1. Peripheral Artery Disease (PAD) & Ankle Brachial Index (ABI) Marge Lovell RN CCRC CVN BEd MEd London Health Sciences Centre London, Ontario, Canada

2. Faculty/Presenter Disclosure Faculty: Marge Lovell Program: 51 st Annual Scientific Assembly Relationships with commercial interests: –NONE

3. Disclosure of Commercial Support This program has received NO financial support This program has received NO in-kind support Potential for conflict(s) of interest: –NONE

4. Mitigating Potential Bias N/A

5. Objectives Provide an overview of PAD Demonstrate the ABI technique Provide Hands on Practice

6. Peripheral Artery Disease (PAD, PVD) A vascular disease in which the arteries supplying a limb are occluded/stenosis The most common cause is atherosclerosis, resulting in plaque and thrombus deposition on the arterial wall, and lumenal stenosis or occlusion

7. Peripheral Arterial Disease PAD is common and will become more common in the next 2 decades. PAD is associated with a marked increase in global cardiovascular health risks: - Heart attack, stroke, and death - Claudication and functional impairment - Gangrene and amputation The current knowledge base permits significantly better: prevention, early diagnosis, integrated treatment, and rehabilitation.

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. Incidence More common in men Estimated 27 million people in North America & Europe suffer from PAD (16%) 16.5 million are asymptomatic In Canada: 1 in 4 people with PAD will have MI or CVA Common cause of disability, morbidity & mortality Under diagnosed and under treated Canadian Cardiovascular Consensus: PAD Executive Summary; Can J Cardiol 2005; 21(12):997-1006

10. ATHEROSCLEROSIS, A MULTIFACTORIAL DISEASE ENVIRONMENTAL FACTORS GENETIC FACTORS AGE SMOKING OBESITY DIET FAMILY HISTORY SEDENTARY LIFESTYLE GENDER THROMBOGENIC FACTORS VASCULAR DISEASE LIPIDS HYPERTENSION DIABETES

11. Defining a Population “At Risk” for Lower Extremity P.A.D. Age > than 40 years with one additional risk factor (e.g., diabetes, smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) Age 50 (male) 60 (female) with risk factor 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 Canadian Cardiovascular Consensus: PAD Executive Summary; Can J Cardiol 2005; 21(12):997-1006

12. How Is PAD Diagnosed? History and physical examination History and physical examination ABI ABI Vascular lab Vascular lab Adapted American Diabetes Association. Diabetes Care. 2003:26;3333-3341.

13. Olson, KWP, et al. J of Vascular Nursing. 2004:22;72-77. Questions to Ask Patients Presenting with Symptoms of PAD 1. Do you have pain in either leg when you walk? 3.How far can you walk without stopping? 4.What stops you when you are walking? 5.Do you walk? 6.Why not? 2. Do you have a similar pain when you are bending, sitting or lying down?

14. Physical Exam Findings of PAD Lesho EP, et al. Am Fam Physician. 2004; 69:525-533. The Physical Exam Should Be Performed With Patient’s Pants/Shoes Off Limb examination (and comparison with the opposite limb) findings might include: Absent or diminished femoral or pedal pulses (especially after exercising the limb) Hair loss Poor nail growth (brittle nails) Dry, scaly, atrophic skin Dependent rubor Pallor with leg elevation after 1 minute at 60 degrees (normal color should return in 10 to 15 seconds; longer than 40 seconds indicates severe ischemia) Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene Arterial bruits

15. 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

16. 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

17. Stabilizing hand

18. 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 Right Leg ABI Left Leg ABI 60 mm Hg 120 mm Hg Right Leg ABI ABI Interpretation ≤ 0.90 is diagnostic of peripheral arterial disease

19. Interpreting the Ankle–Brachial Index: ABI ABI Interpretation 1.0-1.4Normal 0.91-0.99Borderline <0.90 Abnormal >1.4 Non-compressible 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline)

20. A 65 year male, heavy smoker, hypertensive presents with right gangrenous toe and rest pain: Calculate the ABI R Brachial Pressure : _160____ Dorsalis Pedis SBP: ___140____ Posterior Tibial SBP: ___138_____ Dorsalis Pedis SBP : __60_____ Posterior Tibial SBP : __58____ L/Brachial Pressure : __156___ R/ ABI = _____ L/ ABI= _____ ABI Interpretation: Normal, Borderline, Mild, Moderate, Severe, Noncompressible Correct answers are: R/ABI= 0.37 L/ABI= 0.87 Severe PAD R/Side, mild PAD L/side

21. A 76 year old male, heavy smoker, hypertensive & previous MI presents with right calf pain after 2 blocks: Calculate the ABI R Brachial Pressure : _130____ AT SP: ___140____ PT SP: ___138_____ AT SBP: __90_____ PT SBS: __96_____ L/Brachial Pressure : __134___ R ABI = _____ L ABI= _____ ABI Interpretation: Normal, Borderline, Mild, Moderate, Severe, Noncompressible Correct answers are: R/ABI= 0.71 L/ABI= 1.04 Mild PAD R/ leg

22. A Risk Factor “Report Card” for all Individuals with Atherosclerosis Tobacco smoking 3Complete, immediate cessation Hypertension 3BP less than 140/90 mmHg and Diabetics 130/80 Hypercholesterolemia 3LDL Cholesterol < 2.0 Diabetes 3Hb A 1 C : <7.0 Inactivity 3Follow guidelines Antiplatelet therapy (like aspirin or Plavix) is: mandatory