A PhysiciAn's Guide To The Diagnosis - Vascular Cures
A Physician’s Guide to theDiagnosisANDManagementof PeripheralArterialDisease (PAD)
Definition ofPeripheral Arterial Disease (PAD)What is PAD?Peripheral arterial disease(or PAD) is the term used forvascular diseases that alterthe normal structure andfunction, or that block theaorta or some of its branches.These include arteries of thelower abdomen, the renalarteries and arteries of thelower extremities.1,2What causes PAD?The major cause oflower extremity PADis atherosclerosis.1Atherosclerosis is adegenerative diseasecharacterized by a buildup ofplaque and fatty substanceswithin the arterial walls.3Prevalence of PAD:Artery cross-sectionBlood flowHealthy arteryBlood flowMild atherosclerosisPeripheral arterial diseaseaffects a large portion of theBlood flowadult population worldwide.1As many as 27 million peopleare estimated to have PAD inNorth America and Europealone.3 In a 2006 CanadianSevere atherosclerosistelephone survey of adults 50 years of age (n 501), only 36% of respondentsreported familiarity with PAD, although approximately800,000 Canadians are affected by PAD.4-6* Peripheralarterial disease likely affects about 4% of Canadiansover the age of 40* and 20% over 75.5-7*** Based on a results from the U.S. National Health and NutritionExamination Survey, 1999–2000 (n 2174) and Statistics Canada.** Based on Statistics Canada data, and a study of 613 men and women(average age 66) from California assessed for large vessel PAD.
The leading cause of PAD in the lowerextremities is atherosclerosis. Riskfactors for atherosclerosis include1,3: Age Family history Smoking Diabetes Dyslipidemia Hypertension Hyperhomocysteinemia Obesity Sedentary lifestyle10-year survival for PAD vs.non-PAD patients*†1.00Normal (n 408)Survival0.75Asymptomatic(LV-PAD) (n 49)Symptomatic large-vesselPAD (LV-PAD) (n 18)0.500.250.00Severely symptomaticlarge-vessel PAD (LV-PAD)(n 13)024681012YearAdapted from Criqui, et al.8* A study of 565 patients followed for 10 years identified 67 withlarge-vessel PAD. Forty-nine patients were asymptomatic.† Kaplan-Meier survival curves based on mortality from all causesamong normal subjects and subjects with symptomatic orasymptomatic large-vessel peripheral arterial disease (LV-PAD).Risk FactorsRisk Factors
PRESENTATION OF PERIPHERALARTERIAL DISEASE (PAD)Asymptomatic PADMore than 60% of patients with PADmay present with no symptoms.3ClaudicationThe most common manifestation of PADis intermittent claudication, definedas leg pain induced by exercise andrelieved by rest.3Claudication may be intermittent orchronic, with symptoms varying frommild to severe. These include1: Cramping Fatigue Frank pain Aching WeaknessThese symptoms typically occur in thebuttock, thigh, or calf muscles, and rarely,the foot.1Critical limb ischemiaCritical limb ischemia may presentwith pain in the foot at rest, or withnon-healing foot wounds. The discomfortis often worse when the patient is supine(e.g., in bed) and may lessen when thelimb is maintained in the dependentposition.1Narcotics are usually requiredfor analgesia.1
REACH REGISTRY: A REAL-WORLDDATABASE ON ATHEROTHROMBOSISBaseline characteristics in REACH10 Data from 5,473 physician practicesin 44 countries 44% of physicians were from general practice A total of 67,888 patients aged 45 years orolder (recruited in 2003–2004) Roughly 42% of patients were fromgeneral practice 1,976 patients from CanadaPatients with establishedatherothrombotic disease10Coronary artery disease (CAD)n 40,258 (59.3%)Cerebrovascular disease (CVD)n 18,843 (27.8%)Peripheral arterial disease (PAD) n 8,273 (12.2%)1-year Objectives9To determine one-year cardiovascular (CV) eventrates in the global population for outpatients withestablished arterial disease or with multiple riskfactors or atherothrombosis.REACHStudy design9An international, prospective cohort of patientswith either: Established atherosclerotic arterial disease(coronary artery disease [CAD], PAD,cardiovascular disease [CVD]); n 55,814, or At least 3 risk factors for atherothrombosis;n 12,422 1 year follow-up (baseline, to follow-up at12 3 months)
REACH POLYVASCULARPATIENT DISTRIBUTIONPrevalence of polyvascular diseasein PAD9CVD40% havepolyvasculardiseaseCAD25% havepolyvasculardiseasePAD61% havepolyvasculardiseaseWhat is polyvascular disease?9,10In some patients, arterial disease can exist inmore than one vascular bed (CAD, PAD, CVD).This is called polyvascular disease.
KEY FINDINGS OF THE REACH REGISTRYTotal populationPeripheral arterial disease patients(n 8581) experienced higher rates ofCV death and major CV events due toan atherothrombotic event comparedwith CAD (n 38602) and CVD (n 18013)patients (21.14% (20.17–22.09) vs. 15.20%(14.67–15.73) vs.14.53% (13.89–15.16)respectively, 95% CI).9More than 10% of patients with PADunderwent a lower extremityrevascularization procedureor amputation.9Approximately 1 in 5(21.1%) patients withPAD suffered a majorevent (myocardialinfarction [MI], stroke,or CV death) orhospitalization for anatherothrombotic eventwithin 1 year as shownin the REACH Registry. 9
KEY FINDINGS OF THE REACH REGISTRYPatients with establishedatherosclerotic disease1-year event rates in patients with PADalone were lower than those for PADin combination with any other arterialdisease location.9To further explore the relative risk forischemic events, event rates were thereforealso reported for single vs. multiplearterial beds. Overall major CV event ratesincreased in a stepwise fashion with thenumber of symptomatic vascular beds.CV death, MI, stroke or hospitalizationfor an atherothrombotic event25%20%17%13% (16.10–18.75)(12.12–13.04)15%10%5%0%p 0.00126%(23.80–23%22%28.70)(19.43– (21.63–24.56)24.40)*Multiple riskfactor only,n 11766CAD, CVD, orPAD, n 42716PAD alone,n 3246CVD PAD,n 9395%*(4.86–5.75)*CAD PAD,n 3264One-year cardiovascular event ratesCAD CVD PAD,n 1132Adapted from Steg et al.9
DIAGNOSING PERIPHERAL ARTERIALDISEASE (PAD)The Canadian Cardiovascular SocietyConsensus Guidelines indicate that PAD,because it is often asymptomatic, isunder-diagnosed, under-recognized,and under-treated.3Screening for PAD is recommended for3: Men over 40 and women whoare postmenopausal or over 50(Recommendation level 1A) Have diabetes ave a family history of PAD,HCAD or stroke, or havedyslipidemia, or systolicand diastolic hypertensionDiagnosis Screening efforts should targetpatients with a recognized CV riskfactor, i.e., those who Smoke
Basic screening for PAD will includea directed history with key questionsspecific to claudication.3The Edinburgh ClaudicationQuestionnaire is a validatedquestionnaire that can help diagnosearterial claudication in patientssuspected of suffering from PAD.3A complete physical examination willfocus on the following3: Identifying femoral bruits Grading pedal pulses Looking for trophic changesin hair or skin Inspection of the skin temperature,pallor, or rubor Palpation to exclude aneurysms(e.g., an aortic abdominal aneurysm)The most common diagnostic tool is theankle-brachial index (ABI), which is usedin conjunction withDoppler ultrasound tocompare blood pressureelmeasurements at theGupper arm and ankle.3
The Ankle-Brachial Index (ABI)The ABI is a simple, non-invasive testthat is performed using a regular bloodpressure (BP) cuff and a Doppler(ultrasound probe).3ABI 0.9 is diagnostic for pad11ABI interpretation chart3,11 1.3* Noncompressible calcified vessels0.91–1.3 Normal0.41–0.9Mild to moderate PAD0.4 or less Severe PAD* ABI 1.3 is abnormal but cannot be used to diagnose occlusivePAD. However, it is associated with increased vascular morbidityand mortality.3Measurement of the ABI3Right ABI Higher right-ankle pressureHigher arm pressureLeft ABI Higher left-ankle pressureHigher arm ressureDP dorsalis pedis arteryPT posterior tibial artery indicates where the BPcuffs should be placedRight-anklesystolicpressureDP, PTLeft-anklesystolicpressureDP, PTPlease refer to the tear sheet at the backof this booklet for a copy of theEdinburgh Claudication Questionnaire.
MANAGEMENT OF PERIPHERALARTERIAL DISEASE (PAD)Patients with asymptomatic orsymptomatic PAD suffer a three- tosix-fold greater likelihood of MI, strokeand CV death compared to a non-PADpopulation.11Risk factor modification, and provenmedical treatment, therefore, shouldbe actively encouraged.11Risk factor management11 Assess all patients with PAD formodifiable risk factors. Manage risk factors to reduce riskof adverse cardiovascular events andprogression of PAD. Recommend that patients with PAD quitsmoking and have a regular walkingprogram to reduce overall cardiovascularrisk and improve symptoms.Lifestyle changes (nonmedical)Lifestyle changes which include smokingcessation and a supervised exerciseprogram play an important rolein PAD management.1-3
MANAGEMENT OF PERIPHERALARTERIAL DISEASE (PAD)Lifestyle changesThe importance of smoking cessationcannot be overemphasized for peoplewith PAD.2“Individuals with lower extremity PAD . . .should be offered comprehensive smokingcessation interventions, including behaviormodification therapy, nicotine replacementtherapy, or bupropion.”ACC/AHA Guidelines1An exercise program is recommended forall patients with intermittent claudication.2Supervised exercise training for a minimumof 30 to 45 minutes, in sessions performedat least 3 times per week for a minimumof 12 weeks, can significantly improve thelimitation of walking.1-3ManagementSupportive measures2Other non-medical therapies include: Keeping feet clean andwell-moisturized Wearing well-fitting shoes Avoiding shoes made of syntheticmaterials that don’t “breathe”
MANAGEMENT OF PERIPHERALARTERIAL DISEASE (PAD)Pharmacological managementThe basic components of medicalmanagement of PAD include1: Lipid-lowering drugs Antihypertensive drugs Diabetes therapies A ntiplatelet therapyMedical therapies shown to reduceCV events in PAD patients3Evidence supporting medical therapiesto reduce CV events in PADClass of agentsGrade*StatinsIAAngiotensin-converting enzymeinhibitorsIAOral hypoglycemics or insulinIIBAntiplatelet agentsIA* Quality of evidenceI – Evidence obtained from at least one properly randomizedcontrolled trial or one large epidemiological study.II – Evidence based on at least one non-randomized cohortcomparison or multi-centre study, chronological series orextra ordinarily results from large non-randomized studies.Classification and recommendationsA – Evidence sufficient for universal use (usually based onrandomized clinical trials).B – Evidence acceptable for widespread use, evidence less robust,but based on randomized clinical trials.Adapted from the Canadian Cardiovascular Society.3Please see respective Product Monographs for approved indications.
ANTITHROMBOTIC THERAPIES FORPERIPHERAL ARTERIAL DISEASE (PAD) 3AgentRecommendationAcetylsalicylic Lifelong antiplatelet therapywith ASA (75 mg to 325 mg/acid (ASA) orday) or clopidrogrel (75 mg/clopidogrelday) in patients with or withoutclinically manifest coronary orcerebrovascular diseaseis recommended.Grade*IATiclopidine†ASA or clopidogrel isIBrecommended over ticlopidine.Pentoxyfiline‡Pentoxyfiline is notrecommended.IIBVitamin Kantagonists†Anticoagulant therapy withvitamin K antagonistsis not recommended.IIB* Quality of evidenceI – Evidence obtained from at least one properly randomizedcontrolled trial or one large epidemiological study.II – Evidence based on at least one non-randomized cohortcomparison or multi-centre study, chronological series orextra ordinarily results from large non-randomized studies.Classification and recommendationsA – Evidence sufficient for universal use (usually based onrandomized clinical trials).B – Evidence acceptable for widespread use, evidence less robust,but based on randomized clinical trials.† Not currently indicted for peripheral arterial disease.‡ Not currently indicated as antithrombotic therapy in peripheral arterial disease.Adapted from the Canadian Cardiovascular Society.3
PATIENT EDUCATIONWhat is PAD?Peripheral arterial disease is a commoncirculatory problem in which narrowed arteriesreduce the blood flow to your limbs/extremities.1,2When these arteries are healthy, blood flowsthrough them easily.With PAD, the narrowing of the arteries(atherosclerosis) is caused by a buildupof plaque and cholesterol (fatty deposits),and your limbs – usually your legs – can’t getenough blood. Peripheral arterial disease isusually a sign of widespread atherosclerosis.1,3Patients with PAD have a greater risk of heartattacks and strokes from atherosclerosisbecause fat deposits can also build up in arteriesthat supply blood to the heart and the Arteriesof the legsBlood flowArteryAnterior tibialarteryPosteriortibial arteryFibularartery
PERIPHERAL ARTERIAL DISEASE (PAD)Atherosclerosis is the leading cause of PAD.1Over 60% of people with PAD don’t show anysymptoms at all.3Some will feel pain or heaviness in the legsand have trouble walking. This pain oftengoes away when resting.Signs and symptoms of mild PAD includeleg pain when walking – a condition calledintermittent claudication.3Patient Education
MILD PERIPHERAL ARTERIALDISEASE ries of the legsAnteriortibial arteryPosteriortibial arteryBlood flowFibulararteryPlaqueArtery
SEVERE PERIPHERAL ARTERIALDISEASE (PAD) 1,3As PAD progresses, it can lead topotentially serious problems with legs andfeet such as open sores that don’t heal,injury, or infection. There is even greaterrisk of developing these problems if youalso have diabetes.In extreme cases these problems can leadto gangrene and/or amputation.Stroke and heart attack are also commonand serious problems that occurwith PAD.3,9,11If atherosclerosis causes symptomsof PAD, it is likely that other bloodvessels in your body are being affected,such as the arteries supplying your heartand brain. This in turn increases your riskof developing coronary artery disease(angina & heart attack) and stroke.11Signs and symptoms of severe PADmay include1,3: Cramping Aching Fatigue Weakness Pain Pain in the foot at rest that is relievedby putting your foot down
SEVERE PERIPHERAL ARTERIALDISEASE ldupArteries of the legsAnteriortibial arteryPosteriortibial arteryBlood flowFibulararteryPlaqueThrombusArtery
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References:1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines for the managementof patients with peripheral arterial disease (lower extremity, renal, mesenteric, andabdominal aortic). J Am Coll Cardiol. 2006;47:1–192.2. Creager MA, Dzau VJ. Vascular Diseases of the Extremities. In: Harrison’s Online.Available at: ourceID 4.Accessed November 12, 2007.3. Abramson BL, Huckell V, Gupta A, et al. Canadian Cardiovascular Consensus Conference.Available at: http://www.ccs.ca/download/consensus conference/consensusconference archives/CCFinalPre CJC Pub.pdf. Accessed November 9, 2007.4. Lovell M, Harris K, Forbes T. Peripheral Arterial Disease: Lack of Awareness in Canada.Can J Cardiol. 2009;25(1):39–45.5. Selvin E, Erlinger TP. Prevalence of risk factors for peripheral arterial disease in theUnited States. Circulation. 2004;110:738–743.6. Statistics Canada. Canada’s Population Estimates. Available at: http://www.statcan.gc.ca.Accessed April 1, 2009.7. Criqui MH, Fronek A, Barrett-Connor E, et al. The prevalence of peripheral arterial diseasein a defined population. Circulation. 1985;71:510–515.8. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients withperipheral arterial disease. N Engl J Med. 1992 Feb 6;326(6):381–386.9. Steg PG, Bhatt DL, Wilson PWF, et al. One-Year Cardiovascular Event Rates in Outpatientswith Atherothrombosis. JAMA. 2007;297(11):1197–1206.10. Bhatt DL, Steg PG, Ohman EM, et al. International Prevalence, Recognition, andTreatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis. JAMA.2006;295(2):180–189.11. Abramson BL, Huckell V, Anand S, et al. Canadian Cardiovascular Society ConsensusConference: Peripheral arterial disease – Executive Summary. Can J Cardiol.2005;21(12):997–1006.Design: Headcan , Health Education Media, www.headcan.com, Toronto, Canada.Illustrations: 2009 GCT II Solutions and Enterprises Ltd.Headcan is a trademark of GCT II Solutions and Enterprises Ltd. Printed in Canada. (HC969)These materials were developed by sanofi-aventis and Bristol-Myers Squibbin partnership with the P.A.D. Coalition.CDN.CLO.09.01.01E50085336BPX92101E
The Edinburgh Claudication Questionnaire 11. Do you get pain or discomfort in your leg(s)when you walk? q Yes q No q Unable to walkIf you answered yes to question 1, please answerthe following questions:2. Does this pain ever begin when you are standingstill or sitting? q No3. Do you get it when you walk uphill or hurry? q Yes4. Do you get it when you walk at an ordinary paceon the level? q Yes q No5. What happens to it if you stand still? Usually continues more than 10 minutes? q NO Usually disappears in 10 minutes or less? q YES6. Where do you get this pain or discomfort?(see diagram)FrontBackPlease share your completed questionnaire with yourhealth care professional to determine if you have PAD.A positive questionnaire diagnosis of claudicationis made only if the “correct” answer is givento all questions.
What can I do about PAD? 1,2 Stop smoking. T ake your medications as directed by yourdoctor to reduce your risk of heart attackand stroke. Exercise regularly, especially walking. Lower your blood pressure. Lower your cholesterol. Care for your feet and legs by: Keeping feet clean and well-moisturized Wearing well-fitting shoes voiding shoes made of synthetic Amaterials that don’t “breathe”If you have questions or need more information,please speak with your health care professional.References:1. Abramson BL and Huckell V. Canadian Cardiovascular Consensus Conference.Available at: http://www.ccs.ca/download/consensus conference/consensus conference archives/CCFinalPre CJC Pub.pdf. Accessed November 9, 2007.2. Creager MA, Dzau VJ. Vascular Diseases of the Extremities. In: Harrison’s Online. Available resourceID 4. Accessed November 12, 2007.Design: Headcan , Health Education Media, www.headcan.com, Toronto, Canada.Illustrations: 2009 GCT II Solutions and Enterprises Ltd. Headcan is a trademarkof GCT II Solutions and Enterprises Ltd. Printed in Canada. (HC969)These materials were developed by sanofi-aventis and Bristol-Myers Squibbin partnership with the P.A.D. Coalition.CDN.CLO.09.01.01E50085336BPX92101E
Screening efforts should target patients with a recognized CV risk factor, i.e., those who Smoke Have diabetes Have a family history of PAD, CAD or stroke, or have dyslipidemia, or systolic and diastolic hypertension DiAGnosinG PeriPherAl ArteriAl DiseAse (PAD) Diagnosis
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