Join us tomorrow for the launch of a new accredited tweetorial – a case-based program on evidence-based management of #PAD. Free CE/CME for physicians, nurses, pharmacists! Expert author @JoshuaBeckmanMD. FOLLOW US and tell your colleagues to do the same! #MedTwitter #cardio

1) Welcome to our accredited tweetorial on #PAD ! Expert faculty @JoshuaBeckmanMD. Earn 0.5h CME/CE credit by following this thread. Supported by Abbott, AstraZeneca, Bayer, Chiesi, NovoNordisk. #cardiotwitter @MedTweetorials @GameofAcademics @CMichaelGibson

2) First, a case.
72-year-old F presents to the office for annual physical. Neither cardiac nor stroke history. She reports no change in her usual condition. MHx: HTN, T2 diabetes, and 20 pack-year smoking Hx.

3) On exam, HR 72 bpm, BP 148/90, clear lungs, regular rate without murmurs/gallops, 2+ radial pulses, 1+ right DP/PT pulses, and absent left DP/PT pulses.

4) Her current medication regimen includes lisinopril 10 mg, amlodipine 5 mg, metformin 500 mg BID, and atorvastatin 40 mg QD.

5) With what you know now, should antiplatelet therapy be initiated?
a. Yes, aspirin, ASCEND trial makes it clear
b. No, ASCEND shows no mortality difference
c. Yes, ASA, based on absent pulses
d. No, Asx PAD has no benefit w/ASA

6) ASCEND trial (N Engl J Med. 2018 Oct 18;379(16):1529-1539) results are mixed.

7) Very similar number of events prevented as major bleeds caused. No difference in mortality. If there is a benefit, it is very small.

8) How about for asymptomatic PAD? Two trials looked at this. AAA (JAMA 2010; 303: 841–848) and POPADAD (BMJ 2008; 337: a1840).

9) AAA enrolled 3350 M/W screened for PAD and found no benefit with ASA.

10) POPADAD enrolled 1276 M/W w/diabetes & PAD and found no benefit of ASA

11) So, is ASA unnecessary in ASX PAD?

12) It should be noted that both AAA and POPADAD used study entry criteria that lowered the CV risk from PAD. AAA ABI ≤0.95 and the lower instead of higher ankle pressure and POPADAD used ≤0.99.

13) We do know that using standard ABI measures strongly associate with mortality. The aspirin in ASX PAD question remains unresolved if you don’t believe that leg muscle symptoms should determine use.

14) Back to the patient. Discovering absent pulses, you inquire about her walking. She reports that she can’t walk much more than a block without having to stop for a few minutes.

15) The walking limitation has been there for more than a year and makes her worried about going shopping and leaving the house.
You send her to the vascular laboratory for an ankle brachial index. Her ABI on the left is 0.7 and is 0.9 on the right.

16) Now, based on the documentation of a low ankle pressure and left calf symptoms, do you start aspirin?

17) As clinicians, we have two jobs: to make her feel better and live longer. Let’s start with live longer first. You discuss in greater detail that PAD comes with a higher cardiovascular risk in the coming years including death, MI, stroke, and more limb problems.

18) In addition to the aspirin, statin, blood pressure control, and glycemic control, which of the following therapies reduces 3-point MACE?

19) Make your choice and return tomorrow for more education on #PAD and on this case! @vascularsvs, @sirspecialists, @vivaphysicians, @tctmd, @cmichaelgibson, @ethanjweiss, @skathire, @cardiooncology, @heathergornik, @herbaronowmd, @rkollurimd, @drseanlyden, @drsoniaanand1