advancing age\ Gender: female \>70 years of age; male \