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KEY CONCEPTS

KEY CONCEPTS

  • Image not available. The prevalence of peripheral arterial disease (PAD) is related to age and the presence of atherosclerotic risk factors for cardiovascular disease (CVD).

  • Image not available. Despite significant morbidity and mortality, PAD awareness remains low resulting in many undiagnosed and untreated patients.

  • Image not available. The clinical presentation of PAD is variable and includes a range of symptoms. The two most common characteristics of PAD are intermittent claudication (IC) and pain at rest in the lower extremities.

  • Image not available. The ankle-brachial index (ABI) is a simple, noninvasive, quantitative test that is a highly sensitive and specific tool to diagnose PAD.

  • Image not available. Several atherosclerotic risk factors play an important role in the development and progression of PAD. Many of these risk factors are modifiable using various nonpharmacologic and pharmacologic interventions.

  • Image not available. Nonpharmacologic interventions, such as a supervised exercise program, can improve a patient's quality of life and reduce leg symptoms.

  • Image not available. Antiplatelet therapy, such as aspirin or clopidogrel, is recommended to reduce myocardial infarction, stroke, and vascular death in patients with PAD.

  • Image not available.In addition to exercise therapy and risk factor modification, cilostazol is an effective medication to reduce leg symptoms and increase walking distance in patients with IC.

PATIENT CARE PROCESS

Patient Care Process for Peripheral Arterial Disease

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Collect

  • Patient characteristics (eg, age, sex)

  • Social history (eg, smoking status and exercise habits)

  • Current medications including antiplatelets, antihypertensives, lipid-lowering therapies, and diabetes medications

  • Walking assessment including pain-free walking and maximum walking distances

  • Objective data

    • Left and right brachial blood pressures

    • Left and right dorsalis pedis blood pressures

    • Left and right posterior tibial blood pressures

    • Physical exam findings such as diminished/absent peripheral pulses (femoral, popliteal, posterior tibial, and dorsalis pedis), and presence/absence of bruits, muscle atrophy, pallor, cyanosis, ulcers, and gangrene

    • Baseline laboratory parameters including fasting lipid panel and hemoglobin A1c

Assess

  • Ankle-brachial index for both legs

  • Quality of life-related to limitations in mobility

  • Presence of uncontrolled risk factors including hypertension, diabetes, dyslipidemia, and smoking

  • Physical and financial ability to participate in a supervised exercise program (see Table e34-2)

  • Presence of contraindications to antiplatelet and/or claudication therapies (see Table e34-3)

Plan*

  • Drug therapy regimen including antiplatelet therapy (drug, dose, route, frequency, and duration) and claudication therapy

  • Risk factor modification to achieve blood pressure, glucose, and lipid goals

  • Monitoring parameters including efficacy (eg, cardiovascular morbidity and mortality, pain) and safety (eg, sign and symptoms of bleeding); frequency and timing of follow-up

  • Patient education (eg, purpose of treatment, exercise prescription)

  • Self-monitoring for resolution of PAD symptoms (eg, claudication pain and quality of life)

  • Referrals to other providers when appropriate (eg, vascular specialist, PT/OT)

Implement*

  • Provide patient education regarding all elements of the treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up (eg, walking assessment for pain-free and maximum walking distances)

Follow-up: Monitor and Evaluate

  • Resolution of PAD symptoms (eg, claudication pain) and improvement in quality of life

  • Presence of adverse effects (eg, bleeding)

  • Walking assessment

  • Patient adherence to treatment plan using ...

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