2. PAD Flashcards
What is peripheral artery disease?
Disorder that obstructs blood supply to lower or upper extremities.
Why is PAD clinically important?
- marker for subclinical coronary atherosclerosis
- 45% of patients with symptomatic PAD have concurrent clinically significant CAD
- CV events are more common in PAD than limb events
PAD is more prevalent in women than in men. (T/F)
False: more prevalent in men
About what percent of patients with PAD are asymptomatic?
50%
About what percent of patients with PAD have intermittent claudication?
15%
About what percent of patients with PAD have atypical pain?
33%
What is atypical pain associated with PAD?
extremity discomfort that is exertional but does not resolve with rest
What are the 5 P’s of diagnosis?
pain pallor pulselessness paresthesias paralysis
How is ABI calculated?
highest ankle pressure / highest arm pressure
measurements for both right and left
What is a normal ABI?
above 0.90
What ABI is considered mild obstruction?
0.71 - 0.90
What ABI is considered moderate obstruction?
0.41 - 0.70
What ABI is considered severe obstruction?
0.00 - 0.40
How is PAD diagnosed?
- contrast arteriography
- duplex ultrasound
- magnetic resonance angiography
What is the gold standard of PAD diagnosis?
contrast arteriography
What is the best choice for PAD diagnosis in patients with CKD?
Magnetic resonance angiography
What are the goals of treatment for PAD?
- Prevention of CVD
- Relief of symptomatic PAD
- Prevent limb amputation
What are some risk factor management strategies?
- Lifestyle changes
- Blood pressure control
- Diabetes control
- Hyperlipidemia
- Anti platelet therapy
What are the BP goals for patients with PAD?
< 140/90 mmHg if < 60 years old
< 150/90 mmHg if ≥ 60 years old
What is A1c goal for patients with PAD?
6.5%
How should hyperlipidemia be treated in patients with PAD?
high potency statin treatment
All PAD patients should be on regular dose aspirin (325 mg) (T/F)
False: low dose aspirin (81 mg) daily
What is the alternative antiplatelet therapy if aspirin is not tolerated?
Clopidogrel 75 mg
How is symptomatic PAD treated?
- exercise therapy
- pharmacologic therapy
- surgery
What are the pharmacologic therapies for PAD?
- Cilostazol
- Pentoxifylline
What are the surgical methods for PAD?
- endovascular
- arterial bypass
Exercise therapy is the most beneficial in intermittent claudication. (T/F)
True
How does exercise therapy benefit patients with PAD?
- helps with intermittent claudication
- increase duration and distance of walking
What exercise regimen shows the greatest benefit in PAD?
> 30 minutes at least 3 time per week
What is the MOA for Cilostazol?
- Selective inhibitor of phosphodiesterase III
- ↑ in cAMP leads to phosphorylation of PKA substrates
What are the effects of Cilostazol?
- positive lipid effects
- decreased platelet aggregation
- minor cardiac contractility
- decrease in VSMC proliferation
- VSMC relaxation increased
What are the indications of Cilostazol?
symptomatic management of PAD: primarily intermittent claudication
What is the typical dose of Cilostazol?
100 mg BID
taken 30 minutes before or 2 hours after eating
Cilostazol should be stopped after 6 months if not effective. (T/F)
False: stopped after 3 months
Cilostazol is a major substrate of what enzymes?
CYP3A4 and CYP2C19
High fat meals and grapefruit juice _______(↑/↓) peak concentrations of Cilostazol.
↑ increase
What are ADRs of Cilostazol?
- headache/ dizziness
- diarrhea and abnormal stool
- infection
- rhinitis
- palpitation
- peripheral edema
- thrombocytopenia
- bleeding
What is the contraindication of Cilostazol?
hear failure of ANY severity
What is the MOA of Pentoxifylline?
reduces blood viscosity via increased leukocyte and erythrocyte deformability
Pentoxifylline is the first line agent for intermittent claudication. (T/F)
False: 2nd line agent
How is Pentoxifylline dosed?
400 mg TID
Pentoxifylline must be adjusted for renal dysfunction. (T/F)
True
What are the ADRs with Pentoxifylline?
nausea and vomiting
With a CrCl of ~60 mL/min, how must Pentoxifylline be dosed?
400 mg BID
With a CrCl of ~20 mL/min, how must Pentoxifylline be dosed?
400 mg QD
What are some alternate therapies for PAD?
- warfarin
- herbals
What are some herbal supplements used for PAD?
- L-arginine
- L-carnitine
- Ginko bilboa
- Vit E
What are surgical endovascular reconstruction options?
- percutaneous transluminal angioplasty (PTA)
- PTA with stents
What are surgical reconstruction options?
- aortoiliac/aortofemoral reconstruciton
- femoropopliteal bypass
- femorotibial bypass
What are indications for surgical revascularization?
- inadequate response to exercise or medical mgmt
- severely disabled
- lesions
- patient would benefit
- critical limb ischemia
