Peripheral Artery Disease

Front 1

What are the risk factors for peripheral artery disease?

Back 1

-Age >= 70
-Age 50-69 and hx of smoking or DM
-Age < 50 with DM and 1 other atherosclerosis risk factor
-Leg symptoms with exertion or ischemic rest pain
Abnormal lower extremity pulse examination
-Known atherosclerotic coronary, carotid, or renal artery disease

Front 2

What are the atherosclerosis risk factors?

Back 2

smoking, DM, dyslipidemia, HTN, hyperhomocysteinemia

Front 3

What is critical limb ischemia (CLI)?

Back 3

lower extremity ischemic rest pain, ulceration, or gangrene (untreated PAD would lead to major limb amputation within 6 months)

Front 4

What are the factors that reduce blood flow and lead to increased risk of limb loss?

Back 4

DM, severe renal failure, severely decreased cardiac output, vasospastic disease or concomitant conditions

Front 5

What are the factors that increase blood flow demand and lead to increased risk of limb loss?

Back 5

Infection (cellulitis or osteomyelitis), skin breakdown or traumatic injury

Front 6

What is acute limb ischemia?

Back 6

form of CLI in which plaque rupture and lower extremity emboli lead to rapid or sudden decrease in limb perfusion threatening tissue viability

Front 7

What are the hallmark clinical symptoms of acute limb ischemia? (5 Ps)

Back 7

pain, paralysis, paresthesias, pulseless, pallor

Front 8

What criteria do you diagnose a patient with PAD?

Back 8

patient hx, physical exam, ankle-brachial index (ABI), continous-wave doppler ultrasound, 6 minute walking test

Front 9

Who is indicated to have an ankle-brachial index test?

Back 9

patients with exertional leg symptoms, non-healing wounds, >=65 or >= 50 with hx of DM or smoking

Front 10

Is the ankle-brachial index highly sensitive or specific?

Back 10

both highly sensitive and specific

Front 11

What is the normal ABI?

Back 11

1

Front 12

What is PAD ABI?

Back 12

<= 0.9

Front 13

What is mild PAD ABI score?

Back 13

0.7-0.9

Front 14

What is moderate PAD ABI score?

Back 14

0.4-0.7

Front 15

What is severe PAD ABI score?

Back 15

<0.4

Front 16

What are the tx goals in PAD?

Back 16

improve walking distance and pain free walking, control of comorbid conditions (HTN, dyslipidemia, DM), improve QOL, reduction in CV complications and death

Front 17

What tx can be used to reduce vascular events in PAD?

Back 17

decrease or control risk factors, antiplatelet therapy (aspirin, aggrenox, clopidogrel, ticlopidine)

Front 18

What tx can be used to improve symptoms of PAD?

Back 18

cilostazol, pentoxifylline, walking

Front 19

What is the HTN tx in PAD?

Back 19

goal of <130/<85, ACEi for pts with lower extremity PAD to reduce CV events, use compelling indications to select HTN drugs

Front 20

What is the dyslipidemia tx in PAD?

Back 20

LDL < 100, use statins or BAS or nicotinic acid

Front 21

What is the tx for DM pts with PAD?

Back 21

a1c < 7%, ABI screening for PAD in all DM patients > 50 yoa

Front 22

What is the tx for homocysteine lowering in pts with PAD?

Back 22

folic acid and B12 with levels > 14umol/L (level C evidence, not well established)

Front 23

What is the antiplatelet MOA of ASA?

Back 23

irreversible inhibition of platelet cyclooxygenase, blocks the formation of thromboxane A2, reducing platelet aggregation

Front 24

What is the dose of ASA in PAD?

Back 24

75-325mg/day

Front 25

What are the SEs of ASA?

Back 25

bleeding, GI upset

Front 26

What is the MOA of ASA/Dipyridamole?

Back 26

inhibit platelet aggregation and cause vasodilation

Front 27

Is aggrenox superior to ASA in PAD tx?

Back 27

no

Front 28

What patient population with PAD should not recieve aggrenox?

Back 28

pts with CAD

Front 29

What are the SEs of aggrenox?

Back 29

increased risk of bleeding, GI SEs

Front 30

What is the MOA of clopidogrel?

Back 30

The drug specifically and irreversibly inhibits the P2Y12 subtype of ADP receptor, which is important in aggregation of platelets and cross-linking by the protein fibrin.[1] The blockade of this receptor inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa pathway (****prodrug***)

Front 31

What is the dosing of clopidogrel in PAD?

Back 31

75mg daily

Front 32

What are the SEs of clopidogrel?

Back 32

bleeding, rash

Front 33

When is clopidogrel indicated for PAD patients?

Back 33

first line when ASA is not tolerated or is contraindicated; can be used for symptomatic relief in high risk patients along with ASA

Front 34

What is the MOA of ticlopidine?

Back 34

blocks the ADP recpetors on the platelet surface, prevents the activation of GP IIb/IIIa receptor complex

Front 35

What are the SEs with ticlopidine?

Back 35

black box warning for neutropenia/agranulocytosis, thrombotic thrombocytopenia purpura, and aplastic anemia

Front 36

What is the first line pharmacologic therapy in PAD to reduce vascular events? Alternative?

Back 36

Aspirin or clopidogrel is first line with aggrenox as the alternative therapy

Front 37

What is the MOA fo Cilostazol (Pletal)?

Back 37

PDE III inhibitor

Front 38

What is claudication?

Back 38

A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries

Front 39

Who is claudication indicated for?

Back 39

PAD pts with severe intermittent claudication and non-surgical candidates

Front 40

What does cilostazol achieve in PAD pts?

Back 40

increases maximal walking distance and pain free walking

Front 41

What is the dosing for cilostazol?

Back 41

100mg BID

Front 42

What are the SEs of cilostazol?

Back 42

HA, rhinitis, peripheral edema; Black box warning: DO NOT USE IN PTS WITH PAD AND HF

Front 43

What is pentoxifylline?

Back 43

PAD symptomatic drug shown to be no better than placebo

Front 44

What is the non-pharmacologic tx for symptomatic tx in PAD?

Back 44

walking a min of 30-45 min for at least 3x/wk for pts with intermittent claudication

Front 45

Which PAD pts receive revascularization therapy?

Back 45

pts with severe disease who failed other therapy