Medicine II - Cardiology o For example, buttocks, hip and thigh discomfort

PERIPHERAL VASCULAR MEDICINE occur in patients with aortoiliac dse, whereas calf
Lecture 2 – Dr. O. Deduyo claudication develops in px with femoral popliteal
July 30, 2015 10:00-12:00pm AMS 204 dse.
The First Tool to Establish the PAD Diagnosis: THE HPI, ROS AND
Peripheral Arterial Disease PE
- Definition: a clinical disorder in which there is a stenosis or - Individuals with Asymptomatic PAD
occlusion in the aorta or arteries of the limbs - Identified in order to offer therapeutic interventions known
- Causes: to diminish their increased risk of MI, stroke and death
o Atherosclerosis – for patients >40 years old - A history of walking impairment, claudication and ischemic
o Thrombosis rest pain
1. Routine
o Embolus
a. CBC with platelets
o Vasculitis
b. FBS
o Fibromuscular dysplasia c. HBA1c levels
o Entrapment d. Renal fxn (BUN and creatinine)
o Cystic adventitial disease e. Fasting lipid profile
o Trauma f. UA (for microalbuminemia
o 6th and 7th decades of life g. 12 lead ECG
o Patients with atherosclerosis of the coronary and Hemodynamic Noninvasive tests
cerebral vasculature a. Resting Ankle Brachial Index (ABI)
o Increased risk of developing PAD in : b. Exercise ABI
 Cigarette smokers c. Segmental pressure exam
 DM d. Pulse volume recordings
 Hypercholesterolemia ***ABI =
 HPN Lower extremity systolic pressure
 Hyperhomocysteinemia Brachial artery systolic pressure
- Pathology:  The ABI is 95% sensitive and 99% specific for PAD
o Segmental lesions causing stenosis or occlusion are  Establishes the PAD dx
usually localized to large and medium sized vessels Page 3 of 25
o The pathology of the lesion includes: Cardio Team Bam, Cathy, Rowel, Jhoey, Erick, Jhigz, Lar
 Atherosclerotic plaque with calcium deposition
 Thinning of the media
 Patchy destruction of muscle and elastic fibers
 Fragmentation of the internal elastic lamina
 Thrombi composed of platelets and fibrin
- The primary sites of involvement:
o Femoral and popliteal arteries
 80-90% of patients
o The more distal vessels, including the tibial and
peroneal arteries
 40-50% of patients
o The abdominal aorta and iliac arteries
 30% of symptomatic patients
- Atherosclerotic lesions occur preferentially:
o Arterial branch points
o Sites of increased turbulence
o Altered shear stress, and internal injury
o Involvement of the distal vasculature is most
common in elderly individuals and patients with DM
- Manifestatioons of PAD:
o 53% - asymptomatic PAD
o 35% - stable claudication
o 9% - chronic critical limb ischemia
o 3% - acute limb ischemia
- The most common symptom is intermittent claudication
o defined as a pain, ache, cramp, num,bness or a
sense of fatigue in the muscles; it occurs during
exercise and is relieved by rest
o The site of claudication is distal to the location of the
occlusive lesion
  Fall ABI after exercise
 Identifies a pop at high risk of CV ischemic events
 Pop at risk can be clinically and epidemiologically defined: Prognosis
 Exertional leg sx, non healing wounds, age >70 years, age >50 
years with hx of smoking and DM PAD have evidence of CAD
 Toe brachial index (TBI) useful in individuals with non compressible  angiography
pedal pulses  -30% 5 yr mortality rate and a 2 tp 6 fold increased risk of death
from coronary heart dse
ABI Classification System:  severe PAD
 1.3 – incompressible  of PAD appears less than the chance succumbing to CAD
 – 1.30 – normal  -80% of non DM px when present with mild to mod claudication
 0.90 – 0.99 – equivocal/borderline remain symptomatically stable
 0.51 – 0.89 – mild to mod  remainder, with approx 1-2% of the grp ultimately developing critical
 0.41 – 0.50 - mod to severe limb ischemia
 /<0.40 - severe  x 25-30% of px with critical limb
ischemia survive and undergo amputation within 1 year
Exercise ABI  to smoke or who have DM
 Page 4 of 25
 Cardio Team Bam, Cathy, Rowel, Jhoey, Erick, Jhigz, Lar
 normal
Treatment:
a. PX with PAD should receive therapies to”
 such as MI and death

 and


b. Risk factor modification and antiplatelet therapy should be initiated

to improve CV outcomes
c. BP control (ACE-I, B-blockers)
d. Treatment of hypercholesterolemia (statins, recommends tx to
reduce LDL, cholesterol to <100mg/dl
e. Platelet inhibitors


 the routine dual antiplatelet therapy with both aspirin and
clopidogrel
 outcome in px with chronic PAD

Glycemic Control in DM patients

A. Diabetes control and complications trial
 decreased progression of carotid IMT

B. UKPDS subgroup study

 Reductaion in HBA1c by 7% resulted in 18% reduction in MI, 15%
reduction in stroke and 4.2% reduction in PAD

Diabetes Treatment in PAD

-Intensive glycemic control
-HbA1c <7.0%
-No clear benefit on limb events
BP Reduction
1. ACE Inhibitor
Hope: Ramipril significantly reduced the rates of death, MI and
styroke in px at high risk for CV events independent of
antihypertensive impact
2. Beta blockers
intermittent claudication with mild to mod PAD
Supportive Measures include: Page 5 of 25
Cardio Team Bam, Cathy, Rowel, Jhoey, Erick, Jhigz, Lar
1. Meticulous care of the feet, which should be kept clean and
protected against excessive drying, apply moisturizing creams.
2. Well fitting and protective shoes are advised to reduce trauma
3. Elastic support hose should be avoided as they reduce BF to the
skin
4. Supervised exercise training programs for 30-45 mins session, 3
to 5 times per week atleast 12 weeks, prolong walking distance
5. Drugs such as:
a. Alpha adrenergic antagonist
b. CA channel blockers
c. Papaverine and other vasodilators : effective in px with PAD
Cilostazol: a phosphodiesterase inhibitor with vasodilator and
antiplatelet properties, increases claudication distance by 40-60%
and improves measures of quality of life
Pentoxifylline: a substituted xanthine derivative, has been reported to
decrease blood viscosity and to increase red cell flexibility, thereby
increasing blood flow to the microcirculation and enhancing tissue
oxygenation
Statins and propionyl-L-carnitine: a drug that affects skeletal muscle
metabolic fxn, appear promising for tx of intermittent claudication in
initial clinical trial
Pharmacotherpy Dosage Comments
for Claudication
Drugs
Aspirin 81-125mg/day ACCP
Recommended
Clopidogrel 75 mg OD Fewer s/e than
aspirin
Pentoxyfilline 1.2 gm OD Small effect on
walking disability
insufficient data to
support use
Cilostazol 100 mg BID correct dosing
critical
Ticlopidine 500 mg OD