2. PAD

Question 1

What is peripheral artery disease?

Answer 1

Disorder that obstructs blood supply to lower or upper extremities.

Question 2

Why is PAD clinically important?

Answer 2

• marker for subclinical coronary atherosclerosis
• 45% of patients with symptomatic PAD have concurrent clinically significant CAD
• CV events are more common in PAD than limb events

Question 3

PAD is more prevalent in women than in men. (T/F)

Answer 3

False: more prevalent in men

Question 4

About what percent of patients with PAD are asymptomatic?

Answer 4

50%

Question 5

About what percent of patients with PAD have intermittent claudication?

Answer 5

15%

Question 6

About what percent of patients with PAD have atypical pain?

Answer 6

33%

Question 7

What is atypical pain associated with PAD?

Answer 7

extremity discomfort that is exertional but does not resolve with rest

Question 8

What are the 5 P’s of diagnosis?

Answer 8

pain
pallor
pulselessness
paresthesias
paralysis

Question 9

How is ABI calculated?

Answer 9

highest ankle pressure / highest arm pressure

measurements for both right and left

Question 10

What is a normal ABI?

Answer 10

above 0.90

Question 11

What ABI is considered mild obstruction?

Answer 11

0.71 - 0.90

Question 12

What ABI is considered moderate obstruction?

Answer 12

0.41 - 0.70

Question 13

What ABI is considered severe obstruction?

Answer 13

0.00 - 0.40

Question 14

How is PAD diagnosed?

Answer 14

• contrast arteriography
• duplex ultrasound
• magnetic resonance angiography

Question 15

What is the gold standard of PAD diagnosis?

Answer 15

contrast arteriography

Question 16

What is the best choice for PAD diagnosis in patients with CKD?

Answer 16

Magnetic resonance angiography

Question 17

What are the goals of treatment for PAD?

Answer 17

• Prevention of CVD
• Relief of symptomatic PAD
• Prevent limb amputation

Question 18

What are some risk factor management strategies?

Answer 18

• Lifestyle changes
• Blood pressure control
• Diabetes control
• Hyperlipidemia
• Anti platelet therapy

Question 19

What are the BP goals for patients with PAD?

Answer 19

< 140/90 mmHg if < 60 years old

< 150/90 mmHg if ≥ 60 years old

Question 20

What is A1c goal for patients with PAD?

Answer 20

6.5%

Question 21

How should hyperlipidemia be treated in patients with PAD?

Answer 21

high potency statin treatment

Question 22

All PAD patients should be on regular dose aspirin (325 mg) (T/F)

Answer 22

False: low dose aspirin (81 mg) daily

Question 23

What is the alternative antiplatelet therapy if aspirin is not tolerated?

Answer 23

Clopidogrel 75 mg

Question 24

How is symptomatic PAD treated?

Answer 24

• exercise therapy
• pharmacologic therapy
• surgery

Question 25

What are the pharmacologic therapies for PAD?

Answer 25

- Cilostazol | - Pentoxifylline

Question 26

What are the surgical methods for PAD?

Answer 26

- endovascular | - arterial bypass

Question 27

Exercise therapy is the most beneficial in intermittent claudication. (T/F)

Answer 27

True

Question 28

How does exercise therapy benefit patients with PAD?

Answer 28

- helps with intermittent claudication | - increase duration and distance of walking

Question 29

What exercise regimen shows the greatest benefit in PAD?

Answer 29

> 30 minutes at least 3 time per week

Question 30

What is the MOA for Cilostazol?

Answer 30

- Selective inhibitor of phosphodiesterase III | - ↑ in cAMP leads to phosphorylation of PKA substrates

Question 31

What are the effects of Cilostazol?

Answer 31

- positive lipid effects - decreased platelet aggregation - minor cardiac contractility - decrease in VSMC proliferation - VSMC relaxation increased

Question 32

What are the indications of Cilostazol?

Answer 32

symptomatic management of PAD: primarily intermittent claudication

Question 33

What is the typical dose of Cilostazol?

Answer 33

100 mg BID | taken 30 minutes before or 2 hours after eating

Question 34

Cilostazol should be stopped after 6 months if not effective. (T/F)

Answer 34

False: stopped after 3 months

Question 35

Cilostazol is a major substrate of what enzymes?

Answer 35

CYP3A4 and CYP2C19

Question 36

High fat meals and grapefruit juice _______(↑/↓) peak concentrations of Cilostazol.

Answer 36

↑ increase

Question 37

What are ADRs of Cilostazol?

Answer 37

- headache/ dizziness - diarrhea and abnormal stool - infection - rhinitis - palpitation - peripheral edema - thrombocytopenia - bleeding

Question 38

What is the contraindication of Cilostazol?

Answer 38

hear failure of ANY severity

Question 39

What is the MOA of Pentoxifylline?

Answer 39

reduces blood viscosity via increased leukocyte and erythrocyte deformability

Question 40

Pentoxifylline is the first line agent for intermittent claudication. (T/F)

Answer 40

False: 2nd line agent

Question 41

How is Pentoxifylline dosed?

Answer 41

400 mg TID

Question 42

Pentoxifylline must be adjusted for renal dysfunction. (T/F)

Answer 42

True

Question 43

What are the ADRs with Pentoxifylline?

Answer 43

nausea and vomiting

Question 44

With a CrCl of ~60 mL/min, how must Pentoxifylline be dosed?

Answer 44

400 mg BID

Question 45

With a CrCl of ~20 mL/min, how must Pentoxifylline be dosed?

Answer 45

400 mg QD

Question 46

What are some alternate therapies for PAD?

Answer 46

- warfarin | - herbals

Question 47

What are some herbal supplements used for PAD?

Answer 47

- L-arginine - L-carnitine - Ginko bilboa - Vit E

Question 48

What are surgical endovascular reconstruction options?

Answer 48

- percutaneous transluminal angioplasty (PTA) | - PTA with stents

Question 49

What are surgical reconstruction options?

Answer 49

- aortoiliac/aortofemoral reconstruciton - femoropopliteal bypass - femorotibial bypass

Question 50

What are indications for surgical revascularization?

Answer 50

- inadequate response to exercise or medical mgmt - severely disabled - lesions - patient would benefit - critical limb ischemia