Intermittent claudication (IC) refers to lower extremity skeletal muscle pain that occurs during exercise. IC presents when there is insufficient oxygen delivery to meet the metabolic requirements of the skeletal muscles. IC is a common manifestation of peripheral arterial disease (PAD), which includes atherosclerotic stenosis of arteries in the extremities, hip, and buttock (Hamburg & Creager, 2017).
The diagnosis of IC involves taking a thorough patient history, conducting a physical examination with an emphasis on the cardiovascular system. The key feature of IC is that the muscle discomfort is reproducible, with pain typically occurring during physical activity and subsides after a period of rest. The severity of pain can sometimes correlate with the degree of stenosis or blockage of the arteries(Meru, Mittra, Thyagarajan, & Chugh, 2016). In addition to smoking, additional risk factors that would be revealed during collecting history include hypertension, dyslipidemias, obesity, metabolic syndrome, and diabetes mellitus. Non-modifiable risk factors include age, male gender, family history, and congenital predisposition. Other Investigational risk factors that I would look at include alcohol use, a history of getting radiation, poor renal function. Physical examination of these patients may show evidence of arterial insufficiency where the affected limb may feel cool and have diminished pulses. If the Ankle-Brachial index measures less than 0.9, they may have some degree of vascular disease(Hamburg & Creager, 2017).
In addition to a history and physical, diagnostic tests include a complete blood count with platelet count, fasting glucose or A1C, fasting lipid profile, serum creatinine, and urinalysis for glucosuria and proteinuria, and a c-reactive protein. Common imaging modalities include duplex vascular ultrasound, computed tomography angiography, and magnetic resonance angiography, which will help determine the location of the diseased vasculature (Hamburg & Creager, 2017). The goals of treatment are to prevent the progression of vascular disease and cardiovascular complications and to improve exercise performance, functional status, and quality of life. Therapy includes risk-factor modification, particularly smoking cessation, decreasing LDLs, and physical therapy, with revascularization generally being reserved for patients with incapacitating disease (Meru et al., 2016).
Hamburg, N. M., & Creager, M. A. (2017). Pathophysiology of Intermittent Claudication in Peripheral Artery Disease. Circulation journal : official journal of the Japanese Circulation Society, 81(3), 281–289. https://doi.org/10.1253/circj.CJ-16-1286
Meru, A. V., Mittra, S., Thyagarajan, B., & Chugh, A. (2016). Intermittent claudication: an overview. Atherosclerosis, 187(2), 221–237. https://doi.org/10.1016/j.atherosclerosis.2005.11.027
Atrial fibrillation is the most common arrhythmia. The incidence increases markedly with advancing age. Thus, with the growing proportion of elderly individuals, atrial fibrillation will come to represent a significant medical and socioeconomic problem. The consequences of atrial fibrillation have the greatest impact. The risk of thromboembolism is well known; other outcomes of atrial fibrillation are less well recognized, such as its relationship with dementia, depression and death. Such consequences are responsible for diminished quality of life and considerable economic cost and providers should thoroughly explain this to their patients. Atrial fibrillation is characterized by rapid and disorganized atrial activity. The ventricles react irregularly, and may contract rapidly or slowly depending on the health of the conduction system. Clinical symptoms are varied, including palpitations, syncope, dizziness or embolic events. Atrial fibrillation may be paroxysmal, persistent or chronic, and a number of attacks are asymptomatic. Suspicion or confirmation of atrial fibrillation necessitates investigation and, as far as possible, appropriate treatment of underlying causes such as hypertension, diabetes mellitus, hypoxia, hyperthyroidism and congestive heart failure. In the evaluation of atrial fibrillation, cardiac exploration is invaluable, including electrocardiogram (ECG) and echocardiography, with the aim of detecting cardiac abnormalities and directing management (Aronow, 2019).
In elderly patients, the management of atrial fibrillation varies; it requires an individual approach, which largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. This management is essentially based on pharmacological treatment, but there are also nonpharmacological options. Two alternatives are possible: restoration and maintenance of sinus rhythm, or control of ventricular rate, leaving the atria in arrhythmia. Pharmacological options include antiarrhythmic drugs, such as class III agents, beta-blockers and class IC agents. These drugs have some adverse effects, and careful monitoring is necessary. The nonpharmacological approach to atrial fibrillation includes external or internal direct-current cardioversion and new methods, such as catheter ablation of specific foci, an evolving science that has been shown to be successful in a very select group of atrial fibrillation patients. Another serious challenge in the management of chronic atrial fibrillation in older individuals is the prevention of stroke, its primary outcome, by choosing an appropriate antithrombotic treatment (aspirin or warfarin). Several risk-stratification schemes have been validated and may be helpful to determine the best antithrombotic choice in individual elderly patients (Aronow, 2019).
Aronow W. S. (2019). Management of atrial fibrillation in the elderly. Journal of Cardiology, 100(1), 3–24. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/19182738/
Heart failure is a condition in which the pumping mechanism of the heart fails and can no longer supply the needed demand. If this condition is not identified and appropriately managed in the early stages, it can be detrimental. According to (van der Meer et al., 2019) the condition can be secondary to malfunctions of the pericardium, myocardium, endocardium, or heart valves. They made further mention that heart failure is a highly prevalent, progressive condition associated with substantial morbidity and mortality. They added that the bulk of the patients present with symptoms consistent with impaired LV myocardial function.
There are multiple ways in which a patient with heart failure can present, among these, there are common presenting features. (Jameson et al., 2018) mentioned that a primary presentation is fatigue and shortness of breath. Other than these, patients can also present with orthopnea, sudden nocturnal dyspnea, and Cheyne-stokes respiration. They also mentioned that on physical examination, there may be labored breathing and difficulty lying flat for examination. The presence of JVD provides an appraisal of the atrial pressure. Lung sounds may exhibit crackles, due to the presence of fluid transudation and rales which if present in patients without any other underlying lung condition is specific for heart failure. An S3 is most often present and S4, but the latter usually present with diastolic heart failure. Jameson et al. further mention that patients may present with hepatomegaly and affirms that peripheral edema is an important sign of heart failure. In severe cases of heart failure, there may be a presence of weight loss instead of gain and cachexia.
Diagnosis of this condition can be partially made with the presenting signs and symptoms. According to (Jameson et al., 2018) further laboratory workup could include a CBC, BMP/CMP, Lipid Panel, TSH. An important test in the diagnosis and management of the disease is the natriuretic peptide which consists of two, they are BNP and NT-proBNP. According to (Chaplin, 2019) the National Institute for Health and Care Excellence (NICE) recently changed their recommendation to now only measuring the NT-proBNP, wherein previously there was a choice between BNP and NT-proBNP. Further workup would include an EKG, this is to assess for arrhythmias, assess for LV hypertrophy, and previous MI. Normal findings would exclude an LV systolic dysfunction. CXR to assess for cardiomegaly, Lung vasculature, and other underlying findings that may be causing the presenting symptoms. An important finding on CXR is pulmonary edema, regarding this, Jameson et al. state that this finding may not be present in those with chronic heart failure. As stated by (Jameson et al., 2018) a practical test for the evaluation of left ventricular size, function, and visualization of other malfunctioning heart structures such as diseased heart valves and wall motion abnormalities is the 2D echocardiogram. This can also be used in further management of the disease. Assessment of the EF % with this exam will assist in the differentiation between Diastolic and Systolic heart failure among other factors. (Cacciapuoti, 2019) Mentioned that Diastolic Heart Failure also known as Heart Failure with Preserved Ejection Fraction (HFpEF) is differentiated from Systolic Heart Failure also known as Heart Failure with Reduced Ejection Fraction (HFrEF) by the percent of ejection fraction (EF). A EF of > or = 50% is HFpEF and a level < 50% is HFrEF.
Cacciapuoti, F. (2019, January 14). The Dilemma of Diastolic Heart Failure [American Journal of Cardiology and Cardiovascular diseases]. Onomy science. Retrieved December 3, 2020, from https://www.onomyscience.com/admin/uploads/20200113124939.pdf
Chaplin, S. (2019). Chronic heart failure in adults: Diagnosis and management. Prescriber, 30(1), 16–18. Retrieved December 2, 2020, from https://doi.org/10.1002/psb.1730
Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (2018). Harrison’s Principle Of Internal Medicine (20th ed.,Vol. 2). McGraw Hill Education.
van der Meer, P., Gaggin, H. K., & Dec, G. (2019). Acc/aha versus esc guidelines on heart failure. Journal of the American College of Cardiology, 73(21), 2756–2768. Retrieved December 2, 2020, from https://doi.org/10.1016/j.jacc.2019.03.478