Peripheral Arterial Disease (PAD): Presentation, Diagnosis, and Treatment
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2 Peripheral Arterial Disease (PAD): Presentation, Diagnosis, and Treatment Prepared and Presented by Jon Manocchio, Pharm D Blanchard Valley Hospital October 2011
3 Introduction PAD is a condition that is associated with defined risk factors Difficult to diagnose because symptoms can be absent Screenings are appropriate based on patient characteristics Treatment is limited and usually includes exercise therapy
4 Incidence Prevalence Epidemiology Adults 40 years and older Highly age dependent Mortality Same for men and woman Higher for critical leg ischemia
5
6 Pathophysiology Atherosclerosis Familial hypercholesterolemia (FH) Coronary Artery Disease Occurring in the periphery
7 Risk Factors Age > 40 Cigarette smoking Diabetes Mellitus Hypercholesterolemia Hypertension Hyperhomocysteinemia
8 Signs and Symptoms Two most common signs Intermittent claudication (IC) Reproducible Resolution Pain at rest in lower extremities Later in disease progression Limb ischemia Physical exam Not always present so difficult to use in diagnosis
9 Differential Diagnosis Important during clinical work-up Allows for accurate diagnosis Include Peripheral neuropathy Inflammatory conditions Vascular conditions
10 Diagnosis Ankle-brachial index (ABI) Specific measurement for diagnosis Normal: Borderline: PAD: < 0.9 Mild: Moderate: Severe: < 0.4 Can also be used after exercise
11 Treatment Goals of therapy Increase maximal walking distance Increase duration of pain-free walking Improve comorbid conditions Hyperlipidemia Diabetes Mellitus Hypertension Improve overall quality of life Reduce vascular complications
12 Treatment Nonpharmacologic therapy Smoking cessation Counseling Bupropion (Wellbutrin ) Varenicline (Chantix ) Nicotine replacement therapies Exercise Numerous benefits minutes 3 times per week Surgery
13 Treatment Hypertension (<130/85) Thiazide diuretics ACE-I/ARB s Beta Blocker Calcium Channel Blocker Hyperlipidemia (<100 or <70) Statins are the preferred starting agent Other therapy can be added if needed
14 Treatment Diabetes Mellitus (A1C < 7%) Recommended screenings Oral agents Insulin
15 Treatment Anti-platelet Therapy Aspirin mg Clopidogrel 75mg Dipyridamole/Aspirin 400/50mg Ticlodipine 500mg Intermittent Claudication Cilostazol 100mg Pentoxyifylline 400mg
16 Evaluation Laboratory results Glycemic control Lipid management Blood pressure Repeat exercise tests Improvement in quality of life
17 Conclusion Many people are affected by PAD PAD can range from no symptoms to unmanageable symptoms Usually will require surgery Pharmacists can play a role
18 Guideline Update: 2011
19 2005 Guideline Diagnostic Method Resting ABI to diagnose PAD Exertional leg symptoms Non-healing wounds 70 years and older 50 years and older with history Smoking history Diabetes
20 2011 Update Diagnostic Method Resting ABI to diagnose PAD Exertional leg symptoms Non-healing wound 65 years and older 50 years and older with history Smoking history Diabetes Level of Evidence: B
21 2005 Guideline ABI results Interpretation Noncompressible: > 1.30 Normal: Borderline: Abnormal: < 0.9
22 2011 Update ABI results Interpretation Noncompressible: > 1.40 Normal: Borderline: Abnormal: < 0.9 Level of Evidence: B
23 Smoking Cessation 2005 Guideline Patients who use tobacco products Advised by clinicians to quit Offered smoking cessation interventions Pharmacological» Bupropion» Nicotine Replacement Therapy Behavior modification
24 2011 Update Smoking Cessation Current and former tobacco users Evaluate status at each appointment Level of Evidence: A Patient assistance Develop a plan for quitting Pharmacotherapy Counseling program Level of Evidence: A
25 2011 Update Smoking Cessation Pharmacologic therapy should be offered Bupropion Varenicline Nicotine replacement therapy Level of Evidence: A
26 Antiplatelet Therapy 2005 Guideline Therapy used to Reduce risk of Cardiovascular death MI or stroke Aspirin is recommended Clopidogrel is an effective alternative 2011 Update General ideas maintained but wording was refined
27 2011 Update Antiplatelet Therapy Therapy used to Reduce risk of Cardiovascular death MI or stroke Asymptomatic patients with an ABI < 0.9 Level of Evidence: C Patients with borderline ABI is not well established Level of Evidence: A
28 2011 Update Patients with Antiplatelet Therapy Symptoms, revascularization, or prior amputation Risk of cardiovascular events Not at risk of bleeding May be considered for aspirin and clopidogrel combination therapy Level of Evidence: B
29 Critical Limb Ischemia Update 2011 Limb-threatening ischemia AND Life expectancy of < 2years Balloon angioplasty is reasonable to perform as initial procedure to improve blood flow Level of Evidence: B
30 Critical Limb Ischemia Update 2011 Limb-threatening ischemia AND Life expectancy of > 2years Bypass surgery is reasonable to perform as the initial procedure to improve blood flow Level of Evidence: B
31 Abdominal Aortic Aneurysm 2005 Guideline Open repair Acceptable in good surgical candidates Endovascular repair Requires long-term surveillance monitoring 2011 Update Minor wording modifications
32 Abdominal Aortic Aneurysm 2005 Guideline Endovascular repair Reasonable for candidates at a high risk of open operations 2011 Update Deleted from guidelines
33 Abdominal Aortic Aneurysm 2005 Guideline Endovascular repair Consider in patients at low or average surgical risk 2011 Update Deleted from guidelines
34 Abdominal Aortic Aneurysm 2011 Update Open aneurysm repair Reasonable to perform in patients Good surgical candidates Cannot comply with periodic long-term surveillance required after endovascular repair Level of Evidence: C
35 Abdominal Aortic Aneurysm 2011 Update Endovascular repair Patients who are at High surgical risk as determined by the presence of coexisting severe diseases is of uncertain evidence Level of Evidence: B
36 Conclusion Many new things were added to the updates Some changes involved only wording modifications Some changes involved changing the level of evidence New studies published
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