Peripheral arterial disease:

Recognition and medical management

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 73 NUMBER 7 JULY 2006

Dr. Wursito SpJP Dr. N. Tantri Faculty of Medicine, Brawijaya University

ABSTRACT

PAD is common but has a variable presentation and is often unrecognized and under treated. Patients with PAD have an increase risk of cardiovascular events and death. ABI is a quick, reliable diagnostic tool that also helps assess disease severity and prognosis

Case vignette

A 63 year old man comes to the clinic because of fatigue in his right leg : when he walks it feels tired, heavy and tight. The symptoms improve with rest, then recur when he resumes walking. He has quit golfing as aresult He has no known atherosclerotic disease or diabetes. He has smoked 1 packs of cigarettes a day for 45 years

Physical examination :

No ulcerations and no varicose veins Decreased right popliteal, dorsalis pedis and posterior tibial pulses. Blood pressure 159/97mmhg (untreated) in both upper extremities.

Laboratory result :

Total cholesterol 280 mg/dl Triglycerides 358 mg/dl Low-Density lipoprotein cholesterol (LDL-C) 127 mg/dl High density lipoprotein cholesterol (HDL-C) 33 mg/dl

Prevalent but often overlooked

Definition Only 10%-30% present with classic symptoms of claudication Patient who had both PAD and cardiovascular disease were more likely to have been diagnosed. The PARTNERS :

Evaluated 7000 people at risk at primary health practice, 1,865 (29%) detected as having PAD, was not been diagnosed in 800 of them.

Pathophysiology and risk factors

Manifestation of systemic atherosclerosis One of the three major syndromes of atherothrombosis (along with CAD and CVD) Risk factors? similar with CAD Not as simply as mismatch between oxygen supply and demand The chronically ischemic skeletal muscle fiber undergoes important metabolic changes compatible with acquired metabolic myopathy

Symptoms may not correlate with severity

Leg symptom

Vulnerable plaques that may not have caused significant stenosis may unexpectedly ruptured and cause a complete occlusion.

Intermittent caludication

Only 10% PAD pts report this classic patern 50% describe a variety of others leg sypmtoms (fatique, numbness, tightness or heavyness) Characteristic pattern :

It It It It

dose not occur at rest does not resolve with walking prompts the patient to stop walking disappears within 10 mnts of stopping to rest

Critical limb ischemia

Chronis limb threatening ischemia is indicated by pain at rest, ischemic ulcers or gangrene.

Diagnosis

ABI ( our pts ABI was 0,72 in his right leg and 1,0 at his left leg) Pulse volume recordings Arterial duplex ultrasonography Magnetic resonance angiography And conventional angiography

Look for other atherosclerosis elsewhere Predicting factors

The ABI Failed lower extremity revascularization

Treatment

Goals :

Reduce symptoms better quality of life Save the limb Prevent progression of atherosclerosis reduce CAD and CVD

Treatment cont

Smoking cessation Antiplatelet therapy

Indicated for all PAD pts Aspirin 75 160 mg per day Clopidogrel 75 mg per day Target :

Treating dyslipidemia

LDL-C <100 mg/dl, triglycerides <150 mg/dl

statins

Treatment cont

Blood pressure control

Blood glucose control Increasing walking distance

Beta-blockers ACE inhibitors

Exercise Drug treatment

Cilostazol 100mg twice daily ( or 50 mg twice daily for fragile older pts) Pentoxyfilline? Minor effect on improving walking capacity

Angiography and Revascularization

Main indications :

Lifestyle-limiting claudication Ischemic pain at rest Non healing ischemic ulcers

What happened to our patient?

Life style limiting leg disfunction

6 months of conservative therapy

Conservatives Revascularizationn

Statins, titrate the dose up to agoal LDL-C less than 70mg/dl ACE inhibitors to achieves blood pressure < 140/80mmhg Cilostazol 100mg twice daily Aspirin 162 mg/day Smoking cessation

On follow up

Quit smoking Improved walking distance Lost 11.8lb Well controlled BP LDL-C 76 mg/dl HDL-C 46 mg/dl, triglycerides 165 mg/dl

TERIMA KASIH