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Peripheral Arterial Occlusive Disease

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Peripheral Arterial Occlusive Disease Peripheral Arterial Occlusive Disease - ACOI Chicago Hospitalist Meeting Davin Haraway DO,FACOI,FACCWS,RPhS Diplomate – American Board of Venous and Lymphatic Medicine Arterial Issues – Lower extremity encountered by Hospitalists • Acute arterial occlusion • More commonly however • Chronic peripheral vascular disease and manifestations • Ulcers toes, heels,ankles, legs, • Infected ulcers • Cellulitis • Diabetic foot ulcers • Claudication • Edema • Calciphylaxis • Non healing surgical wounds including , BKA,AKA,foot and ankle procedures, • Differentiating from Gout and Charcot Foot Atheroma Prevalence • Dx of PAD ranges from 1–22%, depending on population, risk factors, diagnostic tests • Asymptomatic PAD up to 6 times more common than symptomatic PAD • 8.4 million Americans >40 years old have PAD • High overlap of PAD with CAD and CVD • Prevalence of PAD in persons >70 years 5 times greater than in persons <40 years • Claudication 3-4 times more common in diabetics and 3 times more common in smokers Peripheral Arterial Disease and Intermittent Claudication • Peripheral Arterial Disease (PAD) A disorder caused by atherosclerosis that limits blood flow to the limbs. • Intermittent Claudication (IC) A symptom of PAD characterized by pain, aching, or fatigue in working skeletal muscles. IC arises when there is insufficient blood flow to meet the metabolic demands in leg muscles of ambulating patients. Pathophysiology of Intermittent Claudication • Intermittent claudication is associated with – Metabolic abnormalities stemming from reduced 1 blood flow and O2 delivery – Significant reduction (50%) in muscle fibers compared with controls2 – Smaller type I and II muscle fibers with greater arterial ischemia2 – Hyperplastic mitochondria and demyelination of nerve fibers3 1 Lundgren et al Am J Physiol. 1988;255:H1156-64. 2 Hedberg et al. Eur Vasc Surg. 1989;3:315-22. 3 Farinon et al. Clin Neuropathol 1984;3:240-52. Relative 5-Year Mortality Rates 100 86 80 Patients 60 (%) 39 40 32 23 18 20 8 0 † Prostate Hodgkin's Breast PAD Colorectal Lung Cancer* Disease* Cancer* Cancer* Cancer* *American Cancer Society. Cancer Facts and Figures, 2000. †Criqui MH et al. N Engl J Med. 1992;326:381-6. US Adults’ Perception of Illness Severity (SF-36) Intermittent Severe Mild claudication migraine migraine Chronic Average Average CHF lung well adult disease adult 0 34 36 38 41 49 55 100 30 40 50 Physical Health Component Summary Score Adapted from Understanding Health Outcomes Educational Series (1998). Identifying Patients at Risk for PAD • Consider PAD in: – Any patients with exertional leg pain – Patients >50 years old with risk factors – All patients >70 years old – Any patients with non-healing wounds on the extremities Systemic Manifestations of Atherosclerosis • TIA • Ischemic stroke • Q-wave MI • Non-Q-wave MI • Unstable angina pectoris • Renovascular hypertension • Intestinal ischemia • Erectile dysfunction • Claudication • Critical limb ischemia, rest pain, gangrene, amputation Risk Factors for Atherosclerosis Age Dyslipidemia Diabetes Hypertension Smoking Hypercoagulability Obesity States Hyperhomo- Genetics Atherosclerosis cysteinemia Atherosclerotic Diseases (CAD, CVD, PAD) Prevalence of PAD/Intermittent Claudication in Smokers • Severity of PAD increases with number of cigarettes smoked • Diagnosis is made a decade earlier • Intermittent claudication is 3 times more common in smokers • Smoking is the most powerful modifiable risk factor for PAD TASC Working Group. J Vasc Surg. 2000;31(1 suppl):S1-S296. Kannel WB et al. J Am Geriatr Soc. 1985;33:13-8. Age-Dependent Prevalence of PAD 25 Men 20 Women PAD 15 Prevalence (%) 10 5 0 <60 60-64 65-69 70-74 ³75 Age Groups (y) Adapted from Criqui MH et al. Circulation.1985;71:510-5. Prevalence of Intermittent Claudication in Persons With Diabetes • Intermittent claudication is 2 to 4 times more common among persons with diabetes than among those without the disease – Intermittent claudication is 3.4 times more common among men with diabetes – Among women with diabetes, intermittent claudication is 5.7 times more common Brand FN et al. Diabetes. 1989;38:504-9. Reunanen A et al. Acta Med Scand. 1982;211:249-56. ADA/AHA Consensus Statement • Annual history for exercise-induced leg pain in all diabetic patients • Annual palpation of leg pulses for all adult patients with diabetes • ABI should be performed for insulin- dependent diabetic patients >35 years of age, or patients with ³20 years’ duration of diabetes Orchard TJ et al. Circulation. 1993;88:819-28. Summary: Pathogenesis, Risk Factors • Atherosclerosis is underlying cause of PAD – Obstructions common in aorta or in iliac, femoral, or popliteal artery • Risk factors: smoking, diabetes, ­ BP, dyslipidemia, obesity, hyperhomocysteinemia • Diabetics have fourfold greater risk for PAD • Smoking is greatest avoidable risk factor for PAD; increases mortality almost fourfold – Synergistic effect in presence of other risk factors – ­ Risk with number of cigarettes smoked Prevalence of Atherosclerotic Comorbidities Cerebral Coronary 15% 13% 33% 8% 5% 14% 12% PAD Adapted from Aronow WS. Am J Cardiol. 1994;74:64-5. Important Questions for Patients • Do you develop any cramping or fatigue in the muscles of either leg that occurs when you walk? • Do symptoms only start when you walk? • Do symptoms resolve once you stop walking? • Do the symptoms occur in one or both legs? • Do you have any nonhealing foot wounds? Common Sites of Claudication Obstruction in Ischemia in Aorta or Buttock, hip, iliac artery thigh Femoral artery Thigh, or branches calf Popliteal Calf, ankle, artery foot Arterial Physical Exam for PAD: Lower Extremities • Auscultate abdomen for bruits (systolic/diastolic) • Palpate for abdominal aortic aneurysm • Palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses • Inspect feet for ulcers, fissures, calluses, tinea, or tendinous xanthomas – Evaluate overall foot skin care Diagnosis and Assessment of Disease Severity • Vascular history • Physical examination • Ankle-brachial index (ABI) measurement • Noninvasive vascular laboratory tests Noninvasive Vascular Tests • ABI measurements • Pulse-volume recordings • Segmental pressure measurements • Duplex ultrasonography • Treadmill exercise testing ABI as Predictor of Mortality in PAD ABI 1.0 0.5- 0.91 0.9 0.31- 0.49 0.8 £ 0.3 Cumulative 0.7 Survival 0.6 0.5 0.4 0.3 0 10 20 30 40 50 60 Survival Time (months) Adapted from McDermott MM et al. J Gen Intern Med. 1994;9:445-9. Arteriography • Provides an anatomic but not a physiologic assessment • Perform only when considering a revascularization intervention (eg, surgery, PTA, stents) • Always assess inflow and outflow (ie, aortogram with runoffs) Summary: Diagnosis • Consider PAD in anyone (a) with exertional leg pain, (b) >50 y with risk factors, or (c) >70 y – ~85% have stable Sx or asymptomatic PAD • Diagnosis: vascular Hx, physical exam, noninvasive tests (ABI, treadmill, pulse-volume, etc.) • Sx occur in muscles, are reproducible, remit with 2– 3 min rest • ABI: >0.9 = normal; 0.80-0.89 = mild; >0.7-0.79 = moderate; <0.60 = severe; >1.3 = noncompressible • Refer in cases of rest pain, ischemic ulcers, gangrene Clinical Treatment Goals for Patients With PAD Improve Preserve Prevent Reduce cardiac functional the limb progression of and status atherosclerosis cerebrovascular mortality Improve Decrease Reduce nonfatal symptoms the need for events such as MI Improve QOL revascularization and stroke Improve exercise capacity Smoking is the single most important avoidable risk factor for the development of PAD and intermittent claudication Factors That May Improve Atherosclerosis • Smoking cessation • Antiplatelet therapy • Lipid control – ASA, clopidogrel – LDL-C, £ 100 mg/dL – Raise HDL-C • Achieving ideal body – Lower triglycerides weight • Exercise • BP control – Use ACE inhibitors • Diabetes control – HbA1C £ 7.0% Efficacy of Supervised Exercise: Results of a Meta-Analysis Exercisers Controls Change Pain-Free Walking 180% 40% 2 blocks Distance Maximal Walking 130% 30% 3 blocks Distance 1 block = 80 m • Predictors of improvement – Moderate claudication pain – Walking exercise – >6 months’ exercise training – Supervised exercise Gardner AW. JAMA. 1995;274:975-80. Exercise Training vs PTA: Relative Efficacy for Claudication 600 PTA 500 Exercise Claudication 400 Distance (m) 300 200 100 0 0 3 6 9 12 15 Months Creasy TS. Eur J Vasc Surg.1990;4:135-40. Summary: Lifestyle Modification, Risk Factor Reduction • Patient education, lifestyle changes (exercise, weight, lipids, smoking, BP control, etc.), drugs (antiplatelet agents) – LDL-cholesterol to <100 mg/dL, HbA1C to < 7.0% • Follow claudication treatment algorithm; 3-month monitoring intervals until patient improves • Exercise: 3–5 times/week; supervised programs most effective but not widely available • Set reasonable expectations for patient Medications Currently Indicated for Intermittent Claudication Pentoxifylline Cilostazol Drug class Methylxanthine Phosphodiesterase III derivative inhibitor Approved August 1984 January 1999 Dosing 400 mg tid 100 mg bid Pharmacologic Hemorrheologic Platelet aggregation inhibitor properties agent Vasodilation Weak antiplatelet ­ HDL-C (10%) activity Triglycerides (15%) Some Inhibits smooth muscle cell vasodilation proliferation in vitro Pharmacologic Effects of Cilostazol Antiplatelet In vitro inhibition of activity Cilostazol vascular smooth muscle cells Antithrombotic Decreases activity triglycerides Produces Increases vasodilation HDL-C
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