Atherosclerosis: Diagnosis

00:00 Let's talk about the diagnosis. The diagnosis, again, is usually by history, as we talked about in the basic series. If the patient has no symptoms—doesn't have claudication—you may not detect it unless you were to do some noninvasive tests, such as ultrasound, to show that there's a lot of atherosclerosis already developing. Two factors are important for making the diagnosis: first of all, classification of definite intermittent claudication or an atypical form of intermittent claudication. And the University of Edinburgh in Scotland has created a very excellent questionnaire that's often used by doctors who do vascular medicine, peripheral vascular disease, and it's pretty accurate in predicting, from the patient's responses, whether there's atherosclerosis in the peripheral arteries that are causing symptoms. We've already talked about the ankle–brachial index blood pressure, where one takes blood pressure in the arm and the leg, and when there's decreased pressure in the leg compared to the arm, that tells you that there's obstruction to blood flow to the leg. It's a very simple noninvasive test done in the office all the time.

01:19 Here's some of the questions from the Edinburgh Questionnaire. You can see the first question: "Do you get pain or discomfort in your legs when you walk?" And if you said yes, "Does the pain ever begin when you're standing still or sitting?" If the answer "The pain is there all the time," it's usually not intermittent claudication. And it's particularly brought on if you walk uphill or in a hurry, as you see in question number 3. Continuing with the Edinburgh Questionnaire, it says, "Do you get pain when you walk at an ordinary pace on level ground?" If you only get it when you're climbing a hill, that's less severe than if you get it when you're walking on level ground. It usually means more severe atherosclerosis if you get it walking on level ground. And then, of course, "Does the pain go away when you stand still?" And, of course, "Where do you get it?" You should get it in the calf or the buttock when it's related to poor blood flow to those muscles. So you can see how the questionnaire really reflects what we talked about in the basic series.

02:23 A good history... This directs a good history, tells you something about the likelihood that the patient has atherosclerotic peripheral vascular disease. We already talked about the ankle–brachial index also. It's determined with a small Doppler device for finding the brachial artery and for finding the two foot arteries: the posterior tibial artery and the dorsalis pedis artery. And then use the blood pressure cuff technique to measure the blood pressure in the leg and in the arm. It should be about normal or even a little higher in the leg. When it's below the arm level in the leg, then that is a positive for obstruction—almost always atherosclerotic. And the greater the difference—the more the blood pressure is decreased in the leg or in the foot—then the greater is the obstruction.

03:18 We can actually tell Does the patient have mild arterial disease, moderate arterial disease, or severe arterial disease? We can also do, as we've talked about before, ultrasound, in which we actually can see obstruction. Here, you can see, the red is flow. And you can see, suddenly the flow ceases. And in the next picture, the blood vessel is open and empty. And this is because no flow is detected, and the little waveforms at the bottom—the little triangular forms there—show you that there's very sluggish blood flow in that blood vessel. It's a very abnormal pattern for the Doppler. This is a very easily done noninvasive test, very commonly done. Let's talk a little bit about therapy. Well,