Week 2: peripheral arterial disease

Question 1

Describe clinical symptoms of patients with PAD.

Answer 1

-intermittent claudification: pain or discomfort in lower extremity that occurs w/ walking and is relieved by rest
-pain can affect but, hip, thigh, calf, foot
Triad of: discomfort by exercise, relief within 2-5mins of stopping, reproducible level of activity once discomfort has stopped
-suspect PAD in patients who:
Patients>50 with lower extremity complains, patients>50 with diabetes+1 more risk factor, diabetes+smoking, all patients over 70 yrs, patients w/ evidence of atherosclerotic disease.

Question 2

What is ankle-brachial index? What is considered abnormal?

Answer 2

• uses blood pressure cuff and doppler to take pressure at right and left arm and pressure at posterior tibial and dorsal is pedis arteries in right and left ankles
• right ankle-braichial index=highest right ankle pressure/highest arm pressure
• left ankle-brachial index=highest left ankle pressure/highest arm pressure
• an ABI greater than .90 is considered normal
• if greater than 1.4, could be non compressible, calcified vessels (toe pressure can be taken as alternative)
• the lower the ABI the greater the risk for CV events

Question 3

What are risk factors for PAD?

Answer 3

• age
• gender
• smoking
• diabetes and glycemic control
• hypertension
• increased LDL, decreased HDL
• hsCRP

Question 4

What is the significance of having PAD?

Answer 4

• asymptomatic or symptomatic PAD, patients generally have widespread arterial disease. increased risk of stroke, MI, and CV death
• viewed as sign of potentially diffuse and significant arterial disease

Question 5

What is natural history of PAD? prognosis?

Answer 5

5 year outcome
-most, 73% have stable claudification
-16% have worsening claudification
-7% with leg bypass surgery
-4% with major amputation
in terms of CV morbidity/mortality
-20% have nonfatal events (MI/stroke)
-30% mortality
-similar for both symptomatic and asymptomatic patients
-long term prognosis is worse than patients with CAD, receive less medication than CAD patients

Question 6

Describe pharmacotherapy for PAD/Critical limb ischemia.

Answer 6

Treat like CAD (STEMI/CLI)

• Aspirin+clopidogrel
• statin
• ACE inhibitor
• Beta blockers to decrease ejection fraction
• stop smoking (varenicline)
• walking/prevent amputation
• from a trial: cilostazol improves walking, it inhibits phosphodiesterase III and inhibits platelets