PAD 1 - Exam 3 Flashcards by Johannah Crumpton

What is PAD (peripheral arterial disease)? What is commonly caused by? Where?

The presence of a stenosis or occlusion in the aorta or arteries of the limbs

Commonly caused by atherosclerosis in patients >40 y/o

MC in the lower extremities

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What does PAD increase your risk for?

Associated with increased risk of cardiovascular and cerebrovascular events, including MI, stroke, and death

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**What are the two primary sites for PAD? What age?

femoral and popliteal arteries

Most common in ≥ age 60 with even gender distribution, commonly affects blacks and hispanics

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_____ and ____arteries are most common in diabetic and elderly patients

Tibial and peroneal arteries

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______ and _____ arteries are MC in 50-60 white male smokers

Abdominal aorta and iliac arteries

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**PAD lesions typically present at the _______. Why?

bifurcation of the artery

due to increased turbulence, stress and intimal injury

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Overall prevalence of PAD is 30% in patients who are:
_____ without risk factors
______ with risk factors present

≥70 y/o w/o risk factors

≥50 y/o with risk factors

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According to ACC/AHA who needs to be evaluated for PAD?

≥70 y/o

50-69 y/o with h/o smoking or DM

40-49 with DM and ≥ 1 other risk factor for atherosclerosis

Known atherosclerosis at other sites (coronary, carotid, renal, mesenteric or AAA)

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What are the risk factors for PAD? **What are the 2 highlighted ones?

Smoking**
Diabetes Mellitus**
Hypercholesterolemia
Hypertension
Renal Insufficiency

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_____ is the most typical symptom of PAD. When does it occur? Can you trigger it? When will the s/s resolve?

claudication

occurs during exercise and is relieved by rest

yes! s/s are reproducible

Symptoms completely resolve within ~10 minutes of exercise cessation

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What is another name for pseudoclaudication? What are 2 common causes?

neurogenic claudication

Spinal canal stenosis
Herniated disc impingement on sciatic nerve

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How can you tell claudication apart from pseudoclaudication?

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Patients with tibial and pedal artery disease may not have _____. ____ and _____ may be the first sign of vascular insufficiency

claudication

rest pain or ulceration

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Pts who have tibial and pedal artery disease may have rest pain to the _______. What makes it better? What can it progress to?

dorsum of the foot

dependency: putting the foot down and letting it dangle below the level of the body

Can progress to chronic limb threatening ischemia

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What is Chronic Limb Threatening Ischemia (CLTI)? How long specifically? Who is the MC patient?

presence of PAD in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration

diabetic pts

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______ is the most commonly used classification system for PAD. What is the classification system based on?

Trans-Atlantic Inter-Society Consensus (TASC II)

anatomic distribution of lesions

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_____ and ____ classifications are used to stratify clinical severity. _____ has replaced both previously mentioned systems

Rutherford classification
Fontaine classification

Society for Vascular Surgery (SVS) Lower Extremity Threatened Limb Classification System to Stratify Amputation Risk, Wound, Ischemia and foot Infection (WIfI)

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What needs to be included in the PE if you suspect PAD?

**pulses: ALL OF THEM

BP in both arms

CV exam

abdomen: AAA for bruits

**skin: legs and feet

especially need to check pulses and skin

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What are the grading system for pulses?

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What are the classic PE findings for PAD? May need to use _____ to evaluate

-Decreased or absent pulses DISTAL to the obstruction
-reduced skin temp
-smooth, shiny skin
-ulcerations
-distal hair loss, typically over ankles
-thickened nails
-calf atrophy
-charcot arthropathy

hand-held doppler

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What is PE test that can be performed in the office to test for PAD? What is a positive result?

leg lift test

Elevate leg to 60° for 1 minute
(+) test = pallor occurs if arterial pressure is not adequate to overcome gravity

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What is dependent rubor? Why does it happen?

Red, dusky color in feet when in dependent position (i.e. such as feet hanging off bed)

Occurs due to damaged vessels and chronic dilation - unable to respond appropriately

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T/F: the faster the dependent rubor forms the worse severity of the PAD

TRUE!

faster it forms the worse the PAD is

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Can you dx PAD clinically? What can you order?

yes, combo of risk factors and s/s of PAD is sufficient to dx. most people will order ABI

ABI: ankle brachial index

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What are the non-invasive imaging options for PAD?

**______ is the best screening tool for PAD

ankle brachial index

**Majority of the time, ______, ______ , and _______ will make the clinical diagnosis of PAD and no additional testing is warranted. When would you need to order additional testing?

ABI +history +physical exam ABI shows false negative or if invasive intervention is planned

according to guidelines, patient with history or physical exam findings suggestive of PAD, ________. Patient at increased risk of PAD but WITHOUT H&P findings suggestive of PAD, _______

ABI is recommended ABI is reasonable

Describe an ABI

Involves placement of sphygmomanometric cuffs at the ankles and the use of a Doppler device to auscultate or record blood flow from the dorsalis pedis and posterior tibial arteries aka take BP at ankles and normal BP at arms

**Draw the ABI interpretation chart?

What is the formula to calculate the ABI? What is considered normal?

highest SBP posterior tibial or dorsalis pedis reading/ highest brachial SBP aka highest ankle/ highest arm ABI (normal >0.90)

What are 4 types of patients that commonly have incompressible arteries?

Elderly patients patients with diabetes renal failure patients on chronic steroids

What are 2 things that ABIs do NOT do?

Not designed to define degree of functional limitation Does not define location of disease

What is the average ABI for a pt who has claudication? rest pain? tissue loss/ulcer/gangrene?

Claudication: 0.4 and 0.9 Rest pain: 0.2 to 0.4 Tissue loss (ulcer, gangrene): 0 to 0.4

When is toe brachial index helpful? **What value is considered abnormal and diagnostic for PAD?

useful when ABI is >1.40 (non-compressible) TBI < 0.70 is abnormal and diagnostic of PAD

What is the formula for TBI? What does a higher value predict?

higher TBI predicts better healing

What does the treadmill exercise test assess? When is it used?

Assesses functional capacity by measuring the distance a claudicator can walk at baseline Can be used if symptoms typical for claudication but resting ABI normal Can be used if symptoms are atypical for claudication but patient has PAD

When can you NOT use a treadmill exercise test?

Patient has non-compressible vessels Cannot walk on treadmill (unstable angina, gait instability, etc.)

What is the treadmill exercise test procedure?

the the pt resumes supine position and ABI measurements taken q 1-2 minutes until they reach pre-exercise level

**What treadmill exercise test result is diagnostic for PAD?

A decrease in ABI of more than 20% immediately following exercise is diagnostic of PAD

What is the segmental limb pressure procedure? **What result suggests arterial disease?

Cuffs placed on: Thigh (upper and lower), Calf, Ankle, Transmetatarsal region of foot, Digit Using a Doppler probe, the pressure at each segment is measured **A decrease between two consecutive levels of >30 mmHg suggests arterial disease of the artery proximal to the cuff

Segmental limb pressure or ABI provides more information regarding PAD?

segmental limb pressure provides more specific information that ABI alone

_______ is first line ADDITIONAL imaging for PAD. What can it be useful in determining? especially if???

Arterial Duplex determining the SEVERITY of disease and CONFIRMING PE findings Useful if intervention is being considered to assess risk/benefit ratio

______ should have a MINIMAL role for screening pts for PAD

arterial duplex MRA: not used for screening. consider when surgical intervention is needed Computed Tomographic Angiography (CTA)

_______ provides an excellent arterial picture without using ionizing radiation. Gadolinium cannot be used if ______

Magnetic Resonance Angiography (MRA) if GFR is less than 30ml/min

**Which PAD test that should be considered for sx is necessary requires iodinated contrast?

Computed Tomographic Angiography (CTA)

**What is the gold standard imaging option in PAD? **What is it used for?

Digital Subtraction Angiography (DSA) Used primarily to guide intervention

What are the PAD risk factor modifications?

Antiplatelet therapy (Plavix or ASA) Smoking Cessation Lipid-lowering therapy Glycemic control Blood pressure control Diet and exercise Obesity

What is the tx for symptomatic PAD regarding atiplatelets? Asymptomatic PAD with mild PAD (ABI < 0.90)?

Antiplatelet therapy with ASA alone (75 mg to 325 mg per day) or Clopidogrel alone antiplatelet therapy is reasonable

is DAPT recommended in symptomatic PAD?

DAPT (ASA and clopidogrel) in patients with symptomatic PAD is not well established

______ is super important in PAD and needs to be discussed at EVERY visit

smoking cessation

What is the complete tx for symptomatic PAD?

ASA or plavix statin +/- Ace +/- Cilostazol if claudication is present strict glycemic control in diabetic patients

______ is PAD specific pharm to help improve claudication

Cilostazol (Pletal)

_____ MOA inhibits phosphodiesterase activity and suppress degradation of cAMP resulting in an increase in cAMP in platelets and blood vessels. Has both ____ and ____ properties

Cilostazol (Pletal) Has vasodilator & antiplatelet properties

** When is cilostazol CI? **What is the pt education?

Contraindicated to use in patient with heart failure of any severity Medication is *protein bound* → advise patient to take drug at least 30 min before or 2 h after a meal

What is the exercise therapy recommendations for intermittent claudication?

3-5 x week for 35-50 minutes of walking for at LEAST 6 months

When is surgical bypass indicated in PAD?

indicated in patients with continued intermittent claudication sx’s despite other therapies or in patients with critical limb ischemia

What are the endovascular therapies in PAD?

Angioplasty Stenting Atherectomy need to tx ulcers and gangrene if present

If pt has s/s of PAD but ABI is normal, what do you do next?

exercise ABI

PAD 1 - Exam 3 Flashcards

(60 cards)