Hyperlipidemia: PAD Flashcards
PAD definition
progressive narrowing of arteries due to atherosclerosis
Primary indicator of PAD?
Intermittent claudication
Fatigue, discomfort, cramping, pain or numbness in affected extremities during exercise and resolves within a few minutes of rest
Critical Limb ischemia
chronic ischemia at-rest pain, ulcers, or gangrene in one or both legs
amputation ranges from 10-40%
PAD in males
increase with age
Black patients have highest incidence
PAD in females
increase with age
Black and Native American patients have highest incidence
At what age does incidence seem to jump for PAD?
Around age ~80
Global PAD rates
200 million pts worldwide
8.5 million pts in US
PAD risk factors (from greatest impact to least)
Smoking
Diabetes
HTN
Hypercholesterolemia
C-reactive protein
Black race
Clcr <60
Age >40
Risk factors for increased risk of Limb loss in pts w/ Critical Limb Ischemia
Factors that reduce blood flow to microvascular bed
Factors that increase demand for blood flow to the microvascular bed
Factors that reduce blood flow to microvascular bed?
Diabetes Renal Failure Decreased cardiac output (severe HF or shock) Smoking and tobacco use *Vasospastic diseases
Factors that increase demand for blood flow to microvascular bed?
Infection
Skin breakdown or traumatic injury
% of Asymptomatic patients with PAD?
50%
% PAD Signs and Symptoms
15% - Classic (Typical) Claudication
33% - Atypical Leg pain (functionally limited)
1-2% Critical Limb Ischemia
Claudication signs and symptoms
Ache or burning in leg muscles, or other pain after short exercise
Not present at rest
Critical Limb Ischaemia signs and symptoms
Pain at rest
Ulceration or Gangrene
Acute Limb-threatening ischemia signs and symptoms
Rare but important not to miss.
Sudden onset of symptoms
“6 P’s” = Pan at rest, pallor, Pulseless, Parasthesia, Paralysis, Perishingly cold
How to calculate ABI?
Highest ankle SBP / highest brachial SBP
Can be resting or post exercise
ABI 1.3-1.4, >1.4, then PAD is….
Likely
Artery too calcified to be compressible, need Toe Brachial Index
ABI 1 - 1.3, then PAD is…..
Not likely
ABI 0.91 - 0.99 then PAD is…
Maybe
ABI is < or equal to 0.9, or resting is normal but post exercise is <0.9 or >20% drop in ABI then PAD is…
Diagnosis for PAD
Mild PAD
Resting ABI <0.9 or post exercise <0.9
Moderate PAD
Resting ABI <0.7, or post exercise <0.5
Severe PAD
Resting ABI <0.5, or post exercise <0.15
Goals in treating patients with PAD
Limb outcomes:
Improved ability to walk (measure in distance before get symptoms)
Prevention of progression to CLI and amputation
CVD morbidity and mortality outcomes
Confirmed PAD -> No sig functional disability…..
no treatment require
annual follow up to monitor
Confirmed PAD -> Life style limiting symptoms……
Supervised exercise program for 3 months
+
Drug therapy 3 months (anti platelet) + Cilostazole if claudication present
IF significant disability despite therapy, Endovascular therapy or bypass surgery might be required
Confirmed PAD -> Life style limiting symptoms w/ evidence of inflow disease….
Use more extensive noninvasive or angiographic diagnostic techniques
Endovascular therapy or surgical bypass based on findings
Nonpharmacological Therapy of PAD
Stop smoking
Supervised Exercise (3 times per week for 30-45 min)
Follow NCEP ATP III, DASH, or TLC
*Revascularization Therapy in advanced patients
Supervised Exercise Therapy
Frequency: 3-5 times/week Duration: 36-45 min Type: treadmill, track walking, etc Length: > 3 months Results: 100-150% increase in QOL and distance they can walk
Revascularization Procedures for PAD
Endovascular:
PTA, Stent
Surgical:
Bypass, reconstruction
Antiplatelets based off guidelines
- ASA = Best Data
- Aggrenox = as effective as ASA but more SE
- Clopidogrel = 1st line but only when cant do ASA
- Ticlopidine = Black box, do not use
Cilostazol (Pletal) info
Platelet aggregation inhib
Vasodilation
inc HDL 10%
dec TG 15%
Cilostazol Contraindications
HF (increased mortality)*****
Active Bleedings
Pentoxifylline (Trental)
not recommended
Less effective than cilostazole
Drug w/ goal to reduce ischemic events
ASA or Clopidogrel
Drug w/ goal to improve claudication symptoms
Cilostazol
PAD guidelines w/ Hyperlipidemia
Statins = yes
PAD guidelines w/ HTN
ACEi may offer added protection
PAD guidelines w/ Smoking
Help stop smoking
PAD guidelines w/ Diabetes
Treat DM to goals
PAD guidelines w/ Antiplatelets
PAD symptoms: Antiplatelets = good, ASA 1st or clopidogrel if not
NO PAD symptoms: ABI <0.9 = Antiplatelets
Eval for Amputation if….
Sig necrosis of weight-bearing portion of foot
Paresis of extremity
Refractory ischemic rest pain
Sepsis
Limited life expectancy
Angioplasty ok if…
life expectancy <2yr or cant do bypass
Bypass option if….
life expectancy >2yrs
better life expectancy but higher risk
