Page 80 - Medicine and Surgery

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76 Chapter 2: Cardiovascular system

Age under 55 years Age over 55 years
and non-Black or Black

A: ACE inhibitor or angiotensin receptor blocker
STEP 1 A (or B) C or D B: β-Blocker
C: Calcium channel blocker
D: Diuretic (thiazide)
STEP 2 A (or B) and C or D Combination of B and D increases the risk of new
onset diabetes.

STEP 3 A (or B) and C and D

STEP 4 Add either α-blocker, spironolactone or other diuretic

Figure 2.15 Treatment algorithm for hypertension.

In larger arteries fibrosis of the muscular or elastic
Table 2.11 Comparison of arterial with venous ulcers
media weakens the wall and the vessel lumen enlarges.
Arterial Venous
This can lead to ‘unfolding of the aorta’ and aortic
Position Tips of toes and Gaiter area
regurgitation.
pressure areas
In smaller arteries and arterioles, the predominant Tenderness Very tender Painful at first but

effects are smooth muscle hypertrophy and intimal settles down
thickeningformingconcentriclayersofcollagen,caus- Temperature Surrounding area is Warm
ing luminal narrowing. cold
Size Any size Any size or shape
Edge Punched out edge Sloping purple colour
Clinical features Base Grey/yellow Covered in pink
Chronic peripheral arterial disease in the lower limbs sloughing tissue granulation tissue
causes intermittent cramp-like pain in the muscles dur-
ingexerciseandisrelievedbyrest–so-calledintermittent
claudication. With increasing severity of ischaemia the Hypertension may be the underlying cause or may be
secondary to renal artery stenosis caused by atheroma.
claudication distance falls. Severe claudication may be
The underlying processes are common to the entire
associated with non-healing leg ulcers that progress to
arterial tree, therefore associated symptoms and signs
gangrene. Eventually the patient develops pain at rest
should be elicited, e.g. chest pain, transient ischaemic
and this indicates critical arterial insufficiency and is a
attacks, impotence (due to internal iliac artery disease).
surgical emergency.
On examination, signs include cool, dry skin with loss
of hair, thready or absent pulses in the affected areas Complications
and a lack of venous filling. There is often discoloura- Gangrene and loss of limbs. Diabetics are at particular
tion, i.e. pallor or a dark hue due to slow circulation. risk due to diabetic neuropathy, which allows ulcera-
In advanced cases there is ulceration (see Table 2.11) tion, trauma and infection to progress without pain.
or even gangrene. There may be aneurysms (e.g. ab- Acute arterial occlusion due to thrombus or emboli
dominal or popliteal) and bruits should be listened for. from the heart or a larger vessel may cause pain, pallor,