Steven Hadesman, MD Chief Medical Officer, MeridianRx Internal Medicine Physician, St. John Hospital

Steven Hadesman, MD Chief Medical Officer, MeridianRx Internal Medicine Physician, St. John Hospital

Deep Venous Thrombosis Varicose Veins Venous insufficiency Phlebitis Lymphedema Elephantiasis nostras verrucosa

Albert is a new patient who complains of leg pain

Baker Cyst Chronic Compartment Syndrome Foot Arthritis Hip Arthritis Nerve Root Compression Spinal Stenosis Deep or Superficial Venous Thromboembolism Restless Leg Syndrome Systemic Vasculitis Nocturnal Leg Cramps Muscle or Tendon Strains Peripheral neuropathy

Claudication is defined as effort-induced (usually walking) discomfort of the calf, thigh, and/or buttock Described as cramping, aching, tightness, pain, or fatigue Typically relieved by rest within 10 minutes Claudication is a classic symptom of Peripheral Arterial Disease

In the general population, only 10% of people with PAD have the classic symptom of intermittent claudication. Approximately 40% do not complain of leg pain, whereas the remaining 50% have a variety of leg symptoms different from classic claudication. In an older, disabled population of women, however, as many as two thirds of individuals with PAD had no exertional leg symptoms.

Know the risk factors o Smoking o Diabetes o Hypertension o Dyslipidemia o Obesity o Chronic renal insufficiency o Elevated CRP o Hypercoagulable states o African American ethnicity o Male

Greatest modifiable risk factor for development and progression of PAD is cigarette smoking. o Cigarette smoking increases the risk of PAD 7-fold and progression to symptomatic disease occurs a decade earlier than in nonsmokers. o The risk of developing claudication increases with the intensity of smoking. o The 5-year mortality for patients with claudication who continue to smoke is 40 50%. o Current smokers with PAD also have twice the amputation rate of nonsmokers, an increased risk of graft failure following femoropopliteal bypass surgery and increased postoperative mortality.

Vital Signs: BP General: appearance HEENT: fundoscopic exam Neck: carotid bruits CV: murmurs, gallops Pulm: wheezes, rhonchi, distant breath sounds Abdomen: aortic/renal/iliac/femoral bruits, pulsatile mass Extremities: cool/cold, pulses (absent/diminished), prolonged capillary refill Skin: color changes, ulcers, gangrene, poor hair growth, nail changes Neurologic: sensation, neuropathy, signs of previous stroke (carotid disease)

Every time I see my at risk patients, recheck o Pulses - decreased or absent o Temperature cool to touch o Hair diminished or absent o Skin color Ranges from pale, rubor, blue, to necrotic o Look for early or small ulcers A good physical exam (touch the patient)

Determining location of vascular lesion based on history and physical exam skills Claudication Site Vascular Territory Buttock, Hip Aortoiliac Artery Thigh Upper Calf Lower Calf Foot Common Femoral or Aortoiliac Artery Superficial Femoral Artery Popliteal Artery Tibial or Peroneal Artery

Remember your risk factors! o Fasting CMP o Fasting lipid panel o Hemoglobin A1c o CRP o Homocysteine Special Circumstances o Coagulopathies

CT Angiography and MR Angiography o Usually ordered in anticipation of intervention or surgical procedures

Claudication without critical limb ischemia o ABI usually around 0.7-0.8 Risk factor modifications Follow up in clinic in 3 months Consider intervention if persistent symptoms that significantly limit lifestyle Critical limb ischemia o ABI usually around 0.3-0.4 o Rest pain and/or tissue loss Plan for surgical intervention! Risk factor modifications

Stop Smoking! o Provide support resources and medications as necessary Treat additional risk factors o Hypertension- Ace inhibitors/arbs, Beta-Blockers Goal <130/80 o Hyperlipidemia- Statins Goal LDL <70 Statins also have anti-inflammatory effects on vasculature o Diabetes Goal HgbA1c < 6.5% Keep on Walking! o 35-50 minutes of walking in an exercise-rest-exercise pattern 3-4 times per week This will increase symptom-free walking distance and improve quality of life

Antiplatelet Medications o Aspirin (75mg-150mg/day) typically used alone first o Plavix if intolerant of ASA or if PAD progresses o Cilostazol (Pletal) vasodilation and antiplatelet PDE 3 inhibitor, increases cyclic AMP leading to reversible inhibition of platelet aggregation and to vasodilation Effective for lower extremity PAD with moderate to severe intermittent claudication unresponsive to exercise therapy Contraindicated in pts with heart failure o Pentoxifylline (Trental) evidence of effectiveness is mixed Reduces blood viscosity via increased leukocyte and erythrocyte deformability Avoid drugs that cause vasoconstriction (pseudoephedrine)

PVD is a disease that requires collaboration to avoid CLI PCPs need you to lend a hand o Minimize barriers by cultivating kindness Educate everyone around you o It is better to screen often and refer early

Sontheimer DL. Peripheral Vascular Disease: Diagnosis and Treatment. Am Fam Physician. 2006 Jun 1;73(11):1971-6. Wilson JF, Laine C, Goldmann D. In the Clinic: Peripheral Artery Disease. Ann Intern Med. 2007 Mar 6;146(5). Creager et al. Atherosclerotic Peripheral Vascular Disease Symposium II: Executive Summary. Circulation 2008;118;2811-2825. VascularWeb. The Society for Vascular Surgery www.vascularweb.org American Heart Association. www.americanheart.org National Heart, Lung, and Blood Institute. www.nhlbi.nih.gov

Steven Hadesman, MD Chief Medical Officer, MeridianRx Internal Medicine Physician, St. John Hospital