VA Special: Peripheral Vascular Disease

So your patient can’t walk to the mailbox anymore.  “Doc, I have to stop once I get there, and rest 5 minutes before I can move on back to the house.”
You check, and sure enough ABIs are <1 on both sides.
So you’ve made the diagnosis, now what? How can you improve your patient’s quality of life, and prevent loss of life and limb?
  • Lose your Kools: Get him to quit smoking.  It may not improve his walk distance, but it will prevent him from losing that leg and having the heart attack that’s coming.
  • Watch the numbers: These patients are a CV risk equivalent, so treat them that way. BP and Lipid goals are the same as they would be for someone with known CAD.
  • Stop the clot:  Take an aspirin. See above- mostly for prevention of CAD and CVD.  There has been a study (CAPRIE) to compare aspirin with Plavix, and Plavix may actually be more effective at preventing limb ischemia, however comes with higher risk. 
  • Make them feel better (oh yeah, that):  A few things that might improve their walk distance and quality of life:
    • Move it or Lose it.  There is a lot of evidence that exercise helps, but hard to operationalize, like most behavioral interventions.  But, certainly worth talking to your patient about a paced exercise program.  Simple- walk until it hurts, rest, walk some more.  Keep doing this- you will be able to walk farther each time.  
    • Cilostazol: inhibits platelet aggregation, vascular smooth muscle proliferation, and causes dilatation.  Improves walking distance, quality of life, and maybe even improves ABIs.
  • Warm up the OR:  Time for surgery if his function declines despite the above measures, or if he develops ulcer or other sign of limb ischemia.  

Here’s an article for more: Peripheral Vascular Disease NEJM 2007

Green

You  might have noticed a layer of green over all of Birmingham.  We’ve had a few days of warm weather, and that was enough to get everything blooming.  I have had more  than a few patients tell me that their allergies are worse in Bham than anywhere else.  You can thank the bowl that we sit in (also known as Jones Valley-a little Bham trivia bonus) for that bit of loveliness.
A common question is how to tell between allergic rhinitis and upper respiratory infections.  Both are really common at urgent care visits this time of year, and sometimes its useful to get an accurate diagnosis.

Allergic Rhinitis
Upper Respiratory Infection
Symptoms
Sneezing, rhinorrhea, nasal congestion and itching
Eye symptoms
No fever
Sore throat , nasal obstruction, rhinorrhea, sneezing
Fever, myalgias (particularly with influenza)
Progression
Everything at once, during the right time of year
Perennial allergies can go on year round (indoor allergens)
Usually sore throat first, then nasal sx, then cough
Exam
Pale, bluish mucosa (mouth and nose)
Red, swollen nasal mucosa and pharyngeal erythema
Differential diagnosis
URI
Vasomotor rhinitis
Rhinitis medicamentosa
Pertussis: prolonged severe coughing >2 weeks, not much other sx.
Influenza: high fever, myalgias
Associated Sx/ Prognosis
20-40% with asthma
Eventual acute sinusitis
Acute sinusitis: facial pain, purulent mucus

Rhinitis treatment is often similar to URI treatment, but there is some more data that treatments are beneficial with allergic rhinitis. Mainstay is nasal steroids and antihistamine.   Dr. Huddle would recommend chlorpheneramine (a first generation “sedating” antihistamine) over the second generation antihistamines. However, this is quite sedating, and may have more anticholinergic side effects. Be careful with your elderly patients, and particularly those prone to urinary retention.  Also consider decongestants- pseudoephedrine works better and is worth standing in line at the pharmacy window. 

Evidence based URI treatment is really non-existent. Nasal steroids and antihistamines are probably  less helpful.  Nasal ipatropium or nasal cromolyn may be useful, but are pricey.  I tend to tell people to get one of the myriad combo cold/sinus medicines in the drug store- they want a decongestant, something for aches/fever, and a cough suppressant or expectorant. Again, waiting in line for pseudoephedrine is worth it, particularly if they have a lot of sinus symptoms.

Here’s a link to the Annals of Internal Medicine In the Clinic article on allergic rhinitis
http://annals.org/article.aspx?articleid=734087