Critical Analysis Essay

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Non-Coronary Artery Disease (VIII)

Peripheral Artery Disease: Pathophysiology, Diagnosis, and Treatment
Francisco J. Serrano Hernando and Antonio Martín Conejero
Servicio de Cirugía Vascular, Hospital Clínico San Carlos, Madrid, Spain

Peripheral artery disease is one of the most prevalent conditions, and it frequently coexists with vascular disease in other parts of the body. Early diagnosis is important for improving the patient’s quality of life and for reducing the risk of serious secondary vascular events such as acute myocardial infraction (AMI) or stroke. The best noninvasive measure for identifying the presence of occlusive arterial disease is the ankle-brachial index, which can also be used to indicate the prognosis of the affected extremity and to predict the likelihood of AMI during follow-up. Intermittent claudication in the lower limbs is the most common clinical presentation. The presence of critical ischemia (ie, with rest pain or trophic changes) indicates the need for prompt revascularization because of the high risk of limb amputation. The more proximal the affected arterial segment, the better the outcome of the procedure. Endovascular treatment is usually reserved for lesions affecting multiple segments. It gives poorer results in occluded arteries. In extensive disease, conventional surgery is usually the best option.

Enfermedad arterial periférica: aspectos fisiopatológicos, clínicos y terapéuticos
La enfermedad arterial periférica (EAP) es una de las afecciones más prevalentes y es habitual la coexistencia con enfermedad vascular en otras localizaciones. El diagnóstico precoz es importante para poder mejorar la calidad de vida del paciente y reducir el riesgo de eventos secundarios mayores, como el infarto agudo de miocardio (IAM) o el ictus. El mejor test no invasivo para diagnosticar la presencia de EAP es el índice tobillo-brazo que, además, tiene valor pronóstico para la extremidad afectada y para el desarrollo de IAM durante el seguimiento. La claudicación intermitente de los miembros inferiores es la forma más frecuente de presentación clínica. La presencia de isquemia crítica (dolor en reposo o lesiones tróficas) implica la necesidad de tratamiento de revascularización precoz, por el elevado riesgo de pérdida de la extremidad. El pronóstico del procedimiento realizado es mejor cuanto más proximal sea el sector arterial afectado. El tratamiento endovascular se reserva habitualmente para las lesiones más segmentarias y tiene peor resultado en las oclusiones arteriales. En lesiones más extensas, la cirugía convencional suele ser la mejor alternativa. Palabras clave: Enfermedad arterial periférica. Índice tobillo-brazo. Revascularización de miembros inferiores. Riesgo cardiovascular.

Key words: Peripheral artery disease. Ankle-brachial index. Lower limb revascularization. Cardiovascular risk.

EPIDEMIOLOGY Peripheral artery disease (PAD) affects 15%-20% of persons older than 70 years of age,1-3 though its prevalence is probably even greater if we include asymptomatic persons. The diagnostic test most used to check the asymptomatic population is the ankle-brachial index (ABI). In asymptomatic persons, an ABI 95% and a specificity approaching 100% as compared with arteriography.4 Comparison of patients with PAD versus age-matched controls shows an incidence of cardiovascular death of 0.5% in controls and 2.5% in the patients with PAD. Additionally, in persons with known coronary artery disease, the presence of PAD raises the risk of death by 25% in comparison with controls. It is thus important to examine for PAD, even in asymptomatic patients, in order to control the risk factors as soon as possible and reduce mortality.4 CARDIOVASCULAR RISK FACTORS AND PERIPHERAL ARTERY DISEASE The major risk factors for PAD have been determined from large epidemiologic studies and are concordant with the risk factors for cerebrovascular disease and ischemic
Rev Esp Cardiol.