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OU Module Cardio Spring 2018 > Pharmacotherapy of Peripheral Artery Disease > Flashcards

Pharmacotherapy of Peripheral Artery Disease Flashcards

1
Q

Define peripheral artery disease (PAD)

A
  • Clinical disorder consisting of stenosis or occlusion in the aorta or arteries of the limbs
  • Mainly caused by Atherosclerosis
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2
Q

patients who are at risk for developing PAD

A
  • Age ≥ 65 years of age
  • Age 50–64 years of age, with risk factors for atherosclerosis
  • Age < 50 years of age, with diabetes mellitus PLUS 1 additional risk factor for atherosclerosis
  • Individuals with known atherosclerotic disease in another vascular bed: coronary arteries, carotid arteries, renal arteries, Abdominal Aortic aneurysm (AAA)
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3
Q

risk factors for atherosclerosis

A
  • History of cigarette smoking – PAD is associated with the duration and amount of cigarettes smoked; this is the single most important risk factor to modify
  • Diabetes Mellitus
  • Hypertension
  • Dyslipidemia
  • Family history of PAD
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4
Q

signs & symptoms of lower extremity PAD

A
  • Can be asymptomatic or symptomatic
  • Claudication
  • Atypical leg pain
  • Ischemic rest pain
  • Impaired walking function
  • Diminished pulses
  • Bruits – turbulent sound instead of lub dub
  • Pallor upon elevation of extremity (pale)
  • Trophic changes
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5
Q

example of trophic changes

A
  • Muscle atrophy
  • Shiny, hairless skin
  • Nail changes
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6
Q

Claudication

A

Fatigue, discomfort, cramping, or pain of vascular origin in the muscles of the lower extremities that is consistently induced by exercise and consistently relieved by rest (within 10 minutes)

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7
Q

complications associated with PAD

A
  • Abdominal Aortic aneurysm
  • Coronary artery atherosclerosis  may cause MI
  • Carotid artery atherosclerosis / Cerebral vascular disease -> may cause stroke
  • Renal artery atherosclerosis -> may cause Renal artery stenosis
  • Acute Limb Ischemia (ALI)
  • Critical limb ischemia (CLI)
  • Infection
  • Amputation
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8
Q

How do you measure the ankle-brachial index (ABI)?

A

Taking top # of legs BP and dividing it by arm BP (L or R arm – whichever is higher)

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9
Q

How is the ankle-brachial index (ABI) used to diagnose lower extremity PAD?

A
  • If ratio is < 0.9, that is diagnosis for PAD

- That means that the BP is lower in the legs than it is in the arms

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10
Q

What will help improve morbidity / mortality outcomes?

A
  • Decrease Risk of MI, Stroke, and CV Death
  • Discontinue Tobacco Use
  • Blood pressure control
  • High-intensity statin therapy
  • Antiplatelet therapy
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11
Q

What will help improve limb-related outcomes?

A
  • Improvement in Symptoms, QoL, and/or Prevent Amputation
  • Discontinue Tobacco Use
  • Exercise-program
  • Cilostazol
  • Foot care
  • Revascularization
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12
Q

most important lifestyle modification for the treatment of lower extremity PAD

A
  • BLOOD PRESSURE
  • CIGARETTE SMOKING
  • Diabetes
  • Dyslipidemia
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13
Q

exercise

A
  • should be supervised; highly recommended
  • can improve functional status and QoL and to reduce leg symptoms
  • be careful not to do too much because that can worsen PAD
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14
Q

Antiplatelet therapy

A

aspirin alone (81mg per day) or clopidogrel alone (75mg per day) is recommended to reduce MI, stroke, and vascular death

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15
Q

Antihypertensive therapy

A
  • should be administered to patients with hypertension AND PAD to reduce the risk of MI, stroke, heart failure, and cardiovascular death
  • The use of ACE-inhibitors or ARBs can be effective to reduce the risk of cardiovascular ischemic events in patients with PAD.
  • The use of either of these meds are contraindicated in someone who has renal artery stenosis
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16
Q

Cilostazol

A

effective therapy to improve symptoms and increase walking distance in patients with claudication

17
Q

ASA

A
  • COX and TxA2 inhibitor
  • Prevents platelet from being activated any further
  • 81mg ASA enteric coated once daily
18
Q

Clopidogrel

A
  • blocks ADP from binding to the P2Y12 receptor specifically on the ADP binding site
  • alternative to ASA
  • 75mg once daily
19
Q

Vorapaxar (Zontivity)

A
  • PAR- 1 Inhibitor [protease-activated (PAR) -1 receptor potentiates release of other platelet activators]
  • inhibits thrombin-induced and thrombin receptor agonist peptide (TRAP)-induced platelet aggregation
  • indicated for established PAD
  • Used in combination with ASA and/or clopidogrel
  • Increases risk of serious bleeding
  • 2.08 mg PO once daily
20
Q

High-intensity Statin Therapy

A
  • Atherosclerotic plaque stabilization

- Atorvastatin 40-80 mg/day or Rosuvastatin 20-40 mg/day

21
Q

Cilostazol (Pletal®)

A
  • Inhibits phosphodiesterase III [PDE: Dilation and inhibition of platelet aggregation]
  • Use when refractory to exercise therapy and smoking cessation
  • Use in combination with either ASA or clopidogrel
  • 100 mg twice daily
22
Q

adverse effects of cilostazol

A
  • Headache
  • Dizziness
  • Nausea
  • Diarrhea
  • Cardiovascular effects (tachycardia, palpitation, tachyarrhythmia, and/or hypotension)
23
Q

In which patients should we avoid cilostazol?

A
  • Avoid use in patients who are actively bleeding
  • Patients with history of ischemic heart disease may be at increased risk for exacerbation of angina pectoris or myocardial infarction
  • contraindicated with patients with heart failure of any severity
24
Q

precautions for cilostazol

A

Use with caution in patients with severe renal impairment

25
Q

Pearls of cilostazol

A
  • Administer cilostazol on an empty stomach 30 minutes before or 2 hours after meals (If taken with high fat meal, can bump AUC by 97%)
  • avoid grapefruit juice
26
Q

drug interactions of cilostazol

A
  • Major substrate of CYP450 isoenzymes
  • adjust dose from 100mg BID to 50mg BID if pt is on fluconazole and omeprazole (3A4) or diltiazem, erythromycin, itraconazole, and ketoconazole (2C19)
27
Q

pharmacotherapy after revascularization

A
  • Dual-antiplatelet therapy (aspirin and clopidogrel) may be reasonable to reduce the risk of limb-related events in patients with symptomatic PAD after lower extremity revascularization
  • Usefulness of anticoagulation after revascularization is uncertain
28
Q

the 6 P’s

A
  • Pain
  • Pallor
  • Pulselessness
  • Poikilothermia (cold)
  • Paresthesias
  • Paralysis
29
Q

Acute Limb Ischemia (ALI)

A
  • Acute (<2 weeks), severe hypoperfusion of the limb characterized by the 6 P’s
  • Pt should report to hospital
30
Q

inpatient management of ALI

A
  • UFH using VTE protocol -> Inhibits thrombus propagation and may provide an anti-inflammatory effect that decreases ischemia
  • May need revascularization; if revasc. cannot be performed, perform catherter-based thrombolysis
  • Medical emergency that requires inpatient pharmacotherapy plus nonpharmacologic interventions to salvage limbs
31
Q

Critical Limb Ischemia (CLI)

A
  • chronic (≥2 weeks) ischemic rest pain, nonhealing wound/ulcers, or gangrene in 1 or both legs, attributable to objectively proven arterial occlusive disease
  • Patients should be referred to the hospital
  • May need revascularization
  • Medical emergency that may require non-pharmacologic interventions to salvage limbs
32
Q

What is Peripheral Artery Disease (PAD) caused by?

A
  • ATHEROSCLEROSIS
  • Thrombosis
  • Vasculitis
  • Fibromuscular dysplasia
  • Trauma
33
Q

Ankle-brachial index (ABI) values

A
  • Abnormal: <0.9 abnormal and diagnostic of PAD
  • Normal: 1.00-1.40
  • > 1.40 is indicative of non-compressible arteries secondary to vascular calcification
  • Requires alternative methods of testing
  • 0.91-0.99 is considered borderline and may warrant follow-up
  • Requires alternative methods of testing
34
Q

What are the pharmacotherapy options for smoking cessation?

A
  • Nicotine Replacement Therapy (NRT)
  • Varenicline (Chantix®)
  • Bupropion (Zyban®)
35
Q

Varenicline (Chantix®)

A

black box warning for patients with psychiatric issues

36
Q

Bupropion (Zyban®)

A
  • have to be careful about CV events; can cause drug-induced HTN; can lower seizure threshold
  • take in the morning because can cause insomnia
37
Q

What is revascularization?

A
  • Intervention used to restore blood flow to an ischemic area
  • Surgial: Endarterectomy
  • Endovascular: “Stenting”
38
Q

Endarterectomy

A

pulling out the plaque

OU Module Cardio Spring 2018 (16 decks)

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