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4/20/2015
IM Board Review
Timir Paul, MD, PhD, MPH, FACC
Peripheral Arterial Disease
Lower Extremity Case • 72 year female with CKD (GFR 27) diabetes, CAD, HTN, hyperlipidemia, diastolic HF, presents for evaluation of PAD • Denies any rest or exertional leg pain, fatigue
• No ulcer, gangrene, discoloration or cold foot
What do you do next?
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What do you do next?
1. Proceed with CTA or MRA
2. ABI
3. Exercise ABI
4. Get more history and thorough PE
5. Aggressive risk factor modification
PAD ~ CAD
CAD
PAD
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Non cardiac pain Atypical chest pain
Typical angina
UA/NSTEMI
STEMI
No leg pain
Atypical leg pain
Claudication
Critical limb ischemia
Acute limb ischemia
Clinical Presentations
Asymptomatic: Without obvious symptomatic complaint (but
usually with a functional impairment). This diagnosis should only
be made if the patient is physically active.
Exertional Pain
“Atypical” leg pain: Lower extremity discomfort that is exertional
but that does not consistently resolve with rest, consistently limit
exercise at a reproducible distance, or meet all “Rose
questionnaire” criteria.
Classic claudication: Lower extremity symptoms confined to the
muscles with a consistent (reproducible) onset with exercise and
relief with rest. Yet it has poor sensitivity and specificity for
identifying patients with PAD
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Clinical Presentations
Rest Pain
Critical limb lschemia:
- Ischemic rest pain
- Ulceration/ non-healing wound
- Gangrene
Acute limb ischemia: The five “P”s, defined by the clinical
symptoms and signs that suggest potential limb jeopardy:
 Pain
 Pulselessness
 Pallor
 Paresthesias
 Paralysis (& polar, as a sixth “P”).
PAD
Diagnosis Diagnosis of PAD
 History and physical examination
 Diagnostic tools
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Non-invasive Functional Studies (NIFS)
– Ankle-Brachial Index (ABI), Toe-Brachial
Index (TBI), and Segmental Pressures
– Pulse Volume Recording (PVR)
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Non-invasive imaging studies
–Arterial Duplex ultrasound, MR Angiography,
CT Angiography
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Invasive imaging
– Angiography (gold standard)
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Interpreting the Ankle‐Brachial Index
ABI
1.00–1.4
Interpretation
Normal
0.91–0.99
Borderline
0.41–0.90
Mild-to-moderate disease
≤0.40
Severe disease
>1.40
Noncompressible
ABI is 95% sensitive and 99% specific for PAD
Rooke et al, circulation 2011
Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1‐e192. Figure 6.
Screening for Asymptomatic
Patient With PAD
Screening for Asymptomatic
Patient With PAD
Age ≥50 years with a history of smoking or diabetes or
age ≥65 years ( class I C)
Individuals with asymptomatic PAD should be
identified in order to offer therapeutic
interventions known to diminish their
increased risk of myocardial infarction, stroke,
and death. ( Class I B)
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Patient With Intermittent Claudication
ABI ( Class I B)
Exercise ABI if the resting ABI is
normal (Class I B)
Treatment
Treatment of PAD
The modality to treat
PAD depends on the
following factors:
 Asymptomatic vs.
symptomatic disease
 Location of disease
 Chronic vs. acute
 Critical vs non-critical
Options
• Medical Therapy
• Exercise
• Percutaneous
Transluminal Angioplasty
(PTA)
• Stents
• Laser
• Atherectomy
• Thrombolytics
• Vascular surgery
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Goals of Therapy for Patients With PAD
Limb outcomes
• Improve ability to walk
– Increase in peak walking distance
– Improvement in quality‐of‐
life (QoL)
• Prevention of progression to CLI and amputation
Cardiovascular
morbidity and mortality
outcomes
• Decrease in morbidity from non‐fatal MI and stroke
• Decrease in CV mortality from fatal MI and stroke
Non‐pharmacologic Therapy for Intermittent Claudication
Supervised Exercise Rehabilitation
I IIa IIb III
A program of supervised exercise training is
recommended as an initial treatment modality for
patients with intermittent claudication.
I IIa IIb III
Supervised exercise training should be performed
for a minimum of 30 to 45 minutes, in sessions
performed at least three times per week for a
minimum of 12 weeks.
Provide formal referral to a claudication exercise
rehabilitation program
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Pharmacotherapy for Claudication
FDA Approved Drugs
• Pentoxifylline
• Cilostazol (approved 1999)
Contraindications to Cilostazol
 Class III-IV CHF
 Cilostazol is contraindicated in
patients with symptoms of CHF
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Pletal® (cilostazol) Package Insert. Rockville, Md: Otsuka America Pharmaceutical, Inc; 1999.
Medications for Patients With PAD
Therapeutic Goal
Drug
To Reduce
Ischemic
Events
To Improve
Claudication
Symptoms
Aspirin/Clopidogrel
Yes
No
Cilostazol
No
Yes
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Pharmacotherapy of Claudication
I IIa IIb III
Cilostazol (100 mg orally two times per
day) is indicated as an effective
therapy to improve symptoms and
increase walking distance in patients
with lower extremity PAD and
intermittent claudication (in the
absence of heart failure).
Treatment to Improve Cardiovascular Outcomes
Drug Therapy
• Aspirin
• Cilostazol
• Cilostazol is contraindicated in HF patients
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Question
• A 71 yr male reports of both thighs and calves pain. ABI 0.68 in left and 0.60 in right ankle. His sx improved slightly with exercise and intensive lifestyle modification. He also c/o dyspnea on exertion and mild b/l leg edema. He is taking ASA 325 mg daily
• What is the next step
1. Start cilostazol
2. Duplex lower extremity US
3. 2 D echo
4. Start statin
5. Add plavix
Take Home Message
• ~ 1/3rd US population has PAD
• Smoking is the strongest risk factor followed by diabetes
• ~ 1/2 of the patients are asymptomatic
• < 1/3rd patients presents with typical claudication
• 1‐2% of patients suffer or progress to CLI
• CLI: ischemic rest pain, ulceration or gangrene
• ALI: 5 Ps ‐ pain, pulselessness, pallor, paresthesia, paralysis
Take Home Message
• Screening for asymptomatic patients:
Age >= 50 yrs with smoking or diabetes
and patients age >65 yrs
• ABI is the first test to diagnose symptomatic and asymptomatic PAD
• If resting ABI is normal but clinical suspicion is high exercise ABI is recommended
• If ABI > 1.4, TBI is indicated
• ABI =< 0.4 indicates severe disease
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Take Home Message
• Duplex US is a class I indication for diagnosis, severity, anatomic location and post revascularization f/u
• MRA is also safe and effective (class I) tool
• Supervised graded exercise program is a class I indication and pre‐requisite for revascularization
• Cilostazol increase walking distance to 100‐150% and is a class I recommendation • Cilostazol is contraindicated in HF patients
Take Home Message
• BB is effective and not contraindicated
• ASA 75‐325 mg is the antiplatelet of choice to reduce MI, stroke and vascular death
• Plavix is an alternative
• Risk factor modification is a class I indication
• Prophylactic revacularization is class III
• Endovascular therapy is the Rx of choice for TASC type A iliac and femoro‐popliteal lesions
• Surgery is the Rx of choice for TASC type D iliac and femoro‐
popliteal lesions
• No sufficient evidence for recommendation of TASC B and C lesions
Renal Artery Stenosis (RAS)
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Diagnosis of RAS
Class I indications:
1. Resistant, accelerated and malignant hypertension
2. New azotemia or worsening renal function after administration of ACEI/ARB
3. Sudden unexplained pulmonary edema
4. Unexplained atrophic kidney or discrepancy in size between 2 kidneys > 1.5 cm
5. HTN before age 30 or severe HTN after age 55 years
Diagnostic modalities
Class I
Duplex ultrasound
CT angiogram
MRA Renal angiogram is the gold standard
Indications for Revascularization
Hypertension:
Preservation of renal function
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Indications for Revascularization
Class I:
Percutaneous revascularization is indicated for patients with significant RAS and recurrent unexplained heart failure or sudden unexplained pulmonary edema
Class IIa
Percutaneous revascularization is reasonable for patients with hemodynamically significant RAS and unstable angina
Extra‐cranial Carotid and vertebral Artery Stenosis
AHA/ASA guidelines for secondary prevention of stroke
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AHA/ASA guidelines for secondary prevention of stroke
Carotid Revascularization
Carotid Revascularization
Class I, Evidence B
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Endarterectomy vs Stenting
ASA/ACCF/AHA/ 2011 Guidelines on management of extracranial carotid and vertebral Artery disease. Circulation 2011
Abdominal Aortic Aneurysms (AAA)
Diseases of Aorta
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Screening high risk population
AAA Ruptures AAA surveillance
• If AAA 4‐5.4 US every 6 months
• For smaller AAA every 2‐3 yrs
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QUESTIONS
• Which of the following are indications for infrarenal AAA repair?
• 1. Diameter > 5.5 cm
• 2. Expansion rate greater than 1 cm/yr
• 3. Inflammatory or infectious etiology
• 4. Recurrent atheroembolism
• 5. All of the above
Thoracic Aortic Aneurysm Indications for Thoracic AA Surgery Ascending aortic diameter >= 5.5 cm
Exceptions:
‐ Expansion rate greater than 0.5 cm/yr
‐ Infectious etiology ‐ Traumatic origin
‐ Symptomatic
‐ Bicuspid aortic valve, Marfan or Turner, Ehlers‐Danlos, familial thoracic aortic aneurysm (>4.0‐5.5 cm)
‐ Patients undergoing aortic valve repair or replacement and who
have an ascending aorta or aortic root > 4.5 cm
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Ascending Aortic Aneurysm
Surveillance Aneurysm 3.5‐ 4.4 cm
Annual CT or MR
Aneurysm 4.5‐ 5.4 cm
Semi‐annual CT or MR
Dissecting Ascending Aortic Aneurysm
Type A Dissection
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Chest pain radiating to back
Acute AR murmur and HF
Widened mediastinum
Blood pressure differential between arms
Cardiac tamponade
Evidence of thromboembolism or dissection of branch arteries (stroke, MI )
• In what other conditions you see wide mediastinum?
• This is an emergency
• Treatment is surgery
Types of Dissection
Stanford classification
• Ascending aortic dissection – Type A
• All others dissections – type B
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Diagnostics
• CT scan with contrast or MRA • TEE for critically ill patients who cannot move from a monitored setting
Type B Aortic Dissections
• Uncomplicated Type B dissections usually treated medically
• Beta blockers and nitroprusside for acute dissections
• Long term BB for all patients
• If pain persists then surgery
• If major aortic vessels( renal arteries ) are involved
Questions
• 63 yr male admitted for symptomatic repair of 5.6 cm of AAA. He has h/o DM, dyslipidemia and family h/o Mi in brother at age 58. BP is borderline controlled with ACE and HCTZ. what is the next appropriate step?
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1. Proceed with surgery
2. Nuclear stress test
3. Exercise stress test
4. Titrate up BP meds 5. transfer patient to ICU and start nitroprusside
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Other diseases of aorta
• Aortic atheroma
• Aortic transection
• Penetrating aortic ulcer
– Crescent like thickening of aortic wall
– Absence of dissection flap
• Marfan syndrome
– Aortic root dilatation
– MVP
• Takayasu’s arteritis
Takayasu’s arteritis
• Areas of focal stenosis in multiple major arteries
• Young adult women from Japan and other parts of Asia
• The mainstay therapy is corticosteroids
• Large vessels bypass and angioplasty/stenting is often required
Questions
• A 68 yr male with HTN, DLP, current smoker and family h/o of AAA. He had an US done 2 yrs ago that did not reveal AAA.
• When is the next US should be performed for f/u
• 1. 1 yr
• 2. 3 yrs
• 3. 5 yrs
• 4. no further US
• 5. any time between 70‐75 yrs
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Questions
• 58 yr male with h/o CAD presents with severe chest apin radiating to back. BP 185/100, HR 100/min. A decrescendo murmur was heard in the precordium. • What you should do next:
• 1. Stat surgery consult
• 2. EKG and troponin
• 3. IV nitroprusside
• 4. BB and IV nitroprusside
• 5. CT with contrast
question
• 58 yr male with h/o CAD presents with tearing chest apin radiating to back. BP 100/60 in right arm and 140/70 in left arm, HR 100/min. CXR showed widened mediastinum
• What you should do next:
• 1. EKG and troponin
• 2. Surgery consultation
• 3. BB and IV nitroprusside
• 4. emergent CT with contrast
• 5. 3 and 4
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