PAD - Peripheral Artery Disease √ Flashcards
What is PAD
Systemic Atherosclerosis of the extremities
What increases your chance of PAD
- Current smoker
- GFR < 60 mL/min
- Diabetes
- Hypertension
- Hypercholesterolemia
- Race (Black > White)
- ≥ 65
- 50- 64 with risk factors (diabetes, HTN, DSLIP,CKD, fam)
- < 50 with diabetes and risk factors
- Previous ACS event
What is ABI - ankle brachial index
Measure BP in both arms and ankle (2 spots)
Take the high pressure of each arm and leg
Leg SBP/ arm SBP
What do you see with acute limb ischemia
The 6 P
Pain
paralysis
Paresthesia (pins and needles)
Pulselessness
Poikilothermia (perishing cold)
Pallor (white of the skin)
6 Physical exam signs of PAD
- cool skin temperature,
- Cyanosis ( blueish discoloration of the skin)
- bruits (wooshing or blowing sound in artery)
- thickened toenails,
- muscle atrophy,
- lack of hair on the calf, feet, and/or toes
ABI reference range
.9 or lower is PAD
Lower is mor critical
Goal of treatment
Increase walking distance
improve QOL
Reduce risk of amputation
What is non pharm for PAD
Just like CAD
Quit smoking and exercise
MOST IMPORTANT IS EXERCISE 180% reduction
PAD exercise program supervised exercise
Some watches you walk for 30-45 mins
3 times a week for 6 months ideally
PAD exercise at home
Self directed with at least 6 months
Other comorbidity goals for PAD
lower BP
Lower lipids ≤50%, people with high risk factors get < 70
Glycemic control
PAD treatment therapy
What drug is given for asymptomatic PAD
Consider aspirin and work on nonpharm and other comorbidities
Symptomatic PAD with IC - intermittten claudication
Consider cilostazol
Symptomatic PAD all pts
Aspirin or clopidogrel
Or
Aspirin and Rivaroxaban
Why would you chose a Rivaroxaban combo for systematic PAD pts
Reduces MACE, cerebrovascular events and major limp events
BUT INCREASE BLEEDING
systematic PAD with recent stent or ACS
DAPT
Revascularization PAD surgery like CABG for ACS
Bypass
aspirin or clopidogrel or Rivaroxaban + aspirin
Revascularization PAD endovascular
Give a stent in the lower leg
DAPT then aspirin or clopidogrel or Rivaroxaban + aspirin
Duration of DAPT for lower leg stent
1-6 months
High risk limb loss PAD
lower leg CABG - give Rivo + aspirin or warfarin or DAPT
lower leg stent - consider longer duration of DAPT
What is high risk limb loss pt
Tissue loss
Prosthetic bypass
Poor artery run off
Which P2Y12 inhibitors can you use for PAD
Clopidogrel 75mg bid and ticagrelor 90mg bid
When is it okay to have a patient on Prasugrel for PAD
If they are on it from a ACS treatment
In PAD with P2Y12 is prefered
clopidogrel ( Plavix)
Cilostazol pro
Works really well for intermittent claudication pain
Increase maximum walking distance
Cilostazol cons
No quality of life benefit
X BB warning coexisting HF
D/C if no treatment in 3 months
Takes 2-4 weeks to improve
What is the Black box warning for Cilostazol
cant use in patients with HF
Indication for surgery PAD
Lack of response to exercise
Severe IC resulting from impaired daily activities
management of ALI
usually Need to immediately revascularize and start heparin therapy
ALI treatment tree
If you have complete sensory loss and muscle loss what do you do
nothing
