This document discusses the presentation, evaluation, and treatment of a 62-year-old male with peripheral arterial disease. It recommends investigating PAD with ankle-brachial index and Doppler ultrasound tests. Treatment includes risk factor modification through smoking cessation, exercise, low-dose aspirin, statins, and angiotensin-converting enzyme inhibitors. For severe claudication, procedures like percutaneous angioplasty or surgery may be considered. The overall goal is to reduce cardiovascular risk factors and improve blood flow and oxygen delivery to the legs.

1. ATHEROSCLEROSIS, LIPID
AND CARDIOVASCULAR RISK
MANAGEMENT.
Presenter: Arwa Al-
Onayzan.
ID: 215007943.
Serial number: 66.

2. OUR CASE
 A 62 yo male complain of pain in right leg.
 Past medical history: Ischemic stroke, HT, DM2.
 Present medical history: Severe cramps in right calf on excersize,
after walking 100 meter, no rest pain.
 Medication: Metformin 500mg twice daily, hydrochlorothizide 25
mg once daily.
 Intoxication: Smoking 25 cig/day during 45y.
 Family history: Father had MI (58y), mother had stroke (75y).

3. CON..
 Physical examination:
• Body weight 80 Kg, BMI 28 Kg/m, BP=160/100 mmHg.
• Yellow-colored papules on eyelids and skin surrounding eyes
• Heart: Normal tones, no bruit
• Abdomen: Bruit umbilical region.
• L L: Normal pulses femoral arteries, bruit right groin, no pulses
of right popliteal a, posterior tibial a, dorsalis pedis a, atrophic,
dry skin, lack of hair on right lower leg and foot, low skin
tempreture.

4. QUESTIONS
 Which investigation do you recommend to evaluate P.A.D?
 Which other tests would you like to perform?
 How would you treat the complains of this patient with peripheral
arterial disease?
 What other medical treatments should this patient receive?

5. INTRODUCTION
 What’s Atherosclerosis??
 Is chronic progressive degenerative disease affect vascular wall.
 Atherosclerosis-Related Diseases??
 Atherosclerosis can affect any artery in the body. As a result,
different diseases may develop based on which arteries are affected.
Such as:
 Coronary Heart Diseases.
 Peripheral Artery Disease.
 Chronic Kidney Disease.

6. Q1) WHICH INVESTIGATION DO YOU
RECOMMEND TO EVALUATE
PERIPHERAL ARTERIAL DISEASE?
Q2) WHICH OTHER TESTS
WOULD YOU LIKE TO
PERFORM?

7. GENERAL INFORMATION ABOUT
P.A.D
 (P.A.D.) is atherosclerosis of the extremities (virtually always lower)
causing ischemia.
Medical
history
• Risk factor for P.A.D ( diabetes, smoking, older age, hypertension,
stroke).
• Symptoms (Weak or no pulses in the legs or feet, lower
temperature in one leg, decreased hair growth on the legs,
intermittent claudication symptoms).
Family
history
• Family history of heart and blood vessels diseases.
• Father had MI (58y), mother had stroke (75y).
Physical
examination
• Checking pulses by stethoscope (weak or absent pulses in legs or
feet),
• Lower temperature in one leg, atrophic leg or feet.

8. INVESTIGATION OF P.A.D
 Ankle-Brachial Index (ABI):
• It compares blood pressure in the ankle to blood pressure in the
arm.
• This test shows how well blood is flowing in limbs.
• A normal ABI ( range between 0.90 - 1.30).
• Can be classified as:
• Mild (0.71 to 0.90),
• Moderate (0.41 to 0.70), or severe (≤ 0.40).
• The test takes about 10 to 15 minutes.

9. CON..
 Doppler Ultrasound:
• Looks at blood flow in the major arteries and veins.
• Handheld device is placed on:
• UE: over the axillary, brachial, ulnar, and radial arteries.
• LE: over the femoral, popliteal, dorsalis pedis, and
posterior tibial arteries.
• A computer converts sound waves into a picture of blood
flow in the arteries and veins.
• Provides details of the location and extent of arterial
stenoses or occlusion

10. CON..
Treadmill Test:
• The patient walks on a treadmill while the BP and EKG are
mentored
• A treadmill test can show the severity of symptoms and the
level of exercise.
Magnetic Resonance Angiogram (MRA):
• Uses magnetic and radio wave energy to take pictures of blood
vessels.
• Provides details of the location and extent of arterial stenosis or
occlusion.

11. CON…
 Arteriogram:
• Provides a "road map" of the arteries.
• Dye is injected through a needle into one of arteries. After that an x ray
is taken.
• it show the location, type, and extent of the blockage in the artery.
• tiny ultrasound camera to take picture (Intravascular ultrasound).
 Computed tomography (CT):
• can be of use to the emergency physician in that it does not have the
time.

12. CON…
Transcutaneous oximetry:
• Is a local, non-invasive measurement reflecting the amount of
O2 that has diffused from the capillaries, through the epidermis.
Electrocardiogram (ECG):
• Used to look for evidence of dysrhythmia, prior cardiac injury, or
even acute myocardial infarction.

13. CON…
 Laboratory studies:
• Complete blood count (CBC).
• Blood urea nitrogen (BUN).
• Creatinine.
• Electrolyte studies.
• Lipid profile.
• Coagulation tests.
• blood glucose test

14. Q1) Name 2 tests that we can use in the investigation of P.A.D??
QUIZ TIME !

15. Q3/HOW WOULD YOU TREAT THE
COMPLAINTS OF THIS PATIENT
WITH P.A.D?
Q4/WHAT OTHER MEDICAL
TREATMENTS SHOULD THIS
PATIENT RECEIVE?

16. TREATMENT OF P.A.D
 Risk factor modification.
 Exercise.
 Antiplatelet drugs.
 Sometimes pentoxifylline or cilostazol for claudication.
 Cholesterol lowering medication.
 ACE inhibitors.
 PTA or surgery for severe disease.

17. TREATMENT OF P.A.D
 Risk factor modification, include:
• Smoking cessation.
• Control of diabetes: Metformin 500mg twice daily.
• Control of HT: hydrochlorothiazide 25 mg once daily. (ACE).
• Dietary changes:
Less saturated fat<20 g/day.
More fruits and vegetables.
More fiber (decrease LDL 5%).
Eat fish (EPA  inhibit platelet aggregation).
Eat less red meat (homocystin).

18. TREATMENT OF P.A.D
 Exercise:
• 35 to 50 min of treadmill or track walking 3 to 4 times/wk. (with
underused treatment).
• Mechanisms:
• Increased collateral circulation.
• Improved endothelial function with microvascular vasodilation.
• Decreased blood viscosity.
• Increase HDL.

19. CON..
Antiplatelet drugs:
• lessen symptoms, improve walking distance and modify
thermogenesis.
• Aspirin 81 to 162 mg taking by mouth, once/day. (low dose).
• Aspirin 25 mg plus dipyridamole 200 mg taking by mouth
once/day,
• Action of aspirin:
• Inhibit TXA2.
• Maintain activity of prostacyclin.

20. CON..
 To relief of claudication:
• Pentoxifylline 400 mg, taken by mouth, three time daily.
• or cilostazol 100 mg, taken by mouth, twice daily.
• Mechanisms:
• Relieve intermittent claudication by improving blood flow and
enhancing tissue oxygenation in affected areas.

21. CON…
ACE inhibitors:
• Ramipril 10 mg, taking by mouth once/day.
• Mechanisms:
• They are antiatherogenic.
• Promoting the degradation of bradykinin and the release of nitric oxide.

22. CON…
Cholesterol lowering medication:
• Statin.
• Indication:
• Total cholesterol above 3.5 mmol/L.

23. CON…
 Percutaneous transluminal intervention:
• Is a minimally invasive procedure to open up blocked arteries.
• Work best in large arteries with high flow (iliac and renal).
• They are less useful for smaller arteries and for long
occlusions.
• Indications:
• Intermittent claudication that inhibits daily activities.
• Rest pain.
• Gangrene.

24. CON…
 Surgery:
• Thromboendarterectomy: (surgical removal of an occlusive lesion).
• Revascularization: uses synthetic or natural materials (often the saphenous
or another vein) to bypass occlusive lesions.
• Amputation: is a procedure of last resort, indicated for uncontrolled
infection, unrelenting rest pain, and progressive gangrene.

25. SUMMARY
Atherosclerosis Is chronic progressive degenerative disease affect
vascular wall.
Atherosclerosis can associated with other disease like P.A.D.
General information about P.A.D.
Investigation.
Treatment.

26. QUIZ TIME !
Q1) to treat P.A.D and Atherosclerosis we used:
1- Aspirin with low dose.
2- Aspirin with high dose.

27. ANY QUESTION?

29. REFERENCE
 Kumar & Clark’s Clinical Medicine Book (Ninth Edition), (Page
1049- 1056).
 BNF (65 Edition), (Page 138).
 Merk Manual (19 Edition), (Page 2218-2220).
 Peripheral Vascular Disease Workup. MD, E. S. (2016, Dec. & jan.).
Retrieved February 19, 2017, from
http://emedicine.medscape.com/article/761556-workup#showall
 How Is Peripheral Artery Disease Diagnosed? (2016, June & july).
Retrieved February 19, 2017, from
https://www.nhlbi.nih.gov/health/health-
topics/topics/pad/diagnosis.