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Cardiology (Fall 2023) > Lecture 15: PAD Part 1 > Flashcards

Lecture 15: PAD Part 1 Flashcards

1
Q

What is PAD?

A

Stenosis or occlusion in the aorta or arteries in the limbs

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2
Q

MCC of PAD

A

Atherosclerosis in patients > 40y

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3
Q

Hallmark sign of PAD

A

Intermittent claudication

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4
Q

What kind of vessels does PAD tend to affect?

A

Middle-large size vessels

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5
Q

MCC two arteries affected in PAD

A

Femoral and popliteal arteries

Esp at arterial branch points/bifurcations

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6
Q

Strongest risk factors for PAD

A
  1. DM
  2. Smoking
  3. Hypercholesterolemia
  4. HTN
  5. Renal insufficiency

1st two are most important

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7
Q

Who gets evaluated for PAD?

A
  1. > =70
  2. 50-69 w/ smoking or DM
  3. 40-49 w/ DM and additional risk factor
  4. Anyone with known atherosclerosis
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8
Q

MC sites of atherosclerosis in PAD and their respective demographics

A
  1. Femoral-popliteal - >60 y/o
  2. Tibial artery - MC in DM and elderly
  3. Distal aorta and proximal common iliac disease - white male smokers aged 50-60
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9
Q

What are the common clinical presentations for PAD?

A
  1. Asymptomatic
  2. Atypical leg pain (MC)
  3. Classic claudication
  4. Critical limb ischemia
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10
Q

Describe claudication.

A
  • Occurs during exercise and relieved with rest
  • Reproducible symptom
  • The most typical symptom of PAD.
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11
Q

2 MCC of pseudoclaudication/neurogenic claudication

A
  • Spinal cord stenosis
  • Herniated disc impairment or scaiatic nerve
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12
Q

Claudication vs pseudoclaudication chart

characteristic
exercise induced
occurs with standing
action for relief
time to relief

A
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13
Q

What is often the first sign of vascular insufficiency in PAD?

A

Rest pain or ulceration that is confined to the dorsum of the foot and requires dependency.

Often occurs at night.

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14
Q

What characterizes critical limb ischemia?

A
  • Ischemic rest pain
  • Ulceration
  • Gangrene

ischemic rest pain = pain at night so they hang their legs off the bed

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15
Q

What is the MC anatomic classification scale used in PAD?

A

Trans-Atlantic Inter-Society Consensus (TASC II)

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16
Q

What classification is used for clinical severity of chronic lower extremity ischemia?

A

WIfI (Wound, ischemia, and foot infection)

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17
Q

Classic findings in patients with PAD

A
  • Decreased or absent pulses distal to the obstruction
  • May need to use hand-held doppler
18
Q

What are normal pulses graded as on PE?

A

2+, brisk, expected

19
Q

Berger test for PAD

A
  1. Elevate leg to 60deg for 1 minute
  2. Positive if pallor occurs since arterial pressure is lacking.
  3. Extremely positive if dependent rubor also occurs (when u drop the foot back down and it gets extremely red)
20
Q

First-line screening for PAD

A

Ankle brachial index test

21
Q

When is further testing of PAD required?

A

Only if ABI is a false negative or invasive interventions are needed.

Otherwise, it is a clinical diagnosis.

22
Q

How to diagnose PAD

A

Clinically, only need ABI + history + PE

23
Q

What is diagnostic of PAD on ABI?

A

Anything less than 0.9

24
Q

How do you measure ABI?

A

High brachial SBP divided by highest SBP of PT or DP

Must do ABI on each side.

PT = posterior tibial
DP = dorsalis pedis

25
Q

Limitations of ABI

A
  • Incompressible arteries (> 1.4)
  • Resting may be useless if good collateral circulation was made
  • Does not measure the degree or severity or location of PAD.
26
Q

When do we do toe brachial index screening?

A

When ABI > 1.40

27
Q

What is abnormal/diagnostic TBI?

A

TBI <= 0.7 = PAD

28
Q

What do TBIs predict?

A

Better value = better healing

29
Q

When can you not use a treadmill test for PAD?

A
  • Non-compressible vessels
  • Cannot walk on a treadmill (unstable angina, etc)
30
Q

What is diagnostic of PAD for treadmill stress tests?

A

Decrease in ABI of more than 20% following exercise.

31
Q

What is segmental limb pressure used for?

A

Specific location of artery that has PAD, which is diagnosed by a decrease of >30 mm Hg between two consecutive segments.

32
Q

What is arterial duplex mainly used for?

A

Determining severity and to assess risk/benefit for intervention.

Never use as a screening tool!!!!!!!!!!

33
Q

When is MRA indicated and what is the primary CI?

A

MRA is indicated to assess benefit of surgery and gadolinium cannot be used in ppl with GFR < 30

Does not use ionizing radiation or ionized contrast

NOT SCREENING TEST

34
Q

Difference between MRA and CTA

A

CTA uses iodinated contrast and ionized radiation.

35
Q

What is the gold standard imaging for PAD?

A

Digital subtraction angiography (DSA)

Done by IR to guide intervention.

36
Q

What two antiplatelets are indicated for PAD?

A

ASA alone or plavix alone for symptomatic atherosclerotic lower extremity PAD

Only reasonable for asymptomatic

Do not do DAPT until they have had intervention.

37
Q

What should you advise a patient on EVERY SINGLE VISIT for PAD?

A

Smoking cessation

38
Q

What is the MOA and indication for cilostazol?

A
  • Vasodilator + antiplatelet that improves symptoms in PAD.
  • suppresses cAMP break down causes increased levels of cAMP
  • Protein-bound (can’t eat with food)
  • No vasodilation in renal arteries
  • PDE inhibitor

100mg PO BID

39
Q

Who is cilostazol CId in?

A

Heart failure patients

40
Q

When is bypass indicated for PAD?

A

Continued intermittent claudication sx’s or CLI.

41
Q

What are the 3 types of endovascular therapy?

A
  • Angioplasty
  • Stenting
  • Atherectomy

Cardiology (Fall 2023) (45 decks)

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