PAD

Question 1

What is the most common PVD?

Answer 1

PAD

Question 2

Manifestation of progressive narrowing of arteries due to what?

Answer 2

atherosclerosis

Question 3

What are the arteries affected by PAC (biggest to smallest)?

Answer 3

Femoropopliteal-tibial → Aortoiliac → Carotid and vertebral → Splenic and renal → Brachiocephalic

Question 4

What are the high risk groups of PAC?

Answer 4

1. Elderly
2. AA
3. Current smoking
4. Diabetes
5. HTN
6. Hypercholesterolemia
7. Impaired renal function

Question 5

What is the primary indicator of PAD?

Answer 5

Intermittent claudication

Question 6

What is IC?

Answer 6

1. Reproducible fatigue
2. Discomfort
3. Cramping and pain
4. Numbness in extremities during exercise resolved with rest

Question 7

What are the clinical presentations of PAD?

Answer 7

1. Intermittent claudication
2. Pain at rest in the lower extremities
3. Chronic limb-threatening ischemia

Question 8

What can pain at rest in lower extermities be attributed to?

Answer 8

Blood supply is not adequate to perfuse the extremity (critical limb ischemia)

Occurs at night in the feet upon lying down

Question 9

What is chronic limb ischemia contribute to?

Answer 9

Nonhealing wounds and amputation

Question 10

What type of symptoms of decreased blood flow?

Answer 10

1. Cool skin temp
2. Shiny skin
3. Thickened toe nails
4. Lack of hair
5. Visible sores and ulcers that are slow to heal

Question 11

What is the highly sensitive and specific tool used to diagnose PAD?

Answer 11

Ankle brachial index

Question 12

What tool is reserved for PAD patents being considered for surgical revascularization?

Answer 12

Magnetic resonance angiography (MRA) or computed tomographic angiography (CTA)

Question 13

What are the differential diagnoses?

Answer 13

1. Neurological (peripheral neuropathy)
2. Inflammatory (arthritis)
3. Vascular conditions (DVT and venous congestion)

Question 14

Describe how to take an ABI measurement?

Answer 14

Question 15

How do you calculate ABI?

Answer 15

Question 16

How do you interpret PAD using ABI values?

Answer 16

Question 17

How to undergo diagnostic testing for suspected PAD?

Answer 17

Question 18

What are the treatment goals for PAD?

Answer 18

1. Improvement or alleviation of symptoms
2. Reduction of ASCVD risk
3. Prevention of limb loss

Question 19

What are non-charms of PAD?

Answer 19

1. Smoking cessation
2. Exercise
3. Interventional procedures

Question 20

What are the types of exercises for PAD?

Answer 20

1. Walking programs
2. Supervised exercise training

Question 21

What is the purpose for walking programs?

Answer 21

Increase walking duration and distance → increase pain-free walking and delayed claudication by 179%

Question 22

Impaired exercise/walking distance lead to ___?

Answer 22

Increase in negative long-term outcomes

Question 23

What is supervised exercise training?

Answer 23

1. For patients with IC
2. Minimum of 30-45 minutes 3 times/wk for a minimum of 12 weeks

Question 24

How is supervised exercise training done?

Answer 24

1. Walking should be performed at a speed and grade of incline to produce the symptoms of IC within 3 to 5 minutes
2. Stop walking when the symptoms become moderate in intensity, wait for the symptoms to resolve, and then resume walking

Question 25

When should you consider interventional procedures?

Answer 25

1. Lack of adequate response to exercise and risk factor mod 2. Severe disability from IC impairs daily activities 3. Evaluation of the risks and benefits of intervention

Question 26

What are the types of interventional procedures? Compare the two?

Answer 26

1. Percutaneous trasluminal angioplasty (Minimally invasive) 2. Aortofemoral bypass or femoral popliteal bypass (surgically invasive, for patients with IC → critical leg ischemia

Question 27

What are the pharm therapies used for?

Answer 27

1. Treat underlying HTN, HLD, DM 2. Antiplatelet drug therapy 3. Intermittent claudication treatment

Question 28

What antiplatelet has the mose evidence? Dosing?

Answer 28

Aspirin: 75-325mg/day

Question 29

What can be used when ASA is not tolerated?

Answer 29

Clopidogrel (Plavix) DAPT treatment

Question 30

What can be used in combo with ASA or Plavix but not commonly used? Class?

Answer 30

Vorapaxar (Zontivity) Protease activated receptor 1 antagonist

Question 31

What are specific recs for aspirin and clopidogrel?

Answer 31

1. Symptomatic PAD 2. Asymptomatic patients with PAD (ABI≤0.90) 3. Asymptomatic patients with borderline ABI (0.91-0.99) 4. DAPT

Question 32

What are anticoagulation therapies?

Answer 32

Rivaroxaban (Xarelto)

Question 33

What are the medications for IC?

Answer 33

Cilastazol (Pletal) Pentoxifylline (Dental)

Question 34

MOA of Pletal?

Answer 34

Inhibitor of PDE III → increase in cyclic AMP → reversible inhibition of platelet aggregation, vasodilation, and inhibition of vascular smooth muscle cell proliferation

Question 35

Dosing, BBW, CI, Counseling of Cilostazol?

Answer 35

Dosing: 100 mg BID (caution with severe renal and hepatic) Administer 30 min before or 2 hours after meals (breakfast and dinner) BBW: HF Metabolism: CYP3A4, 2C19 (minor) discontinue if no improvement after 3 months

Question 36

What is the metabolism of Clopidogrel?

Answer 36

CYP2C19

Question 37

How should you assess therapeutic effectiveness? and what do they measure?

Answer 37

1. Exercise treadmill walking test 2. ABI 3. Patient feedback

Question 38

What does Exercise treadmill walking test test?

Answer 38

Repeated quarterly to biannually to assess improvement or decline in walking duration and distance

Question 39

What does ABI assess?

Answer 39

Each patient visit Used to determine stabilization or progression of the disease

Question 40

What does patent feedback assess?

Answer 40

Quality of life

Question 41

What factors are we looking at for the general assessment of PAD?

Answer 41

**HTN:** Home monitoring **DM:** AIC Q3Months, Biannual foot exam **DLD:** General **Tobacco use:** Assess status and cessation **CVD events:** Inquire about any new ones **Meds:** Adverse events