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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2821_Библиотеки_им_академика_М_И_Перельмана
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Emery P, Breedveld FC, Dougados M, et al. Early referral recommendation for newly diagnosed rheumatoid arthritis:
evidencebaseddevelopmentofaclinicalguide.AnnRheumDis.2002;61:290–297.
MahdiH,FisherBA,KällbergH,et al.Specificinteractionbetweengenotype,smokingandautoimmunitytocitrullinated
alpha-enolaseintheetiologyofrheumatoidarthritis.NatGenet.2009;41(12):1319–1324.
Rantapää-Dahlqvist S, deJongBA, Berglin E, et al.Antibodies against cyclic citrullinated peptide and IgA rheumatoid
factorpredictthedevelopmentofrheumatoidarthritis.ArthritisRheum.2003;48(10):2741–2749.
AtzeniF,TurielM,CaporaliR,etal.Theeffectofpharmacologicaltherapyonthecardiovascularsystemofpatientswith
systemicrheumaticdiseases.AutoimmunRev.2010;9(12):835–930.
Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the treatment of
rheumatoidarthritis.ArthritisCareRes(Hobok en).2016;68:1–25.
KhanMA.HLA-B27anditspathogenicrole.JClinRheumatol.2008;14(1):50–52.
D’AgostinoMA,Said-NahalR,Hacquard-BouderC,etal.Assessmentofperipheralenthesitisinthespondylarthropathies
byultrasonographycombinedwithpowerDoppler:across-sectionalstudy.ArthritisRheum.2003;48(2):523–533.
D’AgostinoMA,AegerterP,BecharaK,etal.Howtodiagnosespondyloarthritisearly?Accuracyofperipheralenthesitis
detectionbypowerDopplerultrasonography.AnnRheumDis.2011;70(8):1433–1440.
SieperJ,RudwaleitM,BaraliakosX,etal.TheAssessmentofSpondyloArthritisinternationalSociety(ASAS)handbook:a
guidetoassessspondyloarthritis.AnnRheumDis.2009;68Suppl2:ii1–ii44.
TaylorW,GladmanD,HelliwellP, etal;CASPARStudyGroup.Classificationcriteriaforpsoriaticarthritis:development
ofnewcriteriafromalargeinternationalstudy.ArthritisRheum.2006;54(8):2665–2673.
ThieleRG,SchlesingerN.Diagnosisofgoutbyultrasound.Rheumatology(Oxford).2007;46(7):1116–1121.
Filippou G, Filippucci E, Tardella M, et al. Extent and distribution of CPP deposits in patients affected by calcium
pyrophosphatedihydratedepositiondisease:anultrasonographicstudy.AnnRheumDis.2013;72(11):1836–1839.
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T
hefeetcontainapproximatelyonequarterofthebody’stotalbones,witheachfoothaving
morethan30joints;100tendons,muscles,andligaments;andcountlessnerves,arteries,
andveins.Ourfeetandlowerextremitycan,inaddition,serveasawindowtotherestofthe
body and tell us a greatdeal about the presence or status of concomitant known or occult
systemic disease. Such systemic pathologies include neurologic, rheumatologic, orthopedic,
diabetic, and other endocrine, dermatologic, neoplastic, gastrointestinal, renal, and
psychological disorders. Many cardiovascular pathologies are closely related to those
involving the lower extremityincluding generalizedatherosclerosis,coronaryarterydisease
(CAD), arrhythmias, valvular heart disease, pulmonary disease, cardiac neoplasms, and
cardiomyopathies.Eachofthemhasuniquepedalsignsandsymptomsthatmayinitiallybring
theconditiontotheattentionofahealthcareproviderandmustinturnbecomanaged.
PERIPHERALARTERYDISEASE
Peripheral artery disease (PAD) refers to varied pathologies such as atherosclerosis and
vasculitisinvolvingtheperipheralcirculationseparatefromcardiac andcranialarteriesand
affects more than 8.5 million Americans and 200 million people worldwide.1 It occurs
commonlyinconjunctionwithCAD.Unfortunately,itisalltoofrequentlyunderdiagnosedand
untreated,2resultinginpotentiallyavoidablelowerlimbamputations,myocardialinfarctions,
and cerebral vascular accidents. Individuals with symptoms and signs of PAD have an
increasedriskforheartdiseaseandstroke3andmustbeencouragedtoseekmedicalattention
forevaluationandrulingoutofassociatedcardiovasculardisease.AccordingtotheAmerican
HeartAssociation,individualswithPADhavefourtofivetimes’greaterriskformyocardial
infarctionandacerebralvascularaccidentbecauseatherosclerosisisadiseaseoftheentire
cardiovascularsystem.NearlyaquarterofindividualswithclaudicationduetoPADwilldie
within 5 years because of a myocardial infarction or stroke. Interestingly, patients with
documentedPADhavea1yearhigherincidenceoffatalmyocardialinfarctionthanthosewith
preexistingCAD.
4
Appropriately, the patient diagnosed with PAD should be screened for CAD, and,
conversely, thepatientdiagnosed withCADshould bescreened for PAD.Kowantor etal.
5
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Table3-1.
reportedthat26%of1,340patientswithdocumentedCADpresentedwithundiagnosedPAD.
Arterial fattyplaquebuildupinvessels ofpatientswith atherosclerosis reduces theflow of
bloodinthelowerextremitiesandfeet,andatacriticalthreshold,ischemic-relatedsignsand
symptomswillbegintomanifest.Progressionofuntreateddiseasemayultimatelyreachapoint
ofcriticallimbischemia,whichalltoofrequentlyresultsinlossoflimborultimatelylife.The
lower extremity signs and symptoms are generally subtle at first but eventually become
obvious and ultimately debilitating. Unfortunately, the underlying systemic atherosclerotic
diseasemaybepreviouslyunrecognized,resultinginseriouscomorbiditiesintheheart,brain,
kidney, andotherinternal organs. Well-establishedrisk factorsforCADand strokesuch as
family history, hyperlipidemia, hypertension,diabetes, and smoking likewise increase one’s
riskforPAD.
ThemainsymptomsofPADmayinclude,inproportiontodisease severity,claudication,
fatigue, achiness, burning, and discomfort in the buttocks, thighs, and calves. Erectile
dysfunctionmayalsoresult.Thesesymptomsfirstappearduringextensivewalkingorexercise,
anddisappearafterseveralminutesofrest.AsthePADprogresses,symptomswilloccurwith
less exercise or activity and with an earlier onset. Claudication pain may be likened to
symptomsofanginaseeninpatientswithCAD.Themostcommonlyutilizedsystemtoclassify
intermittentclaudicationandlowerextremityischemiaistheRutherfordclassification,which
isdividedintosevenstages(seeTable3-1).6Lowerextremity ischemialeading toextremity
numbnessorintensepainatrestwithultimatetissuenecrosishasbeeninformallyreferredtoas
aheartattackofthefoot.Thesesymptomsfrequentlyintensifywithelevationofthelimb,andit
is not uncommon to observe the patient maintain the affected limb(s) in a position of
dependency. The presence of pain at rest can be classified as a situation of critical limb
ischemia where some type of intervention is urgently or emergently necessary to prevent
necrosisoftissueandpotentiallossoflimb.
Clinical findings consistent with PAD include decreased posterior tibial (PT) and/or
dorsalis pedis (DP) blood pressure, weak or nonpalpable pulses, arterial bruits, increased
capillary fill time, dermal atrophy, coolness of the skin, increase in temperature gradient,
lowerextremityhairloss,palloronelevation,orcyanosis.Theend-stagecriticallyischemia
limb will frequently manifest dependent edema and a ruborous-like hue resulting from the
chronicallydilatedmicrovascularstructures. Thedevelopmentofnonhealing ulcersor frank
gangreneisfurtherevidenceofcriticallimbischemiarequiringurgentoremergentintervention
(Fig.3-1).
RutherfordClassificationListingStagesofPeripheralArterial
Disease
Stage Findings
0 Asymptomatic
1 Mildclaudication
2 Moderateclaudication—Thedistancethatdelineatesmild,moderate,andsevereclaudicationisnot
specified
3 Severeclaudication
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4 Restpain
5 Ischemiculcerationnotexceedingulcerofthedigitsofthefoot
6 Severeischemiculcersorfrankgangrene
NoninvasivetestingforPADincludestheankle-brachialindex(ABI),whichisapainless
office-based examination that compares the ratio of blood pressure in the distal lower
extremitytothatintheupperextremity.Thisinexpensivetesttakesonlyafewminutesandcan
easilybe performed bythe health careprofessional.Guidelines oftheAmericanCollegeof
CardiologyandAmericanHeartAssociationrecommenditsusefor screeningindividualsat
highrisksuchasthoseover65yearsoldorover50yearsoldindiabeticsorsmokers.4The
appropriate method to measure ABI is to have the patient lying flat, with Doppler
measurementsobtainedfollowing5to10minutesofrest.7Cuffwidthshouldbeatleast40%
of limb circumference. Systolic blood pressure (SBP) is measured in each arm and ankle
includingtheDPandPTarteries.ABIofeachlegisthencalculatedbydividingthehigherof
thePTorDPpressurebythehigheroftherightorleftarmSBP(Fig.3-2).
FIGURE3-1.Techniquetomeasureankle-brachialindex.
Normally, theanklebloodpressureisatleast90%oftheupperextremitypressure;with
severearterialnarrowing,theanklepressuremaybereducedtolessthan50%.LowABIhas
beenestablishedasanindependentriskfactorofCAD.
8–10
Conversely,Allisonetal.11showed
that an abnormally high ABI (whichis due to inelasticity ofthe arterial wall secondary to
plaquebuildup)isalsoassociatedwithincreasedriskofCAD.Thetestcanalsobeperformed
postexerciseonatreadmilltobetterdetectmilderdisease.
IftheABIisabnormalinthepresenceofsymptoms,furthertestingisgenerallyindicatedto
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betterevaluatethemagnitudeandpreciselocationofthedisease.Segmentalpressures,pulse
volume recording,ultrasonography in conjunctionwith Doppler imaging (duplex scan), and
transcutaneous oximetryare other noninvasive techniques that evaluate arterial flow and/or
tissueperfusion.Segmentalpressuresorsoundwavesmeasuring thebloodflowinanartery
can indirectly indicate the extent and location of a blockage. Computed Tomography and
magnetic resonance angiography are additional noninvasive techniques demonstrating the
extent of the disease. Invasive testing including angiography is the most specific test for
determiningthespecificlocationandseverityofocclusivelesions.Intravascularultrasoundis
a newer technique that can image directly a blockage without subjecting the patient to
radiographicdyes.Thisisbeneficialinpatientswithallergiesorrenaldisease.
ThemanagementofearlyPADiscenteredongoalsofreducingrisksoffurtherprogression
ofatherosclerosisandmostnotablylesseningtheincidenceofacutecoronarysyndromesand
cerebralvascularaccidents.Withrespecttothelowerextremitydisease,thegoalistoimprove
function and preserve the limb itself. Accordingly, cardiovascular risk factors such as
hypertension,hyperlipidemia, andhyperglycemia mustbe controlled. Lifestyle modifications
includingsmokingcessationandsupervisedexerciseprogramsarealsoessential.Theuseof
antiplateletagentsmustbeweighedagainsttheriskofincreasedbleeding.Revascularization
procedures are indicated for limb salvage in patients with activity-altering claudication,
ulcerations, or gangrene. They are also indicated in patients who have failed medical
management and lifestyle modificationswherethe procedurecanreasonablybe expected to
resultin increased functionality. In addition toclassic opensurgical bypass procedures, the
trend has been decidedly toward endovascular interventions including angioplasties,
atherectomy, bare metal and drug-eluting stents, and, most recently, drug-eluting balloons.
Appropriatecardiacinterventionsarealsofrequentlyrequiredwhereindicated.
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FIGURE3-2.Criticallimbischemiamanifestingruborandgangrene.
Although generalized atherosclerosis is associated with poor long-term prognosis, the
earlyidentificationandinterventioncanimprovebothqualityoflifeandlongevity.
DIABETES
Diabetesaffectsmorethan24millionAmericans.Ithasbeenestimatedthat6millionpeople
donotevenknowthattheyhavethedisease.Riskfactorsinadditiontofamilialhistoryinclude
thoseassociatedwith classic metabolic syndromesuchas hypertension,hyperlipidemia,and
centralobesity.Theobesitycomponentalsopotentiatesunrelatedmusculoskeletalinjuriesand
overuse syndromes that will cause the patient to present for medical evaluation. It is not
uncommonthatspecificdiabeticfoot–relateddiseaseistheprecipitatingfactorthatstimulates
individualstoseekmedicalattentionandthesubsequentdiagnosesofothersystemicdiabetic
complicationsincluding cardiovascular disease,nephropathy, andretinopathy. Mostcommon
pedal signs and symptoms of diabetes include diminished circulation and peripheral
neuropathies.
12
InadditiontoclassicsignsandsymptomsofPADaffectingthelargevesselsanddiscussed
previously, diabetics can manifest disorders of the microcirculation resulting from altered
permeability of capillary membranes and arteriovenous shunting in the midfoot area.
Consequentlyandparadoxically,itispossibleforapatienttohavedistaldigitalischemiain
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thepresenceofpalpablepedalpulses.Neuropathyisaverycommonandpotentiallyserious
complicationofdiabetesandmaybehyposensoryorhypersensoryinnature.Itcanbepainful,
disabling,andevenfatal.Patientswithdiabeticneuropathyoftenexperienceparesthesiasand
reducedability toexperiencechanges intemperature.Sharplancinatingpainthatworsensat
nightis frequently experienced. Increased sensitivity tothe lightesttouch canbe agonizing.
Muscle weakness, difficulty in waking, and joint contractures may also occur and lead to
increased pressure points and ulcerations. Autonomic neuropathy may dull the senses and
result in lack of awareness that blood glucose is low. Frequent urinary tract infections,
incontinence,erectiledysfunction,aswellasvaginaldrynessandothersexualdysfunctionmay
occur.
Diabeticmononeuropathymayalsodevelop,affectingspecificnervesintheface,torso,or
leg.Thesignsandsymptomsdependuponwhichnerveisinvolved.Visualchangesmayresult
whenoneoftheextraocularmusclesisinvolved;paralysisofonesideofthefacemayoccur
with facial nerve involvement; and pain in the shin, thigh, or foot when other nerves are
affected.
ARTERIALEMBOLISM
Arterialembolismisasuddeninterruptionofbloodsupplytoanorganorbodypartcausedby
amigratedbloodclot,resultingindamageornecrosisoftheareasuppliedbythenativeartery
(Fig.3-3).Arterialembolioftenbecomelodgedinthedistalcirculationofthelegsandfeet.
Embolithatmigratetothecerebralcirculationresultinacerebral vascularaccident.One of
the most common etiologies and sources of emboli is the result of abnormal cardiac
dysrhythmias, often being atrial fibrillation. Atrial fibrillation, which is estimated to affect
slightlyover 4% ofthe populationover 60 years ofage,can beclassified intoparoxysmal
(intermittent/temporary)andchronic.Paroxysmalatrialfibrillationis definedasatleasttwo
separateepisodesofatrialfibrillationthatterminatespontaneouslyinlessthan7 days.Both
paroxysmal and chronic atrial fibrillation have the same rate of cardioembolic events.
13
Symptoms ofatrial fibrillationincludeanirregular,rapid pulse; weakness and shortness of
breath;chestpain;anddecreased blood pressure.Causesofatrialfibrillationincludemitral
stenosis with resultant left atrial enlargement that often results in thrombus and emboli
formation.Other causes of arterial embolism include damageto anarterial wall andblood
clottingabnormalitiessuchasthrombocytosis.
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FIGURE3-3.(AandB)Microemboliinapatientwithatrialfibrillation.
Someofthemorecommonearlysymptomsofarterialembolizationtothelowerextremity
include a cold extremity, decreased or absent pulses in the involved limb (although the
contralateralpulseremainsnormal),lackofabilitytomovetheextremity,severemusclepain
ormusclespasm,numbness,andweakness.14Someofthelatersymptomsincludeskinerosion,
blistering,sloughingoftheskin,andgangreneoftheembolizedarea.
14
Teststodiagnosearterialembolismincludeangiography,Dopplerultrasoundexamination
ofthe extremity, MRI of the extremity, transesophageal echocardiography, Factor VII assay,
plateletaggregationtest,andtissue-typeplasminogenactivatorlevels.
The risk of arterial thromboembolism is increased in individuals who are smokers,
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inactive,overweight,andunderincreasedemotionalstress.
INFECTIVEENDOCARDITIS
Infectiveendocarditisisaninfectionoftheendocardialsurfaceoftheheart,whichmayinclude
one or more heartvalves, the mural endocardium, or a septaldefectandis associatedwith
severalfindingsinthefoot.Itsintracardiaceffectsincludeseverevalvularinsufficiency,which
may lead to congestive heart failure (CHF) and myocardial abscesses. If left untreated,
infectiveendocarditisisoftenfatal.
Low-grade, often intermittent, fever is present in 90% of patients with infective
endocarditis.Heartmurmursarealsoheardinapproximately85%ofpatients.Othersystemic
symptoms include joint pain, hypotension, and hematuria. A generalized, gradual flulike
syndromehasalsobeenreportedinsomecasesofsubacutebacterialendocarditis.Inaddition,
thereareseveralotherclassicsignsofendocarditis,manyseeninthelowerextremity.These
include petechiae, subungual (splinter) hemorrhages (Fig. 3-4), Osler nodes (Fig. 3-5),
Janewaylesions(Fig.3-6),andRothspots.
Splinterhemorrhagesaredarkred,linearlesionsinthenailbeds.Oslernodesaretender,
subcutaneous nodules usuallyfound onthe distal pads of the digitsand are associated with
subacutebacterial endocarditis(approximately10%to23%).15Oslernodulesdemonstratea
temporarycourselastinghourstodays.Janewaylesionsarenontender,hemorrhagicmacules
onthepalmsandsoles,typicallyassociatedwithacutebacterialendocarditis.Theselesions
arearesultofsepticmicroemboliandrepresentmicroabscessesinthedermiswiththrombosis
ofsmallvesselwithoutvasculitis.Janewaylesionstypicallylastforseveraldaystoweeks.
16
Finally,Rothspotsareretinalhemorrhageswithasmallclearcenter.
FIGURE3-4.Splinterhemorrhageinapatientwithendocarditis.
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FIGURE3-5.Oslernodes.
FIGURE3-6.Janewaylesions.
Theetiologiesofinfectiveendocarditis are many, butinclude native valveendocarditis,
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