Peripheral arterial disease

Question 1

1. What is the underlying pathophysiology of peripheral arterial disease?
   A. Inflammation of the arterial wall due to autoimmune processes
   B. Atherosclerotic plaque formation causing stenosis and/or occlusion
   C. Vasospasm due to hyperadrenergic states
   D. Congenital malformation of peripheral arteries

Answer 1

o Answer: B
o Rationale: PAD is primarily caused by atherosclerosis, where plaque formation narrows or occludes the arteries.

Question 2

2. Which risk factor is most strongly associated with the development of PAD?
   A. Obesity alone
   B. Smoking
   C. Hypotension
   D. Regular exercise
   o

Answer 2

Answer: B
o Rationale: Smoking is a major risk factor because tobacco chemicals cause endothelial damage and vasoconstriction.

Question 3

3. At what age does peripheral arterial disease most commonly present?
   A. Second and third decades
   B. Fourth decade
   C. Sixth and seventh decades
   D. Ninth decade

Answer 3

o Answer: C
o Rationale: PAD is most common in the sixth and seventh decades of life.

Question 3

4. Which vascular territory is most frequently affected in PAD?
   A. Carotid arteries
   B. Femoropopliteal segment
   C. Coronary arteries
   D. Pulmonary arteries
   .

Answer 3

o Answer: B
o Rationale: Femoropopliteal involvement is seen in 80% to 90% of patients with PAD

Question 4

5. The ankle–brachial index (ABI) is calculated by dividing which of the following?
   A. Diastolic blood pressure at the ankle by diastolic blood pressure at the arm
   B. Systolic blood pressure at the arm by systolic blood pressure at the ankle
   C. Systolic blood pressure at the ankle by systolic blood pressure at the arm
   D. Mean arterial pressure at the ankle by that at the arm

Answer 4

o Answer: C
o Rationale: ABI is calculated as the systolic blood pressure at the ankle divided by the systolic blood pressure at the brachial artery.

Question 5

8. Which clinical symptom is most commonly seen in patients with PAD?
   A. Rest pain while seated
   B. Intermittent claudication during exercise
   C. Constant burning pain at rest
   D. Sharp, stabbing chest pain

Answer 5

o Answer: B
o Rationale: Intermittent claudication—pain in the legs with exercise relieved by rest—is the hallmark symptom of PAD.

Question 5

6. An ABI of 0.8 indicates which degree of arterial flow reduction?
   A. Normal flow
   B. Mildly decreased flow
   C. Moderately decreased flow
   D. Severe ischemia
   o

Answer 5

Answer: B
o Rationale: An ABI between 0.71 and 0.9 is generally considered mildly abnormal, indicating mildly decreased arterial flow.

Question 6

9. Which physical exam finding is commonly observed in PAD?
   A. Bounding peripheral pulses
   B. Diminished or absent pedal pulses
   C. A bruit over the carotid arteries only
   D. Clubbing of the fingers

Answer 6

o Answer: B
o Rationale: Reduced or absent pulses in the lower extremities are common due to arterial occlusion.

Question 6

7. An ABI of less than 0.5 is concerning for:
   A. Asymptomatic disease
   B. Mild intermittent claudication
   C. Pain on exertion with possible rest pain
   D. Normal findings in the elderly
   o

Answer 6

Answer: C
o Rationale: An ABI below 0.5 suggests severe reduction in blood flow, often associated with rest pain and risk of tissue loss.

Question 7

10. A patient with PAD elevates his legs and develops pallor. This sign is known as:
    A. Dependent rubor
    B. Elevational pallor
    C. Cyanosis
    D. Erythema abi gne

Answer 7

o Answer: B
o Rationale: Elevational pallor occurs because gravity-dependent blood flow is reduced when the limb is elevated, revealing poor perfusion

Question 8

11. Which finding on skin examination is common in chronic PAD?
    A. Thick, brittle nails and hair loss
    B. Hyperpigmentation of the face
    C. Vesicular rash on the trunk
    D. Excessive sweating in the extremities

Answer 8

o Answer: A
o Rationale: Hair loss and thickened nails occur due to chronic inadequate perfusion of the skin.

Question 9

12. What is the most important modifiable risk factor in the management of PAD?
    A. Age
    B. Smoking
    C. Family history
    D. Gender

Answer 9

o Answer: B
o Rationale: Smoking cessation is critical as smoking exacerbates atherosclerosis and causes vasoconstriction.

Question 10

13. Which of the following is a key component in the nonpharmacologic management of PAD?
    A. Bed rest for prolonged periods
    B. Structured exercise therapy
    C. Avoidance of all physical activity
    D. High-intensity interval training only

Answer 10

o Answer: B
o Rationale: Supervised exercise programs have been shown to improve walking distance and symptoms in PAD patients

Question 11

14. Which pharmacologic agent is commonly used to improve symptoms in PAD by inhibiting platelet aggregation?
    A. Beta-blockers
    B. Aspirin
    C. ACE inhibitors
    D. Calcium channel blockers

Answer 11

o Answer: B
o Rationale: Aspirin is used as an antiplatelet to reduce thrombotic risk in PAD

Question 12

15. Statins are used in PAD primarily to:
    A. Lower blood pressure
    B. Reduce serum cholesterol and stabilize atherosclerotic plaques
    C. Increase peripheral vascular resistance
    D. Act as vasodilators in the limb arteries

Answer 12

o Answer: B
o Rationale: Statins lower cholesterol and stabilize plaques, reducing cardiovascular events in patients with atherosclerotic disease.

Question 13

16. Cilostazol is used in the treatment of PAD because it:
    A. Acts as a potent diuretic
    B. Increases cAMP leading to vasodilation and inhibition of platelet aggregation
    C. Decreases heart rate significantly
    D. Is contraindicated in all patients with PAD

Answer 13

o Answer: B
o Rationale: Cilostazol is a phosphodiesterase inhibitor that improves symptoms by vasodilating and inhibiting platelet aggregation.

Question 14

17. Cilostazol is contraindicated in which patient group with PAD?
    A. Patients with diabetes
    B. Patients with coronary artery disease
    C. Patients with heart failure
    D. Elderly patients

Answer 14

o Answer: C
o Rationale: Cilostazol is contraindicated in patients with heart failure due to its inotropic effects

Question 15

18. What is the approximate 5-year mortality rate for patients with PAD?
    A. Less than 5%
    B. 15% to 25%
    C. 50% to 60%
    D. Over 80%

Answer 15

o Answer: B
o Rationale: PAD is associated with significant mortality—approximately 15% to 25% at 5 years—due to concomitant cardiovascular disease.

Question 16

19. Which condition is a life‐threatening complication (“what will kill your patient”) in PAD?
    A. Mild intermittent claudication
    B. Critical limb ischemia with rest pain and tissue loss
    C. Slight hair loss on the legs
    D. Asymptomatic low ABI

Answer 16

o Answer: B
o Rationale: Critical limb ischemia, characterized by rest pain and risk of gangrene, is a limb-threatening and life-threatening complication.

Question 17

20. Acute limb ischemia in PAD is most commonly caused by:
    A. Slow progressive atherosclerosis
    B. Embolism or thrombosis causing sudden occlusion
    C. Vasospasm from cold exposure
    D. Chronic venous insufficiency

Answer 17

o Answer: B
o Rationale: Acute limb ischemia usually results from an embolic event or sudden thrombosis, requiring immediate intervention.

Question 18

22. Endovascular interventions in PAD typically include:
    A. Coronary artery bypass grafting
    B. Angioplasty and stenting
    C. Valve replacement surgery
    D. Pacemaker implantation

Answer 18

o Answer: B
o Rationale: Angioplasty with or without stenting is a common endovascular method to open stenosed peripheral arteries.

Question 18

21. What is the primary goal of revascularization procedures in PAD?
    A. To completely cure atherosclerosis
    B. To relieve pain and prevent limb loss
    C. To reduce cholesterol levels
    D. To eliminate the need for exercise

Answer 18

o Answer: B
o Rationale: Revascularization aims to restore blood flow, relieving symptoms and preventing progression to limb loss.

Question 19

23. Which surgical option is used for revascularization in patients with extensive femoropopliteal disease?
    A. Carotid endarterectomy
    B. Aorto-femoral bypass
    C. Femoropopliteal bypass surgery
    D. Endovascular coiling
    .

Answer 19

o Answer: C
o Rationale: Femoropopliteal bypass is the surgical revascularization of choice for extensive disease in the femoropopliteal segment

Question 19

24. In patients with critical limb ischemia, which factor greatly increases the risk of amputation?
    A. Presence of robust collateral circulation
    B. Smoking and poorly controlled diabetes
    C. Mild intermittent claudication
    D. Use of statins
    .

Answer 19

o Answer: B
o Rationale: Smoking and diabetes worsen atherosclerosis and impair wound healing, increasing the risk of limb loss

Question 20

26. A patient with an ABI of 0.3 is at high risk for: A. Asymptomatic disease B. Mild claudication C. Severe ischemia with rest pain and possible gangrene D. Normal exercise tolerance

Answer 20

o Answer: C o Rationale: An ABI below 0.5, particularly around 0.3, indicates severe arterial obstruction with significant risk for tissue loss.

Question 20

25. Which diagnostic study is most useful for detecting arterial stenosis in PAD? A. Duplex ultrasonography B. Echocardiography C. Electrocardiogram D. Bone scan .

Answer 20

o Answer: A o Rationale: Duplex ultrasonography combines B-mode imaging with Doppler to detect vessel stenosis and assess blood flow

Question 21

27. Which of the following represents a common, noninvasive screening tool for PAD? A. Invasive angiography B. Ankle–brachial index (ABI) measurement C. Coronary CT angiography D. MRI of the lower extremities

Answer 21

o Answer: B o Rationale: ABI is a simple, cost-effective, and widely used noninvasive screening test for PAD.

Question 22

28. What is the significance of collateral circulation in PAD? A. It worsens symptoms of claudication B. It compensates for arterial occlusion by providing alternative blood flow C. It only develops in acute ischemia D. It is a contraindication to revascularization

Answer 22

o Answer: B o Rationale: Collateral circulation can improve tissue perfusion and mitigate symptoms in the setting of arterial blockages

Question 22

29. Which lifestyle modification is critical for patients with PAD? A. Increased salt intake B. Smoking cessation C. Sedentary lifestyle D. Avoidance of all exercise

Answer 22

o Answer: B o Rationale: Smoking cessation is paramount as smoking directly worsens atherosclerosis and vasoconstriction.

Question 23

30. Patients with PAD should be counseled on proper foot care primarily because: A. It prevents diabetic neuropathy B. It reduces the risk of ulceration and subsequent infection C. It improves ABI measurements D. It increases arterial flow

Answer 23

o Answer: B o Rationale: Good foot care is essential to prevent ulcers in patients with poor peripheral perfusion and neuropathy.

Question 24

31. Which medication class is used to reduce platelet aggregation and is a mainstay in the medical management of PAD? A. Beta-blockers B. Antiplatelet agents C. Diuretics D. Calcium channel blockers

Answer 24

o Answer: B o Rationale: Antiplatelet therapy (e.g., aspirin) reduces the risk of thromboembolic events in PAD.

Question 25

32. What is the role of exercise training in PAD management? A. To immediately reverse arterial occlusion B. To improve functional capacity and walking distance C. To reduce cholesterol levels rapidly D. To cure the underlying atherosclerosis

Answer 25

o Answer: B o Rationale: Structured exercise programs can improve symptoms and quality of life by enhancing collateral circulation and endurance.

Question 26

33. Which comorbidity most significantly worsens the prognosis of PAD? A. Hyperthyroidism B. Diabetes mellitus C. Asthma D. Migraine

Answer 26

o Answer: B o Rationale: Diabetes mellitus impairs vascular function and wound healing, leading to worse outcomes in PAD.

Question 27

34. What is a “red flag” sign on physical examination that indicates a vascular emergency in PAD? A. Mild calf discomfort B. Absent distal pulses with pallor and coldness at rest C. Occasional tingling in the feet D. Slight varicosities o

Answer 27

Answer: B o Rationale: Absent pulses combined with rest pallor and cold extremities suggest critical ischemia that requires urgent intervention.

Question 28

35. Which factor would prompt an urgent referral to a vascular specialist in a patient with PAD? A. Mild intermittent claudication that improves with rest B. Severe rest pain with signs of tissue loss or gangrene C. Slightly reduced ABI in an asymptomatic patient D. Stable, controlled hypertension

Answer 28

o Answer: B o Rationale: Severe rest pain and signs of tissue loss indicate critical limb ischemia and require immediate vascular evaluation

Question 29

36. Why is renal insufficiency a risk factor for PAD? A. It directly increases cholesterol levels B. It accelerates atherosclerosis due to uremic toxins and inflammation C. It improves blood viscosity D. It has no known association with PAD

Answer 29

o Answer: B o Rationale: Renal insufficiency is linked with systemic inflammation and accelerated atherosclerosis, increasing the risk of PAD.

Question 30

38. A patient with PAD complains of pain when walking a short distance that resolves with rest. This is an example of: A. Critical limb ischemia B. Rest pain C. Intermittent claudication D. Acute limb ischemia

Answer 30

o Answer: C o Rationale: Intermittent claudication is characterized by exertional leg pain that subsides with rest.

Question 30

37. Which statement best describes the role of antiplatelet therapy in PAD management? A. It is only used during acute events B. It is used long term to reduce the risk of cardiovascular events and thrombosis C. It should be discontinued if claudication is present D. It replaces the need for lifestyle modifications

Answer 30

o Answer: B o Rationale: Long-term antiplatelet therapy (such as aspirin) is essential to reduce thrombotic events and cardiovascular risk in PAD patients.

Question 31

39. Which imaging modality is most appropriate for planning revascularization in PAD? A. Plain radiograph B. CT angiography or MR angiography C. Electrocardiogram D. Dual-energy X-ray absorptiometry.

Answer 31

o Answer: B o Rationale: CT angiography or MR angiography provides detailed vascular imaging for planning revascularization procedures

Question 32

40. What is the mechanism by which atherosclerosis leads to PAD? A. Smooth muscle hypertrophy causes vessel dilation B. Plaque formation and calcium deposition narrow the vessel lumen C. Inflammatory cytokines cause acute vasodilation D. Endothelial regeneration thickens the vessel wall

Answer 32

o Answer: B o Rationale: Atherosclerosis involves plaque buildup, calcium deposition, and vessel narrowing, which reduce blood flow.

Question 33

41. In a patient with PAD and acute limb ischemia, what is the immediate concern (“what will kill your patient”)? A. Gradual worsening of claudication B. Sudden loss of blood flow leading to limb loss and systemic complications C. Development of varicose veins D. Occasional numbness in the toes

Answer 33

o Answer: B o Rationale: Acute limb ischemia is a vascular emergency that can lead to rapid limb loss and systemic shock if not treated promptly.

Question 34

42. Which common finding in PAD is often asymptomatic until advanced disease? A. Intermittent claudication B. Diminished peripheral pulses C. Severe rest pain D. Gangrene

Answer 34

o Answer: B o Rationale: Many patients with PAD are asymptomatic in early stages despite diminished pulses; symptoms often appear later as the disease advances.

Question 35

43. What role does dual antiplatelet therapy play in PAD management? A. It is only used in the acute setting B. It reduces the risk of thromboembolic events and may improve outcomes after revascularization C. It is contraindicated in all PAD patients D. It is used to treat pain associated with claudication

Answer 35

o Answer: B o Rationale: Dual antiplatelet therapy helps reduce thrombus formation and is often used after interventions to prevent reocclusion.

Question 36

44. Which of the following interventions is indicated if conservative management fails in PAD patients with disabling symptoms? A. Increased exercise only B. Revascularization procedures (endovascular or surgical) C. Immediate amputation D. Strict bed rest

Answer 36

o Answer: B o Rationale: Revascularization (angioplasty/stenting or bypass surgery) is indicated when symptoms are severe and unresponsive to conservative treatment.

Question 37

45. Why is early diagnosis and treatment of PAD important? A. It completely cures atherosclerosis B. It reduces the risk of cardiovascular events and progression to critical limb ischemia C. It eliminates the need for lifestyle modifications D. It prevents the need for any medications

Answer 37

o Answer: B o Rationale: Early intervention in PAD lowers cardiovascular risk and can prevent progression to limb-threatening ischemia.

Question 38

46. What is a common complication (“what will harm your patient”) if PAD is left untreated? A. Improved exercise tolerance B. Increased risk of cardiovascular events, including stroke and myocardial infarction C. Decreased incidence of peripheral infections D. Enhanced wound healing.

Answer 38

o Answer: B o Rationale: Untreated PAD significantly increases the risk of major cardiovascular events and mortality

Question 39

48. A patient with diabetes and PAD is at high risk for which complication due to impaired wound healing? A. Spontaneous bleeding B. Chronic non-healing ulcers leading to possible amputation C. Excessive hair growth D. Hyperactive reflexes

Answer 39

o Answer: B o Rationale: Diabetic patients with PAD commonly develop non-healing foot ulcers that can progress to gangrene and require amputation.

Question 39

47. Which laboratory test is most useful in assessing overall cardiovascular risk in a patient with PAD? A. Serum calcium B. Lipid profile C. Complete blood count D. Thyroid function tests

Answer 39

Answer: B o Rationale: A lipid profile helps assess and manage dyslipidemia, a key contributor to atherosclerosis and cardiovascular risk.

Question 40

49. Which nonpharmacologic strategy is essential for improving outcomes in PAD? A. Smoking cessation and supervised exercise programs B. Increased dietary fat intake C. Avoidance of all physical activity D. Daily use of cold packs

Answer 40

o Answer: A o Rationale: Smoking cessation and exercise are cornerstones in managing PAD, reducing progression and improving functional status.

Question 42

50. Which statement best summarizes the critical management principles for PAD? A. Focus solely on pharmacologic therapy and ignore lifestyle modifications B. Early diagnosis, aggressive risk factor modification, appropriate use of medications, and timely revascularization when indicated C. Only consider surgical intervention in all cases D. Use imaging studies exclusively to guide treatment

Answer 42

o Answer: B o Rationale: Effective PAD management combines early detection, risk factor modification (smoking cessation, diabetes control), medical therapy (antiplatelets, statins, cilostazol when appropriate), and revascularization when needed

Question 43

In severe PAD, which complication is a direct life/limb-threatening scenario if not recognized? A. Mild calf pain B. Critical limb ischemia with risk of gangrene C. Occasional leg cramps from dehydration D. Tinea pedis infection

Answer 43

B. Critical limb ischemia with risk of gangrene Rationale: Severe peripheral artery disease (PAD) can progress to critical limb ischemia (CLI), a life- and limb-threatening condition characterized by: Rest pain in the affected limb Non-healing ulcers or gangrene Tissue necrosis due to inadequate blood supply CLI requires urgent vascular intervention to restore perfusion and prevent amputation or systemic complications (e.g., sepsis).

Question 44

What is the first-line diagnostic test for PAD in a patient with classic claudication symptoms? A. Ankle–brachial index (ABI) B. Venous duplex ultrasound C. CT angiography D. Magnetic resonance angiography

Answer 44

A. Ankle–brachial index (ABI) Rationale: The ankle–brachial index (ABI) is the first-line, non-invasive diagnostic test for peripheral artery disease (PAD) in patients with classic claudication symptoms (leg pain with exertion, relieved by rest). ABI is a quick, cost-effective, and reliable screening tool for assessing arterial perfusion in the lower extremities. Interpreting ABI Results: Normal: 1.0–1.4 Borderline PAD: 0.91–0.99 PAD: ≤0.90 Severe PAD/critical limb ischemia: ≤0.40 >1.40 suggests noncompressible arteries (seen in diabetes, chronic kidney disease).