Hyperlipidemia: PAD

Question 1

PAD definition

Answer 1

progressive narrowing of arteries due to atherosclerosis

Question 2

Primary indicator of PAD?

Answer 2

Intermittent claudication

Fatigue, discomfort, cramping, pain or numbness in affected extremities during exercise and resolves within a few minutes of rest

Question 3

Critical Limb ischemia

Answer 3

chronic ischemia at-rest pain, ulcers, or gangrene in one or both legs

amputation ranges from 10-40%

Question 4

PAD in males

Answer 4

increase with age

Black patients have highest incidence

Question 5

PAD in females

Answer 5

increase with age

Black and Native American patients have highest incidence

Question 6

At what age does incidence seem to jump for PAD?

Answer 6

Around age ~80

Question 7

Global PAD rates

Answer 7

200 million pts worldwide

8.5 million pts in US

Question 8

PAD risk factors (from greatest impact to least)

Answer 8

Smoking
Diabetes
HTN
Hypercholesterolemia

C-reactive protein
Black race
Clcr <60
Age >40

Question 9

Risk factors for increased risk of Limb loss in pts w/ Critical Limb Ischemia

Answer 9

Factors that reduce blood flow to microvascular bed

Factors that increase demand for blood flow to the microvascular bed

Question 10

Factors that reduce blood flow to microvascular bed?

Answer 10

Diabetes
Renal Failure
Decreased cardiac output (severe HF or shock)
Smoking and tobacco use
*Vasospastic diseases

Question 11

Factors that increase demand for blood flow to microvascular bed?

Answer 11

Infection

Skin breakdown or traumatic injury

Question 12

% of Asymptomatic patients with PAD?

Answer 12

50%

Question 13

% PAD Signs and Symptoms

Answer 13

15% - Classic (Typical) Claudication
33% - Atypical Leg pain (functionally limited)
1-2% Critical Limb Ischemia

Question 14

Claudication signs and symptoms

Answer 14

Ache or burning in leg muscles, or other pain after short exercise

Not present at rest

Question 15

Critical Limb Ischaemia signs and symptoms

Answer 15

Pain at rest

Ulceration or Gangrene

Question 16

Acute Limb-threatening ischemia signs and symptoms

Answer 16

Rare but important not to miss.
Sudden onset of symptoms
“6 P’s” = Pan at rest, pallor, Pulseless, Parasthesia, Paralysis, Perishingly cold

Question 17

How to calculate ABI?

Answer 17

Highest ankle SBP / highest brachial SBP

Can be resting or post exercise

Question 18

ABI 1.3-1.4, >1.4, then PAD is….

Answer 18

Likely

Artery too calcified to be compressible, need Toe Brachial Index

Question 19

ABI 1 - 1.3, then PAD is…..

Answer 19

Not likely

Question 20

ABI 0.91 - 0.99 then PAD is…

Answer 20

Maybe

Question 21

ABI is < or equal to 0.9, or resting is normal but post exercise is <0.9 or >20% drop in ABI then PAD is…

Answer 21

Diagnosis for PAD

Question 22

Mild PAD

Answer 22

Resting ABI <0.9 or post exercise <0.9

Question 23

Moderate PAD

Answer 23

Resting ABI <0.7, or post exercise <0.5

Question 24

Severe PAD

Answer 24

Resting ABI <0.5, or post exercise <0.15

Question 25

Goals in treating patients with PAD

Answer 25

Limb outcomes: Improved ability to walk (measure in distance before get symptoms) Prevention of progression to CLI and amputation CVD morbidity and mortality outcomes

Question 26

Confirmed PAD -> No sig functional disability.....

Answer 26

no treatment require annual follow up to monitor

Question 27

Confirmed PAD -> Life style limiting symptoms......

Answer 27

Supervised exercise program for 3 months + Drug therapy 3 months (anti platelet) + Cilostazole if claudication present IF significant disability despite therapy, Endovascular therapy or bypass surgery might be required

Question 28

Confirmed PAD -> Life style limiting symptoms w/ evidence of inflow disease....

Answer 28

Use more extensive noninvasive or angiographic diagnostic techniques Endovascular therapy or surgical bypass based on findings

Question 29

Nonpharmacological Therapy of PAD

Answer 29

Stop smoking Supervised Exercise (3 times per week for 30-45 min) Follow NCEP ATP III, DASH, or TLC *Revascularization Therapy in advanced patients

Question 30

Supervised Exercise Therapy

Answer 30

``` Frequency: 3-5 times/week Duration: 36-45 min Type: treadmill, track walking, etc Length: > 3 months Results: 100-150% increase in QOL and distance they can walk ```

Question 31

Revascularization Procedures for PAD

Answer 31

Endovascular: PTA, Stent Surgical: Bypass, reconstruction

Question 32

Antiplatelets based off guidelines

Answer 32

1. ASA = Best Data 2. Aggrenox = as effective as ASA but more SE 3. Clopidogrel = 1st line but only when cant do ASA 4. Ticlopidine = Black box, do not use

Question 33

Cilostazol (Pletal) info

Answer 33

Platelet aggregation inhib Vasodilation inc HDL 10% dec TG 15%

Question 34

Cilostazol Contraindications

Answer 34

HF (increased mortality)***** | Active Bleedings

Question 35

Pentoxifylline (Trental)

Answer 35

not recommended Less effective than cilostazole

Question 36

Drug w/ goal to reduce ischemic events

Answer 36

ASA or Clopidogrel

Question 37

Drug w/ goal to improve claudication symptoms

Answer 37

Cilostazol

Question 38

PAD guidelines w/ Hyperlipidemia

Answer 38

Statins = yes

Question 39

PAD guidelines w/ HTN

Answer 39

ACEi may offer added protection

Question 40

PAD guidelines w/ Smoking

Answer 40

Help stop smoking

Question 41

PAD guidelines w/ Diabetes

Answer 41

Treat DM to goals

Question 42

PAD guidelines w/ Antiplatelets

Answer 42

PAD symptoms: Antiplatelets = good, ASA 1st or clopidogrel if not NO PAD symptoms: ABI <0.9 = Antiplatelets

Question 43

Eval for Amputation if....

Answer 43

Sig necrosis of weight-bearing portion of foot Paresis of extremity Refractory ischemic rest pain Sepsis Limited life expectancy

Question 44

Angioplasty ok if...

Answer 44

life expectancy <2yr or cant do bypass

Question 45

Bypass option if....

Answer 45

life expectancy >2yrs better life expectancy but higher risk