PAD 1 - Exam 3 Flashcards
What is PAD (peripheral arterial disease)? What is commonly caused by? Where?
The presence of a stenosis or occlusion in the aorta or arteries of the limbs
Commonly caused by atherosclerosis in patients >40 y/o
MC in the lower extremities
What does PAD increase your risk for?
Associated with increased risk of cardiovascular and cerebrovascular events, including MI, stroke, and death
**What are the two primary sites for PAD? What age?
femoral and popliteal arteries
Most common in ≥ age 60 with even gender distribution, commonly affects blacks and hispanics
_____ and ____arteries are most common in diabetic and elderly patients
Tibial and peroneal arteries
______ and _____ arteries are MC in 50-60 white male smokers
Abdominal aorta and iliac arteries
**PAD lesions typically present at the _______. Why?
bifurcation of the artery
due to increased turbulence, stress and intimal injury
Overall prevalence of PAD is 30% in patients who are:
_____ without risk factors
______ with risk factors present
≥70 y/o w/o risk factors
≥50 y/o with risk factors
According to ACC/AHA who needs to be evaluated for PAD?
≥70 y/o
50-69 y/o with h/o smoking or DM
40-49 with DM and ≥ 1 other risk factor for atherosclerosis
Known atherosclerosis at other sites (coronary, carotid, renal, mesenteric or AAA)
What are the risk factors for PAD? **What are the 2 highlighted ones?
Smoking**
Diabetes Mellitus**
Hypercholesterolemia
Hypertension
Renal Insufficiency
_____ is the most typical symptom of PAD. When does it occur? Can you trigger it? When will the s/s resolve?
claudication
occurs during exercise and is relieved by rest
yes! s/s are reproducible
Symptoms completely resolve within ~10 minutes of exercise cessation
What is another name for pseudoclaudication? What are 2 common causes?
neurogenic claudication
Spinal canal stenosis
Herniated disc impingement on sciatic nerve
How can you tell claudication apart from pseudoclaudication?
Patients with tibial and pedal artery disease may not have _____. ____ and _____ may be the first sign of vascular insufficiency
claudication
rest pain or ulceration
Pts who have tibial and pedal artery disease may have rest pain to the _______. What makes it better? What can it progress to?
dorsum of the foot
dependency: putting the foot down and letting it dangle below the level of the body
Can progress to chronic limb threatening ischemia
What is Chronic Limb Threatening Ischemia (CLTI)? How long specifically? Who is the MC patient?
presence of PAD in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration
diabetic pts
______ is the most commonly used classification system for PAD. What is the classification system based on?
Trans-Atlantic Inter-Society Consensus (TASC II)
anatomic distribution of lesions
_____ and ____ classifications are used to stratify clinical severity. _____ has replaced both previously mentioned systems
Rutherford classification
Fontaine classification
Society for Vascular Surgery (SVS) Lower Extremity Threatened Limb Classification System to Stratify Amputation Risk, Wound, Ischemia and foot Infection (WIfI)
What needs to be included in the PE if you suspect PAD?
**pulses: ALL OF THEM
BP in both arms
CV exam
abdomen: AAA for bruits
**skin: legs and feet
especially need to check pulses and skin
What are the grading system for pulses?
What are the classic PE findings for PAD? May need to use _____ to evaluate
-Decreased or absent pulses DISTAL to the obstruction
-reduced skin temp
-smooth, shiny skin
-ulcerations
-distal hair loss, typically over ankles
-thickened nails
-calf atrophy
-charcot arthropathy
hand-held doppler
What is PE test that can be performed in the office to test for PAD? What is a positive result?
leg lift test
Elevate leg to 60° for 1 minute
(+) test = pallor occurs if arterial pressure is not adequate to overcome gravity
What is dependent rubor? Why does it happen?
Red, dusky color in feet when in dependent position (i.e. such as feet hanging off bed)
Occurs due to damaged vessels and chronic dilation - unable to respond appropriately
T/F: the faster the dependent rubor forms the worse severity of the PAD
TRUE!
faster it forms the worse the PAD is
Can you dx PAD clinically? What can you order?
yes, combo of risk factors and s/s of PAD is sufficient to dx. most people will order ABI
ABI: ankle brachial index
What are the non-invasive imaging options for PAD?
**______ is the best screening tool for PAD
ankle brachial index
**Majority of the time, ______, ______ , and _______ will make the clinical diagnosis of PAD and no additional testing is warranted. When would you need to order additional testing?
ABI
+history
+physical exam
ABI shows false negative or if invasive intervention is planned
according to guidelines, patient with history or physical exam findings suggestive of PAD, ________. Patient at increased risk of PAD but WITHOUT H&P findings suggestive of PAD, _______
ABI is recommended
ABI is reasonable
Describe an ABI
Involves placement of sphygmomanometric cuffs at the ankles and the use of a Doppler device to auscultate or record blood flow from the dorsalis pedis and posterior tibial arteries
aka take BP at ankles and normal BP at arms
**Draw the ABI interpretation chart?
What is the formula to calculate the ABI? What is considered normal?
highest SBP posterior tibial or dorsalis pedis reading/ highest brachial SBP
aka highest ankle/ highest arm
ABI (normal >0.90)
What are 4 types of patients that commonly have incompressible arteries?
Elderly patients
patients with diabetes
renal failure
patients on chronic steroids
What are 2 things that ABIs do NOT do?
Not designed to define degree of functional limitation
Does not define location of disease
What is the average ABI for a pt who has claudication? rest pain? tissue loss/ulcer/gangrene?
Claudication: 0.4 and 0.9
Rest pain: 0.2 to 0.4
Tissue loss (ulcer, gangrene): 0 to 0.4
When is toe brachial index helpful? **What value is considered abnormal and diagnostic for PAD?
useful when ABI is >1.40 (non-compressible)
TBI < 0.70 is abnormal and diagnostic of PAD
What is the formula for TBI? What does a higher value predict?
higher TBI predicts better healing
What does the treadmill exercise test assess? When is it used?
Assesses functional capacity by measuring the distance a claudicator can walk at baseline
Can be used if symptoms typical for claudication but resting ABI normal
Can be used if symptoms are atypical for claudication but patient has PAD
When can you NOT use a treadmill exercise test?
Patient has non-compressible vessels
Cannot walk on treadmill (unstable angina, gait instability, etc.)
What is the treadmill exercise test procedure?
the the pt resumes supine position and ABI measurements taken q 1-2 minutes until they reach pre-exercise level
**What treadmill exercise test result is diagnostic for PAD?
A decrease in ABI of more than 20% immediately following exercise is diagnostic of PAD
What is the segmental limb pressure procedure? **What result suggests arterial disease?
Cuffs placed on:
Thigh (upper and lower), Calf, Ankle, Transmetatarsal region of foot, Digit
Using a Doppler probe, the pressure at each segment is measured
**A decrease between two consecutive levels of >30 mmHg suggests arterial disease of the artery proximal to the cuff
Segmental limb pressure or ABI provides more information regarding PAD?
segmental limb pressure provides more specific information that ABI alone
_______ is first line ADDITIONAL imaging for PAD. What can it be useful in determining? especially if???
Arterial Duplex
determining the SEVERITY of disease and CONFIRMING PE findings
Useful if intervention is being considered to assess risk/benefit ratio
______ should have a MINIMAL role for screening pts for PAD
arterial duplex
MRA: not used for screening. consider when surgical intervention is needed
Computed Tomographic Angiography (CTA)
_______ provides an excellent arterial picture without using ionizing radiation. Gadolinium cannot be used if ______
Magnetic Resonance Angiography (MRA)
if GFR is less than 30ml/min
**Which PAD test that should be considered for sx is necessary requires iodinated contrast?
Computed Tomographic Angiography (CTA)
**What is the gold standard imaging option in PAD? **What is it used for?
Digital Subtraction Angiography (DSA)
Used primarily to guide intervention
What are the PAD risk factor modifications?
Antiplatelet therapy (Plavix or ASA)
Smoking Cessation
Lipid-lowering therapy
Glycemic control
Blood pressure control
Diet and exercise
Obesity
What is the tx for symptomatic PAD regarding atiplatelets? Asymptomatic PAD with mild PAD (ABI < 0.90)?
Antiplatelet therapy with ASA alone (75 mg to 325 mg per day) or Clopidogrel alone
antiplatelet therapy is reasonable
is DAPT recommended in symptomatic PAD?
DAPT (ASA and clopidogrel) in patients with symptomatic PAD is not well established
______ is super important in PAD and needs to be discussed at EVERY visit
smoking cessation
What is the complete tx for symptomatic PAD?
ASA or plavix
statin
+/- Ace
+/- Cilostazol if claudication is present
strict glycemic control in diabetic patients
______ is PAD specific pharm to help improve claudication
Cilostazol (Pletal)
_____ MOA inhibits phosphodiesterase activity and suppress degradation of cAMP resulting in an increase in cAMP in platelets and blood vessels. Has both ____ and ____ properties
Cilostazol (Pletal)
Has vasodilator & antiplatelet properties
** When is cilostazol CI? **What is the pt education?
Contraindicated to use in patient with heart failure of any severity
Medication is protein bound → advise patient to take drug at least 30 min before or 2 h after a meal
What is the exercise therapy recommendations for intermittent claudication?
3-5 x week for 35-50 minutes of walking for at LEAST 6 months
When is surgical bypass indicated in PAD?
indicated in patients with continued intermittent claudication sx’s despite other therapies or in patients with critical limb ischemia
What are the endovascular therapies in PAD?
Angioplasty
Stenting
Atherectomy
need to tx ulcers and gangrene if present
If pt has s/s of PAD but ABI is normal, what do you do next?
exercise ABI
