Vascular Disease Foundation - Fighting Vascular Disease... Improving Vascular Health.

Interactive Learning : Ask the Doctor

 

Ask the Doctor Live Chat Transcript - Tuesday, May 4, 2010

Dr. Heather Gornik


Department of Cardiovascular MedicineThe Cleveland Clinic FoundationCleveland, OH

Vascular Disease FoundationBoard of Directors

 

 

Dr. Gornik generously donated her time to answer our patients general questions about vascular disease. The below transcript details all of the questions asked by our participants as well as her answers.

Moderator- VDF: Welcome and thank you for joining us today for VDF's Live Chat! I would like to introduce Dr. Heather Gornik from the Cleveland Clinic who will be taking your questions today. You may now go ahead and send Dr. Gornik your questions.


Kari U: Dear Dr. Gornik, Could you explain what Ankle brachial index is and why it is performed?

Speaker- Dr. Gornik: Hi Kari! Great question. The ABI is the basic test used to diagnose arterial disease in the legs. It is done by measuring blood pressures at the ankle and in the arms (basically 1 pressure measured in each of the four limbs). The ABI is the ratio of blood pressure at the ankle to the arm. In a healthy person wtihout arterial disease, the ABI is greater than 1. If it is much less than 1, this suggests PAD.


Lynn W: I have FMD in both renals, both iliacs (with aneurysms on both), both carotids and both vertebrals. Is that unusual?

Speaker- Dr. Gornik: Hello Lynn W. This is a general vascular disease chat, and folks at home may not too very much about "FMD". FMD is the term for fibromuscular dysplasia which is another cause of artery problems that is not typical clogged arteries or atherosclerosis. FMD usually presents in adult patients, and usually in women and can present with vascular disease in the kidney arteries, carotid arteries, vertebral, and also the iliac arteries. The vessels you describe are pretty commonly involved.


akamomma: I have had heart and vascular disease for 7 years. Now my legs and feet are swelling mostly when sitting so much they feel like they will burst open and the bones in the feet hurt.

Dr. Heather Gornik: Dear akamomma - Thanks for your question. Leg swelling can be due to a lot of things, including problems with the veins, blood clots, medications, and also problems with the arteries in some cases. I would recommend that you see your doctor for a careful physical examination and review.


Irene: How is the testing for PAD done and what are the risk factors?

Speaker- Dr. Gornik: Risk factors for PAD are: older age, tobacco smoking, diabetes (most important risk factors), but also high cholesterol, high blood pressure. The simplest way to test for PAD is with the ankle-brachial index/ABI test that was described above.


Ronni H: My Mom is having some swelling issues on her ankles, she has FMD like I do in both carotids, brain, etc. I am taking her to our primary tomorrow. She also wears support hose, yuck. Would a cardiologist be good at this time?

Speaker- Dr. Gornik:
Hi Ronni! Leg swelling, as above, is a common problem, but in addition to vascular causes, could also be a symptom of heart problems, especially in an older patient. Perhaps start by querying your mom's PCP tomorrow as to whether there could be some heart failure present (usually physical exam can distinguish vascular leg swelling from heart failure or medication related leg swelling.). Good luck.


Moderator- VDF: This next question was e-mailed to us ahead of time: Dr. Gornik-- Unfortunately, I can't be with you on "live chat".  What else can I do besides "walk" to stave off bi-aorta-femoral surgery which I avoid like the plague.  I walk an hour daily, but unfortunately I have significant pain in my right leg--I do the "stop and go" routine with my walker which at my tender age of almost 86 is a "safety" measure, and also I can sit for a few seconds when I need to. Thanks for being a "vascular disease" doctor.  These are scarce in this area of the Central Coast in California.

Speaker- Dr. Gornik: In response to question email ahead of time for the 85 year old patient with PAD and right leg pain: I am afraid it's hard to tell without seeing you in the office, examining you, and reviewing you information, how to best tread your PAD. I think the stop and go routine does give you some exercise, which is very good. You could consider trying a medication for PAD, such as cilostazol, and you may wish to discuss this with your doctor. Also important to be sure all of your cardiovascular risk factors, such as cholesterol, smoking (hope you don't), blood pressure, and use of anti-platelet agents (aspirin or clopidogrel) to prevent clotting events is tended to. Good luck. Check out http://www.aboutpad.org or http://www.vdf.org for more information on PAD.


Moderator- VDF: This next question was also e-mailed to us ahead of time by Carol: I have microvascular ischemic disease, old lacunar infarcts, vascular dementia, blocked PACs and a calcified aorta. What are some of the possible side-effects or resulting complications from these conditions (i.e. could they lead to a stroke, PAD, etc)?

Speaker- Dr. Gornik: Dear Carol. It sounds like you have many vascular problems, as the calcification of the aorta and the lacunar infarcts may all be related to atherosclerosis. You may very well have PAD if you have calcium of the aorta --- this is a sign of PAD. I would suggest that you discuss this with your doctor and get an ABI test if she/he thinks appropriate.


akamomma: Once you have PAD does fish oil help any? What other than diet and walking can you do to open or prevent more closings when the preventable factors have been taken?

Speaker- Dr. Gornik: Great questions about PAD (one of my favorite topics along with FMD of course!!). There has been some small studies on fish oils and claudication which are inconclusive as to whether they help leg symptoms. Fish oil may help with raising good cholesterol and lowering triglycerides. Other things I would recommend are statin therapy to achieve a goal LDL target of between 70-100 mg/dL, keeping your blood pressure well controlled, taking medication to prevent blood clots (aspirin or clopidogrel), keeping blood sugar controlled if you are diabetic. Other than that, DO NOT SMOKE, exercise moderately, maintain a healthy body weight. 

akamomma: Is it ok to get massages if you have PAD/CAD?

Speaker- Dr. Gornik: In general, Swedish or European traditional massage is fine for PAD patients. Other types of massage are likely OK too, would of course let your massotherapist known that you have some vascular disease.


Bethel: I don't have any vascular problems (to my knowledge), but am on my feet a lot with work. Is it ok for me to wear compression stockings/pantyhose anyway?

Speaker- Dr. Gornik: Hi Bethel. Great question about compression. You absolutely defniitely can wear them. You just need a low level compression, such as 8-12 mm Hg or 15-20 mm Hg that you can buy without a prescription at a medical supply store or some drugstores. I know many a medical resident and nurse (including myself) who wears these!


Kari U: Dr. Gornik, could you explain to me what essential hypertension is? Does genetics play a role in essential hypertension?

Speaker- Dr. Gornik: Kari asked a great question on essential hypertension. Essential hypertension is high blood pressure that is not due to a reversible cause (such as medications, FMD, atherosclerosis of the renal arteries, endocrine abnormalities, for example). Essential high blood pressure is very common as we age. There is much interest in identifying genetic factors associated wtih esssential hypertension, but my sense of things is that this is still work in progress and there are no clear culprit genes yet identified.


John W: Hi Dr. Gornik! I have a question about DVT - how accurate are ultrasounds at discovering clots?

Speaker- Dr. Gornik: Hi John. Great question. Compression duplex ultrasound is highly accurate at diagnosing blood clots in patients who have leg symptoms that are consistent with DVT (leg pain, swelling). Accuracy is higher for the veins in the thigh than the veins below the knee. Accuracy also varies depending on the quality of equipment used and whether the study is performed in an experienced and accredited lab. In a high quality lab for a patient with leg symptoms, accuracy for diagnosing DVT is 90-95%... but not quite 100%.

John W:Thanks Dr. G! I recently got an ultrasound (four months ago) and it came back negative for blood clots. However, I'm experiencing really bad leg pain in just one leg (behind my calf/up my thigh) and have had no recent trauma. I know I have a few risk factors for DVT (from taking your web site risk assesment) but don't know if that last ultrasound is good enough for me to rule out DVT? I guess part of my question is how short/or long does it take to develop a clot?

Speaker- Dr. Gornik: An ultrasound is not 100% accurate, as we discussed, and also with worsening symptoms, I definitely think it's time for a recheck. The differential diagnosis for what you describe would include artery and vein problems, arthritis, bursitis, Baker's cyst, to name a few. Would recommend seeing a vascular specialist in your area.


Moderator- VDF: This next question was e-mailed to us ahead of time: Many adult patients with disease's such as FMD are put on aspirin therapy. But what about the pediatric patients with significant disease? Is the current recommendation to stay on this therapy for life? Are there any studies on blood thinning therapy on peds patients?

Speaker- Dr. Gornik: In response to the question regarding pediatric patients and evidence to support aspirin use, I'm afraid there is little clinical trial data, and decisions are generally made based on clinical experience and assessment of the patient. As many of you may know, a number of us physicians who take care of patients with FMD are working on a registry of patients that will hopefully include some young patients.


akamomma: Is crossing your legs bad for someone with PAD? Also, if a female artery is to small to be stinted can or should it be grafted in the leg?

Speaker- Dr. Gornik:
Akamomma: 1. I don't know any literature that says that leg crossing is bad for PAD. Sometimes in patients with significant vein disease, leg crossing can worsening leg swelling. 2. Women do tend to have smaller arteries than men, but angioplasty procedures can and have been performed successfully in women. In addition to vessel size, other important factors are the length of the blockage and the location of the blockage.


Senka: Hi Dr. Gornik. Is resveratrol beneficial for artery health?

Speaker- Dr. Gornik:
Hi Senka. Resveratrol as I understand is substance that is rich in flavonoids. It is an antioxidant and may have effects on the vascular endothelium. I'm not familiar with much specific research on this drug and established vascular disease, but I know this field in general is one that is very active and would expect some data in the next few years.


Irene: How accurate is the D-Dimer blood test for showing if a blood clot is in the calf?

Speaker- Dr. Gornik: Hi Irene. In re: D-Dimer, I don't have numbers for sens/spec for calf vs. proximal leg DVT off top of my head, however, I would say that for d-dimer testing, it's a great test to "rule out" a DVT with a high negative predictive value. The negative predictive value for a low d-dimer is > 90-95%. I suspect it performs a little bit less at ruling out small clots in the calf.
In regards to d-dimer, it’s  important to note that while a normal d-dimer can be helpful to "rule out" DVT, a high d-dimer can be caused by lots of things, not just DVT, and you still need an ultrasound to diagnose DVT.


Kari U: Is it normal for renal peak systolic velocities to be different in each kidney? Do velocities in children differ from those of an adult?

Speaker- Dr. Gornik: Kari, regarding vascular ultrasound, very common to have variable values in kidneys and also depending on patient positioning (lying flat versus on the side), how well the kidney arteries are seen, angles the tech uses to sample the renal arteries, etc. Not so important what the exact numbers are, rather broad categoreis (e.g., < 200 cms/sec or > 200 cm/sec). Yes, pediatric patients tend to have high velocities in all vessels in the vascular lab.


Ronni H: I take both Plavix and 81 mg aspirin in the morning and 40mg Nexium at night. So far no one has told me to stop both and I am wondering about my bleeding factor. Is this something your primary can and/or should order? If I stop the Nexium, heartburn comes right back.

Speaker- Dr. Gornik: As you allude to, but all may not be aware, there has been an interaction identified with medications such as Nexium and Plavix, making the Plavix less effective. In some cases, particularly if a patient has cardiac stenting, physicians may recommend not using Nexium and finding an alternative. Each case is different. There are tests that can be done to check if the aspirin and Plavix are thinning the blood properly (aggregation studies), but in most cases these are not needed.


Moderator- VDF: These next questions were also e-mailed to us about swimming and DVT:
1. I read that swimming is a good exercise for this vein problem, but without anything on the legs? If you wore stockings or bandages into a pool, the chlorine would wreck them very quickly, I would think.
2. I have DVT/PE and am fearful of exercising. I wear a knee high compression garment on my left leg and like to swim. Do I swim with the garment on or do I remove it and is that safe?

Speaker- Dr. Gornik:
Two great questions re: swimming and compression. Agree swimming is great exercise for overall health and also for the legs. Most patients take their stockings off to prevent chlorine damage, but I also have 1 patient who likes to swim with his stocking on, and this has worked for years!


Bethel: Dr. Gornik, I have some questions about varicose veins. My mother has what doctor's have called "spider" veins in her legs, where they are very dark and can be seen through the skin. Are they different than varicose veins? If so, could the spider veins lead to varicose veins, and lastly what are some of the 'dangers' of varicose veins that I should tell her to keep an eye out for?

Speaker- Dr. Gornik:Bethel, regarding spider veins --- these are also called telangiectasias. These are the very tiny purple veins that are skinny and often the size of a pencil eraser. Reticular veins are a little bit bigger, blue, and may be what you are describing. These are mild versions of venous disease. They do not always progress to large varicose veins and do not progress in most cases. Nonetheless, they can be cosmetically bothersome. Compression stockings might actually prevent these from getting worse. If the veins are cosmetically bothersome to your mom, she could see a vascular specialist for evaluation, as there are some treatments available (such as sclerotherapy or laser therapy).

Moderator- VDF: Hi Bethel, for more information about varicose veins, you may visit our Web site: http://www.vdf.org/diseaseinfo/varicose/ or contact us at info@vdf.org for a free educational brochure on varicose veins.


Kari U: What is your opinion on the use of l-arginine for patients with FMD vs Atherosclerosis?

Kari U: It seems that all studies done on vascular disease have been on men, have there been any on women? Do you think this will change in the future?

Speaker- Dr. Gornik: 1. re: l-arginine and vascular disease, I remain very skeptical. Dr. John Cooke published a trial of L-arginine in PAD patients that actually showed adverse outcomes with L-arginine.
2. In terms of vascular disease and women, I agree we need more research studies focused on women and all types of vascular disease. I know AHA is working on an initiative related to PAD in women and VDF and venous disease coalition is doing some work on DVTs and women!


Moderator- VDF: Thanks to everyone for joining us today, we appreciate your time! Thank you Dr. Gornik for taking the time to answer everyone's questions. We wish you a great day!

Disclaimer

The material provided on VDF's Web site and Live Ask the Doctor chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.