Thread by @DrJaredDyer

1/ #MRPearls How comfortable are you in diagnosing and managing peripheral artery disease? #Tweetorial @VCU_IMRes @AudreyBJernigan @michellebr00ks @abouzaki_md @AbbateAntonio @VCUHealthHeart @rabihmgeha @cjchiu @AdamRodmanMD @jackpenner @tony_breu

2/ #MRPearls It is estimated that atherosclerotic peripheral artery disease affects more than 200 million persons worldwide, including at least 8.5 million persons in the United States. @JeremyTurling @CVC_Coalition @padadvocate @CardiacRisk @VascProtection @American_Heart

3/ #MRPearls Diabetes and smoking are the strongest risk factors associated with peripheral artery disease. Check out these charts from @CircAHA demonstrating the odds-ratio for PAD in smokers. @GuruKowlgi @kalahasty @SamPowellMD @sammyd56702583 @SampathGundaEP @mitchbk1

4/ #MRPearls So why do we care so much about PAD? According to Steg et al @jama the incidences of CV death, MI, stroke, or hospitalization for atherothrombotic events were 21.4% for those with PAD in a 1 yr outcome study. jamanetwork.com/journals/jama/…

5/ #MRPearls Additionally, an ankle-brachial index (ABI) of 0.9 or less has been associated with more than twice the mortality that is associated with an ABI of 1.11 to 1.40. Therefore, we must properly diagnose and treat this patient population.
jamanetwork.com/journals/jama/…

6/ #MRPearls Claudication is by far the most common presentation of lower extremity PAD; however, can you name any other common signs and symptoms for PAD? @HarvardHealth @totocarbone @marinanaz

7/ #MRPearls For PAD workup, you should start with non-invasive testing. Non-invasive testing includes segmental blood pressure with corresponding segment-brachial indices and continuous wave doppler waveform analysis.

8/ #MRPearls PAD is considered to be present when the ABI is 0.90 or less. In continuous wave doppler waveforms, a triphasic or biphasic response is considered normal. However, a reduced biphasic or monophasic signal indicates significant stenosis. @NEJM @CarlitoBurritoo

9/ #MRPearls This chart from @NEJM perfectly outlines the non-invasive evaluation of peripheral artery disease. @nehahipp @banwang @MVPatroneMD @cameronbyfiat @DrDaniGenMed

10/ #MRPearls Conventional angiography is only indicated in symptomatic patients being considered for revascularization. Also, CT angiography requires vascular contrast material and may provide poor delineation of heavily calcified or small distal vessels.

11/#MRPearls The main goal in treating patients with PAD are to ⬇️ the risks of adverse CV outcomes, ⬆️functional capacity, and preserve limbs. Therefore, must address HLD, HTN, DM, and tobacco cessation. @Lauraathome @B_M_Wiese

12/#MRPearls Per the Heart Protection Study, patients assigned to simvastatin had 25% relative reduction in the risk of CV events over 5 years when compared to placebo. In a Euro Heart Journal study, patients taking statins had lower adverse limb outcomes by 18%.

13/ #MRPearls There is lots of controversy regarding blood pressure targets in PAD; however, more recent trials have established systolic blood pressure goals of <120 mm Hg. Does anyone have any opinions on blood pressure targets? @jaideeppatelmd @AjayPMD @pranav_mankad

14/ #MRPearls One of the most important things you can do for a patient with PAD is to encourage smoking cessation. People who have 🚭 have a ⬇️risk of death, progression of disease, critical limb ischemia and amputation, MI, stroke, and bypass-graft failure rates.

15/ #MRPearls Should consider aspirin in patients with symptomatic peripheral artery disease (dose 75-325mg daily); however, aspirin has not been shown to improve CV outcomes among asymptomatic persons with ABI of 0.95 or less. jamanetwork.com/journals/jama/…

16/ #MRPearls Clopidogrel has also been shown to be more effective than aspirin in reducing stroke, MI, or death from vascular causes. Therefore, can also consider dual antiplatelet therapy in symptomatic PAD patients who are not at increased risk for bleeding.

17/ #MRPearls Supervised exercise that includes walking at least 3x per week (30-60 min/session) for at least 12 weeks should be first line therapy for claudication. The CLEVER study in @CircAHA showed supervised exercise resulted in greater mean peak walking time vs. medical tx.

18/ #MRPearls Cilostazol (PDE inhibitor) is a common PAD med with antiplatelet and vasodilatory properties. It has been shown to ⬆️walking distances on a treadmill by 25% vs. placebo; however, it is associated with ⬆️HR, diarrhea, and ⬆️bleeding. Contraindicated in CHF.

19/ #MRPearls Revascularization can be a strategy when there are limiting symptoms in spite of an exercise program and medical therapy if believed symptoms can be reduced. Therefore, should consider a consult if treatments are failing. @blanksinagrind @khess567 @alanxyou

20/ #MRPearls Aortoiliac angioplasty and stenting have high procedural success rates (~96%) and a 3-yr patency rate of approximately 82%. However, endovascular therapy of isolated infrapopliteal disease is not recommended for claudication. ncbi.nlm.nih.gov/pubmed/17223489

21/ #MRPearls Check out this wonderful diagnostic algorithm by @NEJM as a summary of how to work up a patient with suspected peripheral artery disease. As always, thanks for reading! @cderekleiner @Sullydoc101 @RabiaQaiser3 @AbhiNandanMD @JawadKhafaji @MKIttlesonMD