Intermittent claudication is one of the most common symptoms of peripheral arterial disease (PAD), which is caused by atherosclerosis narrowing and stiffening the arteries that supply blood to the limbs. The main treatment options for intermittent claudication include risk factor modification through smoking cessation, glycemic control, blood pressure control, and lipid lowering; exercise therapy through regular walking sessions; and pharmacologic treatment including pentoxifylline and cilostazol which are FDA-approved for claudication. Revascularization procedures may also be considered if other treatments are ineffective.
Colles fracture is the fracture at the distal end of radius, at its
cortico cancellous junction(about 2cm from the distal articular
surface).
It is not just the fracture of distal radius but the fracture
dislocation of the inferior radio-ulnar joint.
Colles fracture is the fracture at the distal end of radius, at its
cortico cancellous junction(about 2cm from the distal articular
surface).
It is not just the fracture of distal radius but the fracture
dislocation of the inferior radio-ulnar joint.
Buerger's disease (thromboangiitis obliterans) is a rare disease of the arteries and veins in the arms and legs. In Buerger's disease, your blood vessels become inflamed, swell and can become blocked with blood clots (thrombi)
Buerger's disease (thromboangiitis obliterans) is a rare disease of the arteries and veins in the arms and legs. In Buerger's disease, your blood vessels become inflamed, swell and can become blocked with blood clots (thrombi)
PHYSIOTHERAPY IN COMMON VASCULAR CONDITIONS.pptxKunjalPardeshi1
Vascular disease includes any condition that affects your circulatory system, or system of blood vessels. This ranges from diseases of your arteries, veins and lymph vessels to blood disorders that affect circulation.
Blood vessels are elastic-like tubes that carry blood to every part of your body. Blood vessels include:
Arteries that carry blood away from your heart.
Veins that return blood back to your heart.
Capillaries, your tiniest blood vessels, which link your small veins and arteries, deliver oxygen and nutrients to your tissues and take away their waste.
A condition affecting the blood's ability to clot and stop bleeding.
In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places. Causes include inflammation, infection and cancer.
Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts of the body.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
3. CLAUDICATION
• Claudication is derived from the Latin word claudicatio
• Means to limp or be lame
• Claudication is pain, tired or weak feeling that occurs in legs,
usually during activity such as walking, and go away a short
time after rest
• Complete relief of symptoms should occur within 5 to 10 min
• It should not be necessary for the patient to sit to obtain relief
Rutherford’s Vascular Surgery 8th Ed
4. CLAUDICATION
• Classically, claudication is associated with arterial stenosis or
occlusion
• The symptoms are secondary to inadequate or decreased blood
flow to the muscles affected
• AKA “Arterial claudication” or “Intermittent claudication”
Rutherford’s Vascular Surgery 8th Ed
5. CONDITION MIMICKING
ARTERIAL CLAUDICATION
• Differential diagnosis of claudication are musculoskeletal,
neurologic, and venous pathologies
• The most common of which are osteoarthritis, spinal stenosis, and
venous outflow obstruction
• Atypical claudication of nonarterial etiology
• Pain with exertion
• Pain does not stop the patient from walking
• May not involve the calves or other major muscle groups
• Does not resolve within 10 minutes of rest
Rutherford’s Vascular Surgery 8th Ed
9. NEUROGENIC CLAUDICATION
• Caused by lumbar spinal stenosis, nerve root compression
• Whole leg pain, can be associated with tingling and numbness
• Mostly bilateral
• Suddenly pain on standing up or walking
• Relief does not occur promptly once activity has ceased
• Complete symptomatic relief may take 30 to 60 minutes or
longer by sitting, bending forward, or stop walking
• Unable to straighten legs
Rutherford’s Vascular Surgery 8th Ed
10.
11.
12. VENOUS CLAUDICATION
• The “bursting” thigh pain and “tightness” that develops during
exercise
• Usually seen varicose vein, cyanosis and edematous
• Most commonly unilateral
• Gradual onset after beginning to walk
• Relieve on elevating the leg
Rutherford’s Vascular Surgery 8th Ed
13. VENOUS CLAUDICATION
• Symptoms are associated with a proximal venous obstruction
resulting in impaired venous outflow
• The pathophysiology of venous claudication is related to the
high outflow resistance
Rutherford’s Vascular Surgery 8th Ed
14. PATHOPHYSIOLOGY OF
VENOUS CLAUDICATION
Exercise or other activity
Increase arterial flow to extremities
High venous outflow and pressure
Veins become engorged and tense
Rutherford’s Vascular Surgery 8th Ed
15. INTERMITTENT CLAUDICATION
• The three major muscle groups of the lower extremity,
depending on the location of the obstruction:
• The buttock, thigh, or calf
• Symptoms may involve one or more of these muscle groups
• Symptoms will often occur in the muscle group immediately
distal to the obstruction
“Peripheral Arterial Disease”
Rutherford’s Vascular Surgery 8th Ed
16. INTERMITTENT CLAUDICATION
• Gradual onset after walking
• “Claudication distance” is the distance of that patients can walk
until the symptoms aggravated
• One-block Claudication
• Two-block Claudication
• As the process progresses, symptoms occur more frequently
and after shorter distances
Rutherford’s Vascular Surgery 8th Ed
17. PROGRESSION
Pain only when
doing exercise
(Effort
discomfort)
Pain even
at rest
Limit activity of
daily living
(Shorter walking
distance)
Rutherford’s Vascular Surgery 8th Ed
18. Intermittent claudication is one of the
most common symptom of Peripharal
Arterial Disease (PAD), which is caused
by atherosclerosis
19. INTERMITTENT CLAUDICATION
• Risk factors for PAD :
• Smoking
• Underlying of DM, HT, DLP and ESRD
• Obesity
• Long-term use of corticosteroid
• Family history of Cardiovascular disease
Rutherford’s Vascular Surgery 8th Ed
20. SMOKING FACTOR
• The physiologic effects of smoking are incompletely understood
• Nicotine inhalation has been demonstrated to
• Reduce high density lipoprotein (HDL) levels
• Increase platelet aggregation
• Decrease prostacyclin
• Increase levels of thromboxane
• Promote vasoconstriction
21. • Long-term corticosteroid therapy has also been reported to be
associated with a distally accentuated, calcifying peripheral
atherosclerosis, inducing arterial incompressibility
comparable to patients with renal failure or diabetes
Eur J Vasc Endovasc Surg. 2010
22. PATHOPHYSIOLOGY OF
INTERMITTENT CLAUDICATION
• The arteries that supply
blood to your limbs are
damaged, usually as a result
of atherosclerosis
• Atherosclerosis narrows the
arteries and makes them
stiffer and harder
http://www.mayoclinic.org/diseases-conditions/claudication
23. PATHOPHYSIOLOGY OF
INTERMITTENT CLAUDICATION
• The pain sensation results from
• Ischemic neuropathy involving small A delta and C sensory fibers
• Local intramuscular acidosis from anaerobic metabolism
enhanced by the release of substance P
Rutherford’s Vascular Surgery 8th Ed
25. INFLOW OBSTRUCTION
• Lesions in the suprainguinal vessels
• most commonly the infrarenal aorta and iliac arteries
• Occlusive lesions of the infrarenal aorta or iliac arteries
commonly lead to buttock and thigh claudication
• Bilateral and proximal to the origins of the internal iliac a.
• Vasculogenic erectile dysfunction
Rutherford’s Vascular Surgery 8th Ed
26. OUTFLOW OBSTRUCTION
• Occlusive lesions in the lower extremity arterial tree below the
inguinal ligament
• Common femoral artery to the pedal vessels
• Superficial femoral artery is the most common lesion
associated with intermittent claudication
Rutherford’s Vascular Surgery 8th Ed
27.
28. OUTFLOW OBSTRUCTION
• Popliteal and tibial artery occlusions are more commonly
associated with limb-threatening ischemia
• Less collateral vascular pathways beyond these lesions
Rutherford’s Vascular Surgery 8th Ed
29. COMBINATION OBSTRUCTION
• Symptoms frequently begin in the buttock and thigh and then
involve the calf muscles with continued ambulation
• May appear in reverse order if the distal disease is more severe
• Severe combined inflow-outflow disease may result in limb-
threatening ischemia
Rutherford’s Vascular Surgery 8th Ed
30. INTERMITTENT CLAUDICATION
• Symptoms of claudication
associated with PAD
usually manifest in the
muscle groups below the
hemodynamically
significant lesion
Rutherford’s Vascular Surgery 8th Ed
36. INTERMITTENT CLAUDICATION
• The natural history of IC is marked by slow progression to
shorter walking distances, but it rarely reaches the level of CLI
• The risk of major amputation is less than 5% over a 5-year
period
• In a long-term study of 1244 claudicants, only insulin-requiring
diabetes, low initial ABI, and high pack-years of smoking
predicted progression to ischemic rest pain and ischemic
ulceration
J Vasc Surg 34:962–970, 2001
37. • Patients with symptoms of intermittent claudication should
undergo a vascular physical examination, including
measurement of the ABI (Class I, Level of Evidence: B)
• In patients with symptoms of intermittent claudication, the ABI
should be measured after exercise if the resting index is
normal (Class I, Level of Evidence: B)
Circulation. 2006;113:1474 –1547
38. EXERCISE TESTING
• Treadmill Exercise is done :
• Two miles per hour
• Five minutes
• Twelves percents incline
Rutherford’s Vascular Surgery 8th Ed
39. ANKLE BRACHIAL INDEX
• The ankle-brachial index (ABI) is the ratio of the systolic blood
pressure (SBP) measured at the ankle to that measured at the
brachial artery, originally described by Winsor in 1950
𝐴𝐵𝐼 =
𝑆𝐵𝑃 𝑜𝑓 𝑡ℎ𝑒 𝐴𝑛𝑘𝑙𝑒
𝑆𝐵𝑃 𝑜𝑓 𝑡ℎ𝑒 𝐴𝑟𝑚
Circulation. 2012;126:2890-2909
40.
41. ANKLE BRACHIAL INDEX
• ABI values more than 1.40 indicate non-compressible arteries
• Normal ABI range of 1.00 to 1.40
• ABI values of 0.91 to 0.99 are considered “borderline”
• Abnormal values is less than 0.90 (Suspected PAD)
• Intermittent claudication usually seen in ABI 0.5 – 0.95
Circulation. 2011;124:2020 –2045
42. PULSE VOLUME RECORDING
• Pulse volume recordings are reasonable to establish the initial
lower extremity PAD diagnosis, assess localization and
severity, and follow the status of lower extremity
revascularization procedures (Class IIa, Level of Evidence: B)
Circulation. 2006;113:1474 –1547
47. SMOKING CESSATION
• The role of smoking cessation in the treatment of intermittent
claudication is less clear
• Treadmill studies have demonstrated an increase in pain-free
ambulation distances in some but not all patients
• Reduce their risk of cardiovascular events and limit the
progression of PAD
Rutherford’s Vascular Surgery 8th Ed
48. SMOKING CESSATION
• There is a threefold reduded risk of graft failure in patients
who have undergone revascularization
• Bupropion and other pharmacologic agents have increased
smoking cessation rates
Rutherford’s Vascular Surgery 8th Ed
49. SMOKING CESSATION
• Individuals with lower extremity PAD who smoke cigarettes or
use other forms of tobacco should be advised by each of their
clinicians to stop smoking and should be offered
comprehensive smoking cessation interventions, including
behavior modification therapy, nicotine replacement therapy,
or bupropion (Class I,Level of Evidence: B)
Circulation. 2006;113:1474 –1547
51. GLYCEMIC CONTROL
• Each incremental 1% increase in HbA1C is associated with a
28% increase in risk for PAD
• Tighter glucose control regimens exhibited only a
nonstatistically significant reduction in cardiovascular events
and had no effect on the incidence of PAD
Rutherford’s Vascular Surgery 8th Ed
52. GLYCEMIC CONTROL
• Administration of glucose control therapies to reduce the
hemoglobin A1C to less than 7% can be effective to reduce
microvascular complications and potentially improve
cardiovascular outcomes (Class IIa, Level of Evidence: C)
Circulation. 2006;113:1474 –1547
53. BLOOD PRESSURE CONTROL
• Hypertension is associated with a two- to threefold increased
risk of PAD
• Blood pressure goal of
• < 140/90 (nondiabetics)
• < 130/80 (diabetics and individuals with chronic renal disease)
• to reduce the risk of MI, stroke, congestive heart failure, and
cardiovascular death (Class I,Level of Evidence:A)
Circulation. 2006;113:1474 –1547
54. BLOOD PRESSURE CONTROL
• All drugs that are effective at reducing SBP can decrease the
risk of cardiovascular events
• Beta-adrenergic blockers are effective antihypertensive agents
and are not contraindicated in patients with PAD (Class I, Level
of Evidence:A)
• ACE Inhibitors are particularly beneficial, but approve as a
cardioprotective drugs
Circulation. 2006;113:1474 –1547
55. LIPID LOWERING
• Statins are indicated for all patients with PAD to achieve a
target LDL < 100 mg/dl (Class I, Level of Evidence: B)
• Target LDL < 70 mg/dl is reasonable for patients with very
high risk of ischemic events. (Class IIa, Level of Evidence: B)
Circulation. 2006;113:1474 –1547
57. PLATELET AND
THROMBOTIC DRUGS
• Antiplatelet therapy is now widely accepted for the treatment
of cardiovascular disease
• Clopidogrel was associated with an overall 8.7% reduction in
the risk of stroke, MI, and death
• A relative cardiovascular risk reduction of 24% was found in
the clopidogrel group compared with the aspirin group
Rutherford’s Vascular Surgery 8th Ed
59. RECOMMENDATION
• Antiplatelet therapy can be useful to reduce the risk of MI,
stroke, or vascular death in asymptomatic individuals with an
ABI less than or equal to 0.90 (Class IIa, Level of Evidence: C)
• The usefulness of antiplatelet therapy to reduce the risk of MI,
stroke, or vascular death in asymptomatic individuals with
borderline abnormal ABI, defined as 0.91 to 0.99, is not well
established (Class IIb, Level of Evidence:A)
Circulation. 2011;124:2020 –2045
61. EXERCISE THERAPY
• Exercise therapy is the best initial treatment of intermittent
claudication
• Regular aerobic exercise reduces cardiovascular risk by
lowering cholesterol and blood pressure and by improving
glycemic control
Rutherford’s Vascular Surgery 8th Ed
62. EXERCISE THERAPY
• Exercise training, in the form of walking
• Minimum of 30 to 50 minutes per session
• Three to five times per week
• Not less than 12 weeks
• (Class I,Level of Evidence:A)
• During each session, the patient should be encouraged to walk
until the limit of lower extremity pain tolerance is reached,
followed by a short period of rest until pain relief is obtained,
then a return to exercise
Circulation. 2006;113:1474 –1547
64. EXERCISE THERAPY
• Therefore, although exercise therapy in motivated patients
offers proven benefits, its effectiveness is applicable to only
about one third of patients presenting with intermittent
claudication
Rutherford’s Vascular Surgery 8th Ed
66. PHARMACOLOGIC TREATMENT
• Only two drugs (pentoxifylline and cilostazol) have achieved
US FDA approval for the treatment of intermittent claudication
• Other drugs :
• Changes in tissue metabolism (naftidrofuryl, levocarnitine)
• Enhanced nitric oxide production (L-arginine)
• Vasodilatory effects (statins, buflomedil, prostaglandins, ACE
inhibitors, K-134)
Rutherford’s Vascular Surgery 8th Ed
67. PENTOXIFYLLINE
• The first drug approved by the FDA for the treatment of
intermittent claudication
• Pentoxifylline is the methylxanthine derivative that is thought
to improve oxygen delivery
• Pentoxifylline is also believed to inhibit platelet aggregation
and to increase fibrinogen levels
Rutherford’s Vascular Surgery 8th Ed
68. • Pentoxifylline showed that maximal treadmill walking
distances in patients with claudication were improved by 12%
compared with placebo
• Although walking distances improved, patient discomfort with
walking typically persisted
Am Heart J. 1982 Jul;104(1):66-72.
69. PENTOXIFYLLINE
• Pentoxifylline (400 mg 3 times per day) may be considered as
second-line alternative therapy to cilostazol to improve
walking distance in patients with intermittent claudication
(Class IIb, Level of Evidence:A)
• The clinical effectiveness of pentoxifylline as therapy for
claudication is marginal and not well established (Class IIb,
Level of Evidence: C)
Circulation. 2006;113:1474 –1547
70. CILOSTAZOL
• Phosphodiesterase-III inhibitor increases cyclic adenosine
monophosphate (cAMP)
• Physiologic effects :
• Inhibition of smooth muscle cell contraction
• Inhibition of platelet aggregation
• Cilostazol is also thought to decrease smooth muscle cell
proliferation, a process that has been implicated in coronary
artery restenosis after percutaneous transluminal angioplasty
Rutherford’s Vascular Surgery 8th Ed
71. CILOSTAZOL
• Cilostazol has a beneficial effect on lipid concentrations
• Decrease in serum triglycerides
• Increase in HDL
• Although the precise mechanism by which cilostazol improves
the symptoms of intermittent claudication is unknown
Rutherford’s Vascular Surgery 8th Ed
72. • Compared with placebo, Cilostazol improves maximal walking
distance by 40% to 60% after 12 to 24 weeks of therapy
• Cilostazol, 100 mg or 50 mg, twice a day
Vasc Endovascular Surg 2002;36:83-91
73. • Cilostazol was associated with greater improvements in
community-based walking ability and health-related quality of
life (HQL) in patients
• Questionnaires assessing walking ability and HQL provide
important patient-based information about clinical outcomes of
claudication therapy
J Am Geriatr Soc 2002;50:1939–46
74. CILOSTAZOL
• Cilostazol (100 mg orally 2 times per day) is effective improve
symptoms and increase walking distance in patients with lower
extremity PAD and intermittent claudication (in the absence of
heart failure) (Class I,Level of Evidence:A)
• A therapeutic trial of cilostazol should be considered in all
patients with lifestyle-limiting claudication (in the absence of
heart failure) (Class I, Level of Evidence:A)
Circulation. 2006;113:1474 –1547
75. CILOSTAZOL
• Cilostazol has a moderate but notable adverse effect profile
that includes headache, diarrhea, and gastrointestinal
discomfort
• Contraindication : Congestive Heart Failure
• Cilostazol is a phosphodiesterase-3 inhibitor capable of
exacerbating ventricular dysfunction
• Metabolized by the liver via the cytochrome-P450 pathway
• CYP 3A4 and CYP 2C19
Rutherford’s Vascular Surgery 8th Ed
77. REVASCULARIZATION
• Decision making regarding revascularization is based first on
symptom status and the patient’s condition
• Revascularization is recommended only in cases of severe
claudication, and only after medical therapy has failed
Rutherford’s Vascular Surgery 8th Ed
78. REVASCULARIZATION
• The majority of claudicants are stable pattern of disease or have
an improvement with risk factor modification and exercise
• There are 20% to 30% require operation within 5 years as a
result of disease progression
• Risk for mortality and limb loss is 5% and 1% respectively
79. • Walking study consisted of a randomized trial to determine
outcome differences in patients with intermittent claudication
treated with angioplasty and stents versus medical
management (daily low-dose aspirin, lifestyle modification)
after 2 years
• There are no difference in maximal walking distance, treadmill
distance until onset of claudication, and QoL measures
between the two groups
J Vasc Surg 26:551–557, 1997
80. REVASCULARIZATION
• Indications for surgical reconstruction
• Disabling claudication (lifestyle-limiting disability)
• Ischemic rest pain
• Tissue loss
Rutherford’s Vascular Surgery 8th Ed
81. • Supervised exercise therapy has also been compared with primary
stenting revascularization for disabling claudication due to aortoiliac
occlusive disease
• At 6-month follow-up, the peak walking time was greatest for
supervised exercise, intermediate for stenting, and least with
pharmacologic therapy
• Supervised exercise shows the better outcome than stenting (P < .04)
Circulation. 2012 Jan 3;125(1):130-9