A 68-year-old woman recently diagnosed with PAD presents to the clinic for follow-up. A fasting lipid profile obtained prior to the appointment demonstrates a low-density lipoprotein (LDL) level of 145 mg/dL. You decide to initiate therapy with a hydroxymethyl glutaryl coenzyme-A reductase inhibitor (statin).
Which of the following LDL target levels is most appropriate?
Less than 100 mg/dL. The most recent practice guidelines for the management of PAD, updated in March 2013, recommend a target LDL of less than 100 mg/dL for patients with an established diagnosis of PAD.
Reference:
Anderson JL, Halperin JL, Albert NM, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:1425–1443.
A 52-year-old woman with a history of PAD, diabetes mellitus type 2, and active smoking presents to the clinic with a blood pressure of 150/95 mmHg.
What blood pressure target should you recommend for this patient?
Less than 130/80 mmHg. The most recent practice guidelines for the management of PAD, updated in March 2013, recommend a target blood pressure of less than 140/90 mmHg for patients with PAD. The guidelines recommend a lower target, less than 130/80 mmHg, for patients with PAD and concomitant diabetes mellitus or renal insufficiency.
For the above patient you decide to start her on a new antihypertensive medication.
Which of the following class of medications are contraindicated?
None of the above. Thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and β-adrenergic blockers are all acceptable medications to achieve blood pressure targets in patients with PAD.
A 68-year-old man with a 30 pack-year history of smoking is seen in the clinic for follow-up after a non-ST-elevation myocardial infarction (NSTEMI). Because of his smoking history and age you order an ultrasound of his abdomen to rule out abdominal aortic aneurysm (AAA). He is discovered to have an infrarenal AAA measuring 5.0 cm × 4.9 cm.
After this initial baseline study, how often should you repeat the ultrasound of the abdomen?
Every 6 to 12 months. According to the appropriate use criteria published by the intersocietal committee on peripheral vascular testing and the American College of Cardiology Foundation/American Heart Association practice guidelines for PAD, patients with an asymptomatic AAA measuring 4.0 to 5.4 cm should have surveillance imaging every 6 to 12 months in the first year.
At what size measurement should you refer a patient for repair of an asymptomatic infrarenal AAA?
5.5 cm or greater. The patient should be referred for repair once the infrarenal AAA reaches a diameter of 5.5 cm or greater due to an increased risk of spontaneous rupture. Surveillance imaging is advised at regular intervals for aneurysms less than 5.5 cm.
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