Outpatient / Cardiology
Peripheral Arterial Disease (PAD)
# Peripheral Arterial Disease
The 5 P's
-- Pain - worsens with passive movement
-- Pallor - initially pale, then blue and mottled
-- Pulses - absent distal to occlusion
-- Paralysis - initially weakness, then progresses to irreversible paralysis
-- Poikilothermia - cool extremity, but depends on environment
Plan
-- Refer for ABI → segmental ABI with PVRs → CTA vs angiography; Exercise testing if ABIs normal but high concern
-- Lifestyle: *** smoking cessation, weight loss, formal excerise program
-- Statin: *** atorvastatin 80mg
-- Anti-Platelets: *** ASA 81mg daily (sxs or asx) or clopidogrel 75mg daily (sxs only); avoid DAPT unless other reason for it
-- AC: *** rivaroxaban 2.5mg BID along with ASA if not high risk for bleeding
-- Cilostazol 100mg BID *** to increase exercise capacity; avoid in HF
-- Ulcers: *** refer to wound care
-- Refer to vascular surgery for consideration of repair via angioplasty vs stent if symptoms refractory to medical management or concern for threatened limb
Template coming soon!
Patient Guidance and Information
If You Remember Nothing Else
PAD often presents as exertional pain distal to the site of occlusion (classic claudication), relieved by rest. However, atypical pain is more common, and 20-50% of patients can be asymptomatic. Screening for PAD is typically done with ABIs, with abnormal being <0.9 and >1.3 implying decreased compressibility due to calcification. Start the workup with an Ankle-Brachial Index (ABI) test, followed by segmental ABI with Pulse Volume Recordings (PVRs), and then consider Computerized Tomography Angiography (CTA) or angiography if there is evidence of occlusion. For management, lifestyle changes like smoking cessation, weight loss, and regular exercise are crucial. Prescribe high-intensity statin therapy, preferably atorvastatin 80mg. Anti-Platelets, such as ASA 81mg daily for symptomatic or asymptomatic patients, and adding clopidogrel 75mg daily for symptomatic patients, should be considered. The COMPASS Trial (2018) showed that rivaroxaban with ASA was superior to ASA or rivaroxaban alone in reducing major adverse cardiovascular and limb events. Cilostazol 100mg BID can help increase exercise capacity but should be avoided in heart failure patients. During a physical exam, remember the 5 P's: Pain (worsens with passive movement), Pallor (initially pale, then blue and mottled), Pulses (absent distal to occlusion), Paralysis (initially weakness, then progresses to irreversible paralysis), and Poikilothermia (cool extremity, but depends on environment). Don't miss signs of an acute limb - involve vascular surgery ASAP if you are concerned.
Clinical Pearls
- When to Refer: when abnormal ABIs and severe symptoms impacting quality of life even with medical management for consideration of revascularization
- Risk Factors - smoking, DM, HLD, HTN, age >70
- Classic claudication (10-35%) in PAD is exertional pain distal to site of occlusion, relieved by rest; atypical pain is more common (40-50%), and asymptomatic in 20-50%
- Screen for PAD with ABIs - abnormal is <0.9; >1.3 implied decreased compressibility due to calcification - if abnormal get segmental ABI with pulse volume recordings (PVRs) which helps localize the disease followed by CTA with runoff or angiography to help with planning for possible revascularization
Trials and Literature
- CAPRIE Trial 1996 - clopidogrel 75mg > ASA 325mg for reducing composite of stroke, MI, vascular death (5.83% vs 5.32%) signficant because there were 19,000 patients - reason some people claim clopidogrel > ASA for PAD
- EUCLID Trial 2017 - in pts with symptomatic PAD, ticagrelor was non-superior to clopidogrel for reduction in CV events (10.8% vs 10.6% in clopidogrel) with similar major bleeding events (1.6%)
- CHARISMA Trial 2006 - DAPT not superior to ASA monotherapy in reducing MI, stroke, or death from cardiovascular causes; it is extrapolated to PAD
- COMPASS Trial - 2018 - rivaroxaban with ASA > ASA or rivaroxaban alone in reducing major adverse cardiovascular and limb events (composite 5% vs 7%, limb events - 1 vs 2%) but increases major bleeding (3% vs 2%) which is mostly GI bleed
- Meta Analysis for Cilostazol Effect of Pts with Intermittent Claudication - increases maximal and pain-free walking distances by 50% and 67%; also increased QOL assessments
Other Resources
Tweetorials
Video
