Cardio Week 5 - PAD Flashcards
Peripheral artery disease
History of leg pain with activity
Cycle of peripheral artery disease
PAD —> leg pain —> decreased activity —> deconditioning —> Worsening PAD
Asymptomatic PAD
ABI less than or equal to 0.9 without symptoms
Atypical leg pain
Pain with activity, not reproducible in terms of pace, time or rest
Claudication
Pain with activity reproducible in terms of pace, time and rest
Critical limb ischemia
- ABI < 0.3 or 0.4
- Pain at rest
- Non healing wounds and gangrene
- Without revascularization, the pt is likely to require amputation
Neurogenic Claudication
- Spinal stenosis
- Peripheral Neuropathy
- Peripheral nerve pain
- Sciatica
- Restless leg syndrome
Qualities of spinal stenosis
- Impacted by back postition during exercise whether flexed or extended
- Common with bike test
How can peripheral neuropathy be reproduced?
Can be reproduced with special tests or nerve conduction velocity
How can peripheral nerve pain and sciatica be alleviated?
Position change
When is restless leg syndrome present?
Usually present at night, not usually present during activity
Other LE causes of Pain
- Muscle spasms or cramps
- Chronic compartment syndrome
- Hip or knee OA
- Symptomatic baker’s cyst
- Venous disease producing claudication
5 P’s of PAD
- Pain
- Pulselessness
- Pallor
- Paresthesia
- Paralysis
ABI value of greater than or equal to 1.3
- Non compressible
- Likely PAD (narrowed on the inside)
- Measure toe pressures
ABI of 1.00 to 1.29
Considered WNL
ABI value of greater than 1.1
- With risk factors and history should be viewed with suspicion
ABI value of 0.91 to 0.99
Considered borderline PAD
ABI value of 0.41 to 0.90
Considered moderate to mild PAD
ABI value of less than or equal to 0.4
Considered severe disease correlating with critical limb ischemia
Toe Brachial Index (TBI) Measurement
Accurate when ABI values are not possible due to non-compressible pedal pulses
- Divide toe pressure by the higher of the two brachial pressures
- Less than or equal to 0.7 diagnostic for LE PAD
Segmental Pressures
BP measured along the LEs to localize an area of decline in systolic pressure
Pulse Volume Recordings
- Measure ratio of volume changes during systole and diastole
- Relative lack of blood flow during diastole indicative of arterial disease
Exercise ABI Testing
- Confirms the PAD diagnosis
- Assesses the functional severity of claudication
- May detect PAD in the presence of normal resting ABI
Plantar Flexion Exercise ABI
- Used if exercise ABI is impractical
- May be able to reproduce a treadmill-derived fall in ABI
- Can be performed anywhere
- Inexpensive
- Does not measure functional capacity as a treadmill test can
Color Duplex Ultrasonography
Color indicates the area with high or low blood flow
Magnetic Resonance Angiography (MRA)
Can see exactly where blood flow decreases
Computed tomographic angiography (CTA)
Requires iondinated contrast and ionizing radiation
Medical Management for PAD
- Smoking cessation
- Intensive antihypertensive therapy
What is Clopidogrel (plavix)
- Antithrombotic, blocking ADP receptors in platelets
- Treating and preventing stroke and MI with PAD
What is aspirin?
Antithrombotic, less effective than plavix
What is cilostazol (pletal) and what does it do?
Phosphoesterase inhibitor produces vasodilation, inhibits platelet aggregation, not to be used for pts with CHF
What is Pentoxifylline (trental) and what does it do?
Phosphoesterase inhibitor that improves blood flow through occluded areas and inhibits platelet aggregation, but does not improve walking distance as much as pletal
When does plavix have a better effect than aspirin?
For CVA, PAD, all patients
When is aspirin better than plavix?
For a MI
What is pletal favored for?
Improving claudication
What is plavix favored for?
Improving ischemia
Interventions
- Education
- Exercise protocol for PAD
- Home exercise
Exercise protocol for PAD
- 5 to 10 minute warm-up and cool-down each
- Treadmill or track walking
- Resistance exercise complementary, but not a substitute for walking
Intensity for exercise protocol for PAD
Sufficient to cause claudication within 3 to 5 minutes
Time for exercise protocol for PAD
Until moderately severe claudication reached
Rest for exercise protocol for PAD
Until claudication resolves in either sitting or standing
Plan (FITT)
- Frequency - 3 to 5 supervises sessions/week
- Intensity slowly increase by either speed or grade to reach claudication in 3 to 5 minutes
- Time: 35 building to 50 minutes of walking each session + warm-up/cool down
- Up to 6 months
- Type: treadmill or track walking
- OutcomesL 100-150% improvement in maximal walking distance and quality of life
Surgical interventions
- Critical limb ischemia or failure of conservative options
- Endovascular: placement of stent graft, usually for aneurysms
- Angioplasty with/without stents
- Thrombolysis
Bypass grafting options
- Aortoiliac/aortofemoral reconstruction
- Femoropopliteal bypass (above knee and below knee)
- Femorotibial bypass
What does stripping venous valves do?
Improves blood flow and decreases turbulence in the artery
Factors leading to CLI
- Diabetic micro angiopathy
- Atherosclerosis usually secondary to DM, HTN, or smoking
- CHF w/ severely decreased cardiac output
- Vasospastic diseases
- Smoking and other tobacco use
- Infection
- Skin and soft tissue injuries
Education intervention
- Effect of elevating legs
- Energy conservation
- Signs of other arterial disease: CAD, CVA, CRI
- Exercise program
What is diagnosis of PAD based on?
History and physical exam
