Peripheral Arterial
Disease
Ananda Marina
Pembimbing: dr. Deddy Tedjasukmana,
SpKFR-K
Introduction
Peripheral artery disease (PAD) is now the preferred
term for partial or complete obstruction of 1 peripheral
arteries
Other terms used for this condition are peripheral
vascular disease, peripheral arterial occlusive disease,
and lower extremity arterial disease
It is estimated that >200 million people have PAD
worldwide
Criqui MH, Aboyans V. Epidemiology of Peripheral Artery Disease. Circ Res. 2015 Apr 24;116(9):150926.
It has been long recognized that an insufficient blood
supply to the legs could cause pain and dysfunction in
the same way that coronary artery disease could lead to
angina intermittent claudication leg pain
associated with walking and relieved by rest
Prevalence of history of myocardial infarction was 2.5
as high in subjects with PAD (based on ABI<0.9)
Conversely, the prevalence of PAD was 2.1 as high in
patients with a history of myocardial infarction versus
those without
Criqui MH, Aboyans V. Epidemiology of Peripheral Artery Disease. Circ Res. 2015 Apr 24;116(9):150926.
Individuals 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
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
Ankle brachial index (ABI)
The primary non-invasive test for the diagnosis of PAD is
the ABI
In healthy persons, the ABI is >1.0
ABI 0.90 is used to define PAD
The sensitivity and specificity: 79% and 96%
ABI Lower extremity systolic pressure
= Brachial artery systolic pressure
European Stroke Organisation, Tendera M, Aboyans V, Bartelink M-L, Baumgartner I, Clment D, et al. ESC Guidelines on the diagnosis
and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral,
mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of
the European
American Society
College of Cardiology
of Cardiology (ESC). Eur
Foundation andHeart J. 2011 Nov;32(22):2851906.
the American Heart Association. Management of Patients with Peripheral Arterial
Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
Measuring ABI after exercise enables the detection of
additional subjects with LEAD, who have normal or
borderline ABI at rest
The patient is asked to walk (commonly on a treadmill
at 3.2 km/ h at a 1020% slope) until claudication pain
occurs and impedes walking
An ABI drop after exercise seems especially useful when
resting ABI is normal but there is clinical suspicion of
PAD
Atreatment
toebrachial index <0.70 is usually disease ofconsidered
European Stroke Organisation, Tendera M, Aboyans V, Bartelink M-L, Baumgartner I, Clment D, et al. ESC Guidelines on the diagnosis
and of peripheral artery diseases: Document covering atherosclerotic extracranial carotid and vertebral,
diagnostic ofFoundation
PAD
mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of
the European
American Society
College of Cardiology
of Cardiology (ESC). Eur
andHeart J. 2011 Nov;32(22):2851906.
the American Heart Association. Management of Patients with Peripheral Arterial
Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
Critical limb ischemia
CLI limb pain occurring at rest or impending limb loss
that is caused by severe compromise of blood flow to
the affected extremity
This includes patients with chronic ischemia rest pain,
ulcers, or gangrene attributable to objectivitely proven
arterial occlusive disease
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with Peripheral Arterial
Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
Acute limb ischemia
Acute limb ischemia is defined as a rapid or sudden
decrease in limb perfusion that threatens limb viability
The five Ps suggest limb jeopardy:
Pain
Paralysis
Paresthesias
Pulselessness
Pallor
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
American College of Cardiology Foundation and the American Heart Association. Management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal aortic). Elsevier; 2011
Exercise Rehabilitation Programs for
PAD
Clinical studies have defined the optimal methods for
implementing exercise training in PAD
The goals of comprehensive prevention strategies:
(1) to reduce limb symptoms
(2) to improve exercise capacity and prevent or lessen
physical disability
(3) to decrease the occurrence of cardiovascular events
Supervised exercise programs appear to deliver a greater
improvement in functional measures compared with
unsupervised training
Hamburg NM, Balady GJ. Exercise Rehabilitation in Peripheral Artery Disease. Circulation. 2011 Jan 4;123(1):8797.
A Cochrane review in 2006 of 8 small randomized trials
with a total of 319 participants concluded that supervised
exercise training was superior to unsupervised exercise
and yielded a 150-m greater improvement in walking
time
The American Heart Association and the American College
of Cardiology, the American College of Sports Medicine, and
the American Association of Cardiovascular and Pulmonary
Rehabilitation all recommend an exercise treadmill
test before exercise training to evaluate walking capacity
and to assess the degree of exercise limitation
Hamburg NM, Balady GJ. Exercise Rehabilitation in Peripheral Artery Disease. Circulation. 2011 Jan 4;123(1):8797.
Hamburg NM, Balady GJ. Exercise Rehabilitation in Peripheral Artery Disease. Circulation. 2011 Jan 4;123(1):8797.
Hamburg NM, Balady GJ. Exercise Rehabilitation in Peripheral Artery Disease. Circulation. 2011 Jan 4;123(1):8797.
Comprehensive cardiovascular rehabilitation that includes
exercise training is a model for expanded delivery of second-
ary prevention in PAD
Hamburg NM, Balady GJ. Exercise Rehabilitation in Peripheral Artery Disease. Circulation. 2011 Jan 4;123(1):8797.
Rehabilitasi pada PAD
Exercise
Stocking
Elevasi tungkai
Edukasi modifikasi faktor risiko
Keberhasilan rehabilitasi: apabila pada awal pasien
hanya dapat berjalan 5-10 m hingga timbulnya nyeri,
maka diharapkan pasien dapat berjalan sejauh 200
meter tanpa nyeri hingga diharapkan dapat berjalan
sejauh 3000m dalam 30 menit
THANK YOU
