Cardio Exam II: Tsu PAD

A 68-year-old man with diabetes and hypertension complains of calf pain after walking two blocks that resolves after resting for several minutes. He has smoked one pack per day for 30 years.

What is his most likely diagnosis?

PAD with intermittent claudication

A 72-year-old woman reports severe foot pain that wakes her up at night. Walking no longer causes her symptoms because the pain is present even at rest.

What does this progression suggest?

Ischemic rest pain, leading to severe PAD (critical limb ischemia)

A patient with suspected PAD asks why the pain improves after resting.

Exercising increases oxygen demand. Rest decreases demand, allowing Sxs to resolve within minutes

KNOW

A 64-year-old man presents with:

• Diabetes

• Hypertension

• Hyperlipidemia

• Smoking history

Which risk factor contributes the most to PAD progression?

Smoking

True or False:

• Risk factors for PAD include hypertension, smoking, and diabetes.

True

True or False:

• Chest pain during walking is a common symptom of PAD.

False (leg pain)

A 70-year-old smoker complains of calf pain while walking.

Which noninvasive diagnostic test is recommended first?

Ankle-Brachial Index (ABI)

Which patients should receive an ABI?

• ____ leg symptoms

• ____ wounds

• Age >____

• Age >____ or ____

Exertional, non-healing, 65 y/o, 50 y/o with diabetes, smoking Hx

A patient with PAD has:

• BP 148/86

• A1c 8.2%

• Smokes 1 pack/day

• LDL 150

What lifestyle intervention provides the greatest survival benefit?

Smoking cessation

What BP goal should most PAD patients achieve?

<130/80 mmHg

What A1c goal should most PAD patients achieve?

<7%

A 68-year-old patient is newly diagnosed with PAD.

Which statin intensity is recommended?

High-intensity statin (<75 y/o tolerated)

An 82-year-old patient with symptomatic PAD has never taken a statin.

Which intensity should be started?

Moderate-intensity statin

A patient asks what treatment most improves walking distance in PAD.

Supervised exercise therapy

What exercise prescription is recommended?

• Treadmill walking

• ____ minutes

• At least ____

• For ____

30-45 mins, 3x/week, 3-6 months

During supervised exercise, when should the patient stop walking?

Until moderate-to-severe pain develops (3-5 mins), then rest and repeat

A 67-year-old patient with symptomatic PAD has no medication allergies.

Which medication should ALL symptomatic PAD patients receive?

Aspirin 81-325 mg QD OR Clopidogrel 75 mg QD

Why do all symptomatic PAD patients receive aspirin? NOT to improve walking distance.

MI, Stroke, and CV death

A patient with intermittent claudication wants to walk farther without pain.

Which medication is indicated?

Cilostazol

A patient asks how cilostazol works.

• PDE-3 inhibitor

• ↑ cAMp

• ↓ Platelet aggregation

• ↑ Vasodilation

• ↑ Walking distance

KNOW

What is the dose of cilostazol?

100 mg BID (empty stomach)

A patient with HFrEF asks if cilostazol is appropriate.

No, HF is a C/I

When should patients expect improvement with cilostazol?

Weeks to months

Should pentoxifylline be recommended for intermittent claudication?

No

A patient with PAD asks if everyone should receive full-dose anticoagulation.

No

Which low-dose anticoagulant regimen may be used in select PAD patients?

Rivaroxaban 2.5 mg BID and Low-dose aspirin

Which statement regarding PAD is TRUE?

A. Clopidogrel has the strongest evidence for preventing disease progression

B. Rivaroxaban added to aspirin reduces cardiovascular events but increases bleeding

C. Full-dose aspirin improves walking distance

D. Cilostazol works within a few days

B

A patient has:

• Rest pain

• Foot ulcers

• Gangrene

Most likely diagnosis?

Critical limb ischemia

A patient suddenly develops:

• Severe leg pain

• Pallor

• Pulselessness

• Paralysis

• Paresthesias

Diagnosis?

Acute limb ischemia (Medical emergency)

Initial treatment for acute limb ischemia?

Immediate systemic anticoagulation followed by fibrinolysis and/or surgery

BG is a 70-year-old man with:

• Diabetes

• Hypertension

• Former smoker

• Leg pain

Which PAD risk factors does he have?

Age, Diabetes, HTN, and Smoking Hx

Which modifiable risk factor would provide BG the greatest benefit?

Continued smoking cessation

BG's BP is 146/92.

Recommendation?

Intensify antihypertensive therapy (<130/80)

BG's A1c is 7.8%.

Recommendation?

Improve diabetes control (<7%)

BG has newly diagnosed symptomatic PAD.

Which medications should be started?

Aspirin 81-325 mg QD (or clopidogrel 75 mg QD), High-intensity statin, Optimize BP meds, and diabetes meds

A 69-year-old smoker says, "My calf hurts when I walk, but the pain disappears after resting for two minutes."

What is the best initial management plan?

• Confirm diagnosis with ____

• Counsel ____

• Start ____ (or clopidogrel)

• Start a ____

• Refer to ____ therapy

• Control ____

ABI, smoking cessation, aspirin, statin, supervised exercise, BP and diabetes