File Name: history taking and physical examination of cardiovascular system filetype .zip
The Addenda and Questions and Answers companion documents of these guidelines are available at: www.
Guidelines & Clinical Documents
The Addenda and Questions and Answers companion documents of these guidelines are available at: www. Current background information and detailed discussion of the data for these Guidelines can be found in ESC CardioMed - Section 49 Peripheral arterial diseases. Aggressive detection and Management of the Extension of atherothrombosis in high Risk coronary patients In comparison with standard of Care for coronary Atherosclerosis.
Best Endovascular vs. Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition.
Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional s in consultation with the patient and caregiver as appropriate.
Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. A critical evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk—benefit ratio.
The level of evidence and the strength of the recommendation of particular management options were weighed and graded according to predefined scales, as outlined in Tables 1 and 2. Table 1 Classes of recommendations. The experts of the writing and reviewing panels provided declaration of interest forms for all relationships that might be perceived as real or potential sources of conflicts of interest. Any changes in declarations of interest that arise during the writing period were notified to the ESC and updated.
The Committee is also responsible for the endorsement process of these Guidelines. After appropriate revisions the Guidelines are approved by all the experts involved in the Task Force. The Guidelines were developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating. The task of developing ESC Guidelines in collaboration with ESVS also includes the creation of educational tools and implementation programmes for the recommendations including condensed pocket guideline versions, summary slides, booklets with essential messages, summary cards for non-specialists and an electronic version for digital applications smartphones, etc.
These versions are abridged and thus, if needed, one should always refer to the full text version, which is freely available via the ESC Website and hosted on the EHJ Website. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations.
Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of guidelines, disseminating them and implementing them into clinical practice. Health professionals are encouraged to take the ESC Guidelines developed in collaboration with ESVS fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies.
It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. Meanwhile, the ESVS released on a regular basis several guidelines documents on the management of specific localizations of arterial diseases. Both societies emphasized the need for multidisciplinary management of these patients. When the decision was made to update these guidelines, it appeared obvious that a combination of efforts from both societies would provide the most comprehensive single document, providing updated guidelines on peripheral arterial diseases PADs for clinicians.
It is of the outmost importance that every cardiologist should be sensitive in regard to the diagnosis and management of patients with PADs, as many of them are seen and managed for concomitant cardiac conditions. In the ESC Guidelines, a specific chapter was dedicated to patients with combined coronary and peripheral artery diseases, as they mostly share the same aetiology and risk factors. In these guidelines, the Task Force made a step forward and proposed a new chapter on other cardiac conditions frequently encountered among patients with PADs.
Also, as the options for the use and combination of antithrombotic drugs have increased, a specific chapter has been dedicated to their use in the management of PADs. The current background information and detailed discussion of the data for the following section of these Guidelines can be found in ESC CardioMed. Indeed, other peripheral localizations, including the carotid and vertebral, upper extremities, mesenteric and renal arteries, are also frequently affected, mainly by atherosclerosis, and complete the family of PADs.
Regarding the carotid and vertebral arteries, this document covers only their extracranial segments, as specialists other than cardiologists and vascular surgeons often manage intracranial arterial diseases. The Task Force has decided to address only PADs secondary to atherosclerosis, with a few exceptions in specific areas where non-atherosclerotic diseases are a frequent differential diagnosis e.
For other cases, readers should always bear in mind the possibility for non-atherosclerotic conditions and refer to specific documents.
Readers are also invited to refer to the Web addenda for further information. Indeed, while stroke is acknowledged as a serious condition with significant burden throughout Europe, other PADs can be as lethal and disabling. Major efforts are still necessary to sensitize healthcare providers, decision makers and the general population about the need for earlier and more efficient prevention and management strategies for the 40 million individuals of our continent affected by PADs.
General recommendations on the management of patients with peripheral arterial diseases. Key messages Overall, the risk of different localizations of PADs increases sharply with age and with exposure to major cardiovascular CV risk factors, including smoking, hypertension, dyslipidaemia and diabetes. Other risk factors are still under investigation. The strength of association between each risk factor and each vascular territory is variable, but all the major risk factors should be screened and considered.
When a vascular territory is affected by atherosclerosis, not only is the corresponding organ endangered [e. Each vascular territory affected by atherosclerosis can be considered as marker of CV risk. The epidemiology of different patterns of PADs is presented in the Web addenda 3.
See Web addenda 3. Atherosclerosis is often generalized. Patients affected at one site are overall at risk for fatal and non-fatal CV events. Beyond the risk of cerebrovascular events, patients with CAD are also at risk for myocardial infarction MI and cardiac death. Many studies have shown an increased risk of mortality, CV mortality and morbidity MI, stroke in patients with symptomatic or asymptomatic LEAD, even after adjustment for conventional risk factors.
All these data emphasize the importance of general CV prevention beyond the management of the disease related to a specific site of atherosclerosis. Key messages Thorough clinical history and physical examination are key steps in PADs management. The management of PADs includes all interventions to address specific arterial symptoms as well as general CV risk prevention.
Best medical therapy includes CV risk factor management, including optimal pharmacological therapy as well as non-pharmacological measures such as smoking cessation, healthy diet, weight loss and regular physical exercise.
Personal and family clinical history should always be assessed. Lifestyle habits, dietary patterns, walking performances and physical activity need to be systematically interrogated.
Physical activity should be assessed. They may be useful for determining the impairment level and selection of appropriate care. Although physical examination alone is of relatively poor sensitivity and reproducibility, a systematic approach is mandatory see Web Table 2. Beyond their diagnostic importance, clinical signs have a prognostic value. Individuals with carotid bruits have twice the risk of MI and CV death as compared with those without.
It is also a strong marker of generalized atherosclerosis and CV risk see Table 3. Good training is mandatory. Table 3 The Ankle-Brachial Index. Duplex ultrasound DUS is often a first step in the vascular workup both for screening and diagnosis. DUS includes B-mode echography, pulsed-wave, continuous, colour and power Doppler modalities to detect and localize vascular lesions and quantify their extent and severity through velocity criteria.
More recent techniques, such as flow imaging or live three-dimensional 3D echography, as well as the use of ultrasound contrast agents, further improve DUS performances, although their use is still limited. DUS can detect subclinical artery disease e. Digital subtraction angiography DSA was considered the standard reference in vascular imaging.
Given its invasive character and risk of complications, it has been mostly replaced by other less invasive methods except for below-the-knee arterial disease. It may be used in the case of discrepancy between non-invasive imaging tools. Multidetector computed tomography angiography CTA has a short examination time with reduced motion and respiration artefacts while imaging vessels and organs. Advantages of CTA include rapid non-invasive acquisition, wide availability, high resolution and 3D reformatting.
The drawbacks of CTA include the lack of functional and haemodynamic data, exposure to radiation and the use of iodinated contrast agents, which should be limited in the case of CKD, with precautions in case of allergies. Nephrotoxicity can be limited by minimizing contrast agent volume and ensuring adequate hydration before and after imaging. The benefit of acetyl-cysteine to limit nephrotoxicity is uncertain.
MRA is used for peripheral artery imaging using contrast i. These latter techniques have inferior resolution and are susceptible to artefacts, limiting their interpretation. They are a valuable alternative for use in patients with mild to moderate CKD. Compared with CTA, MRA does not need iodine contrast and has higher soft tissue resolution; however, motion artefacts are more frequent and contraindications include pacemakers and implantable cardioverter defibrillators ICDs [except magnetic resonance imaging MRI -conditional and compatible pacemakers, ICDs and leads], claustrophobia and severe CKD.
In the latter case, the risk of nephrogenic systemic fibrosis following gadolinium administration should not be underestimated. Endovascular stents are not evaluable by MRI. The therapeutic approach to patients with PADs includes two aspects.
The first is to address specific symptoms of any localization and the risk related to a specific lesion. This is addressed in the next sections. The second aspect of management in these patients is related to their increased risk of any CV event see section 3. General CV prevention is of the utmost importance and management should be multidisciplinary. Best medical therapy BMT includes CV risk factor management, including best pharmacological therapy, as well as non-pharmacological measures such as smoking cessation, healthy diet, weight loss and regular physical exercise.
In diabetic patients, optimal glucose level control should be obtained as recommended. A body of evidence supports the benefits of smoking cessation in reducing CV events and mortality, especially in patients with cerebrovascular disease and LEAD. Further results are awaited.
Antiplatelet agents are used for secondary prevention of CV events in patients with symptomatic PADs. The evidence is mostly available in patients with LEAD and cerebrovascular disease see chapter 5. Importantly, beta-blockers are not contraindicated in patients with LEAD, as they do not alter walking capacity in patients with mild to moderate LEAD.
Recommendations in patients with peripheral arterial diseases: best medical therapy. Evidence is not available for all sites. When evidence is available, recommendations specific for the vascular site are presented in corresponding sections. Key messages Antiplatelet therapy is indicated in all patients with carotid artery stenosis irrespective of clinical symptoms and revascularization.
Clopidogrel is the preferred antiplatelet drug in LEAD patients. Chronic anticoagulation therapy is given only if there is a concomitant indication and may be combined with SAPT when there is a recent revascularization procedure.
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The patient was referred 1 year before to InCor with a history of progressive dyspnea triggered by less than ordinary activities, lower-extremity edema, and abdominal enlargement. He sought medical care due to the abdominal enlargement, which was diagnosed as an ascites. He denied chest pain, hospitalization due to myocardial infarction or stroke, hypertension, dyslipidemia, and diabetes. The patient was a previous smoker and had stopped smoking at the age of 37 years. He was also an alcoholic and reported drinking alcohol for the last time 1 year before.