Welcome to module 2 week 1, please make sure you watch the educational video before answering the questions. hope you all will enjoy the Module .
Week 1 – Case 1
A 55-year-old gentleman who works as a computer engineer presented to your clinic with calf pain that begins after walking 300 meters and is relieved with rest.
What key history and clinical examination are relevant in this case?
What investigations will you order for this patient ?
What are the key steps in initial management of this patient ?
What evidence supports your management plan?
By history:
– The key point ia asking about signs of ischemic claudication (begin by walking and relieved by rest) to differentiate it from other types of claudication specially neurological claudication
– Also, ask about claudication distance
– Other points:
Smoking, BP, Diabetes, Hypercholesterolemia, Cardiac condition
Family history
Other Vascular problem as ulcer, previous amputation.
By clinical examination:
– palpable pulses at both LL
– examin both LL for coldness, ulcers, tissue loss or other ischemic signs like hair loss
– ABPI at both LL
Investigation:
(1) Labs
– CBC
– Lipid profile
– FBS, 2hPP, HbA1C
(2) Imaging
Arterial duplex at both LL
Initial management:
– stop smoking
– control BP (<140/90)
– Control Diabetes (HgA1C <7%)
– walking exercise (30min/day) for (4 times/week)
– single antiplatlet (ASA 150mg / day)
– Rosuvastatin 20mg / day
– Naftidrofuryl oxalate 600mg / day
Or Cilostazol 100mg / day
evidence : ESVS Guidelines 2024
Thanks all for the excellent comment, so to summarise your excellent participation in the discussion
All patients with PAD ( claudication) should follow the conservative management route which is modifying risk factors ( most importantly stopping smoking) , best medical therapy ( Antiplatelets and Statin), exercise therapy.
early intervention either endovascular or surgical is not without risk, claudication amputation risk is 0.5%. and with endovascular or open surgery intervention that risk might increase up to 6%. just bear this in mind when you treat patient with claudication.
we will move to the next case and i am lookign forward to hear from all of you
What key history and clinical examination are relevant in this case?
History
–> personel history : occupation sedentary life and office work predispose to obesity
Special Habits Smoking increase risk of Atherosclerosis
–> Medical History: Dm & HTN are major risk factor for Atherosclerosis
History of stroke or Cardiac history as Atherosclerosis is systemic disease affect Carotid , Coronary and peripheral arteries
Analysis of the patient complaint should include onset of symptoms site of pain if there concomitant pain in the back or history of DVT
Examination
–> inspection to ensure there’s no ulcer or color change in the foot
–> Palpation to detect peripheral pulsation
Doppler examination with hand held doppler to detect any flow inside distal vessels and to measure ABI
What investigations will you order for this patient ?
if there’s decreased ABI with absent pulsation I will go for Arterial Dupplex on the both lower limb with comment on PSV on the whole Arterial Tree
What are the key steps in initial management of this patient ?
Risk modification –> Smoking cesation
—> Anti hypertensive with target blood pressure <130/85
—> Diabetes control with target HbA1C less than 7
–> Statin to Decrease LDL <100 mg/dl Atrovastatin 80 mg per day
Excercise Walking for more than 30 min / day for more than 3 times per week and the patient shouldn’t stop till the pain is severe
Pharmacological Drugs PDE Inhibitor type 3 Cilostazol 200 mg twice daily will improve the walking free distance
Anti platelet clopidogrel 75 mg once daily
What evidence supports your management plan?
1- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg. 2024 Jan;67(1):9-96. doi: 10.1016/j.ejvs.2023.08.067. Epub 2023 Nov 10. PMID: 37949800.
2- Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. J Am Coll Cardiol. 2015 Mar 17;65(10):999-1009. doi: 10.1016/j.jacc.2014.12.043. Erratum in: J Am Coll Cardiol. 2015 May 12;65(18):2055. PMID: 25766947; PMCID: PMC5278564.
3- Creager MA. Results of the CAPRIE trial: efficacy and safety of clopidogrel. Clopidogrel versus aspirin in patients at risk of ischaemic events. Vasc Med. 1998;3(3):257-60. doi: 10.1177/1358836X9800300314. PMID: 9892520.
Q1. key history
Smoking Hx
DM, HTN: controlled/not
previous stroke, type/any residuals?
cardiac? previous PCI, CABG, CCU admission?
-LL Pain analysis
Clinical exam
-BP, pulse assessment.
-Assessment of LL pulses.
-ABPI, if not conclusive>>> I’d consider performing TBImeasurement
-LL physical examination suggestive of ischemia (hair, nail, skin changes, dependent rubor)
Q2.What investigations
Full lab bloods.
Imaging: If PAD diagnosis is confirmed via Hx, physical exam and non-invasive bedside tests, revascularization is not being considered >> no further imaging.
If diagnosis is yet to be confirmed >> I’d consider further imaging Duplex US – CTA
Q3.What are the key steps in initial management of this patient?
Conservative management
1- CV risk reduction (DM management, lipid lowering, antihypertensive therapy)
2- Smoking cessation.
3- Preventive foot self-care education to patients and their families.
4- Medical TTT;
-Single anti-Plt therapy SAPT (clopidogrel 75 mg once daily)
-Low dose aspirin + rivaroxaban 2.5 mg BID (after thorough assessment of bleeding risk + involving the patient).
-cilostazol to increase walking distance.
5-supervised exercise program
What evidence supports your management plan?
1- 2024 ACC/AHA/AACVPR/APMA/
ABC/SCAI/SVM/SVN/SVS/SIR/VESS
Guideline for the Management of Lower Extremity Peripheral Artery Disease
2-ESVS 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication
Q1.What key history and clinical examination are relevant in this case?
History:
-RFs/PMH:
Smoking Hx
DM, HTN: controlled/not
previous stroke, type/any residuals?
cardiac? previous PCI, CABG, CCU admission?
alcohol? CLD? previous bleeding?
-LL Pain analysis to confirm Dx and exclude DD
-Erectile dysfunction
Clinical exam: (according to 2024 ESVS IC – ACC/AHA/SVS PAD guidelines)
-BP, pulse assessment.
-Assessment of LL pulses.
-ABPI, if not conclusive>>> I’d consider performing TBI/TP measurement, additional physiological assessment (exercise treadmill ABPI test)
-LL physical examination suggestive of ischemia (hair, nail, skin changes, dependent rubor)
Q2.What investigations will you order for this patient? (according to 2024 ESVS IC – ACC/AHA/SVS PAD guidelines)
Full lab bloods.
Imaging: If PAD diagnosis is confirmed via Hx, physical exam and non-invasive bedside tests, revascularization is not being considered >> no further imaging.
If diagnosis is yet to be confirmed >> I’d consider further imaging (Duplex US – CTA/MRA)
Q3.What are the key steps in initial management of this patient?
Conservative management
1- CV risk reduction (DM management, lipid lowering, antihypertensive therapy)
2- Smoking cessation.
3- Preventive foot self-care education to patients and their families.
4- Medical TTT;
-Single anti-Plt therapy SAPT (clopidogrel 75 mg once daily)
-Low dose aspirin + rivaroxaban 2.5 mg BID (after thorough assessment of bleeding risk + involving the patient).
-cilostazol to increase walking distance.
5-Structured Exercise program (either supervised or community/home-based)
6-Ongoing re-evaluation and discussions with the patient, FU the response to above mentioned therapies. If failure to improve, or functionally-impaired >> I’d consider revascularization.
Q4.What evidence supports your management plan?
1- 2024 ACC/AHA/AACVPR/APMA/
ABC/SCAI/SVM/SVN/SVS/SIR/VESS
Guideline for the Management of Lower
Extremity Peripheral Artery Disease
2-ESVS 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication.
Sorry, just checked the chat group and found out the additional questions.
Your patient asking, what exercise you wanted me to do? do you have any type of exercise you will advise your patient about ? ( BTW please read CLEVER trial it is one of the main trial to support SEP over early intervention.
I’d recommend intermittent walking exercise on a treadmill, with rest periods, performed for at least of 30-45 min per 60-min session. Supervised sessions are performed at least 3 times/wk for a min of 12 wk. The patient should walk to mod-to-max pain, aiming to reach to 30-45 min of active walking.
Eman mentioned antiplatelt as part of best medical therapy which one you will prescribe for your patient Aspirin or clopidogrel? ( CAPRIE Trial might help to answer that question)
I’d prescribe clopidogrel. CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) trial showed improved efficacy compared with aspirin for prevention of MACE the with similar rates of bleeding.
Mahmoud mentioned statin if hyperlipidemia present so do you think if the patient has normal lipid profile it is not justified to give statin and why? ( please read heart protection study) ??
We should give statin. The 2018 AHA/ACC cholesterol guideline makes a 1A recommendation for the initiation of high-intensity statin therapy, aiming to achieve a more than 50% reduction in LDL-C levels in all patients who are less than 75 years of age with atherosclerotic disease (including PAD patients). This is a 1A recommendation also
in 2024 ACC/AHA/SVS LL PAD guidelines as well. Subgroup analysis of heart Protection Study firstly established the use of statins to lower the risk of MACE in PAD patients.
.
final question, patient has palpable week pulse and ABPI of left leg of 0.9 ? what is your next step ( investigation wise) ??
An ABI less or equal to 0.90 is the threshold for confirming the diagnosis of PAD.
so I’d consider consider performing TBI/TP measurement, additional physiological assessment (exercise treadmill ABPI test)
if still non-conclusive, I’d consider further imaging (Duplex US – CTA/MRA).
Q1. CBC KFT LFT PT INR RBS FBS HbA1C lipid profile.
ECG ECHO
Q2 DM
Q3.mild calcification of aorta and Stenotic Rt CIA ostium with occluded lt CIA EIA refilling on CFA
Q4.Endovascular or open surgery
Q5. Endovascular with kissing stents
Q1. Assessment of risk factors DM HTN Smoking cardiac renal problems, familly hx drug hx .
Examination generally BP HR skin changes temperature sensory and motor power peripheral pulsation.
Q.2 CBC RFT LFT lipid profile HbA1c PT INR albumin
ABI or TBI duplex ultrasound
Cardiac assessment.
Q.3 life style modification and control of risk factors is the corner stone in ttt.
Exercise programe
BMT
Rivarospire 2.5mg / 12 hr
Q4.
Manage all modifiable risk factors to recommended levels in all patients with suspected CLTI. Class 1B
On top of general prevention, statins are indicated to improve walking distance. IA
In patients with intermittent claudication: supervised exercise training is recommended I A
unsupervised exercise training is recommended when supervised exercise training is not feasible or available. I C
Q3: according to European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication
Initial management will focused on risk factor control mainly.
1.Antiplatelet agent, clopidogrel is the first choice.
2.Cilatazol and naftidrofuryl oxalate.
3.Lipid lowering therapy with target LDL < 100 mg/dl
4.Antihypertensive agents with target < 130/80 mg Hg
5. Control of DM wit target Hb A1c < 7%
6. Smoking cessation with pharmacotherapy or behavior modification.
7. Supervised exercise program: >30 minutes- session with 4 session weekly.
.
..
…
….
……
Q1
Regarding to Hx, I should consider age, smoking, hypertension, DM and hypercholesterolemia.
Hx of presentation of atherosclerosis in other arterial beds as cerebrovascular and coronary arteries.
Onset, course and duration of complaint must be addressed.
Level of claudication should be asked about to suspect level of arterial pathology.
One of the most important points, proper analysis of complaint, when it starts and how it’s relieved which is helpful in differential diagnosis.
Regarding to examination, peripheral distal pulsations should be examined bilaterally.
Signs of chronic ischemia as trophic changes, coldness.
HHD is cornerstone step during examination.
Q2: according to European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication
In relation to bloods, we need to assess risk factors, so
Lipid profile, Hb A1c and other baseline bloods are required.
We usually start with non-invasive measures as resting AP and ABI, if it looks normal, we can move to treadmill testing and TB and TBI.
DUS can be as first line imaging to detect anatomical location of disease and hemodynamics, despite in case like our patient when revascularization is not planned, clinical examination and bedside tests are sufficient
..
.
1/ key history and clinical examination :
middele aged male patient,works and life style may be considered sedentary lifestyle .
we should ask for other risk factors including smoking.
complaint is compatable with arterial condition (ischemic pain).
we should perform full vascular examination.
2/Investigations :
full blood work especially lipid profile, HBA1C to exclude other risk factors.
other diagnostic testings : ABI , Arterial Doppler .
3,4/ key steps in managment :
supervised exerscise is the main managment (according to CLEVER study).
best medical treatment , high intensty statins (according to heart protection study/2013 ACC/AHA Guideline).
Clopidogrel as it is superior to only asprin with no increas in risk of bleeding (CAPRIE study /2014 AHA/ASA Secondary Stroke Prevention Guidelines).
Ramipril ,as ACE inhepetors is considerd safe and beneficial, to risk modifcation.(HOPE study)
Q1: key history: claudication pain 300 m which relieved by rest, ask for smoking, HTN, DM
Examination: full vascular exam with ABPI (ESVS Recommendation 5 level I class B)
Q2:
bloods; FBC, total lipid profile, renal function
if ABPI is normal I will request ABPI after treadmill (ESVS Recommendation 11 level IIb class c), if abnormal I will go for arterial duplex
Q3: I will go for BMT; risk factor modification, antiplatelet and high dose statin (ESVS Recommendation 28 level I class A)
and follow up
Thanks Eman Mahmoud, good start for discussion. as mentioned the key management is to correct the risk factors HTN , DM , smoking, hyperlipidemia etc
I am not sure if there is a supervised exercise program in Egypt as far as know there is no exercise program,
Your patient asking, what exercise you wanted me to do? do you have any type of exercise you will advise your patient about ? ( BTW please read CLEVER trial it is one of the main trial to support SEP over early intervention.
Eman mentioned antiplatelt as part of best medical therapy which one you will prescribe for your patient Aspirin or clopidogrel? ( CAPRIE Trial might help to answer that question)
Mahmoud mentioned statin if hyperlipidemia present so do you think if the patient has normal lipid profile it is not justified to give statin and why? ( please read heart protection study) ??
final question, patient has palpable week pulse and ABPI of left leg of 0.9 ? what is your next step ( investigation wise) ??
looking forward to hear from others
A supervised excercise program comprising more than 30 min walking sessions, walking through the pain, with progressively increasing durations.
I believe statins would decrease major cardiovascular adverse events and reduce general mortality.
An ABI of 0.9 would entail mild disease, however Next step of investigation would be segmental pressures and/or dupplex assessment with flow velocities and waveform measurements to exclude critically ischemic lesions with doubling of PSVs indicative of more than 70% stenosis which would require intervention.
I will ask the patient to walk until he started to feel the claudication pain, after that to have short rest period for total duration of 30-60 min times a week for 2-6 months ( that is the design of SEP)
according to CAPRIE trial clopidogrel is more effective and safer
Heart protection study concluded that simvastatin lowers the risk of cardiovascular events irrespective to initial cholesterol level
3 times a week for 3- 6 months (typing mistake)
Clopidogril safer and more effective than aspirin
–> I will ask for Walking for more than 30 minutes more than 3 times per week and patient shouldn’t stop till the pain is severe
–> Clopidogrel
“clopidogrel is more effective and safer than aspirin in reducing adverse cardiovascular events in patients with atherosclerosis.” according to CAPIRE trial
–> Statins decrease the risk of Stroke & MI & revascularization by one quarter even the lipid profile within the normal range
–> I should investigate for other causes of claudication which include venous causes by venous dupplex and nuerological causes MRI Spine
I will also Measure the ABPI after excercise if there’s decrease in the ABPI or the pulse disappear may indicate popliteal entrapment syndrome
Key Hx, Exam:
Past medical hx including dm, htn, hyperlipidemia, Present Hx regarding claudication criteria, including aggrevating and relieving factors, onset and progression
Exami ation icluding ABI measurement, Segmental pressures, dupplex waveform and velocities, treadmill testing, cta/mra if cli confirmed by non-invasive tests.
investigations:
Segmental pressures, dupplex waveform analysis and velocities, CTA/MRA
Key Mgmt Steps:
Evidence
Evidence ctd
1.male 55
ckaudication pain that +by exercise released by rest
Walking distance 300
Examination general
Local vascular examination inspection both ll skin hair loss brittle nail
Palpation pulse distal to proximal
Hand heels doppler
About
2 lab CBC inr lft kft lipid profile ecg duplex arterial
Cta
3 life style modificatiin ex
Stop smoking
Medical lipid lowering
Antiplatlet
T
D
Abpi
Ic