MedicalContinuing Education

CLINICAL PODIATRY

Goals and Objectives After reading this article, the pod- PeripheralPeripheral ArterialArterial iatrist should be able to: 1) Verbalize a definition of periph- Disease:Disease: DiagnosticDiagnostic eral arterial disease 2) Understand the risk factors asso- EvaluationEvaluation andand ciated with peripheral arterial disease 3) Identify the objective methods used to confirm the diagnosis of pe- CurrentCurrent TherapeuticTherapeutic ripheral arterial disease 4) Appreciate the importance of OptionsOptions risk factor intervention as primary therapy of peripheral arterial disease 5) Develop a strategy for treat- NewNew treatmentstreatments offeroffer anan improvedimproved ment of peripheral arterial disease prognosisprognosis forfor PAD.PAD. using medical, endovascular, and surgical modalities.

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin- uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (you save $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred- its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 190. Other than those entities cur- rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podia- try Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 190).—Editor

By Michael R. Jaff, DO grene. Prompt recognition of this Given the inaccuracy of physical ex- disorder is critical to avoid progres- amination, using pulse examination eripheral arterial disease (PAD) sive deterioration in physical func- as the sole criterion will grossly over- is defined as occlusive arterial tion, limb loss, and premature death estimate the true prevalence. In con- Pdisease of the lower extremities from myocardial infarction or stroke. trast, an historical query for the pres- that reduces arterial flow during ex- The podiatrist plays an important ence of intermittent claudication un- ercise or, in advanced stages, at rest. role in this process, and must under- derestimates the prevalence of PAD. The presentation of PAD is varied, stand the prevalence and natural his- Epidemiological studies have wide- and may appear as asymptomatic ar- tory, presenting symptoms and ranging prevalence rates from 1.6% terial disease with abnormal non-in- signs, objective diagnostic tests, im- to 12%, while other studies using ob- vasive tests; symptomatic disease portance of risk factor intervention, jective disease detection with non-in- presenting as either classic or atypi- and therapeutic alternatives. vasive tests have prevalence rates var- cal intermittent claudication (IC); ing from 3.8% to 33%.(1) Non-inva- and critical limb ischemia (CLI), Epidemiology sive methods for disease definition in manifesting as ischemic rest pain, The prevalence of PAD depends epidemiological surveys have usually non-healing ischemic ulcers, or gan- on how one defines the disease. Continued on page 182 www.podiatrym.com AUGUST 2004 • PODIATRY MANAGEMENT 181 PAD... The first objective test which The higher of the two ankle pres- must be performed in patients either sures (either the dorsalis pedis or Continuingincluded statistically validated at risk for PAD, or with symptoms posterior tibial artery) is used as the claudication questionnaires. The and physical findings of PAD is the numerator of the ABI calculation. Medical Education Edinburgh Claudication Question- ankle-brachial index (ABI). The ABI is The process is repeated on the naire (a modification of the World a safe, simple, highly accurate, and contralateral limb. Health Organization/Rose claudica- reproducible method of determining A normal ABI is defined as a rest- tion questionnaire), when compared * The presence and severity of PAD * ing measurement > 0.90. Any value < with the independent assessment by The cardiovascular risk of myocardial 0.90 represents the presence of PAD. two physicians of 300 patients over infarction, stroke, and vascular death. Obviously, the lower the ABI, the age 55, demonstrated a sensitivity of This test is easily performed in the more severe the PAD. Patients with 91% and specificity of 99% for the di- podiatric specialist’s office. It requires ABI values > 0.70 may be asymp- agnosis of intermittent claudication.1 * Routine sphygmomanometer tomatic, or have very mild symptoms The ankle-brachial index (ABI), * Hand held, continuous wave of intermittent claudication. ABI val- which is a comparison of the systolic Doppler ues between 0.40 and 0.70 represent blood pressure in the dorsalis pedis * Acoustic Gel. patients with mild to moderate inter- and posterior tibial arteries of the In patients with symptoms sug- mittent claudication. Values < 0.40 limb to the brachial artery of the arm gestive of PAD, physical findings in- suggest the most advanced stages of using a hand-held Doppler, has been creasing the likelihood of PAD, or in PAD, with ischemic rest pain, non- validated against angiographically patients at high risk for PAD, the ABI healing ulcerations, and gangrene oc- confirmed PAD and found to be 95% is the ideal office-based objective curring with frequency. sensitive and almost 100% specific.2 evaluation. The ABI provides information In clinical practice, this is the most A sphygmomanometer is placed about the presence or absence of simple, inexpensive, reliable and re- on the upper arm, and the systolic PAD, along with the severity and risk producible method of identifying of co-morbid atherosclerotic patients with PAD. events. If the clinician, however, The age-adjusted prevalence desires more detailed information of PAD, as defined by an ankle- concerning the location of arterial brachial index < 0.9 is 12%1. PAD occlusive disease, whether disease prevalence rates defined by non- is represented by stenoses or oc- invasive testing are reported to be clusions, the length of atheroscle- 2.5% at age 40 to 59 years, 8.3% rotic disease, and the status of the at age 60 to 69 years, and 18.8% ‘run-off’ arteries, other diagnostic at age 70 to 79 years.3 tests such as segmental limb pres- sures, pulse volume recordings, Diagnosis of Peripheral Doppler segmental waveforms, Arterial Disease and arterial duplex ultrasonogra- Classic (“Rose”) intermittent phy should be considered. claudication, the most common pressure is measured using a hand- The ABI is a highly accurate symptom of PAD, is characterized by held Doppler device. This process is method of determining the presence exertional discomfort in a major repeated on the contralateral upper of PAD and its severity. However, if muscle group in a limb, which devel- arm. The higher of the two pressures the ankle vessel is calcified, com- ops with exercise and is promptly re- is used as the denominator of the monly seen in patients with diabetes lieved with rest. A significant propor- ABI calculation. Following this, the mellitus or end-stage renal disease, tion of patients with symptomatic sphygmomanometer is placed on an accurate ankle pressure cannot be PAD will not describe classic symp- the lower leg, just above the ankle. obtained. The pressure in these calci- toms, making the diagnosis more Again utilizing the hand-held fied arteries is often > 200-250 difficult. More than 50 percent of pa- Doppler, an arterial Doppler signal is mmHg. If not recognized as artifac- tients with PAD are either asymp- obtained in the dorsalis pedis artery, tually high, the physician may false- tomatic or have atypical symptoms, the cuff inflated until the arterial ly conclude that arterial circulation one-third have classic symptoms of Doppler signal disappears, and then is adequate, or even normal, in these intermittent claudication, and 10 the cuff is gradually deflated. When patients. In this scenario, other tests percent of patients develop critical the arterial Doppler signal returns, available in the vascular diagnostic limb ischemia.4 The spectrum of PAD this represents the arterial pressure in laboratory are necessary, including is not a continuum. Patients com- the dorsalis pedis artery. The photoplethysmography, digital pres- monly present with CLI without Doppler device is then positioned sures, arterial duplex ultrasonogra- having experienced prior symptoms posterior to the medial malleolus, phy, and even assessments of wound (the classic example is the patient and the arterial Doppler signal of the healing potential utilizing transcuta- with diabetes mellitus who sustains posterior tibial artery is obtained. neous oximetry (TcP02). minor trauma to a foot after wearing Using the identical method as de- Patients with classic historical ill-fitting shoes and develops gan- scribed for the dorsalis pedis artery, symptoms of PAD may have a normal grene, never having experienced the pressure is then determined in physical examination and ABI. In this claudication in the past). the posterior tibial artery. Continued on page 183

182 PODIATRY MANAGEMENT • AUGUST 2004 www.podiatrym.com MedicalContinuing Education PAD... require a highly trained technologist, need of revascularization, as well as a physician who under- this examination is as accu- scenario, the astute clinician must stands the subtleties of waveform in- rate as arteriography in predict- pursue an exercise physiologic study terpretation. ing the optimal revascularization performed in the vascular diagnostic Segmental arterial Doppler wave- method. laboratory. Patients have resting pres- forms may also be performed, and In patients who are being sures measured, and are then placed are easier to interpret. Using a bidi- considered for revascularization, du- on a treadmill at a constant speed and rectional Doppler probe, Doppler plex ultrasound scanning, magnetic constant grade of incline. The patient waveforms are obtained at each arte- resonance angiogram (MRA), and is asked to report initial symptoms of rial level. Normal Doppler wave- more recently computer tomograph- limb discomfort, and then terminate forms are triphasic. Mild to moderate ic angiography (CTA) are valuable in the exercise when the discomfort is PAD are represented by biphasic localizing arterial disease. Duplex ul- limiting. After exercise, pressures are Doppler waveforms. Severe PAD re- trasonography can be used for direct again measured. A significant de- sults in monophasic and ultimately, visualization of arteries and is espe- crease in post-exercise pressures con- flat waveforms. Segmental Doppler cially useful after revascularization firms the diagnosis of PAD, and also waveforms are easy to perform, and (surgical bypass grafts or stent place- characterizes the functional limita- require little training to interpret. In ment). MRA is considered one of the tion of the symptoms. most significant advances in di- With the use of sequential agnostic techniques in the past limb blood pressure cuffs and 10 years, as blood flow imaging is commercially available equip- possible without the administra- ment, segmental limb arterial tion of radiocontrast media. Stud- blood pressures may be obtained. ies have demonstrated the MRA Each pressure measurement is technique is accurate and compa- compared to its proximal cuff, rable to angiography. Both of and to the cuff on the contralat- these tests are noninvasive and eral limb. For example, the pres- thus pose no significant risk for sure obtained in the proximal anaphylaxis or nephrotoxicity. thigh cuff is normally > 30 CTA is emerging as a very useful mmHg higher than the brachial test to plan revascularization pressure. If this is not found, this strategies. This technique requires would suggest the presence of in- the administration of intra- flow aorto-iliac artery disease. venous contrast. Angiography Each cuff pressure should be no should be reserved for those pa- lower than 20 mmHg than the tients in whom revascularization pressure cuff proximal to that is mandatory. level. Disease localization occurs one segment proximal to the cuff Risk factors for the with the lower pressure. There- Development of PAD fore, if the pressure in the lower The risk of developing PAD thigh cuff is 40 mmHg lower can be predicted by age and well- than the high thigh cuff, this defined atherosclerotic risk fac- would suggest superficial femoral tors, including tobacco use, dia- artery occlusive disease. betes mellitus, hypercholes- Pulse volume recordings terolemia and hypertension. The (PVR’s) are plethysmographic tests the scenario of non-compressible ar- Framingham Heart Study data has which provide qualitative informa- teries, however, Doppler waveforms defined age, sex, serum cholesterol tion. Simply put, a blood pressure lose accuracy. level, hypertension, tobacco use, dia- cuff is inflated to a level that does Arterial duplex ultrasonogra- betes mellitus, and coronary heart not interrupt arterial flow (usually ~ phy is a highly accurate examina- disease as factors associated with an 60-65 mmHg). As each arterial pulse tion, which may be performed from increased risk for PAD and intermit- passes through the segment of artery the aortic bifurcation to the ankles. tent claudication.5 This “risk factor beneath the cuff, the volume of Utilizing currently available Duplex profile” is useful in determining pop- blood causes distention of the artery. ultrasound scanners, arteries are vi- ulations and patients at risk. This is sensed by the cuff, which sualized, often with color imaging, then transmits the volume change to and Doppler velocities are obtained. Age a recorder, providing a waveform. In A doubling in the peak systolic ve- The prevalence of PAD increases the normal setting, this waveform is locity suggests a 50-99% stenosis. Ar- sharply with age, from 3% in pa- similar in appearance to an intra-ar- terial duplex ultrasonography re- tients < 60 years of age to 20% in pa- terial pressure waveform. As the arte- quires a highly skilled technologist. tient >75 years of age.4 Data from rial circulation worsens, the PVR In addition, a complete examination subjects in the Framingham study re- looses the dicrotic notch, lowers in of both lower extremities is time- vealed that the prevalence of PAD amplitude, and widens. These tests consuming. In patients who are in Continued on page 184 www.podiatrym.com AUGUST 2004 • PODIATRY MANAGEMENT 183 PAD... long-term risk of complications, in- ed with simvastatin for 2 years, the cluding progression of PAD, myocar- intima-media thickness in the Continuingincreased 10-fold from men dial infarction and mortality. In a femoral artery decreased by a mean aged 30-44 to men aged 65-74 study by Jonason et al., the rate of de- of 0.283 mm. This suggests Medical Education and almost 20-fold in women from velopment of rest pain in intermittent atherosclerotic disease reversal with the younger to older age-groups.6 In claudication patients was 0% in non- statin treatment in high-risk hyperc- the Rotterdam and San Diego epi- smokers and 16% in smokers, while holesterolemic patients.24 demiological studies, prevalence 10 year rates of myocardial infarction rates increased with advancing age were 11% and 53%, 10 year cumula- Hyperhomocyteinemia both for IC and for PAD defined tive rates of cardiac death were 6% Multiple prospective and case with the use of objective tests.7,8 and 43% and 10-year survival rates controlled studies have suggested 82% and 46% among non-smokers that an elevated plasma homocys- Hypertension and smokers respectively.15 From the teine concentration is an indepen- The role of hypertension as a limb standpoint, tobacco cessation is dent risk factor for atherothrombotic major risk factor for the develop- associated with improved post-opera- vascular disease in the coronary, ment and progression of PAD is well tive graft patency rates.16 cerebral, and peripheral vasculature. demonstrated in the Framingham In a meta-analysis of 27 studies, a Offspring Study and the German Diabetes Mellitus modest increase in homocysteine Epidemiological Trial on Ankle PAD is prevalent in patients with was independently associated with Brachial Index (GET ABI study).9,10 No diabetes mellitus. A survey of pa- an increased risk of CAD, cerebrovas- studies are available, however, to tients with diabetes 50 years of age cular disease and PAD.25 In a prospec- evaluate whether antihypertensive or older demonstrated a prevalence tive study of patients with symp- therapy directly alters the progres- of PAD of 29%.17 In the Rotterdam tomatic PAD, for each 1.0 mol/L in- sion of symptomatic PAD. The Ap- study, diabetes was present in 11.9% crease in the plasma homocysteine propriate Blood Pressure Control in and 16% of male and female patients level, there was a 3.6% increase in Diabetes (ABCD) Study demonstrat- respectively, with abnormal ABI, ver- the risk of all-cause mortality at three ed a marked reduction in cardiovas- sus 6.7% and 6.3% for those without years and a 5.6% increase in the risk cular events in normotensive PAD PAD.18 In the Cardiovascular Health of cardiovascular-related death. patients with diabetes when treated Study, diabetes was associated with a with an intensive blood pressure- 3.8-fold increased prevalence of PAD C-Reactive Protein lowering strategy as compared to in patients over age 65.19 In a Veter- C-reactive protein (CRP) has re- standard antihypertensive therapy.11 ans Administration patient popula- cently emerged as a novel risk factor In the most recent guidelines from tion with intermittent claudication, associated with risk of systemic the Joint National Committee on the diabetes was the major independent atherosclerosis. CRP together with Detection, Evaluation, and Treat- predictor of death.20 the total cholesterol-HDL-C ratio ment of hypertension, PAD is con- were the strongest independent pre- sidered equivalent in risk to ischemic Hyperlipidemia dictors of development of symp- heart disease, therefore supporting The Lipid Research Clinics (LRC) tomatic PAD in a study by Ridker aggressive blood pressure control.12 Prevalence Study confirmed the asso- PM, et al. CRP in the same study pro- ciation of dyslipoproteinemia vided additive prognostic informa- Tobacco Use (specifically low HDL-cholesterol and tion over standard lipid measures.26 The single most important modifi- elevated LDL-cholesterol) with able risk factor for the development of symptoms and signs of PAD.21 In the Natural History of Peripheral atherosclerotic disease is tobacco use. National Cholesterol Education Pro- Arterial Disease The amount and duration of tobacco gram Adult Treatment Panel III re- The impact of peripheral arterial use correlate directly with the devel- port on detection, evaluation and disease on limb and life is quite differ- opment and progression of PAD. treatment of high blood cholesterol ent, and has implications on manage- Smoking increased the risk of inter- in adults, PAD (regardless of diagnos- ment strategies. Weitz, et al., defined mittent claudication by 8 to 10-fold in tic methods) is considered a coro- the 5-year outcomes (on both limb the Reykjavik Study and cessation of nary artery risk equivalent.22 Lipid- and life) of PAD on patients over age tobacco use resulted in a 50% reduc- lowering agents, most commonly 55 with IC. The majority of patients tion in rates of intermittent claudica- HMG-CoA reductase inhibitors have no progression of limb symp- tion over a 20-year period among Ice- (“statins”) are thought to benefit toms over the subsequent five years landic men.13 The best evidence for a PAD patients by decreasing risk for after initial presentation. Of the re- causal role of tobacco use in coronary events and by potentially maining, 27% demonstrate progres- atherosclerotic PAD is an improve- reversing atherosclerotic lesions. sion of symptoms, while the need for ment in outcome with tobacco cessa- Data from the Scandinavian Simvas- revascularization or limb loss occurs tion. Tobacco cessation results in im- tatin Survival Study (4S) of 4,444 pa- in a minority (<10%) of patients.1 proved ankle pressure and exercise tol- tients with known cardiovascular Despite the relatively stable prog- erance in patients with intermittent disease revealed that use of simvas- nosis for the affected limb, there is a claudication as early as 10 months tatin reduced episodes of new or marked risk of cardiovascular mor- after tobacco cessation.14 Tobacco ces- worsening IC by 38%.23 In familial bidity and mortality over 5-years sation also has a major impact on the hypercholesterolemic patients treat- Continued on page 185

184 PODIATRY MANAGEMENT • AUGUST 2004 www.podiatrym.com MedicalContinuing Education PAD... prevent limb loss, and improve func- diovascular morbidity tional status of patients with inter- and mortality. Platelet acti- after diagnosis of intermittent claudi- mittent claudication. Patients with vation is increased in patients cation. The rate of nonfatal cardio- PAD must be approached with the with PAD, suggesting an under- vascular events (myocardial infarc- same intensity for secondary cardio- lying prothrombotic state.33 Until tion and stroke) is 20%, with 5-year vascular disease prevention and risk recently, however, the use of aspirin mortality rates of 30 %.27 At the time factor modification as recommended in patients with PAD was not based of diagnosis of IC, at least 10% of pa- for patients with coronary artery or on direct evidence, but only on tients with PAD have concomitant carotid artery disease. In 2001, a analogous data in coronary and cerebrovascular disease, and 28% multidisciplinary task force of the cerebral atherosclerosis, where anti- have coronary heart disease. American College of Cardiology and platelet therapy has documented The overall mortality rate in pa- American Heart Association pub- clear efficacy. tients with intermittent claudication lished recommendations for risk fac- A meta-analysis of anti-platelet is 30% at 5 years, 50% at 10 years, tor modification in patients with treatment in patients after peripheral and 70% at 15 years. The mortality atherosclerotic cardiovascular dis- arterial bypass surgery, albeit demon- of patients with intermittent claudi- ease.32 In these guidelines, all pa- strating a non-significant effect on cation is approximately 2.5-fold that tients diagnosed with PAD must re- cardiovascular outcomes and sur- of an age-matched general popula- ceive aggressive therapy to prevent vival, revealed a mildly positive ef- tion.34 The majority of these deaths subsequent atherosclerotic disease fect on the patency of peripheral ar- are caused by coronary artery dis- and clinical events. Secondary pre- terial bypass grafts.34 ease, cerebrovascular disease, and The Antithrombotic Trialists’ other vascular diseases (i.e. abdomi- Collaboration summarized the re- nal aortic aneurysm, mesenteric is- Regular aerobic sults from 287 studies involving chemia).28 Subjects with asymp- 135,000 patients randomized to anti- tomatic PAD appear to have the exercise reduces platelet therapy or placebo. This same risk of cardiovascular events cardiovascular risk meta-analysis also evaluated 77,000 and death seen in patients with in- patients treated with different anti- termittent claudication. (by lowering cholesterol, latelet regimens. In the subset of pa- For patients with critical limb is- blood pressure, tients treated with anti-platelet ther- chemia, the outcomes are signifi- apy for PAD (N=9214), anti-platelet cantly worse. In addition to the and improving glycemic therapy demonstrated a 23% reduc- marked increase in rates of limb loss, control) and produces tion in serious vascular events, with 20% of these patients die within 6 similar benefits among patients with months. The annual mortality rate symptomatic intermittent claudication and those in patients with CLI is 25%. Virtually improvement patients undergoing lower extremity all patients who present with gan- revascularization.35 grene and/or ischemic rest pain are in patients with PAD. Ticlopidine, a thienopyridine dead within 10 years. 34, 29 derivative which blocks the activa- Severity of PAD can be defined tion of platelets by adenosine based on ABI values. An abnormal vention strategies include: diphosphate (ADP), has demonstrat- ABI is a potent predictor of cardio- 1. Tobacco cessation ed significant benefit in patients vascular events and premature mor- 2. Physical activity with PAD. Enthusiasm for this drug tality. In the Heart Outcomes Pre- 3. Dietary modification has been tempered, however, by the vention Evaluation (HOPE) study, an 4. Weight maintenance/ reduc- substantial risk of thrombocytope- abnormal ABI was a strong predictor tion with target BMI 18.5-24.9 nia, neutropenia (which occurs in of cardiovascular morbidity and kg/m2 and waist circumference <35 2.3 % of treated patients), and mortality during 4.5 years of follow- in women and <42 inches for men. thrombotic thrombocytopenic pur- up, even in patients without symp- 5. Blood pressure control pura (which occurs in 1 in 2000- toms suggestive of PAD.30 6. Modification of elevated total 4000 patients).36 We do not recom- These findings have prompted and LDL-cholesterol levels mend the routine use of ticlopidine the American Diabetes Association 7. Anti-platelet therapy. in patients with PAD. to recommend screening ABI in all 8. ACE inhibitor therapy Clopidogrel (Plavix), a second diabetic patients over age 50, and in 9. Glycemic control in patients thienopyridine derivative, has an ac- diabetic patients < 50 with other with diabetes mellitus Modification tion similar to ticlopidine without PAD risk factors (e.g., smoking, hy- of risk factors requires knowledge, the serious hematological side ef- pertension, hyperlipidemia, or dura- patience, and perseverance by the fects. The Clopidogrel Versus Aspirin tion of diabetes >10 years).31 clinician, as most patients find this in Patients at Risk of Ischemic Events aspect of their care very challenging (CAPRIE) Study, a multicenter, The Management of PAD with limited short-term rewards. multinational, prospective random- The goals of therapy for patients ized trial, evaluated aspirin versus with PAD are to prevent systemic Anti-platelet Therapy clopidogrel in over 19,000 patients atherosclerotic disease progression Anti-platelet agents are recom- with recent stroke, MI, or symp- and clinical cardiovascular events, mended to prevent associated car- Continued on page 186 www.podiatrym.com AUGUST 2004 • PODIATRY MANAGEMENT 185 PAD... duces symptomatic improvement in termittent claudication.42 patients with PAD. The beneficial Continuingtomatic PAD. Clopidogrel was effects of exercise may be explained Pharmacologic Treatment of associated with a modest yet sig- by several mechanisms, including Peripheral Arterial Disease Medical Education nificant reduction in the primary improvements in endothelial va- Pentoxifylline (Trental®), a composite endpoint of MI, ischemic sodilator function, skeletal muscle methylxanthine derivative, improves stroke, and vascular death when metabolism, blood viscosity and in- red cell deformability, lowers fibrino- compared with aspirin. In a sub- flammatory responses. Exercise gen levels, and retards platelet aggre- group analysis of 6,452 patients en- training also improves oxygen ex- gation. It is the first medication ap- rolled in CAPRIE due to PAD, clopi- traction and walking efficiency by proved by the FDA (in 1984) for the dogrel offered a relative risk reduc- decreasing oxygen consumption for treatment of patients with IC.1 A re- tion of 24% over aspirin. the same workload.40 cent review of all available trials con- Clopidogrel is well-tolerated, In a meta-analysis of randomized cluded that the actual improvement with no increase in adverse events or trials of exercise in patients with in- in walking distance attributable to discontinuation when compared to termittent claudication, exercise pentoxifylline is unpredictable, may aspirin. Clopidogrel has been associ- therapy significantly improved pain- not be clinically important com- ated with a low risk of adverse hema- free walking time by 180% and max- pared with the effects of placebo, tologic effects. The estimated risk of imal walking time by 150% over 6 and does not justify the added ex- thrombotic thrombocytopenic pur- months. When compared to percuta- pense for most patients.43 Based on pura is 4 per million patients, a level neous revascularization, supervised current evidence we do not recom- that does not warrant routine hema- exercise produced significant im- mend the routine use of pentoxi- tologic monitoring.37 Clopidogrel is fylline in patients with PAD. the only anti-platelet agent approved Cilostazol, a phosphodiesterase by the United States Food and Drug III inhibitor, was the second oral Administration (FDA) specifically for Revascularization agent approved for the treatment of the reduction of cardiovascular attempts are warranted mild to moderate intermittent clau- events in patients with PAD.38 dication in 1999. In addition to its The combined effect of aspirin in patients with antiplatelet properties, cilostazol pro- plus clopidogrel has been demon- symptom-limiting motes vasodilatation, increases plas- strated in patients with acute coro- ma HDL and decreases plasma nary syndromes.39 Currently en- intermittent claudication triglycerides, and potentially inhibits rolling trials will address combina- or in those patients smooth muscle cell accumulation tion therapy in PAD; however, this who progress to after percutaneous coronary inter- recommendation cannot be made at vention.1 The true mechanism present. ischemic rest pain with whereby cilostazol improves pain- We recommend anti-platelet or without ulceration. free walking distance is unknown. therapy in every eligible patient with Cilostazol increases pain-free PAD. If the economic issues of long- and maximal walking distances by term clopidogrel are manageable, 40-70% and 65-83% respectively this agent is superior to aspirin in re- provements in walking time at six after 12-24 weeks when used at the ducing the risk of major cardiovascu- months, and did not differ signifi- recommended dose of 100 mg oral- lar events and vascular death. cantly from surgical treatment.41 ly twice daily. Treatment with We recommend a supervised ex- cilostazol is also associated with im- Exercise Therapy ercise program which encompasses provements in health-related quali- Patients with intermittent claudi- specific factors. Supervised exercise ty of life.44 cation have marked impairment in therapy is the most effective symp- In the pivotal prospective, multi- exercise performance and overall tomatic therapy for patients with center, 24-week randomized trial functional capacity. Reduced walk- IC. Supervised exercise therapy in- comparing cilostazol to pentoxi- ing capacity is associated with im- cludes 6-month programs, with ses- fylline and placebo in 698 patients pairment in the performance of ac- sions three times per week, walking with intermittent claudication, the tivities of daily living and in general as the main form of exercise, and improvement seen with cilostazol (a quality of life. Their peak oxygen sessions lasting 60 minutes. The mean percent increase of 54% from consumption measured during grad- main factors limiting success of ex- baseline) was significantly greater ed treadmill exercise is 50 % of age- ercise therapy include lack of pa- than that seen with either pentoxi- matched subjects with normal pe- tient motivation and compliance, fylline (a 30% mean percent in- ripheral arterial circulation, indicat- and the economic obstacles for re- crease) or placebo. Side effects, such ing a level of impairment similar to imbursement in the United States. as headache, palpitations, and diar- patients with debilitating congestive Available data analyzing the imple- rhea, were more common in the heart failure.23 mentation of supervised exercise in cilostazol group, but discontinuation Regular aerobic exercise reduces patients with PAD are pessimistic. rates were similar between cilostazol cardiovascular risk (by lowering In the United Kingdom, regular and pentoxifylline (16% vs. 19%).45 cholesterol, blood pressure, and im- walking exercise was not followed Chronic use of phosphodi- proving glycemic control) and pro- by almost 50% of patients with in- Continued on page 187

186 PODIATRY MANAGEMENT • AUGUST 2004 www.podiatrym.com MedicalContinuing Education PAD... therapy, first proposed more than 35 Med. 2001 May 24; 344(21): years ago by Dotter and Judkins51 for 1608-21. esterase III inhibitors in patients the treatment of diseased coronary 5 Murabito JM, D’Agostino RB, Sil- with congestive heart failure has arteries, revolutionized the manage- bershatz H, Wilson WF. Intermittent clau- been associated with an increase in ment of certain patients with periph- dication. A risk profile from The Framing- ham Heart Study Circulation. 1997 Jul 1; 96(1): mortality due to a proarrhythmic ef- eral arterial disease (PAD). This ap- 44-9. fect. Therefore, cilostazol must not proach, however, with its reliance on 6 Kannel W, Skinner JJ, Schwartz M et al. be prescribed to patients with inter- techniques such as angioplasty, Intermittent claudication; incidence in the mittent claudication who have con- stents, stent-grafts, and various me- Framingham study. Circulation 1970; 41: 875- gestive heart failure.46 The safety data chanical devices, was not viewed by 83. from eight phase 3 clinical trials in- the practicing interventionist as a vi- 7 Criqui M, Fronek A, Barrett-Connor E et volving 2,702 patients and from able option for individuals with PAD al. The prevalence of peripheral arterial disease postmarketing surveillance in the until the 1980’s. Since then, interest in a defined population. Circulation 1985; 71: United States representing 70,430 has rapidly grown and endovascular 510-5. 8 patient-years of exposure did not re- therapy has now become a primary Meijer WT, Hoes AW, Rutgers D et al. Pe- ripheral arterial disease in the elderly: the Rot- veal increased cardiovascular mor- option in the treatment of PAD.52 terdam Study. Arterioscler Thromb Vasc Biol bidity or mortality risk in patients re- While the technology and de- 1998; 18: 185-92. 47 ceiving cilostazol. vices available for endovascular ther- 9 Murabito JM, Evans JC, Nieto K, Larson Cilostazol should be taken one- apy in PAD have become increasing- MG, Levy D, Wilson PW. Prevalence and clini- half hour before or two hours after ly more sophisticated and reliable, a cal correlates of peripheral arterial disease in food, as high-fat meals markedly in- review of the data reveals that en- the Framingham Offspring Study Am Heart J. crease its absorption. Diltiazem, grape- dovascular therapy is not risk-free. 2002 Jun; 143(6): 961-5. fruit juice or omeprazole can increase Early experience with angioplasty for 10 Diehm C, Schuster A, Allenberg JR, Dar- serum concentration of cilostazol if PAD in 352 patients (453 angioplas- ius H, Haberl R, Lange S, Pittrow D, von they are taken concurrently. Cilostazol ties) resulted in 59 complications in Stritzky B, Tepohl G, Trampisch HJ High prevalence of peripheral arterial disease and co- can be safely administered with as- 53 patients53 The advent of endovas- morbidity in 6880 primary care patients: cross- pirin or clopidogrel without any fur- cular stents led to improved patency, sectional study Atherosclerosis. 2004 Jan; 48 ther increase in bleeding time. We but not a significant reduction in ad- 172(1): 95-105. recommend the use of cilostazol as verse events, including access site 11 Mehler PS, Coll JR, Estacio R, Esler A, initial therapy for patients with mild complications. In a series of patients Schrier RW, Hiatt WR Intensive blood pressure to moderate intermittent claudication. with iliac artery atherosclerosis for control reduces the risk of cardiovascular whom 147 iliac artery stents in 98 events in patients with peripheral arterial dis- Revascularization for limbs were deployed, there were 29 ease and type 2 diabetes. Circulation. 2003 Feb Peripheral Arterial Disease (19.4%) complications.54 11; 107(5): 753-6. 12 Revascularization for peripheral Vascular surgical procedures are Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, arterial disease cannot occur on the classically reserved for patients with Materson BJ, Oparil S, Wright JT, Roccella EJ. basis of angiographic or non-inva- critical limb ischemia (ischemic rest The seventh Report of the Joint National Com- sive physiologic test results alone. pain, non-healing ischemic ulcers, mittee on prevention, detection, evaluation, The finding of a stenosis or short gangrene). These patients have mul- and treatment of high blood pressure. JAMA segment occlusion of these vessels tilevel arterial disease, and require 2003; 289:2560-2572. does not indicate the need for revas- bypass procedures to targets below 13 Ingolfsson IO, Sigurdsson G, Sigvalda- cularization. It is the clinical symp- the knee. The autogenous saphenous son H, Thorgeirsson G, Sigfusson N. Marked tomatology of the patient, coupled vein is the ideal conduit to use for decline in the prevalence and incidence of in- with the presence of atherosclerotic such procedures, and if performed by termittent claudication in Icelandic men 1968- risk factors, other co-morbid medical skilled and experienced surgeons, 1986: a strong relationship to smoking and serum cholesterol—the Reykjavik Study. J Clin conditions, and the results of non- limb salvage and patency rates are Epidemiol. 1994 Nov; 47(11):1237-43. 55 invasive tests that allows for appro- quite acceptable. 14 Quick CR, Cotton LT The measured ef- priate decisions concerning the need fect of stopping smoking on intermittent clau- for revascularization. It is unlikely References: dication. Br J Surg. 1982 Jun; 69 Suppl: S24-6. 15 that a patient presenting with mild 1 Leng GC, Fowkes FGE. The Edinburgh Jonason T, Bergstrom R. Cessation of symptoms will require revasculariza- Claudication Questionnaire: an improved ver- smoking in patients with intermittent claudi- tion. Risk factor modification, enroll- sion of the WHO/Rose Questionnaire for use cation. Effects on the risk of peripheral vascular ment in a supervised exercise pro- in epidemiological surveys. J Clin Epidemiol. complications, myocardial infarction and mor- gram49 or an experimental trial of 1992; 45:1101-1109. tality. Acta Med Scand. 1987; 221(3):253-60 16 pharmacotherapy for intermittent 2 Bernstein EF, Fronek A: Current status of Ameli FM, Stein M, Provan JL, Prosser R. The effect of postoperative smoking on claudication50 seems more appropri- non-invasive tests in the diagnosis of peripher- femoropopliteal bypass grafts Ann Vasc Surg. ate. al arterial disease. Surg Clin North Am 1982; 62:473-487. 1989 Jan; 3(1):20-5. Revascularization attempts are 17 3 Criqui MH, Denenberg JO, Langer RD, Hirsch AT, Criqui MH, Treat-Jaconson warranted in patients with symp- Fronek A. The epidemiology of peripheral arte- D, Regensteiner JG et al.. Peripheral Arterial tom-limiting intermittent claudica- rial disease: importance of identifying the pop- Disease detection, awareness and treatment in tion or in those patients who ulation at risk. Vasc Med. 1997; 2(3): 221-6. primary care. JAMA 2001;286:1317-1324. 18 progress to ischemic rest pain with 4 Hiatt WR. Medical treatment of periph- Meijer WT, Grobbee DE, Hunink MG, or without ulceration. Endovascular eral arterial disease and claudication. N Engl J Continued on page 188 www.podiatrym.com AUGUST 2004 • PODIATRY MANAGEMENT 187 PAD... peripheral arterial disease. Eur Heart J. 2004 tent claudication. Am J Cardiol. 2002 Dec 15; Jan; 25(1): 17-24. 90(12): 1314-9. Continuing 31 45 Hofman A, Hoes AW. Determinants of American Diabetes Association Peripher- Dawson DL, Cutler BS, Hiatt WR, Hob- peripheral arterial disease in the elderly: the al arterial disease in people with diabetes. Dia- son RW 2nd, Martin JD, Bortey EB, Forbes WP, Medical Education Rotterdam study. Arch Intern Med. 2000 Oct betes Care. 2003 Dec; 26(12): 3333-41. Strandness DE Jr. A comparison of cilostazol 23; 160(19): 2934-8. 32 Smith SC Jr, Blair SN, Bonow RO, Brass and pentoxifylline for treating intermittent 19 Newman AB, Siscovick DS, Manolio TA LM, Cerqueira MD, Dracup K, Fuster V, Gotto claudication Am J Med. 2000 Nov; 109(7): et al. Ankl-arm index as a marker of atheroscle- A, Grundy SM, Miller NH, Jacobs A, Jones D, 523-30. rosis in the Cardiovascular Health Study. Car- Krauss RM, Mosca L, Ockene I, Pasternak RC, 46 Evaluation of the effect of phosphodi- diovascular Heart Study (CHS) collaborative Pearson T, Pfeffer MA, Starke RD, Taubert KA. esterase inhibitors on mortality in chronic Research Group. Circulation 193;88(3):837-45. AHA/ACC Guidelines for Preventing Heart At- heart failure patients. A meta-analysis Eur J 20 Muluk SC, Muluk VS, Kelley ME, Whit- tack and Death in Patients with Atherosclerotic Clin Pharmacol. 1994; 46(3): 191-6. tle JC, Tierney JA, Webster MW, Makaroun Cardiovascular Disease: 2001 update. A state- 47 Pratt CM. Analysis of the cilostazol safe- MS. Outcome events in patients with claudica- ment for healthcare professionals from the ty database Am J Cardiol. 2001 Jun 28; tion: a 15-year study in 2777 patients. J Vasc American Heart Association and the American 87(12A):28D-33D. Surg. 2001 Feb;33(2):251-7. College of Cardiology. 48 Medical Letter 2003:45:46. 21 Pomrehn P, Duncan B, Weissfeld L, 33 Brittenden J Platelet activation is in- 49 Patterson RB, Pinto B, Marcus B, et. al. Wallace RB, Barnes R, Heiss G, Ekelund LG, creased in peripheral arterial disease. J Vasc Value of a supervised exercise program for the Criqui MH, Johnson N, Chambless LE. The as- Surg. 2003 Jul; 38(1):99-103. therapy of arterial claudication. J Vasc Surg sociation of dyslipoproteinemia with symp- 34 Dorffler-Melly J, Koopman MM, Adam 1997;25:312-9. toms and signs of peripheral arterial disease. DJ, Buller HR, Prins MH. Antiplatelet agents for 50 Diehm C, Balzer K, Bisler H, et. al. Effica- The Lipid Research Clinics Program Prevalence preventing thrombosis after peripheral arterial cy of a new prostaglandin E1 regimen in out- Study Circulation. 1986 Jan; 73(1 Pt 2):I100-7. bypass surgery Cochrane Database Syst Rev. patients with severe intermittent claudication: 22 Third report of the National Cholesterol 2003 ;( 3): CD000535. results of a multicenter placebo-controlled Education Program (NCEP) Expert Panel on 35 Antithrombotic Trialists’ Collaboration. double-blind trial. J Vasc Surg 1997;25:537-44. detection, evaluation, and treatment of high Collaborative meta-analysis of randomised tri- 51 Dotter CT, Judkins MP: Transluminal blood cholesterol in adults (Adult Treatment als of antiplatelet therapy for prevention of treatment of arteriosclerotic obstruction: de- Panel III). Circulation 2002;106:3143. death, myocardial infarction, and stroke in scription of a new technic and a preliminary 23 Pedersen TR, Kjekshus J, Pyorala K, Ols- high risk patients. BMJ. 2002 January 12; 324 report of its applications. Circulation 30:654- son AG, Cook TJ, Musliner TA, Tobert JA, (7329): 71-86. 670, 1964. Haghfelt T. Effect of simvastatin on ischemic 36 Bennett CL, Weinberg PD, Rozenberg- 52 Isner JM, Rosenfield K: Redefining the signs and symptoms in the Scandinavian sim- Ben-Dror K, Yarnold PR, Kwaan HC, Green D. treatment of peripheral artery disease. Role of vastatin survival study (4S). Am J Cardiol. 1998 Thrombotic thrombocytopenic purpura asso- percutaneous revascularization. Circulation Feb 1; 81(3):333-5. ciated with ticlopidine. A review of 60 cases 88:1534-1557, 1993. 24 Nolting PR, de Groot E, Zwinderman Ann Intern Med. 1998 Apr 1; 128(7):541-4. 53 Gardiner GA Jr, Meyerovitz MF, Stokes AH, Buirma RJ, Trip MD, Kastelein JJ. Regres- 37 Bennett CL, Connors JM, Carwile JM, et KR, et al: Complications of transluminal angio- sion of carotid and femoral artery intima- al. Thrombotic thrombocytopenic purpura as- plasty. Radiology 159:201-208, 1986. media thickness in familial hypercholes- sociated with clopidogrel. N Engl J Med 2000; 54 Ballard JL, Sparks SR, Taylor FC, et al: terolemia: treatment with simvastatin Arch In- 342:1773-1777. Complications of iliac artery stent deploy- tern Med. 2003 Aug 11-25; 163(15):1837-41. 38 CAPRIE Steering Committee: A ran- ment. J Vasc Surg 24:545-555, 1996. 25 Boushey CJ, Beresford SA, Omenn GS, domized, blinded, trial of clopidogrel versus as- 55 Kalra M, Gloviczki P, Bower TC, et al. Motulsky AG. A quantitative assessment of pirin in patients at risk of ischemic events (CA- Limb salvage after successful pedal bypass plasma homocysteine as a risk factor for vascu- PRIE). 1996 Lancet 348:1329-1339 1996. grafting is associated with improved long-term lar disease. Probable benefits of increasing folic 39 Yusuf S, Zhao F, Mehta SR, Chrolavicius survival. J Vasc Surg 2001;33:6-16. acid intakes JAMA. 1995 Oct 4; 274(13): 1049- S, Tognoni G, Fox KK; Clopidogrel in Unstable 57. Angina to Prevent Recurrent Events Trial In- 26 Ridker PM, Stampfer MJ, Rifai N Novel vestigators Effects of clopidogrel in addition to Dr. Jaff. is cur- risk factors for systemic atherosclerosis: a com- aspirin in patients with acute coronary syn- rently the Direc- parison of C-reactive protein, fibrinogen, ho- dromes without ST-segment elevation. N Engl tor of Vascular mocysteine, lipoprotein(a), and standard J Med. 2001 Aug 16; 345(7):494-502 Medicine and cholesterol screening as predictors of peripher- 40 Stewart KJ, Hiatt WR, Regensteiner JG, the Vascular Di- al arterial disease JAMA. 2001 May Hirsch AT. Exercise training for claudication. N agnostic Labora- 16;285(19):2481-5. Engl J Med. 2002 Dec 12; 347(24): 1941-51. tory and Associ- 27 Weitz JI, Byrne J, Clagett GP, Farkouh 41 Gardner AW, Poehlman ET. Exercise re- ate Program Di- ME, Porter JM, Sackett DL, Strandness DE Jr, habilitation programs for the treatment of rector in Inter- Taylor LM. Diagnosis and treatment of chronic claudication pain. A meta-analysis. JAMA. nal Medicine at arterial insufficiency of the lower extremities: a 1995 Sep 27; 274(12): 975-80. Lenox Hill Hospi- critical review. Circulation 1996; 94:3026- 42 Bartelink ML, Stoffers HE, Biesheuvel CJ, tal in New York City. He is president of 3049. Hoes AW Walking exercise in patients with in- the Society for Vascular Medicine and 28 Duprez D. Natural history and evolution termittent claudication. Experience in routine Biology, and serves as a member of the of peripheral obstructive arterial disease. Int clinical practice. Br J Gen Pract. 2004 Mar; Board of Directors for the Intersocietal Angiol. 1992 Jul-Sep; 11(3): 165-8. 54(500): 196-200. Commission for the Accreditation of 29 Dormandy JA, Heeck L, Vig S. The fate 43 Radack K, Wyderski RJ. Conservative Vascular Laboratories. He is a member of patients with critical leg ischemia. Semin management of intermittent claudication. of the editorial board of several journals Vasc Surg1999; 12:142-147. Ann Intern Med.. 1990; 113:135-146. including Vascular Medicine, Angiology, 30 Ostergren J, Sleight P, Dagenais G, 44 Thompson PD, Zimet R, Forbes WP, Catheterization and Cardiovascular In- Danisa K, Bosch J, Qilong Y, Yusuf S; HOPE Zhang P. Meta-analysis of results from eight terventions, the Journal of Vascular Sur- study investigators. Impact of ramipril in pa- randomized, placebo-controlled trials on the gery, Annals of Internal Medicine, and tients with evidence of clinical or subclinical effect of cilostazol on patients with intermit- the Journal of Endovascular Therapy.

188 PODIATRY MANAGEMENT • AUGUST 2004 www.podiatrym.com MedicalContinuing Education EXAMINATION

See answer sheet on page 191.

1) The most common symptomatic program for intermittent B) The Doppler is malfunctioning manifestation of peripheral arterial claudication? C) You are performing the test disease is A) Six month duration incorrectly A) Ischemic ulceration B) Supervision by an exercise D) The patient’s circulation is B) Classic “Rose” intermittent physiologist/physical therapist normal. claudication C) Each session lasts 10 minutes C) Atypical exertional limb D) 3 sessions per week. 9) A patient with hypertension and symptoms hyperlipidemia describes a history D) Gangrene 6) Clopidogrel has demonstrated a classic for intermittent claudication significant reduction in myocardial of the right lower extremity. There 2) Peripheral arterial disease affects infarction, stroke, and vascular death are no rest symptoms or ulcerations. what percent of adults over age 60 in patients with intermittent Both pedal pulses are easily in the United States? claudication and peripheral arterial palpable. The ankle-brachial index is A) 1% disease when compared to similar normal. Your next step is B) 8% patients treated with aspirin. A) Prescribe custom orthotic C) 15% Cilostazol has demonstrated devices for plantar fasciitis D) 50% A) Antiplatelet effects which B) Either refer the patient for a exceed that of aspirin and treadmill challenge test or 3) The ankle-brachial index clopidogrel perform toe raises in your office A) Has a 15% risk of invoking B) A reduction in stroke when followed by repeat ABI significant limb pain during the compared to aspirin therapy determination. examination. C) An improvement in pain-free C) Order an MRI of the B) Carries sensitivity and walking distance to a statistically lumbosacral spine looking for specificity rates of ~80%. significant degree over placebo lumbar canal stenosis C) Requires an advanced degree in and pentoxifylline. D) Order an MRA of the lower physiology to accurately perform D) Similar impact on pain-free extremity arteries. D) Requires a sphygmomanometer, walking distance when acoustic gel, and Doppler. compared to clopidogrel. 10) Which of the following diagnostic tests will not help plan 4) A 57 y.o. female presents with 7) A patient presents with a painless revascularization in a patient with bilateral buttocks numbness with ulcer on the plantar aspect of the ischemic rest pain of the foot? walking 50 yards. These symptoms left foot. The patient is unsure as to A) Magnetic resonance have been noticeable for the past 3 how the ulcer formed, and does not arteriography years, and have progressively know the duration of the ulcer. The B) Arterial duplex worsened over the past 6 months. patient has no history of exercise- ultrasonography When the patient stops and stands, induced limb discomfort, and has C) Transcutaneous oximetry the numbness resolves within 5 never been told of peripheral D) Computed Tomographic minutes. She does not experience arterial disease in the past. The ulcer Angiography similar symptoms at rest, or with is located on the plantar aspect of standing. Her right arm blood left second metatarsal head. The 11) The most important modifiable pressure is 170 mmHg; left arm base of the ulcer has extensive risk factor for the development of blood pressure 200 mmHg. The yellow exudate, and there is a large peripheral arterial disease is pressure via hand-held continuous amount of surrounding callus A) Male sex wave Doppler of the right dorsalis formation. The patient has no B) Hypertension pedis artery is 140 mmHg, posterior pinprick or light touch sensation, C) Age tibial artery 130 mmHg; left dorsalis proprioception, or vibratory D) Tobacco Use pedis artery 110 mmHg, posterior sensation of the feet. The first step tibial artery 90 mmHg. Which of the in the management of this patient is 12) In the Cardiovascular Health following is a true statement: A) Schedule the patient for an Study, diabetes was associated with A) Based on the history and arteriogram a ___-fold increased prevalence of Doppler pressures, the B) Perform an ankle-brachial PAD in patients over age 65. symptoms are clearly non- index at the bedside A) 2.0 vascular in nature. C) Debride the ulcer B) 3.8 B) The right leg ankle-brachial D) Order transcutaneous C) 5.0 index is 0.65. oximetry D) 7.0 C) The left leg ankle-brachial index is 0.65. 8) When performing an ankle- 13) Patients with asymptomatic PAD D) The patient has right brachial index, if a systolic Doppler have mortality rates which are subclavian artery disease. pressure exceeds 250 mmHg, one ______to those patients can presume that with intermittent claudication? 5) Which of the following is not a A) The patient’s circulation is A) Similar component of an effective exercise abnormal Continued on page 190 www.podiatrym.com AUGUST 2004 • PODIATRY MANAGEMENT 189 EXAMINATION PM’s Continuing (cont’d) Medical Education CPME Program

B) Lower than Welcome to the innovative Continuing Education C) Higher than Program brought to you by Podiatry Management D) Unknown Magazine. Our journal has been approved as a 14) Secondary prevention strategies in patients with sponsor of Continuing Medical Education by the PAD include all of the following EXCEPT A) Tobacco Cessation Council on Podiatric Medical Education. B) Weight loss C) Use of wool socks Now it’s even easier and more convenient D) Reduction in LDL-cholesterol to enroll in PM’s CE program! 15) The CAPRIE study demonstrated superiority of You can now enroll at any time during the year what agent over aspirin in preventing recurrent heart attacks, strokes, or dying from vascular disease? and submit eligible exams at any time during your A) Persantine enrollment period. B) Inderal PM enrollees are entitled to submit ten exams C) Trental D) Clopidogrel (Plavix) published during their consecutive, twelve–month enrollment period. Your enrollment period begins 16) Cilostazol is a phosphodiesterase III inhibitor whose mechanism of action includes all of the with the month payment is received. For example, following EXCEPT if your payment is received on September 1, 2003, A) Increased dilation of arteries your enrollment is valid through August 31, 2004. B) Promotes platelet aggregation and adhesion C) Reduction in triglycerides and elevation of If you’re not enrolled, you may also submit any HDL-cholesterol exam(s) published in PM magazine within the past D) Inhibition of smooth muscle cells in coronary arteries after angioplasty twelve months. CME articles and examination questions from past issues of Podiatry Man- 17) Which of the following instructions for use of agement can be found on the Internet at cilostazol is correct? A) Take immediately after eating http://www.podiatrym.com/cme. All lessons B) Avoid spicy foods are approved for 1.5 hours of CE credit. Please read C) Avoid diltiazem or omeprazole D) Take each dose with grapefruit juice the testing, grading and payment instructions to de- cide which method of participation is best for you. 18) Indications for revascularization in patients with Please call (631) 563-1604 if you have any ques- PAD include all of the following EXCEPT A) Limb discomfort after walking 1.0 miles tions. A personal operator will be happy to assist you. B) Rest pain that awakens a patient from sleep Each of the 10 lessons will count as 1.5 credits; C) Gangrene D) Non-healing ulceration on the toe thus a maximum of 15 CME credits may be earned during any 12-month period. You may se- 19) Which of the following treatment strategies is lect any 10 in a 24-month period. most appropriate? A) Surgical bypass in a patient with 10 block intermittent claudication The Podiatry Management Magazine CME B) Percutaneous transluminal angioplasty in a patient with 10 block intermittent claudication program is approved by the Council on Podiatric C) Risk factor modification, antiplatelet therapy, Education in all states where credits in instruction- exercise in a patient with 10 block intermittent al media are accepted. This article is approved for claudication D) Pentoxifylline in a patient with 10 block 1.5 Continuing Education Contact Hours (or 0.15 intermittent claudication CEU’s) for each examination successfully completed. 20) Complication rates of patients who undergo iliac artery intervention occur in what % of cases? PM’s CME program is valid in all states A) 0.5 except Kentucky. B) 10 C) 20 D) 50 Home Study CME credits now See answer sheet on page 191. accepted in Pennsylvania

190 PODIATRY MANAGEMENT • AUGUST 2004 www.podiatrym.com ✄ MedicalContinuing Education Enrollment/Testing Information and Answer Sheet Note: If you are mailing your answer sheet, you must complete exam during your current enrollment period. If you are not en- all info. on the front and back of this page and mail with your rolled, please send $17.50 per exam, or $109 to cover all 10 check to: Podiatry Management, P.O. Box 490, East Islip, exams (thus saving $66 over the cost of 10 individual exam fees). NY 11730. Credit cards may be used only if you are faxing or Facsimile Grading phoning in your test answers. To receive your CPME certificate, complete all information and TESTING, GRADING AND PAYMENT INSTRUCTIONS fax 24 hours a day to 1-631-563-1907. Your CPME certificate will (1) Each participant achieving a passing grade of 70% or be dated and mailed within 48 hours. This service is available for higher on any examination will receive an official computer form $2.50 per exam if you are currently enrolled in the annual 10-exam stating the number of CE credits earned. This form should be safe- CPME program (and this exam falls within your enrollment period), guarded and may be used as documentation of credits earned. and can be charged to your Visa, MasterCard, or American Express. (2) Participants receiving a failing grade on any exam will be If you are not enrolled in the annual 10-exam CPME pro- notified and permitted to take one re-examination at no extra cost. gram, the fee is $20 per exam. (3) All answers should be recorded on the answer form Phone-In Grading below. For each question, decide which choice is the best an- You may also complete your exam by using the toll-free ser- swer, and circle the letter representing your choice. vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday (4) Complete all other information on the front and back of through Friday. Your CPME certificate will be dated the same day this page. you call and mailed within 48 hours. There is a $2.50 charge for (5) Choose one out of the 3 options for testgrading: mail-in, this service if you are currently enrolled in the annual 10-exam fax, or phone. To select the type of service that best suits your CPME program (and this exam falls within your enrollment peri- needs, please read the following section, “Test Grading Options”. od), and this fee can be charged to your Visa, Mastercard, Ameri- TEST GRADING OPTIONS can Express, or Discover. If you are not currently enrolled, the fee Mail-In Grading is $20 per exam. When you call, please have ready: To receive your CME certificate, complete all information 1. Program number (Month and Year) and mail with your check to: 2. The answers to the test Podiatry Management 3. Your social security number P.O. Box 490, East Islip, NY 11730 4. Credit card information There is no charge for the mail-in service if you have already In the event you require additional CPME information, enrolled in the annual exam CPME program, and we receive this please contact PMS, Inc., at 1-631-563-1604.

ENROLLMENT FORM & ANSWER SHEET

Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: FIRST MI LAST Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card payment may be used for fax or phone-in grading only. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is a $17.50 check payable to Podiatry Management Magazine for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $109.00 (thus saving me $66 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 191 ✄ (cont’d) www.podiatrym.com 11. A12. B A13. C B A14. D C B A15. D C B A16. D C B A17. D C B A18. D C B A19. D C B A20. D C B A D C B D C D (Jaff) EXAM #7/04 Peripheral Arterial Disease Peripheral 1. A2. B A3. C B A4. D C B A5. D C B A6. D C B A7. D C B A8. D C B A9. D C B A D C B D C D 10. A B C D LESSON EVALUATION exam Please indicate the date you completed this ______the lesson? How much time did it take you to complete ______hours ______minutes How well did this lesson achieve its educational objectives? ______Very well ______Well all ______Somewhat ______Not at lesson? What overall grade would you assign this A B C D Degree______Additional comments and suggestions for future exams: ______Circle: ENROLLMENT FORM & ANSWER SHEET & ANSWER FORM ENROLLMENT PODIATRY MANAGEMENT • AUGUST 2004

192

Continuing Medical Education Medical