PAD

Question 1

Clinical Presentation of PAD

Answer 1

-No sx
-Intermittent Claudication: fatigue, discomfort, cramping, numbness
-Pain at rest

Physical exam may show:
-cool skin temperature
-cyanosis, bruits
-thickened toenails
-muscle atrophy
-lack of hair on the calf, feet, and/or toes

Question 2

Ankle – Brachial Index (ABI)

Answer 2

• Quick, non-invasive way to diagnose PAD
• Measure BP in both arms and both ankles
• Steps to calculating the ABI for each leg:
  -Determine highest brachial pressure (left or right)
  -Determine hight ankle pressure for each leg (PTA or DPA)
  -Divide the highest ankle pressure on each side by the highest overall brachial pressure
  -Up to 0.9 = PAD (0-0.9)

Question 3

Nonpharmacologic Therapy

Answer 3

-Smoking cessation
-Exercise (walking)
-Treatment of major risk factors (diabetes, lipids, BP)

Question 4

ASYMPTOMATIC TX

Answer 4

ASYMPTOMATIC
-Consider aspirin

Question 5

SYMPTOMATIC TX

Answer 5

SYMPTOMATIC
-Consider cilostazol (IC pain)
-ALL: aspirin or clopidogrel, or aspirin + rivaroxaban
-Stent or ACS: dual antiplatelet therapy

Question 6

REVASC TX

Answer 6

REVASCULARIZATION
-Endovascular: DAPT for 1-6 mo
-Surgical + after endo: aspirin or clop OR aspirin + rivaroxaban
-High limb risk: Intensify therapy (aspirin + riva + warfarin + DAPT)

Question 7

Clopidogrel (plavix)

Answer 7

Really only P2Y12 for PAD

DDI: Avoid omeprazole/esomeprazole, use pantoprazole or H2RA
– Use PPIs only if GI bleed risk

Genetic variability

Question 8

Platelet reactivity units (PRU) of _____ is the suggested “target” or “goal” to reduce ischemic risk

Answer 8

< 230

Question 9

Ticagrelor (Brilinta)

Answer 9

-Not yet indicated PAD
-Data looks promising for prevention of limb events in PAD

Question 10

Rivaroxaban

Answer 10

PAD s/p previous limb arterial surgery, bypass, or PTCA, previous limb or foot amputation, or IC with ABI < 0.9 or peripheral artery stenosis ≥ 50%

Dose: 2.5 mg PO BID (+ aspirin)

Question 11

Cilostazol

Answer 11

-Used for sx management in IC

-Dose: 100 mg PO BID

-2-4 weeks but can take 12 weeks for improvement

-DC if no improvement after 3 months

-CI in HF (BBW)

Question 12

Management of Acute Limb Ischemia

Answer 12

– Amputation or urgent /
emergent revascularization
– Underlying anticoagulation (systemic heparin tx)

*this is a severe case: paralysis, can’t move, severe sx, etc