PAD DR. SHWETA PHADKE.

Peripheral Arterial Disease and Claudication Peripheral Arterial Disease (PAD) A disorder caused by atherosclerosis that limits blood flow to the limbs Claudication A symptom of PAD characterized by pain, aching, or fatigue in working skeletal muscles. Claudication arises when there is insufficient blood flow to meet the metabolic demands in leg muscles of ambulating patients Claudication is a symptom of PAD Symptom assessment can be very difficult. A patient with very severe PAD may not experience claudication because of some other condition that limits activity Many individuals with claudication are elderly and consider leg pain a part of normal aging, and so do not report them to their physicians. PAD is asymptomatic in many individuals. However, even asymptomatic patients can benefit from early detection of disease

Defining a Population “At Risk” for Lower Extremity PAD Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) Age 50 to 69 years and history of smoking or diabetes Age 70 years and older Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal artery disease When evaluating patients, it is helpful to keep in mind which patients are at risk for development of PAD. These include those who are 50 years of age or older with risk factors, those aged 70 years or older, those who have leg symptoms that are consistent with claudication, those with abnormal pulses, and those with known atherosclerosis in other vascular beds.

Systemic Manifestations of Atherosclerosis TIA Ischemic stroke TIA Ischemic stroke TIA Ischemic stroke Myocardial Infarction Unstable angina pectoris Renovascular hypertension Erectile dysfunction Systemic Manifestations of Atherosclerosis This slide shows the global nature of atherosclerosis and its effects on different parts of the circulatory system. Lesions in the cerebral or carotid circulation can lead to transient ischemic attacks (TIAs) or stroke. Those in the coronary circulation can result in acute coronary events, such as angina and myocardial infarction (MI). Approximately one-third of all cases of kidney failure are due to renal artery stenosis. Atherosclerosis is a common cause of erectile dysfunction Atherosclerosis in the peripheral circulation can lead to claudication and critical limb ischemia. Claudication Critical limb ischemia, rest pain, gangrene, amputation

Risk Factors for PAD Smoking Diabetes Hypertension Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia C-Reactive Protein Relative Risk 1 2 3 4 5 6 Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Pathogenesis of Progressive Atherosclerosis Atherosclerotic plaque causes a narrowing in the vessel, leading to decreased blood flow When the plaque cracks or ruptures it releases substances that promote thrombosis Sometimes the thrombus is incorporated into the atheroma and the plaque becomes stabilized, but larger, causing further narrowing of the vessel. This can lead to gradual worsening of claudication Acute events can happen when the thrombus occludes the vessel. This can occur not only in a vessel with a high grade stenosis, but also in vessels with mild to moderate stenosis.

A Risk Factor “Report Card” for all Individuals with Atherosclerosis Tobacco smoking Complete, immediate cessation Hypertension BP less than 130/85 mmHg Diabetes Hb A1C <7.0 Dyslipidemia LDL Cholesterol less than 100 mg/dl Raise HDL-c Lower Triglycerides Inactivity Follow activity guidelines When caring for patients with PAD it is helpful to use a risk factor “Report Card” that reminds both the patient and the clinician to continue to work to reduce risk of disease progression and cardiovascular ischemic events through normalization of risk factors including Tobacco cessation Control of hypertension Normalization of lipids Good control of diabetes Encouragement to increase activity Assuring that the patient is taking an antiplatelet agent unless contraindicated. Antiplatelet therapy (like aspirin or Plavix) is: Mandatory

Pathway of Disability in Intermittent Claudication PAD Reduced muscle strength Poor walking ability and IC Disability Denervation, muscle-fiber atrophy, decreased type II fibers, decreased oxidative metabolism Pathway of Disability in Intermittent Claudication Chronic ischemia in the peripheral circulation leads to physiologic changes to skeletal muscles and nerves. These changes leave patients with claudication at increased risk of losing their mobility and suffering functional decline. As muscle strength erodes, so does the patient’s ability to walk. People who can’t walk without pain for sufficient distances enter into a cycle of physical decline. This physical inactivity can contribute to poorer control of other atherosclerotic risk factors such as cholesterol, blood pressure and blood glucose. The worsening of risk factors can contribute to progression of disease, creating a cycle of decline. Cycle of deconditioning: decreased HDL, poorer glycemic control, poorer BP control Adapted from McDermott M. Am J Med. 1999;CE (I):18-24.

Location of Obstruction Influences Symptoms Buttock, hip, thigh Thigh, calf Calf, ankle, foot Obstruction in: Aorta or iliac artery Femoral artery or branches Popliteal artery Claudication in: Location of Obstruction Influences Symptoms The signs and symptoms of ischemia in the peripheral circulation generally occur below the site of stenosis. Thus, stenosis of the abdominal aorta or iliac artery produces symptoms in the buttocks, penis, or thighs. Stenosis of the femoral artory (or its branches) affects the thigh or calf, Stenosis of the popliteal artery causes symptoms in the calf, ankle, or foot.

Claudication: A Symptom of Peripheral Arterial Disease Exertional aching pain, cramping, tightness, fatigue Occurs in muscle groups, not joints (buttocks, hips, legs, calves) Reproducible from one day to the next on similar terrain Resolves completely with rest Occurs again at the same distance once activity has been resumed Patients experience claudication in many different ways. It may be described as an aching, cramping, tightness, tiredness, or pain. The discomfort can affect the buttock, hip, thigh, or calf or all of these areas. Although the description may vary, the presentation is fairly consistent. Symptoms occur in muscle groups, not in joints. Symptoms repeatedly develop with a specific level of activity (usually walking) and are relieved by rest. Symptoms are reproducible whenever the patient engages in that same level or duration of activity, and they are always relieved after a fixed amount of rest (usually, 2 to 5 minutes).

Clinical Assessment of Peripheral Arterial Disease This next section of this presentation will focus on the clinical assessment of peripheral arterial disease in the primary care setting

Components of Clinical Assessment Complete history Risk factor assessment Activity assessment Review of medications Physical examination Inspection of lower extremities Pulse exam Components of Clinical Assessment These are the components of clinical assessment that are employed in the primary care setting Claudication can be diagnosed accurately in most cases with a careful vascular history and physical examination A complete history should be completed including assessment of risk factors The functional impact of symptoms on walking ability and quality of life (QOL) is also important. Ask the patient how far they are able to walk and what stops them from walking. The physical examination should include inspection of the lower extremities and palpation of the peripheral pulses. However, because pulse palpation is subject to observer error, the use of more objective tests is also advisable—for example, the ankle-brachial index (ABI), which will be described later.

Questions for Patients Do you develop discomfort in your legs when you walk? Cramping, aching, fatigue Do you get this pain when you are sitting standing, or lying? Do symptoms only start when you walk? Does the discomfort always occur at about the same distance? Do symptoms resolve once you stop walking? Important Questions for Patients This slide lists some specific questions that may be asked of patients while taking a vascular history. If claudication is suspected, the patient should be asked to describe the following: • The character of the discomfort or pain • Its location • The duration of symptoms • The time or distance the patient can typically walk before discomfort develops The clinician should also inquire about : • The speed of walking and grade of the surface on which walking occurs • How long it takes the symptoms to resolve once the patient stops walking • Whether the patient must sit or stand to obtain symptom relief (in intermittent claudication, all that’s necessary to get relief is for the patient to stop walking) • Whether the symptoms can be reliably reproduced by walking for the same amount of time or the same distance

PAD Pulse Evaluation Right Left Femoral Popliteal Dorsalis pedis Posterior tibial Ankle–brachial index PAD Pulse Evaluation Most vascular specialists grade leg pulses on a scale of 0 to 4, as shown in this slide. The popliteal pulses should be examined with the patient supine and his or her knees slightly bent. The dorsalis pedis artery may not be palpable in 10% to 12% of normal individuals. Even the most experienced clinician often cannot accurately palpate pulses. This is why it’s so important to measure the ankle–brachial index (or ABI) in suspected cases of PAD. Note: 0-4 scale, where 0 = absent, 2 = Diminished, 4 = Normal Limits

The Ankle-Brachial Index (ABI) The first diagnostic assessment that should be done to evaluate a patient for PAD after a pulse exam in the presence of risk factors or if claudication is suspected. Inexpensive, accurate and can be done in the primary care setting The ABI is 95% sensitive and 99% specific for PAD Predicts limb survival, potential for wound healing, and mortality The Ankle Brachial Index (ABI) The ABI is a very useful office-based test that can effectively determine whether an individual has PAD It can be done by a physician, nurse or trained clinic technician in the clinic It has excellent sensitivity and specificity for diagnosing PAD. Provides prognostic information on the risk of cardiovascular events and also predicts limb survival, potential for wound healing, and mortality

The Ankle-Brachial Index (ABI) Indicated In the absence of palpable pulses, or if pulses are diminished In the presence or suspicion of claudication, foot pain at rest, or a non-healing foot ulcer Age greater than 70 years of age, >50 years with risk factors (diabetes, smoking) The Ankle-Brachial Index (ABI) The ABI is indicated In an individual who does not have palpable pulses If a patient reports activity-related discomfort when walking, or if they have foot pain at rest, or a non-healing foot ulcer If they are over age 70 or over age 50 with risk factors such as diabetes or a smoking history

÷ ≈ 1 Concept of ABI Leg pressure Arm pressure Approved Speaker Training 3 25 05 # 69-050110 Concept of ABI The systolic blood pressure in the leg should be approximately the same as the systolic blood pressure in the arm. Arm pressure Leg pressure ÷ ≈ 1 Therefore, the ratio of systolic blood pressure in the leg vs the arm should be approximately 1 or slightly higher. The ankle-brachial index is an easy-to-use tool that can performed in an any clinician’s office with a stethoscope and a hand-held Doppler device. The concept of the ABI is as follows: The systolic blood pressure in the leg should be approximately the same as the systolic blood pressure in the arm. Therefore, the ratio of systolic blood pressure in the leg vs the arm should be approximately 1. ABI has been found to be 95% sensitive and 99% specific for angiographically diagnosed PAD. Weitz JI, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation. 1996;94:3026-3049. ABI has been found to be 95% sensitive and 99% specific for angiographically diagnosed PAD. Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049.

Understanding the ABI Performed with patient resting in supine position All pressures are measured with a arterial Doppler and appropriately sized blood pressure cuff Both brachial pressures are measured Ankle pressures are measured using the posterior tibial and/or dorsalis pedis arteries The ABI measurement is performed after the patient has rested in a supine position for at least 10 minutes Arm and leg BP measurements should be made with appropriately sized cuffs and an arterial Doppler. (20% larger than the arm or ankle) The systolic pressure is determined in both arms Ankle pressures are measured in the posterior tibial and dorsalis pedis arteries You have the choice of measuring both arms and then both ankles or rotating around the body arm, both legs and finishing with the second arm.

Measuring the Ankle-Brachial Index (ABI) Step 1: Gather Equipment Needed Approved Equipment needed: Blood Pressure Cuff Hand-held 5-10 MHz Doppler probe Ultrasound Gel Step 1: You will need the following equipment to measure the ankle-brachial index (ABI): a blood pressure cuff, and a hand-held 5-10 MHz Doppler probe. American Diabetes Association. Diabetes Care 2003: 26; 3333–3341. American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care 2003;26:3333–3341.

Place patient in supine position for Approved Measuring the Ankle-Brachial Index (ABI) Step 2: Position the Patient Place patient in supine position for 5 – 10 minutes minutes Step 2: Place the patient in the supine position for 5 minutes, as shown on the slide. American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care 2003;26:3333–3341. American Diabetes Association. Diabetes Care 2003: 26; 3333–3341.

Approved Measuring the Ankle-Brachial Index (ABI) Step 3: Measure the Brachial Blood Pressure Place the blood pressure cuff on the arm above the elbow. Apply gel to the skin surface. Place the Doppler probe over the brachial pulse Inflate the cuff to approx. 20 mm/hg above the point where systolic sounds are no longer heard. Deflate the cuff slowly until the arterial signal returns (systolic pressure) Repeat in the other arm Step 3: Measure the brachial blood pressure in both arms; record the higher of the two pressures. The Doppler probe can be used instead of a stethoscope to detect the first sound of blood flow after the cuff is deflated. American Diabetes Association. Diabetes Care 2003;26:3333–3341. American Diabetes Association. Diabetes Care 2003: 26; 3333–3341.

Approved Measuring the Ankle-Brachial Index (ABI) Step 4: Position the Cuff Above the Ankle Place blood pressure cuff just above the ankle of one leg, apply gel over the area of the dorsalis pedis artery Step 4: Place the blood pressure cuff just above the corner of the ankle and inflate. Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

Approved Measuring the Ankle-Brachial Index (ABI) Step 5: Measure the Pressure in the Dorsalis Pedis Artery Place Doppler probe over the dorsalis pedis artery; inflate the cuff Deflate the cuff; when the return of blood flow is detected, record this as the systolic pressure of the DP artery of that leg Step 5: Position the Doppler probe over the dorsalis pedis artery, below the cuff. Deflate the cuff. When the probe detects the return of blood flow, record the value as the systolic pressure for that leg. Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

Measure the pressure, record as posterior tibial pressure for that leg Approved Measuring the Ankle-Brachial Index (ABI) Step 6: Measure the Pressure in the Posterior Tibial Artery Place gel and Doppler probe over the posterior tibial artery (below the cuff) Measure the pressure, record as posterior tibial pressure for that leg Step 6: Measure the pressure of the posterior tibial artery below the cuff. Record the pressure. Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

Approved Measuring the Ankle-Brachial Index (ABI) Step 7: Repeat the Process in the Opposite Leg Repeat the same process in the other leg and record the pressures of the dorsalis pedis and posterior tibial arteries Step 7: Repeat the process on the opposite leg, recording the systolic pressures from the dorsalis pedis and the posterior tibialis. Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

Interpreting the Ankle–Brachial Index ABI Interpretation 0.90–1.30 Normal 0.70–0.89 Mild 0.40–0.69 Moderate 0.40 Severe >1.30 Noncompressible vessels Interpreting the ABI This slide gives the ranges at which ABI measurements are considered normal or representative of peripheral atherosclerosis. Although there is some disagreement regarding these values, in general an ABI of 0.90 is considered to be normal. Adapted from Hirsch AT. Family Practice Recertification. 2000;22:6-12.

ABI Limitations Possible false negatives in patients with noncompressible arteries, such as some diabetics and elderly individuals Insensitive to very mild occlusive disease and iliac occlusive disease Not well correlated with functional ability and should be considered in conjunction with activity history or questionnaires There are some limitations to the use of the ABI Calcification of arteries in elderly or diabetic patients makes it difficult or impossible to abolish systolic pressure, resulting in falsely elevated readings Patients with iliac disease can have a normal ABI at rest that decreases with exercise The ABI is not always well correlated with functional ability and should be used in conjunction with questionnaires or an activity history to determine functional limitations and help guide intervention decisions

Indications for Referral for Vascular Specialty Care Lifestyle-disabling claudication (refractory to exercise or pharmacotherapy) Rest pain Tissue loss Severity of ischemia Indications for Referral for Vascular Specialty Care It is important to understand when referral to a vascular specialist is indicated for patients with PAD The greater the severity of disease, the more likely referral to a vascular specialist is warranted. Severely disabling claudication that doesn’t respond to exercise or pharmacotherapy Signs of critical limb ischemia such as Rest pain Ischemic ulcers Gangrene

Summary PAD is a common atherosclerotic disease associated with risk of cardiovascular ischemic events and significant functional disability PAD can be effectively assessed in the primary care setting. The ankle brachial index is an effective and efficient measurement tool for diagnosis of PAD Early detection of PAD allows for appropriate disease management and decreased likelihood of ischemic events and disease progression