pad

risk factors

smoking, DM, HTN, dyslipidemia

known atherosclerosis in another vascular bed (ex: carotid, coronary, renal)

65 +

50-64 w/ atherosclerosis risk factors (DM, htn, dyslipidemia, current or prior smoking, fam hx of pad)

<50 w/ dm and at least one additional risk factor for atherosclerosis

factors that contribute to increase risk in pad

impaired endothelial fxn

heightened inflammation

propensity toward thrombosis

impaired functional capacity w/ reduced physical activity

clinical presentation

asymptomatic

intermittent claudication

chronic limb-threatening ischemia

acute limb ischemia

claudication

fatigue, discomfort, cramping or pain of vascular origin in the muscles of the lower extremities that is consistently induced by exercise and consistently relieved by rest (w/in 10 mins)

tissue loss

minor: nonhealing ulcer, focal gangrene w/ diffuse pedal ischemia

major: extending above trans-metatarsal level; functional food no longer salvageable

critical limb-threatening ischemia (CLTI)

condition characterized by chronic (>2 wk) ischemic rest pain, nonhealing wounds/ulcers, or gangrene attributable to objectively proven arterial occulsive disease. current nomenclature has evolved from the prior commonly used term of critical limb ischemia (CLI) to reflect the chronic nature of this condition and its potentially limb threatening nature w/ associated risk for amputation and to distinguish it from acute limb ischemia (ALI)

acute limb ischemia (ALI)

acute (<= 2 wks)hypoperfusion of th elimb that may be characterized by the following features: pain, pallor, pulselessness, poikilothermia, parestheaias, and /or paralysis

dx testing

ankle-brachial index (ABI)

segmental limb pressures

pulse volume recordings

doppler ultrasound

functional testing (treadmill exercise testing)

advanced imaging techniques

ankle-brachial index (ABI)

systolic ankle pressure / highest systolic brachial pressure

abnormal value: ≤0.90

tx to control ascvd risk

asa or clopidogrel

oral anticoag

tx for claudication

cilostazol

structured exercise

tx for acute limb ischemia

iv anticoag (iv ufh)

tx for asymptomatic pad

single antiplatelet therapy (aspirin or clopidogrel, not together)

tx for symptomatic pad

SAPT or low dose aspirin + rivaroxaban 2.5 mg bid

tx for revascularized pad

rivaroxaban 2.5 mg bid + low dose aspirin

tx to help reduce sx

cilotazol! → helps increase walking distance and reduce sx

box warning for cilostazol

pt w/ HF (use can increase risk of death)

moa of cilostazol

phosphodiesterase 3 inhibitor

dosing of cilostazol

100 mg po bid

take on empty stomach 30 mins prior or 2 hours after meals (food increases absorption → increases side effects)

ddis for cilostazol

CYP3A4 inhibitors → increase cilostazol exposure (decrease to 50 mg bid if used in combo)

CYP2C19 inhibitors → increase cilostazol exposure (decrease to 50 mg bid if used in combo)

cig smoking → decrease effectiveness of cilostazol

cilostazol adrs

abnormal stools, diarrhea, dizziness, HA, palpitations

how long does it take for citostazol to work

2-4 wks until walking distance is impacted

when should you dc citostazol

if no benefit is observed after 12 wks

what helps with cv risk management (what meds/nonpharm therapy should they be on)

high intensity statin, acei arb, maintain bp goal, smoking cessation, glp-1 or sglt2i for dm

preventative foot care recommendations

education, foot inspection my clinician at every visit, therapeutic footwear if at high risk for ulcers/amputation, comprehensive foot eval annually to identify risk factors for ulcers and amputation

when is supervised exercise therapy recommended

chronic symptomatic PAD, post revascularization for chronic symptomatic PAD, functionally limiting claudication

first line for pts w/ acute limb ischemia (ALI)

heparin

which medications are cardioprotective in pad

acei/arb and high intensity statins