Peripheral Vascular Disease A Primary Care Perspective 2010

1. Peripheral Vascular DiseaseA Primary Care Perspective 2010 FareedBhatti Sunnybank Medical Centre Dec 2010

2. Sources • SIGN guidelines-Diagnosis and management of peripheral arterial disease 2006. • BMJ clinical review-Management of peripheral arterial disease in primary care 15th March 2003 • BMJ clinical review-Secondary prevention of peripheral vascular disease- 6th May 2000. • BMJ E-learning module-Peripheral arterial disease: an update on management. • GP Update course handbook 2010. • British National Formulary. • E-Medicine-Peripheral Arterial Occlusive Disease-updated October 2009. • NHS Clinical Knowledge Summaries • GP Notebook

3. Introduction Peripheral arterial disease arises when there is significant narrowing of arteries distal to the arch of the aorta. Incidence(Including asymptomatic- assessed by non-invasive tests) PAD affects 20% of people >70years age(Cochrane 2007). • 13.9-16.9% in men • 11.4-20.5% in women over 55 years of age Usually about 60% of affected will be asymptomatic. Mechanisms • Atherosclerosis • Vasospasm • Inflammation/ vasculitis • Thrombosis/ Embolism

4. Why is this important?

5. Scenario 1 • 60 year old smoker, pain in legs for 2 months • What will you ask about in history? Discussed in coming slides. • What if the pain which was previously intermittent on walking is now even at rest? ?Progression to critical limb ischaemia. • What if the pain is ‘all over and achy’, takes about 30 minutes to get better on rest, and feels better on sitting forward? ?Neurospinal pain.

6. Claudication It is the ischaemic pain due to decompensation of the blood supply typically occurring with physical activity. Determining how much physical activity is needed before the onset of pain is crucial. It is most common with the distal superficial femoral artery (located just above the knee joint), which corresponds to claudication in the calf muscle area (the muscle group just distal to the arterial disease). If proximal vessels are involved, pain might be felt in thighs and buttocks too. There should be no weakness or numbness. Pain resolves quickly on rest(<5mins). Spinal pain( nerve root irritation, spinal stenosis) usually gives symptoms localised to a muscle group, accompanied by weakness or heaviness on walking and often by leaning forward.

8. Fontaine classification of claudication • Stage I – Asymptomatic • Stage II a – Intermittentclaudication after more than 200 meters of pain free walking • Stage II b – Intermittent claudication after less than 200 meters of walking • Stage III – Rest pain • Stave IV – Ischemic ulcers Risk Factors Smoking biggest risk factor. DM is a close second. Rest are hypertension, hyperlipidaemia, family history, sedentary lifestyle. Drugs: Certain drugs can also reduce blood flow to the extremities. These can cause Raynaud's phenomenon. e.g. Oral contraceptives,Clonidine, Ergotamine, Cyclosporin, Cocaine. According to BHF fact file, betablockers are ok. Others don’t share this advice. Probably shouldn't be stopped if already on them and no progression of illness.

9. Scenario 2 What could be wrong with a 30 year old Asian female having leg pain on walking. It sounds ischaemic. Arteritis(Takayasu arteritis). Takayasu's arteritis or pulseless disease typically affects young females who are of Asian origin. It is an occlusive arteritis of the branches of the aortic arch. Common features are Neck bruits, Absent pulses in the arms, TIAs, Visual disturbances.

10. Scenario 3 Young heavy smoker male aged 34 years, vascular sounding pain in arms. Also gets painful nodules here and there over limbs. He also has disfigured nails on both hands with a small scabbed over ulcer on one finger. Thromboangiitis Obliterans(Buerger’s disease) Occurs in young men(20-35Yrs) who smoke heavily. Asian/Jewish origin people more commonly affected. Patients typically have a history of superficial migratory thrombophlebitis. It causes occlusive vascular disease and thus cold extremities and ischaemic ulcers in the fingers and toes. Also consider occupational related diagnoses e.g. Vibration white finger-(would cause ulceration very rarely)

11. Assessment History. (Likelihood ratio of positive diagnosis 4.8) Duration, distance, time taken for pain to go away on rest, rest pain, skin changes, colour, changes, hair, nails, infections/healing, medication, occupation, smoking, FH, other risk factors. Also ask for pain in other limbs, TIAs, erectile dysfunction in men, visual problems, Raynaud’s features. Examination • Gait, colour, hair, temperature, muscle bulk, toenails, renal, femoral and carotid bruits, aortic aneurysm (abdominal palpation). • BPs both arms • Pulses(Abnormality has LR of 3.1) • Femoral artery bruit has LR of 4.8 • Cool skin in those with positive history has LR of 5.9 • ABPI in all Remember the 5 Ps- Pain, Pulseless, Pallor, Paraesthesia, Paralysis. (+ cold!)

12. ABPI • ABPI = Ankle systolic pressure/ Brachial systolic pressure. • In the absence of significant stenosis or occlusion in these vessels the two values are usually within 10 mmHg of each other even in the presence of more proximal disease. • The maximum cuff pressure at which the pulse can just be heard with the probe is recorded . • BP measures in both arms and the higher of both used. Interpretation of values • Symptom free - 1 or more • Intermittent claudication - 0.95 - 0.5 • Rest pain - 0.5 - 0.3 • Gangrene and ulceration - <0.2 Critical ischaemia

13. ABPI continued…. • The measured ankle cuff pressure may be falsely elevated in patients with calcified arteries (particularly occurs in diabetic and renal patients). An ABPI of >1.3 has been suggested as a strong indicator of calcification . • Measurement of great toe artery pressure for calculation of Toe brachial index (TBI) is commonly advocated in diabetic patients because of the increased prevalence of calcification in the crural vessels. • In patients with chronic venous ulceration, it is currently recommended that the ABPI should be >0.8 if compression bandaging is to be applied safely in the community. • The Edinburgh Artery Study has shown that even a near-normal ABPI (0.9-1.0) is associated with reduced 5 year survival -This shows even asymptomatic PVD is related to increased mortality and morbidity.

14. How to do an ABPI? • http://www.youtube.com/watch?v=bTVYl9URdSI&feature=related

15. Investigations in Primary care: Bloods The basic panel of tests is . UEs . TSH . Fasting lipids . Fasting sugar (important to screen everyone for DM as up to 20% of symptomatic may be diabetic). . Autoantibodies, Bone profile, Coagulation screen, CRP, ESR, Myeloma screen if other pathology suspected. Other investigations USS useful for screening for renal artery stenosis & aortic aneurysm.

16. Treatment • All symptomatic peripheral vascular must be treated as secondary prevention. Quit Smoking! Look at medication Exercise :Near pain threshold for at least 6 months, upto an hour a day 24% reduction in cardiovascular related mortality and nearly 150% increase in walking distance. Statins:Targets Total cholesterol <5 and LDL <2.5. Start with Simvastatin, recommended to start statin if total chol higher than 3.5. They lead to risk reduction from vascular events but no benefit to actual walking etc. Antiplatelet agents:Aspirin 75mgOD or Clopidogrel 75mg OD(if intolerant to Aspirin). Shown to have reduced 22% reduction in vascular events and ?increase in walking distance. Blood Pressure control: Target < 140/85mmHg Reduced Stroke/MI etc risk but no effect on walking. ACE-inh are better but because these patients are at risk of renal artery stenosis, their U&Es have to be watched carefully. Betablockers are ok too apparently! Glycaemic control: Reduces mortality risk and amputation risk. Weight reduction: ….Continued

17. Treatment ….Continued. Both Cilostazol and Naftidofuryl have a long list of contraindications so do look at them before prescribing. • Cilostazol- Phosphodiestrase inh. A peripheral vasodilator with anti-platelet effects. For patients with intermittent claudication in particular over short distances should be considered , and stopped after 3 months if no better. Effects- increased walking distance, no change to mortality risk. Side Effects- major ones dizziness, diarrhoea, palpitations. Dose- 100mg BD Price- 56 Tabs of 50 or 100mg = £35.31 (Not recommended under NHS in Scotland). • Naftidofuryl- For moderate disease, increases walking distance, reviewed at 3-6 months. SEs- Nausea, Epigastric pain, rash, Hepatitis and liver failure. Dose- 100-200mg TDS Price- 84 Caps of 100mg = £5.30 • Nifedipine mentioned for Raynaud’s not proper Peripheral Vasc Disease, though could be used. • Oxypentifylline, oral prostaglandins not recommended. • Endovascular and surgical Rx not recommended in majority of patients.

18. Referral • Younger patients because higher chances of alternative diagnoses, • Diagnosis uncertain esp if history is not very clear and not supported by ABPI, or normal ABPI with a clear history. • Symptoms limiting lifestyle • Meds not controlling symptoms

20. Critical limb ischaemia

22. Differential Diagnosis • Raynaud’s White Blue and red phases • Chill Blains Painful, burning or itching erythematous lesions of hands or feet (rarely ulceration) precipitated by damp and cold • Acrocyanosis Persistent cold, blue, and rather sweaty appearance, usually of hands • Venous disease: Described as a dull, aching pain that typically occurs at the end of the day or after prolonged standing, venous disease is not exacerbated by exercise. • Osteoarthritis: This is associated with arthritic pain that is variable from day to day and may be aggravated by certain weather patterns or movements. Rest does not relieve pain. • Neurospinal disease: Pain occurs in the morning and is not relieved by short resting periods. Neurospinal pain is frequently relieved by leaning forward against a solid surface or by sitting. • Vibration white finger • Diabetic neuropathy: Pain is due to a peripheral neuritis. Differentiation from intermittent claudication can be difficult because of accompanying skin discoloration and diminished pulses. An extensive neurologic evaluation is essential.

23. Differential diagnosis…continued • Reflex sympathetic dystrophy or minor causalgia: This is characteristically described as a burning pain. The superficial pain is often distributed along a somatic nerve and is often related to a past trauma in the extremity. • Venous thrombosis: Swelling and leg pain occur with walking. Pain is relieved by extremity elevation, which distinguishes this entity from arterial insufficiency. • Chronic compartment syndrome: This is rare. It is usually observed in runners and other athletes with large, developed calf muscles. Muscles swell during activity, leading to increased compartment pressure and decreased venous return. Consistent with claudication pain, this pain occurs with exercise and is relieved with rest. However, the type of exercise is at a more strenuous level and the recovery period is prolonged. • Popliteal entrapment syndrome: This syndrome is similar to intermittent claudication but is usually observed in active young people. The syndrome is caused by various abnormal anatomical configurations of the insertion of the medial gastrocnemius muscle head, which causes compression of the popliteal artery. Upon physical examination, tibial pulses may disappear when the knee is at full extension. Pain is aggravated with walking but not with running because knee extension is not as severe with running.

24. Summary • Diagnosis of peripheral arterial disease is based mainly on the history, with examination and ankle brachial pressure index being used to confirm and localise the disease. • Peripheral arterial disease is a marker for systemic atherosclerosis; the risk to the limb in claudication is low, but the risk to life is high. • Patients should be treated for symptoms as well as for secondary prevention. • Patients should be referred if there is doubt about the diagnosis, evidence of aortoiliac disease, if the patient has not responded to best medical treatment or has severe disease.

25. Primary Raynaud’s Begins in teens and early 20's. Exaggerated physiological response to cold. Not assoc with any other disease. Symmetrical in both upper or lower limbs. No ulcers and/ or gangrene. ABPI normal. ESR and Autoantibodies normal. Secondary Raynaud’s Older age (e.g. > 30 years) and particularly in males.(Remember occupational Hx too) Occurs in over 90% of patients with systemic sclerosis and in up to 40% of patients with SLE and idiopathic inflammatory myositis. Ulcers Year-round symptoms Pain and discomfort is higher in severity Abnormal nail fold capillaries (viewed with an ophthalmoscope with the +20 lens) Assymetric upper limb pulses or bruits Puffiness/tightness of the finger skin Raised ESR Positive Autoantibodies Any other clinical features suggestive of an underlying connective tissue disease. Raynaud’s Disease Raynaud’s is very well written in CKS if you want to know more about it.

27. Raynaud’s treatment • Keep warm • Stop smoking • Change of temp more important than temp itself. • Nifedipine • Other calcium channel blockers • Cilostazol/ Naftidofuryl ? • Alpha blockers/ ACE inh/ARBs • Primary or secondary prevention not required.

28. Venous peripheral vascular disease Diseases include: • Deep vein thrombosis • Superficial vein thrombosis • Thrombophlebitis migrans • Varicose ulcers • Varicose veins • Venous gangrene

29. Thank you