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Cardiovascular > PAD pt 1 > Flashcards

PAD pt 1 Flashcards

1
Q

The presence of a stenosis or occlusion in the aorta or arteries of the limbs

A

Peripheral Arterial Disease (PAD)

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2
Q

Peripheral Arterial Disease (PAD) is MCC by?

A

atherosclerosis in >40 y/o

Other potential causes: thrombosis, embolism, vasculitis, fibromuscular dysplasia, entrapment, cystic adventitial disease, and trauma

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3
Q

PAD can occur in any limb but MC affects ?

A

lower extremities

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4
Q

Clinical Manifestations of PAD

A
  1. Carotid Artery Disease
    - TIA
    - Cerebrovascular accident
  2. CAD
    - stable angina pectoris
    - ACS
  3. Renovascular Disease
    - HTN
    - renal insufficiency
  4. PAD
    - intermittent claudication
    - critical limb ischemia

Associated with increased risk of CV and cerebrovascular events (MI, stroke, death)

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5
Q

pathology of PAD

A
  1. Atherosclerotic plaques with calcium deposits
  2. Thinning of the media
  3. Patchy destruction of muscle and elastic fibers
  4. Fragmentation of internal elastic lamina
  5. Thrombus development
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6
Q

Segmental lesions in PAD typically localized to what type of vessels

A

large or medium-size vessels

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7
Q

Primary sites where PAD is involved:

A
  • Abdominal aorta and iliac arteries (30% of sx pts)
  • Femoral and popliteal arteries (80-90% of pt)
  • Tibial and peroneal arteries (40-50% of pt)
  • Lesions at arterial branch points - D/t increased turbulence, altered shear stress, & intimal injury
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8
Q

Risk Factors for PAD

A
  • Smoking
  • Diabetes Mellitus
  • Hypercholesterolemia
  • Hypertension
  • Renal Insufficiency
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9
Q

Prevalence of PAD is 30% for patients who are what ages?

A
  • ≥70 y/o without RF
  • ≥50 y/o with RF present
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10
Q

ACC/AHA recommends patients in the following categories be evaluated for PAD:

A
  • ≥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)
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11
Q

The location of atherosclerosis has its own population demographic, name the 3:

A
  1. Distal aorta & proximal common iliac (30% of symptomatic pts)
    - White, male smokers aged 50-60 years
  2. Femoral-popliteal (80-90%)
    - ≥ age 60, no gender
    - Blacks and Hispanics
  3. Tibial artery (40-50%)
    - MC DM and elderly
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12
Q

PAD Clinical Presentations

A
  1. asx (20-50%)
  2. atypical leg pain (40-50%)
  3. classic claudication (10-35%)
  4. critical limb ischemia (1-2%)
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13
Q

Most typical symptom of PAD
pain, aching, cramping, numbness, or muscle fatigue that occurs during exercise and is relieved by rest within 10 min of cessation

A

intermittent claudication

Can occur in the buttocks, thigh, calf or foot depending on level of vessel occlusion - occur distal to sight of occlusive lesion

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14
Q

Beware of ___, which can mimic true PAD induced claudication

A

pseudoclaudication/neurogenic claudication

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15
Q

MCC of neurogenic claudication

A
  1. Spinal canal stenosis
  2. Herniated disc impingement on sciatic nerve
  3. Other: Peripheral neuropathy, peripheral nerve pain, OA of the hip/knee, venous claudication, chronic compartment syndrome
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16
Q
  • Same, tingling, burning, numbness
  • locations of discomfort is the same
  • Sometimes exercised induced
  • distance of claudication is variable
  • Occurs with standing
  • Relieved when sitting, or change position
  • Takes up to 30 minutes

what type of claudication

A

Pseudoclaudication

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17
Q
  • Cramping, tightness, aching, fatigue
  • Location of discomfort usually buttock, hip, thigh, calf, foot
  • Always induced by exerise
  • Distance of discomfort is consistent
  • Does not occur with standing
  • Relieved while standing
  • Relieved in less than 5 minutes

what type of claudication

A

actual claudication

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18
Q

PAD patients with tibial and pedal artery disease may do not have claudication, what other signs may they present?

A
  • Rest pain / ulceration may be the first sign of vascular insufficiency
  • Classically, rest pain is confined to the dorsum of the foot and is relieved with dependency
  • Can progress to critical limb ischemia
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19
Q

Clinical Classification systems for PAD is based on ____
What are these systems?

A

anatomic distribution of lesions

  • Trans-Atlantic Inter-Society Consensus (TASC II) - MC
  • Global Limb Anatomic Staging System (GLASS) Classification - Has yet to be validated
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20
Q

Limb Staging in Chronic Lower Extremity Ischemia

A
  • 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) - Has replaced Rutherford and Fontaine
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21
Q

how to approach a suspected PAD pt

A
  • Pulse exam - Carotid, Brachial, Radial/Ulnar, Femoral, Popliteal, Dorsalis pedis, Posterior tibial
  • PE - BP in bilateral arms, CV, Abdomen (AAA), auscultation for bruits, skin (legs & feet)
  • Skin temperature with dorsum of hand
  • Skin visualization
  • Hair distribution
  • Nails
  • Lower extremity musculature (measure leg circumference for accuracy)
  • Bony anatomy of feet
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22
Q

grading of pulses

A
  • 3+ Bounding
  • 2+ brisk, expected (normal)
  • 1+ diminished, weaker than expected
  • 0 absent, unable to palpate
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23
Q

Classic finding of pulse eval in PAD

A

Decreased or absent pulses distal to the obstruction

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24
Q

PE findings in PAD

A
  • Reduced skin temp / cool
  • Smooth, shiny with pallor or cyanosis; ulceration
  • Distal hair loss, typically over ankles, calves
  • Thickened
  • Calf atrophy
  • Abnormality, especially in diabetics (charcot arthropathy)
  • Leg lift test - pallor occurs if arterial pressure is not adequate to overcome gravity
  • Dependent rubor
25
Q

what is the leg lift test

A
  • Elevate leg to 60° for 1 minute
  • (+) test = pallor occurs if arterial pressure is not adequate to overcome gravity
  • Repetitive dorsiflexion and plantar flexion of the foot may precipitate pallor of the sole of the foot
26
Q

how to assess for dependent rubor

A
  • Evaluate when pt becomes seated after being supine
  • Qualitatively assesses collateral blood flow
  • Time to the development of dependent rubor is indicative of severity of PAD
27
Q

best screening tool for PAD is ?

A

Ankle Brachial Index

  • Objective assessment of the presence and severity of disease
  • Easily performed with no risk to patient
  • Can be performed at bedside
  • placement of sphygmomanometric cuffs at ankles and use of a Doppler to auscultate or record blood flow from dorsalis pedis and posterior tibial arteries
28
Q

how to dx PAD?

A

MC - ABI + H&P

Further testing is only needed if ABI shows false negative or if invasive intervention is planned

29
Q

Who Should Be Screened for PAD

A
  • Pt with H&P findings suggestive of PAD, ABI is recommended (Class I LOE B)
  • Pt at increased risk of PAD but without H&P findings suggestive of PAD, ABI is reasonable (Class IIa, LOE B)
29
Q

interpretations of ABI

A
  • > 1.40 - Non-compressible vessel
  • 1.40 - 1.00 - Normal
  • 0.99 - 0.91 - Borderline
  • 0.90 - 0.70 - Diagnostic of PAD / Mild
  • 0.69 - 0.40 - Moderate
  • <0.40 - Severe
30
Q

ABI Limitations

A
  1. Incompressible arteries
  2. Resting ABI may be insensitive or in pts who are well collateralized
    - Normal resting values in symptomatic pts may become abnormal after exercise
  3. Not for degree of functional limitation
  4. Does not define location of disease
31
Q

What type of pts may have incompressible arteries that limit for use of ABI

A
  • Elderly
  • diabetes
  • renal failure
  • patients on chronic steroids
32
Q

types of noninvasive imaging

A
  1. toe brachial index (TBI)
  2. treadmill exercise test
  3. segmental limb pressure
  4. Arterial Duplex Ultrasonography
  5. MR Angiogram (MRA) & CT Angiography (CTA)
33
Q
  • Screening – useful when ABI is >1.40 (non-compressible) - Digital vessels spared from medial arterial disease
  • Helps predict wound healing

what noninvasive imaging is this

A

TBI

34
Q

interpretations of TBI

A
  • Higher values predict better healing
  • TBI = (Toe systolic pressure)/(Highest brachial systolic pressure)

TBI <= 0.70 = abnormal and dx of PAD

35
Q
  • Assesses functional capacity
  • Measures the distance a claudicator can walk at baseline
  • Can clarify if a patient’s sx are related to PAD - typical sx but resting ABI normal; atypical sx but patient has PAD

what noninvasive imaging is this

A

Treadmill Exercise Test

36
Q

when to not use Treadmill Exercise Test

A
  • non-compressible vessels
  • Cannot walk on treadmill (unstable angina, gait instability, etc.)
37
Q

Patient then walks on a treadmill for the treadmill exercise test until:

A
  • Maximally tolerated claudication symptoms occur
  • Test must be stopped secondary to other cause (SOB, chest pain, joint pain, etc.)
  • If neither of the above occur, then test stopped when patient reaches high functioning end point
38
Q

interpretation of treadmill exercise test procedure

A

After walking, patient resumes supine position and ABI measurements taken every 1-2 min until they reach pre-exercise level

A decrease in ABI of >20% immediately following exercise is diagnostic of PAD

39
Q
  • Can obtain more specific information than ABI alone
  • 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

what noninvasive imaging is this

A

Segmental Limb Pressure

40
Q

interpretation of Segmental Limb Pressure

A

decrease between two consecutive levels of >30 mmHg suggests arterial disease of the artery proximal to the cuff

41
Q
  • Use of ultrasound to map blood flow through lower extremities
  • Determines severity of disease (stenosis vs occlusion) and confirming PE findings
  • Useful if intervention is being considered to assess risk/benefit ratio
  • Should have minimal role in screening pts

what noninvasive imaging is this

A

Arterial Duplex

42
Q
  • Excellent arterial picture
  • No ionizing radiation
  • Non-iodine-based intravenous contrast medium rarely causes renal insufficiency or allergic reaction
  • Not used for screening! Should be considered when surgical intervention is considered

what noninvasive imaging is this

A

Magnetic Resonance Angiography (MRA)

43
Q

Magnetic Resonance Angiography (MRA) is not a good option for these types of pts

A

claustrophobia
pacemaker/implantable cardioverter-defibrillator
obesity

44
Q

Use of gadolinium in patients with chronic kidney disease can result in ?

A

nephrogenic systemic fibrosis (NSF)

Gadolinium cannot be used if GFR < 30 ml/min

45
Q
  • Requires iodinated contrast
  • Requires ionizing radiation
  • Produces an excellent arterial picture
  • Not used for screening! Should be considered when surgical intervention is considered

what noninvasive imaging is this

A

Computed Tomographic Angiography (CTA)

46
Q

Gold standard for peripheral vascular imaging

A

Digital Subtraction Angiography (DSA)

Used primarily to guide intervention

47
Q

Risk Factor Modification for PAD

A
  • Antiplatelet therapy
  • Smoking Cessation
  • Lipid-lowering therapy
  • Glycemic control
  • Blood pressure control
  • Diet and exercise
  • Obesity

PAD is a coronary heart disease risk equivalent

48
Q

TX for PAD

A
  1. Antiplatelets - ASA/Clopidogrel
    - sx atherosclerotic LE PAD
    - asx pt with PAD
    - asx pt with borderline ABI
  2. smoking cessation
  3. ACEI
  4. Statin
  5. Glucose control in DM
  6. Specific PAD pharm - Cilostazol (Pletal)
  7. Exercise therapy for intermittent claudication
  8. Invasive tx
    - surgical bypass
    - Endovascular Therapy
49
Q

smoking cessation is recommended for PAD as it decreases the likelihood of:

A
  • Amputation
  • Need for revascularization
  • Failure of arterial bypass grafts

Improves pain-free and maximal walking times
Improves survival

50
Q

indications for Cilostazol (Pletal)

A

Effective therapy to improve sx (Class I, LOE A) - Improves claudication distance by 40-60%

51
Q

MOA of cilostazol (pletal)

A

Has vasodilator & antiplatelet properties

  1. inhibits phosphodiesterase activity and suppress degradation of cAMP resulting in an increase in cAMP in platelets and blood vessels
    - reversibly inhibits platelet aggregation induced by ADP, collagen, arachidonic acid, epinephrine, thromboxane A2, platelet activating factor, and shear stress
    - vasodilation, with greater dilation in femoral beds than in vertebral, carotid, or superior mesenteric arteries, but without effect in renal arteries
52
Q

CI of Cilostazol (Pletal)

A

heart failure of any severity

53
Q

SE of Cilostazol (Pletal)

A

edema, GI upset, dizziness, HA, palpitations, bleeding

54
Q

PK of Cilostazol (Pletal)

A
  • No dose adjustments for CKD or liver failure
  • protein bound → advised to take drug 30 min before or 2 h after a meal
55
Q

Exercise Therapy for Intermittent Claudication

A
  • Aimed at improving walking distance and quality of life
  • Frequency: 3-5 supervised sessions/week
  • Duration: 35 to 50 minutes of exercise/session
  • Type of exercise: treadmill or track walking to near-maximal claudication pain
  • Length: 6 months or more
  • Results: 100%-150% improvement in maximal walking distance
56
Q

Bypass grafts with prosthetic material or native veins has good long-term outcomes with durability

what invasive PAD tx is this

A

Surgical Bypass

57
Q

Ways for Endovascular Therapy

A
  1. Multiple treatment strategies available
    - Angioplasty
    - Stenting
    - Atherectomy
58
Q

indications for invasive PAD tx?

A

Surgical Bypass & Endovascular Therapy

continued intermittent claudication sx’s despite other therapies or in patients with critical limb ischemia

Cardiovascular (24 decks)

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