Peripheral Artery Disease Cases

Question 1

What to ask about pt history in interview for peripheral artery disease?

Answer 1

Describe the pain: Location, severity, exacerbating and alleviating factors
Has it happened before?
What is he/she doing?
How long did it last?
Does the patient have any other medical history?
What medications do they take?
Do they smoke tobacco?
Family history?

Question 2

What is intermittent claudication?

Answer 2

• pain caused by too little blood flow during exercise
• Cramping, tightness, fatigue
• Involves buttock, hip, thigh, calf, foot usually
• Exercised-induced - does not occur when standing

Question 3

What relieves intermittent claudication?

Answer 3

Relieved by rest (Usually within 5 minutes)

Question 4

What pt present with classic intermittent claudicaiton?

Answer 4

Only ~ 1/3 of the PAD patients experience classic IC and the remaining have either atypical symptoms or are asymptomatic

Question 5

PAD is as serious as CAD, what are CAD pt almost always told to do that PAD pts are not?

Answer 5

EXERCISE!!!! it can help with PAD just as much as CAD

Question 6

What is the mortality rate of PAD?

Answer 6

32% over a period of 10 years - which is pretty darn high

Question 7

What should you look for in physical exam for a pt with PAD?

Answer 7

1. Auscultate the abdomen, femoral arteries, for the presence of bruits
2. Palpate for the presence of an abdominal aortic aneurysm
3. Palpate the femoral, popliteal, posterior tibial, and dorsalis pedis pulses
4. Inspect the feet for ulcers, fissures, calluses, tinea, tendinous xanthomas, and evaluate overall skin care

Question 8

How do you grade pulses?

Answer 8

• normal: 2
• diminished: 1
• absent: 0

Question 9

What should you visually inspect on a pt with PAD?

Answer 9

• Hair loss
• Thickened and brittle toenails
• Smooth and shiny skin
• Subcutaneous fat atrophy
• muscle atrophy
• Skin fissures
• Ulceration
• Gangrene

Question 10

When would you find pallor in pt with PAD?

Answer 10

in the supine position or with elevation = not good

Question 11

PAD can have dependent rubor what is that?

Answer 11

Filling of dilated skin capillaries with deoxygenated blood

Question 12

What non-invasive evaluation should be done with PAD pts?

Answer 12

Ankle-Brachial Index**
Ankle-Toe Index**
Exercise treadmill testing
Segmental limb pressures

Question 13

What is ankle brachial index?

Answer 13

ratio of ankle systolic pressure to brachial artery systolic pressure. the ratio correlates with severity of disease: the lower the ABI the higher the mortality

Question 14

How can you treat a pt with PAD?

Answer 14

• Risk factor modification
• Exercise
• Antiplatelet therapy
• RBC rheology modifiers
• Phosphodiesterase inhibitors
• Percutaneous vs Surgical

Question 15

Overall treatment goal for pt with PAD?

Answer 15

Decrease risk factors!!!!

• smoking
• lipid control
• BP control
• diabetes control
• exercise
• ideal body weight

Question 16

How much does cigarette smoking increase your risk of PAD?

Answer 16

Two to fivefold increased risk of PAD: Approximately 84%-90% of patients with claudication are current or ex-smokers

Question 17

Does smoking have a greater risk for PAD or CAD?

Answer 17

Smoking increases the risk of PAD»CAD

Question 18

What happens to pt with PAD who continue to smoke?

Answer 18

More common progression to CLI and limb loss & Decreased the LE arterial bypass patency rates

Question 19

How much does diabetes increase your risk of PAD?

Answer 19

Two to fourfold increased risk of PAD and more likely to have an amputation

Question 20

Does reduction in HbA1c help PAD?

Answer 20

Risk reduction per 1% reduction in HgA1c:

• Risk for amputation 37%
• Death from PAD 43%
• Myocardial infarction 14%
• Stroke 12%
• Heart failure 16%

Question 21

What kind of pham therapy is there for PAD?

Answer 21

Pentoxifylline, cilostazol clopidogrel, aspirin, warfarin

Question 22

What does Pentoxifylline?

Answer 22

A methylxanthine derivative: hemorrheologic agent
weak antiplatelet activity
some vasodilation

Question 23

What does cilostazol do?

Answer 23

A phosphodiesterase III inhibitor:
platelet aggregation inhibitor
vasodilator
decrease TG
inhibits SMC proliferation

Question 24

What are the exercise recommendations for pt with PAD?

Answer 24

• Sessions of 30 min in duration
• At least 3 times a week
• At least 6 months

Question 25

What are the indications for revascularization

Answer 25

• Lifestyle-limiting symptoms
• Continued disability despite appropriate non-surgical management
• Technically feasible revascularization options exist
• Expectation of favorable risk/benefit ratio

Question 26

What should you carefully examine in a pt with chest pain?

Answer 26

Vital signs at baseline
Cardiac exam- Murmurs, heaves, and pulses
Pulmonary exam- Rales
Neuro exam: Focal deficits

Question 27

What tests should you use on a pt with chest pain?

Answer 27

Chest xray: heart size & contour
ECG: identify ischemia, pericardial effusion
Echo: look at valves, cardiac function, aortic disease
CT chest: pulmonary emboli or aortic dissection
Blood work

Question 28

If a pt has aortic dissection what can you do to reduce wall stress?

Answer 28

IV metoprolol to lower BP and HR or can use CCB if intolerant to beta blockers then can follow with vasodilators but not before rate control otherwise you reflex tachycardia.