1. Peripheral Arterial Disease Education and ABI Training for Vascular Nurses Presented by The Society for Vascular Nursing Comprehensive In-Service Lecture Kit Supported by an educational grant from Bristol-Myers Squibb/Sanofi Partnership

2. PERIPHERAL ARTERIAL DISEASE Education and ABI Training for Vascular Nurses A Train the Trainer Program The Ankle Brachial Index: The Key to Early Detection and Management of Peripheral Arterial Disease

3. Acknowledgements Course Development – –ABI Registry Task Force Diane Treat-Jacobson, Ph.D., R.N. Carolyn Robinson MSN, RN, CNP,CVN Marge Lovell RN, CCRC, CVN, BEd Patricia Lewis, MS, FNP, CVN M. Kate Schmidt, BSN, RN, CVN Contact Information Society for Vascular Nursing 203 Washington St., PMB 311 Salem, MA 01970 888-536-4786; 978-744-5005; Fax: 978-744-5029

4. Peripheral Arterial Disease and Claudication Peripheral Arterial Disease (PAD) A disorder caused by atherosclerosis that limits blood flow to the limbs Claudication A symptom of PAD characterized by pain, aching, or fatigue in working skeletal muscles. Claudication arises when there is insufficient blood flow to meet the metabolic demands in leg muscles of ambulating patients

5. New PAD Guidelines Enhanced quality of patient care Enhanced quality of patient care Increased recognition of the importance of atherosclerotic lower extremity PAD: Increased recognition of the importance of atherosclerotic lower extremity PAD: –Prevalence –Cardiovascular risk –Quality of life Improved ability to detect and treat renal artery disease Improved ability to detect and treat renal artery disease Improved ability to detect and treat AAA Improved ability to detect and treat AAA The evidence base has become increasingly robust, so that a data-driven care guideline is now possible The evidence base has become increasingly robust, so that a data-driven care guideline is now possible

6. Defining a Population “At Risk” for Lower Extremity PAD Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) Age 50 to 69 years and history of smoking or diabetes Age 70 years and older Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal artery disease

7. Relative Prevalence of Peripheral Arterial Disease Criqui MH et al. N Engl J Med. 1992;326:381-6. Hiatt W et al. Circulation. 1995;91:1472-9. Porter J. Mod Med. 1987;55:66-75. US Census Data, 1998 estimates. Web address www.census.gov/population/estimates/nation/infile2-1.txt 4.2 8.4113.5 2.5 4.724.8  70 0.8 1.619.860-69 0.92.168.940-59 Claudication (millions) PAD (millions) Population (millions) Age (years)

8. Systemic Manifestations of Atherosclerosis TIA Ischemic stroke Claudication Critical limb ischemia, rest pain, gangrene, amputation Renovascular hypertension Erectile dysfunction TIA Ischemic stroke TIA Ischemic stroke Myocardial Infarction Unstable angina pectoris

9. 0%5%10%15%20%25%30%35% 29% 11.7% 19.8% 19.1% 14.5% 4.3% Prevalence of PAD PARTNERS 5 Aged >70 years, or 50–69 years with a history diabetes or smoking San Diego 2 Mean age 66 years Diehm 4 Aged 65 years Rotterdam 3 Aged >55 years NHANES 1 Aged 70 years NHANES 1 Aged >40 years NHANES=National Health and Nutrition Examination Study; PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program]. 1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743. 2. Criqui MH et al. Circulation. 1985;71:510-515. 3. Diehm C et al. Atherosclerosis. 2004;172:95-105. 4. Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 5. Hirsch AT et al. JAMA. 2001;286:1317-1324. In a primary care population defined by age and common risk factors, the prevalence of PAD was approximately one in three patients

10. 1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Criqui MH, et al. Circulation. 1985;71:510-515. Prevalence of PAD Increases with Age Rotterdam Study (ABI <0.9) 1 San Diego Study (PAD by noninvasive tests) 2 0 10 20 30 40 50 60 Patients With P.A.D. (%) 55-5960-6465-6970-7475-7980-8485-89 Age Group, years ABI=ankle-brachial index

11. Gender Differences in the Prevalence of PAD Diehm C. Atherosclerosis. 2004;172:95-105. Prevalence (%) Women Men 6880 Consecutive Patients (61% Female) in 344 Primary Care Offices <70 0 2 4 6 8 10 12 14 16 70–7475–7980–74>85 Age (years) 18

12. Diabetes Increases Risk of PAD 22.4* 19.9* 12.5 0 5 10 15 20 25 Normal glucose tolerance Impaired glucose tolerance Diabetes Prevalence of PAD (%) Impaired Glucose Tolerance was defined as oral glucose tolerance test value ≥140 mg/dL but <200 mg/dL. *P .05 vs normal glucose tolerance. Reprinted with permission from Lee AJ et al. Br J Haematol. 1999;105:648-654. www.blackwell-synergy.com

13. Ethnicity and PAD: The San Diego Population Study NHW Black Hispanic Asian 0 1 2 3 4 5 6 7 8 9 10 % PAD NHW = Non-hispanic white Criqui et al. Circulation. 2005: 112: 2703-2707.

14. Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Relative Risk Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia C-Reactive Protein ReducedIncreased Risk Factors for PAD 123 456 0

15. Pathogenesis of Progressive Atherosclerosis

16. Risk of Ischemic Events Previous MI – –5-7 times more likely to have another MI – –3-4 times more likely to have a stroke Previous stroke – –9 times more likely to have another stroke – –2-3 times more likely to have an MI PAD – –4 times more likely to have an MI – –2-3 times more likely to have stroke

17. Long-term Survival in Patients With PAD Criqui MH et al. N Engl J Med. 1992;326:381-386. Copyright © 1992 Massachusetts Medical Society. All rights reserved. Normal subjects Asymptomatic PAD Symptomatic PAD Severe symptomatic PAD 100 75 50 25 024681012 Survival (%) Year

18. Contemporary PAD Rates of Myocardial Infarction and Death % Hooi JD, et al. J Clin Epid. 2004;57:294–300. 3649 subjects (average age 64 yrs) followed up for 7.2 years

19. Association Between ABI and All ‑ Cause Mortality* Baseline ABI Total mortality (%) Age range=mid- to late-50s; *Median duration of follow-up was 11.1 (0.1–12) years. Adapted from O’Hare AM et al. Circulation. 2006;113:388-393. N=5748 Risk increases at ABI values below 1.0 and above 1.3

20. A Risk Factor “Report Card” for all Individuals with Atherosclerosis Tobacco smoking 3 3 Complete, immediate cessation Hypertension 3 3 BP less than 130/85 mmHg Diabetes 3 3 Hb A 1 C <7.0 Dyslipidemia 3 3 LDL Cholesterol less than 100 mg/dl 3 3 Raise HDL-c 3 3 Lower Triglycerides Inactivity 3 3 Follow activity guidelines Antiplatelet therapy (like aspirin or Plavix) is: Mandatory

21. Pathway of Disability in Intermittent Claudication Adapted from McDermott M. Am J Med. 1999;CE (I):18-24. PAD Reduced muscle strength Poor walking ability and IC Disability Denervation, muscle-fiber atrophy, decreased type II fibers, decreased oxidative metabolism Cycle of deconditioning: decreased HDL, poorer glycemic control, poorer BP control

22. Impact of PAD on Quality of Life PAD Diagnosis and Management Symptom Experience Limitation in Physical Functioning Limitation in Social Functioning Compromise of Self Uncertainty Adaptation

23. No. of people 30 3438 4050 55 CHF Chronic lung disease Average adult Average well adult 36 Intermittent claudication Physical Component Summary Score SF-36 Scores in Health and Disease

24. Location of Obstruction Influences Symptoms Buttock, hip, thigh Thigh, calf Calf, ankle, foot Obstruction in: Aorta or iliac artery Femoral artery or branches Popliteal artery Claudication in:

25. Claudication: A Symptom of Peripheral Arterial Disease Exertional aching pain, cramping, tightness, fatigue Occurs in muscle groups, not joints (buttocks, hips, legs, calves) Reproducible from one day to the next on similar terrain Resolves completely with rest Occurs again at the same distance once activity has been resumed

26. Symptoms in PAD Patients with PAD Symptomatic PAD ~39% 1 Asymptomatic PAD ~61% 1 Typical Symptoms (Intermittent Claudication) ~9% Atypical Symptoms ~91% 1.American Heart Association. Heart Disease and Stroke Statistics—2005 Update. 2005. 2.Hirsch AT, et al. JAMA. 2001;286:1317-1324.

27. Clinical Assessment of Peripheral Arterial Disease

28. Components of Clinical Assessment Complete history – –Risk factor assessment – –Activity assessment Review of medications Physical examination – –Inspection of lower extremities – –Pulse exam

29. Questions for Patients Do you develop discomfort in your legs when you walk? – –Cramping, aching, fatigue Do you get this pain when you are sitting standing, or lying? Do symptoms only start when you walk? Does the discomfort always occur at about the same distance? Do symptoms resolve once you stop walking?

30. PAD Pulse Evaluation RightLeft Femoral Popliteal Dorsalis pedis Posterior tibial Ankle–brachial index Note: 0-4 scale, where 0 = absent, 2 = Diminished, 4 = Normal Limits

31. The Ankle-Brachial Index (ABI) The first diagnostic assessment that should be done to evaluate a patient for PAD after a pulse exam in the presence of risk factors or if claudication is suspected. Inexpensive, accurate and can be done in the primary care setting The ABI is 95% sensitive and 99% specific for PAD Predicts limb survival, potential for wound healing, and mortality

32. The Ankle-Brachial Index (ABI) Indicated – –In the absence of palpable pulses, or if pulses are diminished – –In the presence or suspicion of claudication, foot pain at rest, or a non-healing foot ulcer – –Age greater than 70 years of age, >50 years with risk factors (diabetes, smoking)

33. Concept of ABI ABI has been found to be 95% sensitive and 99% specific for angiographically diagnosed PAD. The systolic blood pressure in the leg should be approximately the same as the systolic blood pressure in the arm. Therefore, the ratio of systolic blood pressure in the leg vs the arm should be approximately 1 or slightly higher. Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049. Arm pressure Leg pressure ÷ ≈ 1

34. Performed with patient resting in supine position All pressures are measured with a arterial Doppler and appropriately sized blood pressure cuff Both brachial pressures are measured Ankle pressures are measured using the posterior tibial and/or dorsalis pedis arteries Understanding the ABI

35. Equipment needed: 1.Blood Pressure Cuff 2.Hand-held 5-10 MHz Doppler probe 3.Ultrasound Gel American Diabetes Association. Diabetes Care 2003: 26; 3333–3341. Measuring the Ankle-Brachial Index (ABI) Step 1: Gather Equipment Needed

36. Measuring the Ankle-Brachial Index (ABI) Step 2: Position the Patient Place patient in supine position for 5 – 10 minutes minutes American Diabetes Association. Diabetes Care 2003: 26; 3333–3341.

37. Measuring the Ankle-Brachial Index (ABI) Step 3: Measure the Brachial Blood Pressure 1. Place the blood pressure cuff on the arm above the elbow. 2. Apply gel to the skin surface. 3. Place the Doppler probe over the brachial pulse 4. Inflate the cuff to approx. 20 mm/hg above the point where systolic sounds are no longer heard. 5. Deflate the cuff slowly until the arterial signal returns (systolic pressure) 6. Repeat in the other arm American Diabetes Association. Diabetes Care 2003: 26; 3333–3341.

38. Measuring the Ankle-Brachial Index (ABI) Step 4: Position the Cuff Above the Ankle Place blood pressure cuff just above the ankle of one leg, apply gel over the area of the dorsalis pedis artery Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

39. Measuring the Ankle-Brachial Index (ABI) Step 5: Measure the Pressure in the Dorsalis Pedis Artery Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296. 1.Place Doppler probe over the dorsalis pedis artery; inflate the cuff 2.Deflate the cuff; when the return of blood flow is detected, record this as the systolic pressure of the DP artery of that leg

40. Measuring the Ankle-Brachial Index (ABI) Step 6: Measure the Pressure in the Posterior Tibial Artery 1.Place gel and Doppler probe over the posterior tibial artery (below the cuff) 2.Measure the pressure, record as posterior tibial pressure for that leg Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

41. Measuring the Ankle-Brachial Index (ABI) Step 7: Repeat the Process in the Opposite Leg Repeat the same process in the other leg and record the pressures of the dorsalis pedis and posterior tibial arteries Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

42. Calculating the ABI ABI Interpretation ≤ 0.90 is diagnostic of peripheral arterial disease Hiatt WR. N Engl J Med. 2001;344:1608-1621. Higher right-ankle pressure (DP or PT pulse) Higher arm pressure (of either arm) = Right Leg ABI Higher left-ankle pressure (DP or PT pulse) Higher arm pressure (of either arm) = Left Leg ABI

43. Calculating the ABI Example Calculation Hiatt WR. N Engl J Med. 2001;344:1608-1621. 60 mm Hg 120 mm Hg = Right Leg ABI 66 mm Hg 120 mm Hg = Left Leg ABI

44. Calculating the ABI Example Calculation 66 mm Hg 120 mm Hg Hiatt WR. N Engl J Med. 2001;344:1608-1621. = 0.50 = 0.55 Left Leg ABI 60 mm Hg 120 mm Hg Right Leg ABI ABI Interpretation ≤ 0.90 is diagnostic of peripheral arterial disease

45. ABI Limitations Possible false negatives in patients with noncompressible arteries, such as some diabetics and elderly individuals Insensitive to very mild occlusive disease and iliac occlusive disease Not well correlated with functional ability and should be considered in conjunction with activity history or questionnaires

46. Interpreting the Ankle–Brachial Index Adapted from Hirsch AT. Family Practice Recertification. 2000;22:6-12. ABIInterpretation 0.90–1.30Normal 0.70–0.89Mild 0.40–0.69Moderate  0.40 Severe >1.30Noncompressible vessels

47. Referring to the Vascular Lab Caveats for referral to vascular lab Assessment of the location and severity is desired Patients with poorly compressible vessels Normal ABI where there is high suspicion of PAD Vascular Lab Evaluation Segmental pressures Pulse volume recordings Treadmill PAD Diagnosis PAD Diagnosis

48. Indications for Referral for Vascular Specialty Care Lifestyle-disabling claudication (refractory to exercise or pharmacotherapy) Rest pain Tissue loss Severity of ischemia

49. Summary PAD is a common atherosclerotic disease associated with risk of cardiovascular ischemic events and significant functional disability PAD can be effectively assessed in the primary care setting by primary care nurses The ankle brachial index is an effective and efficient measurement tool for diagnosis of PAD Early detection of PAD allows for appropriate disease management and decreased likelihood of ischemic events and disease progression

51. The Graying of U.S. Society Seniors 12.4 percent of the population Baby boomers will number 75 million 2030 – –20 percent will be over age 65 – –1/2 population > age 40

52. Nurse Competence in Aging Imperatives Moving to an aging society 85+ population > 8.9 million in 2030 Older adults – –Utilize 50% of hospital days – –45% of the direct care – –primary patient population of most specialty nurses. Geriatric preparation significantly improve health care to older adults.

53. Classifying the Elderly ages 65 to 74 - the young old ages 75 to 84 - the middle old ages 85 and older - the old old

54. Impact of Aging ↑ risk of health ↑ co-morbidities ↑ disabilities ↑ dementia ↑ seniors with chronic illness requiring care ↓ quality of life

55. Age Related Changes Cardiac Pulmonary Renal Gastrointestinal CNS Integument

56. Cardiac Function Coronary artery blood flow – –decreases 35% between ages 20 and 60. Cardiac output decreases Systolic and diastolic murmurs There is a decrease in cardiac responsiveness rate with exercise.

57. Cardiovascular Function and Aging Central and peripheral circulation decreases Aerobic capacity decreases about 1% per year Maximum heart rate decreases about 1 beat per year Maximum stroke volume decreases Maximum cardiac output decreases Peripheral blood flow decreases

58. Physiological Changes to the Body with Aging Heart muscle – –Contractile strength and efficiency decreases – –Left ventricular wall thickens Heart valves – –fibrotic and sclerotic SA node and AV tracts – –Infiltrated by fibrous tissue. Aortic and mitral valves – –Calcify

59. Changes in Blood Vessels Veins and arteries – –dilate and stretch – –decreased strength and elasticity. Peripheral arteries – –Tortuous – –Less resilient. Aorta and large arteries – –stiffen Aorta – –may lengthen and become tortuous.

60. Blood Pressure Changes Systolic blood pressure – –May rise disproportionately higher than diastolic. Changes in the cardiovascular system – –Direct effects on other organs. Hypertension – –Atherosclerotic changes in blood vessels – –May result in the loss of vision, renal

61. Strength Changes With Aging Maximal strength decreases Muscle mass decreases Total number and size of muscle fibers decreases Nervous system response slows

62. Exercise and the Elderly 1996 report 30% of the elderly exercise regularly. Results in decreased risk for a number of chronic and debilitating illnesses. US Department of Health and Human Services Assess – –Motivation. – –Level of activity that a person is capable of doing, – – Help him/ her to understand how to change

63. Health Care for the Elderly Include – – health promotion, – –disease prevention, – –health maintenance Anatomical and physiological changes – –cardiovascular respiratory – –Genitourinary endocrine – –Neurologicalskin – –musculoskeletal