Cochin Cardiac Club

Health Blog by Dr.Uday Nair


Peripheral arterial disease (P.A.D.) is a disease in which plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of fat, cholesterol, calcium, fibrous tissue, and other substances in the blood.

When plaque builds up in the body's arteries, the condition is called atherosclerosis. Over time, plaque can harden and narrow the arteries. This limits the flow of oxygen-rich blood to your organs and other parts of your body.

P.A.D. usually affects the arteries in the legs, but it also can affect the arteries that carry blood from your heart to your head, arms, kidneys, and stomach. This post focuses on P.A.D. that affects blood flow to the legs.If severe enough, blocked blood flow can cause tissue death. If this condition is left untreated, a foot or leg may need to be amputated.
Signs and Symptoms of PAD.

While many people with peripheral artery disease have mild or no symptoms, some people have leg pain when walking (intermittent claudication).

Intermittent claudication symptoms include muscle pain or cramping in your legs or arms that's triggered by activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is most common.

The severity of intermittent claudication varies widely, from mild discomfort to debilitating pain. Severe intermittent claudication can make it hard for you to walk or do other types of physical activity.

Classical Symptoms of PAD:

Painful cramping in your hip, thigh or calf muscles after activity, such as walking or climbing stairs (intermittent claudication)
  • Leg numbness or weakness
  • Coldness in your lower leg or foot, especially when compared with the other leg
  • Sores on your toes, feet or legs that won't heal
  • A change in the color of your legs
  • Hair loss or slower hair growth on your feet and legs
  • Slower growth of your toenails
  • Shiny skin on your legs
  • No pulse or a weak pulse in your legs or feet
  • Erectile dysfunction in men
If peripheral artery disease progresses, pain may even occur when you're at rest or when you're lying down (ischemic rest pain). It may be intense enough to disrupt sleep. Hanging your legs over the edge of your bed or walking around your room may temporarily relieve the pain.

Also note that the pain of PAD usually goes away when you stop exercising, although this may take a few minutes. Working muscles need more blood flow. Resting muscles can get by with less. If there's a blood-flow blockage due to plaque buildup, the muscles won't get enough blood during exercise to meet the needs. The "crampy" pain (called "intermittent claudication"), when caused by PAD, is the muscles' way of warning the body that it isn't receiving enough blood during exercise to meet the increased demand.

Please also note that many people with PAD may have no symptoms or may mistake their symptoms for something else.

Risk factors for PAD

An individual is at risk for developing PAD when one or more of these risk factors are present:

  • Smoking
  • Diabetes
  • Obesity(a body mass index over 30) 
  • History of heart or blood vessel disease: A personal or family history of heart or blood vessel disease may be an indicator for PAD
  • High blood pressure (hypertension)
  • High cholesterol (hyperlipidemia)
  • Excess levels of homocysteine, a protein component that helps build and maintain tissue

Diagnosis and Tests.

First your physician asks you questions about your general health, medical history, and symptoms. In addition, your physician conducts a physical exam. Together these are known as a patient history and exam. As part of your history and exam, your physician will ask you if you smoke or have high blood pressure. Your physician will also want to know when your symptoms occur and how often. As part of the physical exam, your physician will conduct pulse tests, which measure the strength of your pulse in arteries behind your knees and feet.

After your exam, if your physician suspects peripheral artery disease, he or she may perform tests, such as:

    Ankle-brachial index (ABI), which compares the blood pressure in your arms and legs
    Blood tests for cholesterol or other markers for artery disease

To better understand the extent of your leg artery disease, your physician may also recommend duplex ultrasound, pulse volume recording, magnetic resonance angiography (MRA), or angiography.

    Duplex ultrasound uses high-frequency sound waves to measure real-time blood flow and detect blockages or other abnormalities in the structure of your blood vessels
    Pulse volume recording measures the volume of blood at various points in the legs using an arm blood pressure cuff and a Doppler probe
    Magnetic resonance angiography (MRA) uses magnetic fields and radio waves to show blockages inside your arteries
    Computed tomographic angiography (CTA) uses specialized CT scans and contrast dye to show blockages inside your arteries
    Angiography, which produces x ray pictures of the blood vessels in your legs using a contrast dye to highlight your arteries

Physicians usually reserve angiography for people with more severe forms of leg artery disease.

Treatment of PAD

Lifestyle changes, medications and interventional procedures are the treatments available for PAD.

Lifestyle Changes. Initial treatment of PAD includes making lifestyle changes to reduce your risk factors.
Changes you can make to manage your condition include:

    Quit smoking. Ask your doctor about smoking cessation programs available in your community.
    Eat a balanced diet that is high in fiber and low in cholesterol, fat and sodium. Limit fat to 30 percent of your total daily calories. Saturated fat should account for no more than 7 percent of your total calories. Avoid trans fats including products made with partially-hydrogenated and hydrogenated vegetable oils. If you are overweight, losing weight will help you lower your total cholesterol and raise your HDL (good) cholesterol. A registered dietitian can help you make the right dietary changes.
   Exercise. Begin a regular exercise program, such as walking. Walking is very important and can aid the treatment of PAD. Patients who walk regularly can expect a marked improvement in the distance they are able to walk before experiencing leg pain.
    Manage other health conditions, such as high blood pressure, diabetes or high cholesterol.
    Practice good foot and skin care to prevent infection and reduce the risk of complications.

Medications may be recommended to treat conditions such as high blood pressure (anti- hypertensive medications) or high cholesterol (statin medications).

An antiplatelet medication such as aspirin or clopidogrel (Plavix) may be prescribed to reduce the risk of heart attack and stroke.

Cilostazol (Pletal) may be prescribed to improve walking distance. This medication has been shown to help people with intermittent claudication exercise longer before they develop leg pain and to walk longer before they must stop because of the pain. However, not all patients are eligible to take this medication. Your doctor will tell you if you are eligible.

Interventional procedures. More advanced PAD can be treated with interventional procedures such as angioplasty (to widen or clear the blocked vessel), angioplasty with stent placement (to support the cleared vessel and keep it open), or atherectomy (to remove the blockage).

In some cases,surgical procedures such as peripheral artery bypass surgery may be performed to reroute blood flow around the blood vessel blockage.

Please Note

Many people dismiss leg pain as a normal sign of aging. You may think it's arthritis, sciatica or just "stiffness" from getting older. For an accurate diagnosis, consider the source of your pain. PAD leg pain occurs in the muscles, not the joints.

Those with diabetes might confuse PAD pain with a neuropathy, a common diabetic symptom that is a burning or painful discomfort of the feet or thighs. If you're having any kind of recurring pain, talk to your doctor and describe the pain as accurately as you can. If you have any of the risk factors for PAD, you should ask your doctor about PAD even if you aren't having symptoms.


A rare anomaly where the heart is located on the right side of the chest instead of the normal left side of the chest. The condition is generally asymptomatic but is often associated with other abnormalities such as inverted location of other abdominal organs.  It is present at birth (congenital).

There are several types of dextrocardia, also called looping defects. Dextrocardia is frequently diagnosed in a routine prenatal sonogram, although not every radiologist will catch it, particularly if there are no cardiac structural abnormalities.

Mirror image dextrocardia is a very rare condition. It may be present in about one in 100,000 people. In this looping defect, not only does the heart flip the wrong way and develop on the wrong side of the chest, but also all the other organs in the middle of the body are reversed. In essence, an x-ray of mirror image dextrocardia looks like a mirror image of the normal heart and organ placement.
Mirror image dextrocardia was first noted in the 1920s, when x-rays revealed this abnormal placement. Fortunately, this type of looping defect does not involve structural abnormalities of the heart or other organs. In some cases, cilia, tiny hair-like structures, in the nose and lungs move in the opposite direction, causing a greater susceptibility to colds or illness. Aside from this susceptibility, a person with this condition does not require any special treatment or surgeries.
The most common heart defects seen with dextrocardia include:
  • Double outlet right ventricle
  • Endocardial cushion defect
  • Pulmonary stenosis or atresia
  • Single ventricle
  • Transposition of the great vessels
  • Ventricular septal defect

Dextrocardia with abnormal heart is a far more serious condition, which usually requires one or more surgeries to address structural abnormalities. It is a more common condition than mirror image dextrocardia, and in most cases, the position of the other organs in the middle of the body is not reversed. The outcome and survival rates for dextrocardia with abnormal heart depends upon the severity of the defects, which generally include a complicated form of transposition of the arteries, called levo-transposition, or both arteries arising from the right ventricle, called double outlet right ventricle.
Large ventricular septal defects are also common in dextrocardia with abnormal heart. The right and left ventricle may be so similar, unlike in the normal heart, that it is difficult to differentiate which ventricle is right or left. In many cases, the ventricular septal defect is so large that the ventricles are termed a single ventricle. One or both ventricles may be smaller than usual.
Dextrocardia may also be present in a condition called heterotaxy, which involves not only abnormal heart placement and structural abnormalities, but also the absence of a spleen, or the presence of a number of small spleens. Treatment depends upon the degree and severity of these structural anomalies. Lack of a spleen, asplenia, can complicate any operations because natural resistance to infection is significantly reduced. 

Causes of Dextrocardia:

- Marden-Walker Syndrome: A rare genetic disorder characterized by blepharophimosis, joint contractures and fixed facial expression.
- Kartagener syndrome: A rare genetic disorder characterized by enlarged bronchial tubes, sinusitis and cross-positioning of body organs.
-Campomelia Cumming type: A rare syndrome characterized by limb and multiple abdominal organ abnormalities. The disorder results in death before birth or soon after.

There are no symptoms of dextrocardia if the heart is normal.
Conditions that may include dextrocardia may cause the following symptoms:
  • Bluish skin
  • Difficulty breathing
  • Failure to grow and gain weight
  • Fatigue
  • Jaundice (yellow skin and eyes)
  • Pale skin (pallor)
  • Repeated sinus or lung infections

    Signs and tests

    There are no signs of dextrocardia if the heart is normal.
    Conditions that can include dextrocardia may cause the following signs:
    • Abnormal arrangement and structure of the organs in the abdomen
    • Enlarged heart
    • Problems with the structure of the chest and lungs, seen on x-rays
    • Rapid breathing or problems breathing
    • Rapid pulse
    Tests to diagnose dextrocardia include:
    • Computed tomography (CT) scans
    • Magnetic resonance imaging (MRI) of the heart
    • Ultrasound of the heart (echocardiogram)
    • X-rays

      Common ECG findings:

      not all of these are always present
      - Global negativity in lead I, (a negative p wave, QRS, and negative T wave).
      - Positively deflected QRS in aVR
      - Negative p wave in lead II
      - Reverse R wave progression in precordial leads


      Treatment for this condition depends on the extent of physical problems caused by this incorrect placement of the heart. Some individuals may not require treatment.

      Mirror Image Dextrocardia

      • No treatment is required for complete mirror image dextrocardia if other deformities are not detected

      1. Other Abnormalities

        • An infant may require surgery if the heart is not able to function properly, or if other conditions also exist. It is not uncommon for individuals exhibiting this condition to have additional physical abnormalities.

        Surgical Procedures

        • Surgical procedures can range from minor to very involved, depending on the individual situation. Surgery may also be necessary to correct other congenital organ problems within the abdominal cavity in some cases of dextrocardia.


        • Diuretics and blood pressure medication may be prescribed to lessen stress on the heart. Medication may also be prescribed before surgery to strengthen the general health of the infant with dextrocardia.



The period of rapid physical and mental growth between the childhood and adulthood is called adolescence. For girls it is in the period between 8-18 years and for boys it is 7-19 years. Adoloscence extends from puberty to complete sexual maturity.

Problems in Adolescence

Most problems of adolescence are due to failure in understanding the anatomical, morphological and psychological changes expected during adolescence. Psychologically, adolescence is such a vulnerable stage that boys / girls of this age are easily carried away by perceptions generated by
  • Misleading and misguiding parents, teachers, friends, brother/sisters.
  • Ignorance of elders.
  • Half - informed or ill - informed friends, brothers, sisters.
  • Wrongful messages depicted through TV serials, advertisements, films
  • Publications carrying partially or fully false information.
Such perceptions can be anything in the range of studies, sex, society, married life, career, religion, politics, or any relevant subject.
Every adolescent boy or girl is prone to such exposures - which ultimately are retained as perceptions in their minds to form their behavioural patterns.
The problems of adolescence are classified as
  • morphological / developmental
  • psychological
  • social
  • educational
Some problems are absolutely unimportant and trivial. They could be easily ignored. But even such problems cause great concern to adolescent people.

Social and moral implications of Adolescence

Adolescence is a preparatory phase for the adult life. It is formative period of both physical and psychological health. A healthy adolescence is very essential for a healthy adulthood. During this period the individual moves out of the family. He or she begins to identify and defines his or her position in relation to the outer world. He undergoes physiological and behavioral transformation and acquires higher levels of moral standings.

Oppositional defiant disorder (ODD).

Parents already know that all children occasionally throw tantrums and misbehave. But when does problem behavior cross the line from normal acting out to something more serious, such as a behavior disorder? Especially during certain periods (like the “terrible twos” or adolescence), it is normal for certain kinds of problem behavior to increase. But because all children go through stages of misbehavior, it can be hard for parents to know whether their child is just going through a phase or has a behavior disorder. The good news is that parents can often change their children's behavior by making changes themselves.

Even the best-behaved children can be difficult and challenging at times. But if your child or teen has a persistent pattern of tantrums, arguing, and angry or disruptive behavior toward you and other authority figures, he or she may have oppositional defiant disorder (ODD).

Possible symptoms of oppositional defiant disorder (ODD)

The child often:
  • Loses his or her temper
  • Argues with adults
  • Refuses requests made by adults and refuses to follow rules set by adults
  • Deliberately annoys people
  • Blames others for his or her mistakes
  • Is touchy or is easily annoyed by others
  • Is angry or resentful
  • Is spiteful or vindictive
Most children behave this way from time to time. However, if the description in the table above matches your child's behavior, the first step is to make an appointment with your child's pediatrician, who will help you decide if a psychiatrist could be helpful.
Causes of ODD

There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including:
  • A child's natural disposition
  • Limitations or developmental delays in a child's ability to process thoughts and feelings
  • Lack of supervision
  • Inconsistent or harsh discipline
  • Abuse or neglect
  • An imbalance of certain brain chemicals, such as serotonin.
  • Treatment.
  • Behavioural approach

Typical behavioural approach will help you learn how to deal with your child’s defiance in an effective manner, using tried and tested techniques such as setting achievable goals and reinforcing positive behaviours.
It can be carried out on a one-to-one basis with parents, or in a group if there are several families needing help at any one time. Group work can be helpful because it offers extra support for parents and confirmation that it’s not just your family going through the difficulties of ODD.
ODD children can be very demanding, so learning new ways of dealing with your child's behaviour can prove challenging. For example, although you may feel at the end of your tether, arguing or shouting back at your child isn’t the best approach.
Instead you’ll be encouraged to learn new ways of dealing with behaviour such as confrontations, arguing and impulsive rages. Insight will be given into how oppositional children think, so you can begin to understand why your child acts this way.
Treatment is likely to encourage talking to your child and helping him to acknowledge his behaviour. It will also focus on ways of using praise to improve behaviour and address the issue of control - one of the things ODD children strive for.

Treatment as a family

At home, you can begin chipping away at problem behaviors by practicing the following:
  • Recognize and praise your child's positive behaviors. Be as specific as possible, such as, "I really liked the way you helped pick up your toys tonight."
  • Model the behavior you want your child to have.
  • Pick your battles. Avoid power struggles. Almost everything can turn into a power struggle — if you let it.
  • Set limits and enforce consistent reasonable consequences.
  • Set up a routine. Develop a consistent daily schedule for your child. Asking your child to help develop that routine may be beneficial.
  • Build in time together. Develop a consistent weekly schedule that involves you and your child spending time together.
  • Work with your partner or others in your household to ensure consistent and appropriate discipline procedures.
  • Assign your child a household chore that's essential and that won't get done unless the child does it. Initially, it's important to set your child up for success with tasks that are relatively easy to achieve and gradually blend in more important and challenging expectations. Give clear, easy-to-follow instructions.
At first, your child probably won't be cooperative or appreciate your changed response to his or her behavior. Expect that you'll have setbacks and relapses, and be prepared with a plan to manage those times. In fact, behavior can temporarily worsen when new limits and expectations are set. However, with perseverance and consistency, the initial hard work often pays off with improved behavior and relationships.
Please Note-
Be consistent about rules and consequences at home. Don't make punishments too harsh or inconsistent.
Model the right behaviors for your child. Abuse and neglect increase the chances that this condition will occur.