Professional Documents
Culture Documents
Masrul Syafri
Dept Cardiology and Vascular Medicine
Worldwide Causes of
Death
PAD
Characterized by arterial stenosis and
occlusions in the peripheral arterial bed
Prevalence
Prevalence
Components
Varicose veins
Arterial Aneurysms
Why it is important to
recognize patients with
PAD?
PAD is a marker of
systemic
atherosclerosis
Patients with
either symptomatic
or asymptomatic
PAD generally have
widespread
arterial disease
Why it is important to
recognize patients with
PAD?
Coexisting vascular Disease:
CAD-- 35 % to 92%
CVD-- 25 % to 50%
Why it is important to
recognize patients with
PAD?
Cause of death:
CAD 40%-60%
CVD 10%-20%
Non-cardiovascular causes--Only
20% to 30 %
Patients with PAD have a 6 fold
increased risk of cardiovascular
disease mortality compared to
patients without PAD
Predictors of Mortality in
PAD
297 patients
Results
Hypertension
Smoking
Obesity
Genetics
Dyslipidemia
Age
Atheroscleroris
What is Peripheral
Arterial Disease?
PAD=POAD=PVD
Arteriosclerotic occlusive disease of aortoiliac
and/or femoropopliteal arterial system
ALI : Acute Limb Ischaemic
CLI : Critical Limb Ischaemic
CI : Claudication Intermittent
Cardiac Risk
Clinical Presentation
Claudication
Calf
Thigh
Foot
Diagnostic tests
Ankle-brachial index
Diagnostic Tests
Duplex U/S
MRA
Conventional angiography
Angiography
Indicated for:
Evaluating therapy
Documenting disease
PRIMARY SITES
OF INVOLVEMENT
Femoral & Popliteal
arteries: 80-90%
Tibial & Peroneal
arteries: 40-50%
Aorta & Iliac arteries:
30%
Harrisons
Principles of Int
Med
Pathogenesis
Pathogenesis
Asymptomatic
How do we diagnose
PAD?
Symptomatic
History
Physical Examination
ABI measurement
Non-invasive tests (arterial
duplex,
CTA, MRA)
Invasive test (Conventional
Asymptomatic
angiogram)
ABI
measurement
How do we diagnose
PAD?
Symptomatic
10%
Asymptomatic
90%
Indicates
<0.9
0.8- 0.9
0.5- 0.8
<0.5
<0.25
Abnormal
Mild PAD
Moderate PAD
Severe PAD
Very Severe PAD
The ABI has limited use in evaluating calcified vessels that are not
compressible as in Diabetics
Investigations
Investigations
Natural History
Annual risk :
- Mortality 6.8%
- MI 2.0%
- Intervention
1.0%
- Amputation
0.4%
Strategies in treating
patients with PAD
Risk Factors
Modification
Strategies in treating
patients with PAD
Risk Factors Modification
Strategies in treating
patients with PAD
Improve Lower Limb Circulation
Conservative (Exercise Program)
Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Surgical Bypass
Percutanous Transluminal
Angioplpasty
PTA
Surgical Bypass
Acute Limb
Ischemia
Embolus
Thrombosis
Others
Trauma
Iatrogenic
Arterial dissection
Non-Cardiac source
Proximal AS plaque, Proximal Aneurysm,
Paradoxical emboli
Iatrogenic (20%)
Angiographic manipulation
Surgical manipulation
Investigations
Treatment
Surgical Thrmboemblectomy
Procedure
Thrombolysis
Injury
Local
Compartment Syndrome
Systemic
Hyperkalemia
Acidosis
Myoglobulinuria
Claudication
intermittent
Claudication
DIFFERENTIAL DIAGNOSIS
CALF
Venous occlusion
Tight bursting pain /
dull ache that worsens
on standing and
resolves with leg
elevation
Positional pain relief
Chronic compartment
syndrome
Tight bursting pain
Positional pain relief
Nerve root compression
Positional pain relief
Bakers cyst
Positional pain relief
HIP/THIGH/BUTTOCK
Arthritis
Persistent pain, brought
on by variable amounts
of exercise
Associated symptoms in
other joints
Spinal cord compression
History of back pain
Symptoms while
standing
Positional pain relief
FOOT
Arthritis
Buerger disease
(thromboangitis obliterans)
Am J Cardiol 2001; 87
(suppl): 3D-13D
DIAGNOSIS
History taking
Careful examination of leg
Pulse evaluation
Ankle-brachial index (ABI):
SBP in ankle (dorsalis pedis and posterior
tibial arteries)
___________________________________
SBP in upper arm (brachial artery)
Ankle-Brachial Index
Values and Clinical
Classification
Clinical PresentationAnkle-Brachial Index
Normal
> 0.90
Claudication
0.50-0.90
Rest pain
0.21-0.49
Tissue loss
< 0.20
WHY IS IT NECESSARY TO
TREAT INTERMITTENT
CLAUDICATION ?
Peak exercise performance is about 50% that of agematched controls, equivalent to moderate to severe
heart failure patients
Am J Cardiol 2001; 87 (suppl): 14D-18D
Am J Med 2002; 112: 49-57
GOALS OF TREATMENT
MANAGEMENT
Intermittent
claudication
5%
(5-year outcomes)
Stable
Worsening Leg bypass Major
claudicationclaudication surgery amputation
73%
7%
4%
16%
Nonfatal eventsMortality
(MI/stroke)
30%
20%
MODIFICATION OF RISK
FACTORS
Smoking cessation
Diabetes control (FBG 80-120 mg/dl, PPG <
180 mg/dl, HbA1c < 7%)
Dyslipidemia management (LDL < 100
mg/dl, TG < 150 mg/dl): Statins (RR 38%;
4S)
Hypertension control (BP < 130/85 mmHg)
Ramipril [RR 28%; HOPE (n=4051)]
EXERCISE PROGRAM
Compartment Syndrome
Thank You
.
Pathogenesis