3. Peripheral arterial disease

Question 1

Describe Peripheral Arterial Disease (PAD)

Answer 1

PAD is a condition where peripheral blood vessels outside the heart and become narrowed, leading to insufficient delivery of blood, oxygen, and nutrients to the body.

Question 2

Define Atherosclerosis in the context of PAD

Answer 2

Atherosclerosis is the development of fatty deposits in peripheral arteries, restricting blood flow to the affected limb(s) in PAD.

Question 3

How does Functional PAD differ from Organic PAD?

Answer 3

Functional PAD has no organic cause and is often short-term or intermittent, related to spasms triggered by factors like cold exposure, while Organic PAD stems from structural changes in blood vessels due to blockage or damage.

Question 4

Do plaques in atherosclerosis have the potential to rupture?

Answer 4

Yes, plaques in atherosclerosis can rupture, leading to a blood clot formation that may completely block the artery.

Question 5

Describe Intermittent Claudication (IC) in the context of PAD

Answer 5

IC is the most common symptom of PAD, characterized by pain in the lower limb during walking or exercise due to diminished circulation, which is relieved by rest.

Question 6

What are some modifiable risk factors for PAD?

Answer 6

Hypercholesterolemia, smoking, excess alcohol consumption, sedentary lifestyle, hypertension, poor diet, overweight/obesity, and diabetes mellitus are modifiable risk factors for PAD.

Question 7

Define Critical Limb Ischaemia (CLI) in the context of PAD

Answer 7

CLI, also known as chronic limb-threatening ischaemia (CLTI), occurs when circulation is severely impaired, posing a risk of limb loss due to chronic inadequate tissue perfusion at rest.

Question 8

How does atherosclerosis progress in stages?

Answer 8

Atherosclerosis progresses from fatty material build-up in artery walls (fatty streak) to the formation of fibrous plaque, enlargement of plaque, artery narrowing, and potential plaque rupture leading to blood clot formation.

Question 9

Describe the symptoms of more progressive PAD.

Answer 9

Chronic rest pain, changing skin color, skin changes like ulcers and gangrene, muscle wasting, absent foot pulses, erectile dysfunction in males.

Question 10

What are the long-term complications of PAD?

Answer 10

Increased risk of cardiovascular diseases, risk of amputation, complications from poor-healing wounds, increased risk of abdominal aortic aneurysm, poorer prognosis, and higher mortality rate.

Question 11

How is PAD diagnosed?

Answer 11

Through history of symptoms and risk factors, physical examination, ankle-brachial pressure index measurement, blood tests, and imaging of arteries.

Question 12

Define ankle-brachial pressure index (ABPI).

Answer 12

A ratio used to assess peripheral arterial disease by comparing blood pressure in the ankle to blood pressure in the arm.

Question 13

What are the potential tests for PAD diagnosis?

Answer 13

Imaging of arteries like CTA or MRA, ECG, blood glucose, lipid profile, liver function tests, blood pressure, BMI, and renal function tests.

Question 14

Describe what to ask in the vascular history for PAD diagnosis.

Answer 14

Ask about the nature, location, and timing of symptoms, impact on daily life, non-healing foot wounds, cardiovascular risk factors, and family history of PAD.

Question 15

Describe the red flags for suspecting acute limb ischemia based on the vascular history provided.

Answer 15

The red flags include sudden onset or deterioration of the 6 P’s: Pain, Pulseless, Pallor (or cyanosis or mottling), Power loss or paralysis, Paraesthesia, and Perishing with cold.

Question 16

What are some components of the multi-factorial management approach for acute limb ischemia according to the content?

Answer 16

Components include identification and management of CV risk factors, supervised or unsupervised exercise program, surgical intervention (revascularization), and vasodilators.

Question 17

Define the role of antiplatelet therapy in the management of CV risk factors for patients with acute limb ischemia.

Answer 17

Antiplatelet therapy is recommended for all patients (unless contraindicated) to reduce CV risk, increase pain-free walking distance, and prevent adverse limb events.

Question 18

How should the baseline liver function and full lipid profile be monitored in patients receiving statin therapy for acute limb ischemia?

Answer 18

Baseline LFT and FLP should be checked initially, followed by monitoring at 3 months, 12 months, and then yearly. Creatinine kinase should also be checked if muscle effects are experienced.

Question 19

Describe the preferred antiplatelet therapy and considerations for prescribing it in patients with acute limb ischemia.

Answer 19

Clopidogrel 75mg OD daily is preferred, with aspirin 75mg OD as an alternative if contraindicated or not tolerated. PPI should be prescribed if there is a high risk of GI adverse effects.

Question 20

What are some counseling points to consider when prescribing antiplatelet therapy for acute limb ischemia patients?

Answer 20

Counseling should include rationale for treatment, how to take the medication, monitoring requirements, potential side effects (e.g., myalgia, sleep disturbance), and adherence strategies.

Question 21

Describe the supervised exercise programme (SEP) for managing cardiovascular risk factors and improving perfusion of extremities.

Answer 21

The supervised exercise programme involves 2 hours of supervised exercise per week for a 3-month period, encouraging exercising to the point of maximal pain. It improves perfusion of extremities, walking distance, and physical functioning.

Question 22

What is the recommendation if supervised exercise is not available for managing cardiovascular risk factors?

Answer 22

If supervised exercise is not available, unsupervised exercise is recommended. This involves 30 minutes of exercise 3-5 times per week, walking until the onset of symptoms, then resting to recover.

Question 23

Define revascularisation in the context of managing cardiovascular risk factors.

Answer 23

Revascularisation refers to surgical intervention recommended when there is no satisfactory improvement with cardiovascular risk modification and exercise.

Question 24

How do vasodilators like Naftidrofuryl oxalate work in managing cardiovascular risk factors?

Answer 24

Vasodilators like Naftidrofuryl oxalate cause vasodilation, widening peripheral blood vessels to improve blood flow to extremities.

Question 25

Describe the management approach for critical/chronic limb ischemia.

Answer 25

For critical/chronic limb ischemia, urgent referral to a vascular multidisciplinary team is crucial, along with managing cardiovascular risk factors and pain.

Question 26

What is the recommended action for managing acute limb ischemia?

Answer 26

For acute limb ischemia, emergency assessment by a vascular specialist for surgical intervention is necessary, followed by managing cardiovascular risk factors.

Question 27

How should pain be managed in the context of critical/chronic limb ischemia?

Answer 27

Pain in critical/chronic limb ischemia can be managed with paracetamol and weak or strong opioids, with referral to a pain specialist if poorly controlled.

Question 28

What are some potential side effects of vasodilators like Naftidrofuryl oxalate?

Answer 28

Potential side effects of Naftidrofuryl oxalate include diarrhea, nausea, vomiting, rash, and rarely, liver injury or kidney stones.