CLI: Find It, Recognize I t, Refer It

1. CLI: Find It, Recognize It, Refer It J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of Endovascular Interventions Director of Cardiovascular Research Metro Health Hospital, Wyoming, MI Clinical Assistant Professor of Medicine Michigan State University COM jihad.mustapha@metrogr.org

2. Objectives: • The Primary Care Physician’s role in PAD/CLI • The role of Multi-disciplinary team in PAD/CLI • The evaluation of at risk patient population • The importance of knowing when to refer

3. Financial Disclosures • Abbott Vascular • Consultant/Speaker • Bard Peripheral Vascular • Research/Consultant/Medical Advisory Board/Speaker/Trainer • Bard Peripheral Vascular – Lutonix • Research/Speaker • Bayer • Medical Advisory Board • Biotronic • Research • Boston Scientific • Speaker • Cardiovascular Systems, Inc. • Research/Consultant/Medical Advisory Board/Speaker/Trainer • Cook Medical • Research/Consulting/Speaker/Trainer • Cordis • Consultant/Trainer • Covidien • Consulting/Speaker/Trainer • IdevTechnologies • Research • Lake Region Medical • Consulting • Terumo • Consulting/Speaker/Trainer • Trireme • Research • Rex Medical • Research • Spectranetics • Research

4. The PCP’s role in PAD/CLI • The Medical Home Model of medicine • Standard of care: It’s good medicine • Performance measure: You are evaluated on it and paid for it • ADA Screening recommendations* • Annual foot exam • Inspection to identify risk factors for ulcers etc. • Assess foot pulses • Test for protective sensation • Consider ABI screening *ADA. VI Prevention, Management of Complications. Diabetes Care 2012; 35 (suppl1):s37

5. The PCP’s role in PAD/CLI (cont.) • ACC/AHA Screening recommendation for ABI’s* • <50 years with DM and +1 CVD risk factor • >/=50 years with hx of smoking or DM • >/=65 years (independent of risk factors) • TASC II Screening recommendations for ABI’s** • Patient’s with exertional claudication • 50-69 years with CVD risk factors • >/=70 years and older- regardless of risks factors • Framingham 10 years risks of CV event 10-20% * Rooke et al. 2011 ACCF/AHA Focused Update of Guidelines for the Management of Patients with PAD. J AM Coll Cardiol 2011: 58:2020 ** Norgren et al. TASKII. J Vasc Surg. 2007; 45 Supplement S:S5

6. Find It • Evaluation of at-risk patient population: • Think globally: CVD is a systemic disease • Start from the top (head) and work down (toes) • ALWAYS have the patient remove socks and shoes • Look, Feel and Listen

7. 74 year old Male Left BKA with Stump Ulcer & Right Lower Extremity Ulcers

8. Recognize It • Most PAD is asymptomatic • Know the symptoms • Pain: Foot, leg, thigh, hip, buttock and low back • Pain may be exertional or at rest • Pain may “typical” or “atypical” • Know the signs • Shiny and hairless skin • Skin discoloration • Absent or weak pulses • Ulcers

9. Recognize it (cont.) • The differential diagnosis of “leg pain” • Spinal or foraminal stenosis • Mechanical low back pain • Peripheral neuropathy • Ischemic neuropathy • Peripheral venous disease i.e. stasis etc.

10. What Not to Say • To the patient with leg pain: “Don’t worry. It’s just your back” • To the patient with loss of sensation: “It’s just peripheral neuropathy” (CLI is ischemic neuropathy) • To the patient with the blue toe: “It’s just venous insufficiency” • To the patient with a small non-healing wound: “Let’s just wait and see.”

11. Refer It • When to refer to a vascular specialist: • Classic claudication in the presence of risk factors • Skin discoloration • Skin ulceration • Non healing wound • Absent or weak pulses • What testing is necessary before a referral? • ABI’s • Arterial Doppler study • Nice to know, but should not delay referral. Especially in patients with CLI

12. Role of the PCP in the Multi-Disciplinary Team • The coordinator of care: Tying the pieces together • Nutritional support • Healthy and balanced diet • Good diabetic control (HgA1c): Critical for wound healing • Exercise: Walk, walk and walk • Risk factor modification • Blood pressure control • Dyslipidemia management • Diabetes Management • Smoking cessation • Wound Care • Refer appropriately to podiatry/wound care specialist • PAD education for the patient • Patient needs to know warning signs and when to call/return

13. Post-Revascularization Follow Up • Address follow up • Communication with the multi-disciplinary team is key to success • How to address regression and how quickly to refer back to vascular specialist

14. This is How I Do It • High volume Family Medicine practice • Large diabetes patient population • Relationships with multi-disciplinary team • Vascular Surgery • Interventional Cardiology • Podiatry • Wound Clinic • With technology evolving so rapidly, education is key to staying current • Attendance at meetings such as AMP • Educational meetings with vascular specialists and podiatrists

15. Final Thoughts • The “number needed to treat” to listen, reassure and treat a patient with an acute problem is…ONE!* • The “number needed to treat” to save one life, one limb is also…ONE! * J Hickner, MD. JFP. July 2013. Vol 62. No 7. p 333

16. THANK YOU J.A. Mustapha, MD, FACC, FSCAI Director of Cardiovascular Catheterization Laboratories Director of Endovascular Interventions Director of Cardiovascular Research Metro Health Hospital, Wyoming, MI Clinical Assistant Professor of Medicine Michigan State University COM jihad.mustapha@metrogr.org