amjad almahameed, md, mph division of cardiology beth israel deaconess medical center boston...
TRANSCRIPT
Amjad AlMahameed, MD, MPH
Division of Cardiology
Beth Israel Deaconess Medical Center
Boston
Differentiating Lower Extremity Pain: Arteries, Veins, and Nerves!
The Value of the ABI
Objectives
• Review the differential diagnosis of lower extremity dysfunction
• Beyond intermittent claudication: Recognize the different clinical presentations of PAD
• PAD as the cause of symptoms: Reflect on clinical evaluation
HTN 50 million
Stroke4.4 million
CHF4.6 mill
Heart 16.8 million
AMI7.2 mill
Angina6.3 mill
68 Million Americans with CVD
PAD8.4 million
PAD incidence expected torise by 40% (M) and 15% (W)
till 2030
Musculoskeletal Causes:
- Arthritis (lumbar disk, hip, knee) - Bursitis - Tendonitis - Tight hamstring/quadriceps
Neurogenic Causes
- Lumbar canal stenosis
- Peripheral neuropathy
Podiatric Causes:
- Planter fasciitis
- Tarsal Tunnel Syndrome
Other Vascular:
- Venous claudication - Takayasu’s, giant cell vasculitis - Thromboangiitis obliterans - Chronic Pernio
D Dx of Leg Pain
PAD Venous Claudication
Neurogenic Claudication
Location muscle group whole leg Poorly localize
Quality of pain Cramping “Bursting” Electric shock-like
Onset Gradual, predictable
Variable Variable
Exacerbation Walking, biking, leg elevation
Dependency (sitting, standing), walking,
biking
Standing, walking, lying prone, exten-ding lumbar spine
Relief Stopping or standing
Leg elevation,
compression Rx
Sitting, flexing
lumbar spine
Legs affected Usually one Usually one Often both
Are the Limb Symptoms Related to PAD?Are the Limb Symptoms Related to PAD?
Intermittent Claudication
Predictable Leg pain induced by walking
Relief with resting (stopping/standing)
Recurs when walking is resumed
Classic triad of
symptomsin patients
with IC is seen in
(11-33%)
of all PAD pts
NormalFatigue,
heaviness Mild Moderate Severe Rest pain
Poor wound
healing
Impendingor overt
gangrene
Claudication Limb-Threatening Ischemia
Worsening Flow Limitation
Spectrum of Peripheral Arterial Disease Presentation
Pain Soreness
Ache Weakness
Tiredness Numbness
Tightness Discomfort
Indications for the ABI
• Non palpable pulses
• Unexplained leg pain
• Rest pain
• Non healing sores or ulcers
• Claudication
• Risk stratification
ABI is 95% sensitive and 99% specific for PAD
A/B Index SEVERITY OF DISEASE
0.9 – 1.0 Normal
0.70 – 0.89 Mild disease
0.40 – 0.69 Moderate disease
< 0.40 Severe disease
Lower extremity systolic pressureLower extremity systolic pressure________________________________________________________________________________________
Brachial artery systolic pressureBrachial artery systolic pressureABI =ABI =
180 mmHg
180 mmHg
170 mmHg
130 mmHg 180 mmHg
170 mmHg
R DP 130 mmHgR PT 110 mmHgABI 0.72
R DP 180 mmHgR PT 180 mmHgABI 1.0
R transmit R Toe L transmit L Toe
Post Exercise
R Ankle L Ankle
Higher R-Ankle SBP
Higher Arm SBPRight ABI
Higher R-Ankle SBP
Higher Arm SBPLeft ABI
Usefulness of the ABI
• Diagnosis, localization, and monitoring PAD progression
• Assess functional capacity (even asymptomatic pts)
• Predictor of cardiovascular morbidity and mortality
PAD Survival as a Factor of the ABI
Year
100
80
60
40
200 108642
Pat
ien
ts S
urv
ival
(%
) ABI >0.85
ABI 0.40–0.85
ABI <0.40
McKenna M, et al. Atherosclerosis. 1991;87:119-128.
PAD and Functional Impairment
•Peripheral arterial disease (PAD) is associated with
– Poorer walking endurance– Slower walking speed– Poorer balance
• Compared to individuals without PAD
Limited leisure and Work activities
Olin JW. AM J Med 10-17,1998.Scherer SA. Arch phys Med Rehab 79:529-531,1998 Regensteiner JG. J Vasc Med Biol2:142-152,1990
McDermott M et al. JAMA 2004; 292:453-461.
Outcome Asymptomatic PAD
Without
PAD
p
Mean annual decline in 6-minute walk performance (ft) (95% CI)
- 76.8(- 135 to - 18.6)
- 8.67(-36.9 to -19.5)
0.04
Walking Performance in Asymptomatic Peripheral Arterial Disease
Clinical Tips
• The DP pulse is congenitally absent in up to 32% of normal individual but the absence of PT pulse is always abnormal
• Lack of hair on the shins is not always a sign of PAD
• Patients with rest pain may present with pitting edema
• Persistence of pallor > 40 second after 1 minute elevation is indicative of severe disease