Week 10 - PAD - Moodle version_3 PDF

Peripheral Arterial Disease Module CMS200 Poonam Patel, ND, MEd Learning Outcomes 1. Evaluate the definitions, epidemiology, and presentation of Peripheral Arterial Disease (PAD), Peripheral Vascular Disease (PVD), and Atherosclerosis, including classic claudication and critical limb ischemia. 2...

Peripheral Arterial Disease Module CMS200 Poonam Patel, ND, MEd Learning Outcomes 1. Evaluate the definitions, epidemiology, and presentation of Peripheral Arterial Disease (PAD), Peripheral Vascular Disease (PVD), and Atherosclerosis, including classic claudication and critical limb ischemia. 2. Interpret the prevalence of PAD and PVD in different populations and the impact of factors such as age, ethnicity, and comorbid conditions on disease prevalence. 3. Analyze the significance of risk factors for PAD and PVD, including smoking, diabetes mellitus, hypertension, hyperlipidemia, chronic kidney disease, and non-modifiable factors. 4. Perform a comprehensive clinical history, review of symptoms, and physical examination, including skin examination, pulse examination, and grading peripheral pulses for the assessment of PAD and PVD. 5. Analyze the use, interpretation, and limitations of the ankle-brachial index (ABI) and other diagnostic tests, such as Doppler studies, CT angiography, MRA, transcutaneous oximetry, and ECG in evaluating PAD and PVD. 6. Investigate the importance of early detection, differential diagnosis, and the association between PAD, PVD, and other vascular diseases or comorbid conditions, such as abdominal aortic aneurysm, intermittent claudication, neurogenic claudication, and venous thromboembolism (VTE). Learning Outcomes 7. Examine the progression and complications of PAD, PVD, and atherosclerosis, including the association with cardiovascular and cerebrovascular events, limb loss, and the impact on walking endurance and mental health. 8. Advocate the importance of addressing underlying cardiovascular risk factors, foot hygiene, and regular foot inspection for ulcers in patients with PAD and PVD. 9. Appraise the limitations and recommendations for screening tools, such as the Rose Questionnaire, Edinburgh Claudication Questionnaire, and the U.S. Preventive Services Task Force's guidelines on PAD screening. 10.Understand the role of interprofessional teamwork and collaboration in the evaluation and diagnosis of PAD and PVD to improve patient outcomes and prevent disease progression. 11.Predict the prognosis of PAD, PVD, and atherosclerosis, and their impact on patients' quality of life. Atherosclerosis: Epidemiology Atherosclerotic vascular disease is a leading cause of morbidity and mortality worldwide Atherosclerosis is considered a major cause of cardiovascular diseases Atherosclerosis is the most common, serious and clinically relevant form of arteriosclerosis Arteriosclerosis = a general term for several disorders that cause thickening and loss of elasticity in the arterial wall Causes coronary artery disease and cerebrovascular disease Atherosclerosis can affect all large and medium-sized arteries, including: Coronary, carotid, and cerebral arteries Aorta and its branches Major arteries of the extremities Atherosclerosis is rapidly increasing in prevalence in low- and middle-income countries, and as people live longer, incidence will increase Atherosclerosis: Epidemiology Predominantly an asymptomatic condition – difficulty to determine incidence accurately Atherosclerotic Cardiovascular Disease (ASCVD) - mainly involves the heart and brain: ischemic heart disease (IHD) and ischemic stroke IHD and stroke are the world's first and fifth causes of death respectively, and major cause of long-term disability in adults in the US In the US – 1 of every 4 deaths caused by heart disease in Canada, ASCVD is the second leading cause of death and the 10-year risk of a CV event is 8.9% Atherosclerotic stenosis of the internal carotid or intracranial arteries causes up to 15% of strokes Peripheral artery disease affects up to one in five people in the United States who are 60 years and older and nearly one-half of those who are 85 years and older Renal artery stenosis may affect up to 5% of people with isolated hypertension and up to 40% of people with other atherosclerotic diseases  Demographics 75% of acute myocardial infarctions occur from plaque rupture Incidence in men > 45 years Incidence in women, > 50 years Image: https://www.medicoverhospitals.in/diseases/atherosclerosis/  Lifestyle Sedentary Diets Other risk factors: Chlamydia pneumoniae infection, elevated levels of homocysteine, and elevated levels of lipoprotein-a (Lpa) Image: https://www.grepmed.com/images/3126/pathophysiology-atherosclerosis-nonmodifiable-riskfactors-cardiology Atherosclerosis Review of pathophysiology (reference) https://www.youtube.com/watch?v=R6QTiBfzULE&t=354s Loscalzo et al. (2008) Atherosclerosis: Symptoms Depend on arteries affected and blockage: Coronary heart disease: angina/chest pain, cold sweats, dizziness, extreme tiredness, heart palpitations, shortness of breath, nausea and weakness PAD: Pain, aching, heaviness, or cramping in the legs when walking or climbing stairs that may be relieved by rest Vertebral artery disease/TIA: memory issues, weakness or numbness on one side of the body or face, and vision trouble are all early symptoms of vertebral artery disease. Mesenteric artery ischemia: Severe pain following meals, weight loss, and diarrhea Atherosclerosis General symptoms Image: https://www.pcrm.org/news/blog/warning-signs-clogged-arteries Atherosclerosis: Signs Physical Exams Blood pressure Peripheral pulses Carotid or abdominal artery bruits Abdominal palpation Cardiovascular and Peripheral vascular exam Respiratory exam Skin exam - xanthomas Atherosclerosis: Further Testing Labs: Lipid profile (LDL-cholesterol) Plasma glucose High-sensitivity C-reactive protein (hsCRP) (in certain instances) Imaging: Ultrasound of the abdomen to screen for an abdominal aneurysm (ASCVD, elderly) Doppler device – measure ankle-brachial index (normal 1.0 to 1.40) (PAD – as a marker for ASCVD in other beds (coronary artery disease [CAD], cerebrovascular disease, among others) Sonography of the carotids (Coronary artery stenosis, a carotid bruit) Electrocardiogram (ECG), stress ECG Electron beam computed tomography (EBCT) (to confirm ASCVD, determines calcium score, interpreted according to age, establishes plaque burden) Atherosclerosis: Further Testing Angiography - primary method for imaging atherosclerotic lesions in the coronary circulation, invasive procedure, reserve for high-risk patients or those with symptomatology; Not a screening test. Computed Tomography (CT) angiography – in ASCVD used to detect the presence of low-attenuated plaques and in predicting future acute coronary events. noninvasive assessment Cardiovascular Magnetic Resonance Imaging (cardiac MRI) - costly Image: https://www.mdpi.com/2077-0383/9/12/3925 Atherosclerosis: Complications 1. Occlusion of vessel: Symptoms, signs, and results depend upon organ supplied. 2. Disruption of plaque: Hemorrhage within plaque or rupture or ulceration of plaque (with exposure of the thrombogenic components) can result in thrombus formation. 3. Emboli: Plaque can break free and be carried in the blood stream farther down the vessel. 4. Aneurysm: Atherosclerosis begins as an intimal process, but over time the thickened intima puts pressure on and causes atrophy of the media, often resulting in an aneurysm (i.e., dilation or saccular outpouching of the vessel). - can lead to rupture of the vessel and resultant hemorrhage 5. Peripheral vascular disease 1. Claudication, which is characterized by ache or cramping in the extremities with exertion that is relieved by standing still. Patients also have cool extremities, diminished distal pulses, and shiny, hairless skin. Patients with severe peripheral vascular disease have pain at rest. Ischemic ulcerations are a common cause of morbidity. 2. Cause: Atherosclerosis of vessels of the lower extremities. Atherosclerosis: Clinical Course Complications: ASCVD can present as coronary artery disease (CAD), cerebrovascular disease (CVA), transient ischemic attack (TIA), peripheral artery disease (PAD), abdominal aneurysms, renal artery stenosis, mesenteric artery ischemia Prognosis: may be very good with management of risk factors such as LDL- cholesterol with statin therapy, BP, diabetes, smoking cessation, exercising regularly, and adhering to a prudent diet Worse with full-blown, end-organ disease such as heart failure, ischemic stroke with paralysis and impaired cognition and gangrene necessitating amputation and rupture of an abdominal aneurysm Pre-existing ASCVD has been shown to predict recurrent CV events – in patients with acute coronary syndromes (ACS) found that the rate of subsequent CV events over 8–17 months was 7.5%–19.9% Atherosclerosis: Healthcare Teams All healthcare practitioners - promote preventative measures Educate patients on regular exercise, discontinue smoking, maintain a healthy body weight, eat a healthy diet and use medications used to lower lipids when indicated Evidence shows these can significantly reduce the risk of adverse cardiac events and stroke Management Treat risk factors such as elevated LDL-C, blood pressure, diabetes, obesity Medications: statins, antihypertensives (ACEs, ARBs, diuretics, beta-blockers, CCB, vasodilators), diabetes therapies, thrombolysis therapies Exercise and healthy diet low in saturated and trans fats, reduce salt intake, increase monounsaturated fats, fatty fish, fruits, vegetables, maintain healthy body weight Stop smoking Revascularization procedures: angioplasty, bypass, etc. Image: https://www.osmosis.org/learn/Peripheral_vascular_disease:_Clinical_practice Case: Mr. T. with Leg Pain Mr. T., a 65-year-old male presents with chief concern of leg pain that is worse with walking and better with rest. He has noticed it for the past 6 months, but it has been getting worse and is making it difficult for him to go on his walks with his friends which is affecting his mood. What additional questions would you ask? What physical exams would you conduct? What are red flags to consider? Peripheral Vascular Disease (PVD) Peripheral vascular disease (PVD) - an overarching term that encompasses vascular diseases that result from circulatory dysfunction caused by damage to arteries or veins may affect any blood vessel outside of the heart including arteries, veins and lymphatic vessels The most common types of PVD are peripheral artery disease (PAD), chronic venous insufficiency (CVI), and deep vein thrombosis (DVT) primarily driven by progressive atherosclerotic disease resulting in the reduction of major organ blood flow and end-organ ischemia  Peripheral Arterial Disease (PAD) Peripheral Arterial Disease (PAD) is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion of the major arteries distal to the aortic arch Known as lower extremity occlusive disease can involve both the upper and lower extremities typically affects the abdominal aorta, iliac arteries, lower limbs to the level of the tibial arteries at the foot, and occasionally the upper extremities i.e. in carotid artery stenosis Progressive occlusion results in arterial stenosis, reduced blood flow, and claudication  PVD/PAD Epidemiology PAD Prevalence: American Heart Association estimates 8 to 12 million Americans have PAD - prevalence of 3% to 10% Study: 29% in those aged >70, and between ages of 50-69 with a history of smoking or diabetes Increased to nearly 50% in those >85 yoa PVD Prevalence: 15% to 20% in those > 70 yoa Demographics Age: prevalence increases with age with up to 20% of people older than 75 years Sex: male gender is risk factor Race/ethnicity: non-Hispanic black race (African Americans to have an odds ratio of 2.12) Socioeconomic: lower poverty-income ratios (PIR) have a nearly 2-fold increase in the risk of PAD compared to higher PIR lower educational level to be significantly associated with PAD Image: https://www.usavascularcenters.com/blog/understanding-differences-pad-vs- pvd/#:~:text=PAD%20afflicts%20only%20your%20arteries,including%20veins%20and%20lymphatic%20vessels. PVD/PAD Risk Factors Risk factors: Advanced age, male gender, and positive family history Prior history of coronary artery disease, sedentary lifestyle Cigarette smoking history Study: > 80% of patients with PAD were current or former smokers Increases odds for PVD by 1.4 for every 10 cigarettes smoked/day and by 2.6 in patients with diabetes Cardiovascular mortality rates of current smokers with PAD are more than double that of those with PAD who have never smoked Diabetes mellitus Smoking and diabetes are associated with the highest relative risk for developing lower- extremity PAD PVD/PAD Risk Factors Hypertension Hyperlipidemia Patients with other vascular disease have a high prevalence of PAD (19% in patients with ischemic heart disease and 26% in patients with stroke) Low High-density lipoprotein (HDL) cholesterol (< 1.04 mmol/L [40 mg/dL] in men and < 1.29 mmol/L [50 mg/dL] in women Chronic kidney disease/renal insufficiency (eGFR < 60 mL/minute/1.73 m2) *NHANES: Most significant risk factors - hyperlipidemia, hypertension, diabetes mellitus, chronic kidney disease, and smoking; Odds of having PAD increase with each additional risk factor, from a 1.5-fold increase with one risk factor to a 10-fold increased risk with three or more risk factors PVD/PAD – Risk Factors In one series from the Netherlands, the likelihood of a patient having PVD (as defined by an ankle-brachial index [ABI] of less than 0.9) was increased by: being male (odds ratio [OR] 1.6) being older than 60 years (OR 4.1) having hypercholesterolemia (OR 1.9) having a history of ischemic heart disease (OR 3.5), cerebrovascular disease (OR 3.6), diabetes mellitus (OR 2.5), or intermittent claudication (OR 5.6) smoking (OR 1.6) [Stoffers et. al. (1997)] PVD/PAD: Symptoms Classic/Intermittent Claudication Classic/intermittent claudication = defined as fatigue, muscle discomfort, cramping, or pain of vascular origin in the lower limbs (primarily in the calves and buttocks) that is consistently induced by exercise (i.e. after walking a fixed distance) and is consistently relieved by rest within 10 minutes Occurs in only 10-30% of patients with PAD Approximately 42% are asymptomatic (no leg pain) Others have atypical (non-classical) symptoms of leg pain (47%) Symptoms may include exertional pain that does not stop the individual from walking, does not involve the calves, or does not resolve within 10 minutes of rest à potentially related to comorbid musculoskeletal or neuropathic conditions à The presence of classic claudication has an LR+ 3.30 à The absence of classic claudication has an LR− 0.89 History - include an estimate of the walking distance  Nonspecific but Common Symptoms/Findings *Additional non-classical symptoms Leg pains or sensations Skin, hair, nail changes Nonhealing wounds/ulcers Edema Image: https://www.usavascularcenters.com/blog/understanding-differences-pad-vs- pvd/#:~:text=PAD%20afflicts%20only%20your%20arteries,including%20veins%20and%20lymphatic%20vessels. PVD Dx – Edinburgh Claudication Questionnaire for diagnosing intermittent claudication in symptomatic patients a series of six questions and a pain diagram that are self-administered by the patient Specificity: 91%, Sensitivity: 99% à LR+ 11, LR- 0.01 Image: Sontheimer (2006) Case: Mr. T. - Leg Pain Pain – cramping sensation and tightness in calves and buttocks, worsens after walking about 2-3 blocks and is better after 10 minutes of rest. Onset 6 months ago, progressively getting worse. PHx – hypertension and hyperlipidemia (medicated with bisoprolol, atorvastatin) SHx – smoker – ½ PPD for 40 years  PAD: Physical examination Vitals – Blood pressure 1 Inspection/Palpation: Gait: Impaired walking function/Intermittent claudication à ischemic rest pain Observe skin on lower extremities: Nonhealing lower extremity wound Arterial ulcerations - well-demarcated, “punched-out” lesions 2 feet inspection for ulcers between the toes (“kissing ulcers”) and ulcers related to ill-fitting footwear Lower extremity gangrene Image: (1) https://www.vascularsociety.org.uk/patients/conditions/12/arterial_ulcer (2) https://drclementlo.com/refer/index.php/dermatology-jean-l?view=article&id=189&catid=95 PAD: Physical examination Observe skin perfusion: Pallor on leg elevation or dependent rubor followed by pallor or blanching of the extremity with elevation  PAD: Physical examination Inspection/Palpation: Skin temperature: Cool skin Nails: Dystrophic nail changes Capillary refill: Abnormal capillary refill time Hair: Hair loss on toes and distal ankles, shiny skin, and muscle atrophy Pulses (grade): Diminished lower extremity pulses Abdominal palpation: abdominal aortic aneurysm PAD: Physical examination Auscultation: vascular bruits – aortic, carotid, femoral, iliac and popliteal Most reliable physical findings: diminished or absent pedal pulses, presence of femoral artery bruit, abnormal skin color, and cool skin – however their absence does not preclude PVD Image: https://heart.bmj.com/content/107/22/1835 PAD: Physical Examination LR’s Finding Symptom LR+ LR- Skin changes Cool skin 5.9 0.92 Presence of Foot Ulcer 5.9 0.92 *Skin changes (atrophic or cool skin, blue/purple skin, absence of lower limb hair) are not useful in assessing for PAD in asymptomatic patients. Bruit Presence of Iliac, Femoral OR Popliteal bruit 5.6 0.39 (absence in Symptomatic patients all three locations) Bruit Presence of Femoral bruit 4.8 *no change in Asymptomatic patients probability Pulse Abnormal Femoral 7.2 Abnormal Posterior tibial 8.1 Abnormal Dorsalis pedis 1.9 Absence of any abnormal pulse 0.38-0.87 Capillary Refill *neither sensitive nor specific for diagnosing PAD Case: Mr. T. - Leg Pain Physical exams: BP: 144/82 LAS HR: 78 beats/min RR: 20 breaths/min Appears well, alert, no abnormal gait Skin: well perfused, cool, some hair loss on lower legs, weak femoral pulse, audible femoral bruit, no other abnormal pulse or bruit, no ulcers Capillary refill: