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Mamdouh El-Nahas

Professor of Internal Medicine


Endocrinology and Diabetes Unit
Mansoura University
Peripheral Arterial Diseases
(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
Peripheral Arterial Diseases
(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
One in three patients with diabetes
mellitus have PAD (ADA 2006)
20% of in people with diabetes >40 years of had PAD.

30% of patients with diabetes >50 years of age had


PAD.

Practical Diabetes Int 16:163166, 1999


JAMA 286:13171324, 2001
Peripheral Arterial Diseases
(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The impact of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
1. Age
2. Sex predominantly male
3. Genetic predisposition
4. Dyslipidaemia
5. Hypertension
6. Smoking
7. Obesity
8. Alcohol
9. Diet
10. Sedentary lifestyle
Smoking
Tobacco use in any form is the single most important
modifiable cause of PAD internationally.

The magnitude of the association is greater than that


reported for coronary heart disease.

Lu et al 2013: Meta-analysis of the association between cigarette smoking


and peripheral arterial disease
Smoking
More than 80%-90% of patients with lower extremity
peripheral arterial disease are current or former
smokers.

The most effective treatment for PAD is to stop


smoking. This single measure reduces the risk of
disease progression amongst patients with peripheral
arterial disease and dramatically reduces the need for
limb amputation and the risk of premature death
Peripheral Arterial Diseases
(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
1- Increased risk of foot ulceration and failure of the
ulcer to heal
2- Patients with foot infections and PAD are at
particularly high risk for major limb amputation.
3- A major risk factor
for lower-extremity
amputation.
Coronary
heart 4- A marker for systemic
disease Cereb vascular disease.
VD

PAD
Eur J Vasc Endovasc Surg 2007; 33: S14 4
Peripheral Arterial Diseases
(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
Intermittent Claudication

Cramping, or
aching pain
related to
walking and
relieved by
rest.
Atypical presentation
Inspection of the foot
Pedal pulses
Other clinical signs of PAD

Temperature gradient
Color changes
Capillary refill time
Simple bedside tests to diagnose
PAD
A low ABI (<0.9)
indicates PAD.

While ABI values (>0.9)


may be unreliable in
ruling out of PAD.
ADA recommendations for ABI (2016)
Diabetic patients 50 years of age and older

Patients under 50 years of age who have other PAD risk


factors (e.g., smoking, hypertension, dyslipidemia, or
duration of diabetes >10 years)

Any patient with symptoms or signs of PAD.


Handheld Doppler Ultrasound
Toe pressure
Imaging modalities

Duplex ultrasonography,
Magnetic resonance angiography,
Computed tomographic angiography,
Angiography
Biochemical Tests
Screening for atherosclerotic risk factors e.g. lipid
abnormalities, proteinuria, renal insufficiency
For patients with early-age onset of disease, family
history of thrombotic events, or when there is a lack
of common risk factors for atherosclerosis:
Hypercoagulability screening
Homocysteine levels (either fasting or after
methionine loading)
Peripheral Arterial Diseases
(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The impact of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
Management of PAD

1. Risk Factor Modification


2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
Management of PAD

1. Risk Factor Modification


2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
Tobacco smoking
Cigarette smoking is one of the most important
preventable risk factor for PAD in both men and
women
Treatment of dyslipidemia
Lifestyle modification should be recommended. A
Statin therapy should be added to lifestyle therapy,
regardless of baseline lipid levels, for diabetic patients:
with overt CVD A
without CVD who are over the age of 40 years and have
one or more other CVD risk factors (family history of
CVD, hypertension, smoking, dyslipidemia, or
albuminuria). A
For lower-risk patients than the above (e.g., without
overt CVD and under the age of 40 years), statin
therapy should be considered in addition to lifestyle
therapy if LDL cholesterol remains above 100 mg/dL or
in those with multiple CVD risk factors. C
Hypertension
In an analysis of the UK Prospective Diabetes Study
(UKPDS) data, a reduction of systolic BP by 10 mm Hg
conferred a 16% decrease in rate of limb amputation or
death from PAD ((UKPDS 36) BMJ 2000).
All pharmacologic agents that lower BP reduce the risk
of cardiovascular events.

ACE inhibitors have shown benefit, specifically in


PAD, potentially beyond their blood pressure
lowering effect.
Control of hyperglycemia
Management of PAD

1. Risk Factor Modification


2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
Aspirin has been shown to be effective in reducing
cardiovascular morbidity and mortality in high-risk
patients with previous MI or stroke (secondary
prevention).

Its net benefit in primary prevention among patients


with no previous cardiovascular events is more
controversial.
Aspirin vs. Clopidogrel
For patients with CVD and documented aspirin
allergy, clopidogrel (75 mg/day) should be used. B

Dual antiplatelet therapy is reasonable for up to a year


after an acute coronary syndrome. B
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
Supervised exercise programs are as effective as
endovascular revascularization in their effectiveness to
improve functional capacity and do so at a much lower
cost (J Vasc Surg 2008; 48:1472)
The recommended exercise regimen is supervised
exercise for 30 minutes 3 times a week for at least 12
weeks, with further increase of exercise time to an hour
each session.
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
1. Cilostazol
2. Naftidrofuryl
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
Patient education
Appropriate footwear
Daily foot inspection
The use of topical moisturizing creams
Skin lesions should be addressed urgently
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
For patient with critical limb ischemia

Revascularization either endovascular or bypass


surgery.
Peripheral arterial disease is a common problem in
diabetes.

Clinicians should actively seek out patients for PAD


because they are at very high risk for future
cardiovascular events and mortality.
Once the diagnosis of PAD is established, all patients
must receive a comprehensive program to lower their
risk for future cardiovascular events.

Patients with critical Limb ischemia should be


immediately refereed for vascular specialist.

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