Summary of Comments on Chapter 108

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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 1:17:58 PM

Prognostic Value of Ankle Brachial Index: ABI results are recommended to be

reported with noncom- pressible values defined as greater than 1.40, normal
values 1.00 to 1.40, borderline 0.90 to 0.99, and abnormal 0.90 or less,,,The
ABI correlates well with the mortality risk associ- ated with PAD, regardless of
whether leg symptoms are present,,,ACCF/AHA 2011 writing group
recommended ABI diagnos- tic screening for patients 65 years or for
patients 50 with a history of smoking or diabetes.
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 1:12:54 PM

Critical limb ischemia :(CLI) is the most severe form of PAD and represents
approximately 1% of the total number ,,,CLI is associated with a higher risk of
limb loss in the absence of revascularization,,,the arterioles become
maximally vasodilatated and insensitive to vasodilatory stimuli as a result of
the chronic exposure,,,These dilatated peripheral arterioles have decreased
wall thickness and cross-sectional area, leading to edema, which is
aggravated by keeping the limb dependent ,,,The common major
manifestations of CLI are rest pain and ischemic ulceration or gangrene of the
forefoot or toes,,, systolic ankle pressure less than 50 mm Hg, toe pressure
less than 30 mm Hg, or ABI less than 0.40,,, the term CLI was never intended
to be applied to patients with diabetes and foot wounds,,,Arte- rial ulceration
in a nondiabetic patient is characterized by a shallow, nonhealing, pallid
erosion of the skin in the distal footin a distribution similar to that of rest
pain,,,The pain of such ulcerations, described as aching or burning, is often
unremitting and severe and is occasionally refractory to even high-dose oral
narcotic analgesics,,,Diabetic foot ulcerations are broadly divided into
ischemic, neuroischemic, and neuropathic ulcers,,, 50% of diabetic foot ulcers
are of ischemic or neuroischemic origin,,, Progression to gangrene occurs in
40% of patients with DM, compared with only 9% in nondiabetic patients with
CLI,,, In patients with diabetes, arterial occlusive disease primarily affects the
 crural and pedal arteries,,,The best method of assessing the prevalence of
chronic lower extrem- ity arterial occlusive disease is to record the ABI and
correlate it with risk factors,,,
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 2:40:55 PM

Metabolic syndrome is estimated to be present in at least 25% of the

population.39 This syndrome is defined as having three or more of the
following: blood pressure elevation (130 mm Hg/85 mm Hg), triglyceride
count 150 mg/dL, high-density lipoprotein count 50 mg/dL for women or
40 mg/dL for men, fasting blood glucose 110 mg/ dL, and abdominal
obesity (BMI 30 kg/m2 or waist circum- ference 102 cm in men, 88 cm in
women),,, 38% of the population with PAD also had metabolic
syndrome,,,cigarette smoking risk is higher in women than in men, and
smoking cessation is associated with substantial risk reduction for
development of PAD.
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 2:15:39 PM

Prevalence of PAD: -Prevalence Based on ABI: prevalence was slightly higher

in men than in women, the prevalence dramatically increased with age, rising
from 0.9% in those younger than 50 years to 14.5% in those 70 years or older
. -Prevalence Based on Demographics:PAD is now reported to be associated
with equal morbidity and mortality and comparable, or possibly higher, cost
compared with coronary heart disease and stroke,,, black women had a
signifi- cantly greater prevalence of PAD than did white or Hispanic women.
-Prevalence Based on Risk Factors: Hypertension increases the risk of
developing symptoms of IC 2.5-fold in men and 3.9-fold in women,and is
present in 55% of patients with PAD,,, PAD prevalence is 20% to 30% higher
in diabetics than in the general population,,,Patients with diabetes are more
likely to have symptomatic PAD, with a 3.5-fold increased risk in men and an
8.6-fold increased risk in women.
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 2:50:20 PM

one fourth of patients with IC ever deterio- rate significantly, and deterioration
is most frequent during the first year after diagnosis (6% to 9%) compared
with 2% to 3% per annum thereafter,,,The risk of major amputation is less
than 5% over a 5-year period.
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 2:46:02 PM

The more rapid deterioration in women with PAD was attributed to the poorer
functional performance and smaller baseline calf muscle mass, resulting in
women being closer at baseline to the thresholds for immobility
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 2:54:12 PM

Questionnaire, SF-36, ABI, and 6-minute walking test.55 The results of the 6-
minute walking test correlated well with quality-of-life scores
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 3:09:45 PM

severe PAD is often associated with advanced coro- nary artery and
cerebrovascular disease. CAD has been estimated to be present in
approximately half of patients with CLI
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:13:09 PM

A review of major series reporting the fate of patients with CLI noted that 26%
died within 1 year of diagnosis75 and had 5- and 10-year mortality of 50%
and 70%, respectively
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 3:07:55 PM

severely ischemic limbs with ulceration who could not undergo

revascularization, only 15% of patients with an ABI greater than 0.50 required
major amputation, whereas 34% of those with an ABI less than 0.50
sustained major limb loss at the end of 1 year.
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:20:39 PM

elevated homocysteine level increase the patients likelihood of developing

PAD nearly sevenfold,,, folate supplementation has not been found to benefit
patients with elevated homo- cysteine levels
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:32:38 PM

Patients who develop manifestations of PAD at an early age, without other

identifiable risk factors, should have a plasma homocysteine level
documented ,,,High levels of this amino acid may be toxic to endothelial cells
and reduce their ability to generate and release nitric oxide,,,may promote
 medial smooth muscle cell proliferation and arterial wall inflammation and
increased levels of plasminogen activator inhibitor,,,
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:29:02 PM

(CRP) is the leading biomarker for clinical application because of its relatively
long half-life and stability,,, CRP has a strong correlation with a reduced ABI
but in patients with cardiac and cerebrovascular disease. CRP was not
associated with ABI in patients without arterial occlusive disease in these
vascular beds
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:35:12 PM

Resting left ventricular function alone is not a specific indicator of

perioperative MI
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:45:44 PM

The Variables, Output Methods, and Early and Late Outcomes for Low-,
Medium-, and High-Risk Group: 3 scoring systems are: 1- Finland Vascular
(FINNVASC) is 1-4 on sum points measure 30-day mortality or amputation. 2-
Prevention of Infrainguinal Vein Graft Failure (PREVENT) III up to> 8points
and < than 3 . 3- Bypass Versus Angioplasty in Severe Ischemia of the Leg
(BASIL) :Survival 6, 12, 24 months
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 7:50:15 PM

exercise testing : after the recording of ankle pressures at rest, a patient

walks at 3.5 km/hr on a treadmill at a 12% incline until the onset of
claudication-like symp- toms. At that time, ankle pressures are measured
again. A more than 20% decrease in ankle pressures for more than 3 minutes
after the cessation of exercise indicates vascular clau- dication.115 No
decrease or a small decrease in pressure after exercise suggests a
nonvascular cause of symptoms
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 8:03:26 PM

The treatment of hyperlipidemia with a statin to achieve a low-density

lipoprotein level less than 100 mg/dL (2.59 mmol/L) is recommended for all
patients with PAD (<70 mg/ dL in those who are at very high risk of ischemic
events) to reduce the risk of MI
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 8:05:59 PM

TASC II guidelines consider ACEI and thiazide diuretics first-line therapy for
patients with PAD to reduce the risk of cardiovascular events,,,, -Adrenergic
blockers are cardio- protective and does not reduce walking distance or
worsen the pain of IC
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Type: Text Author: ghassan Subject: Sticky Note Date: 7/27/2016, 8:01:18 PM

A statistically significant benefit, documented by a reduction in MI, stroke, or

death, was noted in patients with symptomatic lower extremity ischemia
treated with aspirin and clopidogrel com- pared with those who received
aspirin and placebo