PERIPHERAL ARTERY DISEASE (PAD) PRACTICE QUESTIONS AND ANSWERS

C. Various procedures are available for patients with severe, debilitating claudication who have attempted, and failed, other means of nonpharmacologic and pharmacologic therapy. A patient with severe debilitation, despite optimized therapy, should participate in a discussion on the potential risks and benefits of vascular procedures. 1. Which of the following criteria is most appropriate to consider prior to receiving an interventional vascular procedure? A. Adequate response to exercise therapy and risk factor modification B. Minimal disability from claudication or impairment of daily activities C. Thorough evaluation of the risks and benefits of an intervention D. Claudication pain and nonspecific symptoms affecting both lower limbs D. The ABI is a simple, noninvasive, quantitative test that has been proven to be a highly sensitive and specific (≥90%) tool in the diagnosis of PAD. For measurement of the ABI, the patient lies in the supine position as the systolic blood pressure is measured at the brachial arteries on both arms and the dorsalis pedis and posterior tibial arteries of the legs with a standard sphygmomanometer and a continuous-wave Doppler device. 2. All of the following test characteristics are consistent with an ankle-brachial index, EXCEPT: A. Highly specific B. Highly sensitive C. Quantitative result D. Invasive technique C. Calculating the ankle-brachial index should be done in both legs using the highest brachial pressure (regardless of the leg) and the highest leg pressure (based on dorsalis pedis and posterior tibial pressures). The left leg would be estimated as 0.92 (ABI = 130/142 or dorsalis pedis/left brachial) and the right leg would be estimated as 0.86 (ABI = 122/142 or posterior tibial/left brachial). 3. Using the following information below regarding the pressures measured in this patient's arms and legs, which of the following is the best estimate of this patient's ankle-brachial index? A. 1.12 B. 1.01 C. 0.86 D. 0.75 B. Aspirin is the preferred therapy in all patients with asymptomatic and symptomatic PAD. The ACC/AHA guidelines recommend 81 to 325 mg PO daily. A loading dose is not necessary for a chronic disease like PAD. A very low dose of aspirin (50 mg) is used in combination with dipyridamole has not been shown to significantly reduce serious vascular events 4. Which of the following aspirin regimens would be most preferred in a patient with PAD? A. Aspirin 50 mg PO daily B. Aspirin 81 mg PO daily C. Aspirin 325 mg chewed and swallowed, followed by 50 mg PO daily D. Aspirin 325 mg, chewed and swallowed, followed by 81 mg PO daily D. Hyperhomocysteinemia is a known risk factor for PAD. However, therapies that lower serum homocysteine levels, such as vitamin B12, have not resulted in a reduction in cardiovascular morbidity or mortality. Hypertension, diabetes, and dyslipidemia should be managed with pharmacotherapy to achieve treatment goals. 5. Which of the following PAD risk factors is not modified with available risk reduction interventions? A. Diabetes B. Hypertension C. Dyslipidemia D. Hyperhomocysteinemia B. The guidelines recommend a supervised exercise prescription consisting of a minimum of 30 to 45 minutes of activity performed at least three times per week for a minimum of 12 weeks. During exercise sessions, walking should be performed at a speed and grade of incline to produce the symptoms of IC within 3 to 5 minutes. 6. Which of the following characteristics should be included in an exercise prescription? A. Scheduled for a minimum of 4 weeks B. Supervised by qualified healthcare provider C. Utilized free weights for strength conditioning D. Performed for a minimum of 15 to 20 minutes B. In randomized trials, cilostazol has demonstrated a significant improvement in walking distance greater than pentoxifylline (54% vs 30%). Furthermore, improvement in walking distance between pentoxifylline and placebo was not found to be different (P = 0.82). For these reasons, the ACC/AHA guidelines do not recommend pentoxifylline for treatment of claudication. 7. Which of the following rankings best describes the efficacy of claudication medications at standard doses? A. cilostazol > pentoxifylline = placebo B. cilostazol = pentoxifylline > placebo C. cilostazol = pentoxifylline = placebo D. cilostazol > pentoxifylline > placebo A. Cilostazol is contraindicated in patients with heart failure of any severity. Cilostazol and several of its metabolites inhibit phosphodiesterase III. Phosphodiesterase III inhibitors have been shown to decrease survival when compared to placebo in patients with class III-IV heart failure. 8. Which of the following conditions is a contraindication to using cilostazol? A. Ejection fraction <40% (0.40) B. Hemoglobin A1c >10% (0.10; 86 mmol/mol Hb) C. Creatinine clearance <30 mL/min (0.5 mL/s) D. Serum platelets >100 × 109 cells/L B. Cilostazol is appropriate in patients with intermittent or exertional claudication pain. Fontaine Stage I refers to an asymptomatic patient. Fontaine Stages III and IV are reserved for patients with ischemic leg pain at rest. Fontaine Stage IIa is defined as a moderate claudication (able to walk without stopping >2 blocks or 200 m or 4 min). 9. Which of the following Fontaine Stages would be most appropriate to initiate cilostazol? A. Fontaine Stage I B. Fontaine Stage IIa C. Fontaine Stage III D. Fontaine Stage IV C. PAD treatment should target the following goals: (a) increase maximum walking distance, (b) increase maximum walking duration, (c) increase pain-free walking, (d) optimize risk factor control and management, (e) improving overall quality of life, and (f) reducing cardiovascular complications and death. Current PAD therapies slow the progression of PAD, but cannot reverse the atherosclerotic burden in peripheral arterial beds which compromises blood flow. 10. Which of the following treatment goals is NOT appropriate for a patient with PAD? A. Decrease cardiovascular mortality B. Increase maximum walking distance C. Increase the ankle-brachial index ratio D. Optimize risk factor control and management C. Clopidogrel is ADP antagonist that prevents platelet activation resulting in a reduction in cardiovascular mortality. Aspirin also reduces cardiovascular mortality, but prevents platelet activation by irreversibly inhibiting prostaglandin cyclooxygenase in platelets resulting in a reduction in thromboxane A2. Cilostazol is a phosphodiesterase inhibitor that suppresses platelet aggregation. Pentoxifylline alters RBC flexibility, decreases platelet adhesion, and reduces blood viscosity. 11. Which of the following medications reduces cardiovascular mortality in PAD by preventing ADP analogues from binding to its receptor causing irreversible inhibition of platelets? A. Aspirin B. Cilostazol C. Clopidogrel D. Pentoxifylline D. The pathophysiology of PAD is best described as atherosclerosis in which the arterial lumen of the lower extremities becomes progressively occluded by an atherosclerotic plaque. The clotting factors are primarily responsible for thrombosis in the venous system. 12. Which of the following disease processes best describes the pathology of PAD? A. Blood viscosity thickens reducing arterial blood flow B. Arterial wall thickens reducing the overall lumen diameter C. Clotting factors form a thrombus impeding arterial blood flow D. Atherosclerotic plaque progressively occludes the arterial lumen B. Atherosclerosis resulting in arterial lumen narrowing causes conditions such as PAD, stable angina, and ischemic stroke. Deep vein thrombosis is caused by the activation of clotting factors. An aneurysm is a bulge in the wall of a blood vessel, most commonly seen in the aorta. Damaged venous valves may not close completely as your muscles relax leading to the pooling of blood called varicose veins. 13. Based on underlying pathophysiology, which of the following disease states is most similar to PAD? A. Varicose veins B. Stable angina C. Aortic aneurysm D. Deep vein thrombosis D. Erythema would not be consistent with PAD, a condition in which the lower extremities have reduced blood flow. More commonly, cool skin temperature, pallor, and cyanosis is detected. 14. Which of the following physical findings is NOT consistent with symptomatic PAD? A. Bruits B. Cyanosis C. Hair loss D. Erythema A. The Heart Outcomes Prevention Evaluation (HOPE) study demonstrated that ACE inhibitors reduced not only blood pressure but also other cardiovascular events (eg, AMI, stroke, and death) in high-risk patients. Medications used for risk factor reduction reduce cardiovascular events, but do not affect walking distance or claudication pain. 15. Which of the following statements best describes a potential benefit of using an ACE-inhibitor in PAD? A. Decreases cardiovascular events B. Decreases claudication pain severity C. Increases pain-free walking distance D. Increases maximum walking distance A. Walking exercise programs for patients with PAD have been proven to result in an increase in pain-free and maximum walking duration and distance. Walking distance can also be used as a prognostic tool for future outcomes in patients with normal and impaired ABIs. Walking distance can be used as a monitoring tool for claudication medications by comparing their current walking distance to their baseline.76trf5d2xqe 16. All of the following statements describe one of the potential benefits of exercise therapy in PAD, EXCEPT: A. Increases the ankle-brachial index B. Prognostic tool for future outcomes C. Increases pain-free walking distance D. Monitoring parameter for claudication Answer c is correct. Influenza vaccination is recommended for all patients with PAD because they are at a high risk of cardiovascular morbidity and mortality. There is clinical evidence that the seasonal influenza vaccine was associated with a significant reduction in 1-year cardiovascular death rates among patients with established cardiovascular disease Which of the following immunizations is recommended for patients with peripheral arterial disease (PAD)? A Pneumococcal PPSV-23 B Pneumococcal PCV-13 C Annual influenza vaccine D Zoster vaccine Answer d is correct. Resting ABI is the preferred test to confirm diagnosis of PAD in patients who have findings suggestive of PAD upon examination or who are high risk of PAD. Answer a is incorrect. Fecal occult blood test is used to screen for colorectal cancer or to test for blood in stool samples. Answer b is incorrect. Toe-brachial index is only recommended as an alternative to ABI as a PAD diagnostic test. Answer c is incorrect. Cardiac catheterization can diagnose atherosclerotic arterial disease in the heart vasculature, not in the lower extremities.