peripheral arterial disease education and abi training for vascular nurses presented by the society...

Peripheral Arterial Disease Education and ABI Training for Vascular NursesPresented by The Society for Vascular Nursing

Comprehensive In-Service Lecture Kit Supported by an educational grant from

Bristol-Myers Squibb/Sanofi Partnership

PERIPHERAL ARTERIAL DISEASE Education and ABI Training for Vascular Nurses A Train the Trainer Program

The Ankle Brachial Index: The Key to Early Detection and Management of Peripheral Arterial Disease

Acknowledgements

Course Development– ABI Registry Task Force

Diane Treat-Jacobson, Ph.D., R.N.Carolyn Robinson MSN, RN, CNP,CVNMarge Lovell RN, CCRC, CVN, BEdPatricia Lewis, MS, FNP, CVNM. Kate Schmidt, BSN, RN, CVN

Contact InformationSociety for Vascular Nursing203 Washington St., PMB 311Salem, MA 01970888-536-4786; 978-744-5005; Fax: 978-744-

5029

Peripheral Arterial Diseaseand Claudication

Peripheral Arterial Disease (PAD)A disorder caused by atherosclerosis that limits blood flow to the limbs

Claudication A symptom of PAD characterized by pain, aching, or fatigue in working skeletal muscles. Claudication arises when there is insufficient blood flow to meet the metabolic demands in leg muscles of ambulating patients

New PAD Guidelines

Enhanced quality of patient careEnhanced quality of patient care Increased recognition of the importance of Increased recognition of the importance of

atherosclerotic lower extremity PAD:atherosclerotic lower extremity PAD:– PrevalencePrevalence

– Cardiovascular riskCardiovascular risk

– Quality of lifeQuality of life Improved ability to detect and treat renal artery Improved ability to detect and treat renal artery

diseasedisease Improved ability to detect and treat AAAImproved ability to detect and treat AAA The evidence base has become increasingly The evidence base has become increasingly

robust, so that a data-driven care guideline is robust, so that a data-driven care guideline is now possiblenow possible

Defining a Population “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

Relative Prevalence of Peripheral Arterial Disease

Criqui MH et al. N Engl J Med. 1992;326:381-6.Hiatt W et al. Circulation. 1995;91:1472-9.Porter J. Mod Med. 1987;55:66-75.US Census Data, 1998 estimates. Web address www.census.gov/population/estimates/nation/infile2-1.txt

4.28.4113.52.54.724.870

0.81.619.860-69

0.92.168.940-59

Claudication

(millions)PAD

(millions)

Population (millions)

Age

(years)

Systemic Manifestations of Atherosclerosis

•TIA• Ischemic stroke

• Claudication

• Critical limb ischemia, rest pain, gangrene, amputation

• Renovascular hypertension

• Erectile dysfunction

•TIA• Ischemic stroke•TIA• Ischemic stroke

• Myocardial Infarction• Unstable angina pectoris

0% 5% 10% 15% 20% 25% 30% 35%

29%

11.7%

19.8%

19.1%

14.5%

4.3%

Prevalence of PADPrevalence of PAD

PARTNERS5

Aged >70 years, or 50–69 years with a history diabetes or smoking

San Diego2

Mean age 66 years

Diehm4

Aged 65 years

Rotterdam3

Aged >55 years

NHANES1

Aged 70 years

NHANES1

Aged >40 years

NHANES=National Health and Nutrition Examination Study; PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program].1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743.2. Criqui MH et al. Circulation. 1985;71:510-515.3. Diehm C et al. Atherosclerosis. 2004;172:95-105. 4. Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 5. Hirsch AT et al. JAMA. 2001;286:1317-1324.

In a primary care population defined by age and common risk

factors, the prevalence of PAD was

approximately one in three patients

1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Criqui MH, et al. Circulation. 1985;71:510-515.

Prevalence of PAD Increases with Age

Rotterdam Study (ABI <0.9)1 San Diego Study (PAD by noninvasive tests)2

0

10

20

30

40

50

60

Pat

ien

ts W

ith

P.A

.D.

(%)

55-59 60-64 65-69 70-74 75-79 80-84 85-89

Age Group, years

ABI=ankle-brachial index

Gender Differences in the Gender Differences in the Prevalence of PADPrevalence of PAD

Diehm C. Atherosclerosis. 2004;172:95-105.

Pre

vale

nce (

%) Women

Men

6880 Consecutive Patients (61% Female)

in 344 Primary Care Offices

<700

2

4

6

8

10

12

14

16

70–74 75–79 80–74 >85

Age (years)

18

Diabetes Increases Risk of PADDiabetes Increases Risk of PAD

22.4*19.9*

12.5

0

5

10

15

20

25

Normal glucosetolerance

Impaired glucose tolerance

Diabetes

Pre

vale

nce o

f P

AD

(%

)

Impaired Glucose Tolerance was defined as oral glucose tolerance test value ≥140 mg/dL but <200 mg/dL.*P.05 vs normal glucose tolerance. Reprinted with permission from Lee AJ et al. Br J Haematol. 1999;105:648-654. www.blackwell-synergy.com

Ethnicity and PAD:Ethnicity and PAD:The San Diego Population StudyThe San Diego Population Study

NHW Black Hispanic Asian0

1

2

3

4

5

6

7

8

9

10

% P

AD

NHW = Non-hispanic white Criqui et al. Circulation. 2005: 112: 2703-2707.

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Relative Risk

Smoking

Diabetes

Hypertension

Hypercholesterolemia

Hyperhomocysteinemia

C-Reactive Protein

Reduced Increased

Risk Factors for PADRisk Factors for PAD

1 2 3 4 5 60

Pathogenesis ofProgressive Atherosclerosis

Risk of Ischemic Events

Previous MI – 5-7 times more likely to have another MI– 3-4 times more likely to have a stroke

Previous stroke– 9 times more likely to have another stroke– 2-3 times more likely to have an MI

PAD– 4 times more likely to have an MI– 2-3 times more likely to have stroke

Long-term Survival in Patients With Long-term Survival in Patients With PADPAD

Criqui MH et al. N Engl J Med. 1992;326:381-386. Copyright © 1992 Massachusetts Medical Society. All rights reserved.

Normal subjects

Asymptomatic PAD

Symptomatic PAD

Severe symptomatic PAD

100

75

50

25

0 2 4 6 8 10 12

Su

rviv

al (%

)

Year

Contemporary PADContemporary PADRates of Myocardial Infarction and Rates of Myocardial Infarction and DeathDeath

0

10

20

30

40

50

MI Death

No PAD Asymptomatic PAD Symptomatic PAD

%

Hooi JD, et al. J Clin Epid. 2004;57:294–300.

3649 subjects (average age 64 yrs) followed up for 7.2 years

Association Between ABI and Association Between ABI and All‑Cause Mortality*All‑Cause Mortality*

0

10

20

30

40

50

60

70

80

<0.61

(n=156)

0.61-0.70

(n=141)

0.71-0.80

(n=186)

0.81-0.90

(n=310)

0.91-1.00

(n=709)

1.01-1.10

(n=1750)

1.11-1.20

(n=1578)

1.21-1.30

(n= 696)

1.31-1.40

(n=156)

>1.40

(n=66)

Baseline ABI

Tota

l m

ort

alit

y (

%)

Age range=mid- to late-50s; *Median duration of follow-up was 11.1 (0.1–12) years.

Adapted from O’Hare AM et al. Circulation. 2006;113:388-393.

N=5748Risk increases at ABI values below 1.0 and above 1.3

A Risk Factor “Report Card” for all Individuals with AtherosclerosisTobacco smoking Complete,

immediate cessation

Hypertension BP less than 130/85

mmHg

Diabetes Hb A1C <7.0

Dyslipidemia LDL Cholesterol less

than 100 mg/dl Raise HDL-c Lower Triglycerides

Inactivity Follow activity

guidelinesAntiplatelet therapy (like aspirin or Plavix) is:

Mandatory

Pathway of Disability in Intermittent Claudication

Adapted from McDermott M. Adapted from McDermott M. Am J MedAm J Med. 1999;CE (I):18-24. . 1999;CE (I):18-24.

PAD Reduced muscle

strength

Poor walking ability and IC

Disability

Denervation, muscle-fiber atrophy, decreased type II fibers, decreased oxidative metabolism

Cycle of deconditioning: decreased HDL, poorer glycemic control, poorer BP control

Impact of PAD on Quality of Life

PAD Diagnosis and Management Symptom Experience Limitation in Physical Functioning Limitation in Social Functioning Compromise of Self Uncertainty Adaptation

No. of people

30 34 38 40 50 55

CHFChronic

lung disease

Average adult

Average well adult

36

Intermittent claudication

Physical Component Summary Score

SF-36 Scores in Health and Disease

Location of Obstruction Influences Symptoms

Buttock, hip,Buttock, hip,thighthigh

Thigh, Thigh, calfcalf

Calf, ankle,Calf, ankle,footfoot

Obstruction in:Aorta orAorta oriliac arteryiliac artery

Femoral arteryFemoral arteryor branchesor branches

PoplitealPoplitealarteryartery

Claudication in:

Claudication: A Symptom of Peripheral Arterial Disease

Exertional aching pain, cramping, tightness, fatigue

Occurs in muscle groups, not joints (buttocks, hips, legs, calves)

Reproducible from one day to the next on similar terrain

Resolves completely with rest Occurs again at the same distance once

activity has been resumed

Symptoms in PAD

Patients with PAD

Symptomatic PAD

~39%1

Asymptomatic PAD

~61%1

Typical Symptoms(Intermittent Claudication)

~9%

Atypical Symptoms

~91%

1. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. 2005.2. Hirsch AT, et al. JAMA. 2001;286:1317-1324.

Clinical Assessment of Peripheral Arterial Disease

Components of Clinical Assessment Complete history

– Risk factor assessment– Activity assessment

Review of medications Physical examination

– Inspection of lower extremities– Pulse exam

Questions for Patients Do you develop discomfort in your

legs when you walk? – Cramping, aching, fatigue

Do you get this pain when you are sitting standing, or lying?

Do symptoms only start when you walk?

Does the discomfort always occur at about the same distance?

Do symptoms resolve once you stop walking?

PAD Pulse Evaluation

Right Left

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

Ankle–brachial index

Note: 0-4 scale, where 0 = absent, 2 = Diminished, 4 = Normal Limits

The Ankle-Brachial Index (ABI)

The first diagnostic assessment that should be done to evaluate a patient for PAD after a pulse exam in the presence of risk factors or if claudication is suspected.

Inexpensive, accurate and can be done in the primary care setting

The ABI is 95% sensitive and 99% specific for PAD

Predicts limb survival, potential for wound healing, and mortality

The Ankle-Brachial Index (ABI)

Indicated– In the absence of palpable pulses,

or if pulses are diminished– In the presence or suspicion of

claudication, foot pain at rest, or a non-healing foot ulcer

– Age greater than 70 years of age, >50 years with risk factors (diabetes, smoking)

Concept of ABIConcept of ABI

ABI has been found to be 95% sensitive and 99% specific for angiographically diagnosed PAD.

The systolic blood pressure in the leg should be approximately the same as the systolic blood pressure in the arm.

Therefore, the ratio of systolic blood pressure in the leg vs the arm should be approximately 1 or slightly higher.

Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049.

Arm pressure

Leg pressure

÷ ≈ 1

Performed with patient resting in supine position

All pressures are measured with a arterial Doppler and appropriately sized blood pressure cuff

Both brachial pressures are measured Ankle pressures are measured using

the posterior tibial and/or dorsalis pedis arteries

Understanding the ABI

Equipment needed:Equipment needed:

1.1. Blood Pressure Blood Pressure CuffCuff

2.2. Hand-held 5-10 Hand-held 5-10 MHz Doppler MHz Doppler probeprobe

3.3. Ultrasound GelUltrasound Gel

American Diabetes Association. Diabetes Care 2003: 26; 3333–3341.

Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 1: Gather Equipment NeededStep 1: Gather Equipment Needed

Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 2: Position the PatientStep 2: Position the Patient

Place patient Place patient in supine in supine position for position for 5 – 10 minutes 5 – 10 minutes minutesminutes


Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 3: Measure the Brachial Blood Step 3: Measure the Brachial Blood PressurePressure

1.1. Place the blood pressure cuff Place the blood pressure cuff on the arm above the elbow. on the arm above the elbow.

2.2. Apply gel to the skin surface.Apply gel to the skin surface.3.3. Place the Doppler probe over Place the Doppler probe over the brachial pulsethe brachial pulse

4.4. Inflate the cuff to approx. 20 Inflate the cuff to approx. 20 mm/hg above the point where mm/hg above the point where systolic sounds are no longer systolic sounds are no longer heard. heard.

5.5. Deflate the cuff slowly until Deflate the cuff slowly until the arterial signal returns the arterial signal returns (systolic pressure)(systolic pressure)

6.6. Repeat in the other armRepeat in the other arm


Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 4: Position the Cuff Above the Step 4: Position the Cuff Above the AnkleAnkle

Place blood Place blood pressure cuff pressure cuff just above the just above the ankle of one leg, ankle of one leg, apply gel over apply gel over the area of the the area of the dorsalis pedis dorsalis pedis arteryartery

Dormandy JA et al. J Vasc Surg. 2000;31:S1-S296.

Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 5: Measure the Pressure in the Step 5: Measure the Pressure in the Dorsalis Pedis ArteryDorsalis Pedis Artery


1.1. Place Doppler probe Place Doppler probe over the dorsalis over the dorsalis pedis artery; inflate pedis artery; inflate the cuffthe cuff

2.2. Deflate the cuff; when Deflate the cuff; when the return of blood the return of blood flow is detected, flow is detected, record this as the record this as the systolic pressure of systolic pressure of the DP artery of that the DP artery of that legleg

Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 6: Measure the Pressure in the Step 6: Measure the Pressure in the Posterior Tibial ArteryPosterior Tibial Artery

1.1. Place gel and Place gel and Doppler probe over Doppler probe over the posterior tibial the posterior tibial artery (below the artery (below the cuff)cuff)

2.2. Measure the Measure the pressure, record as pressure, record as posterior tibial posterior tibial pressure for that pressure for that legleg


Measuring the Ankle-Brachial Index Measuring the Ankle-Brachial Index (ABI)(ABI)Step 7: Repeat the Process in the Step 7: Repeat the Process in the Opposite LegOpposite Leg

Repeat the same Repeat the same process in the process in the other leg and other leg and record the record the pressures of the pressures of the dorsalis pedis dorsalis pedis and posterior and posterior tibial arteriestibial arteries


Calculating the ABICalculating the ABI

ABI InterpretationABI Interpretation

≤ ≤ 0.90 is diagnostic of peripheral arterial 0.90 is diagnostic of peripheral arterial diseasedisease

Hiatt WR. N Engl J Med. 2001;344:1608-1621.

Higher right-ankle pressure (DP or PT pulse)

Higher arm pressure (of either arm)

=

Right Leg ABIRight Leg ABI

Higher left-ankle pressure

(DP or PT pulse)

Higher arm pressure (of either arm)

=

Left Leg ABILeft Leg ABI

Calculating the ABIExample Calculation


60 mm Hg

120 mm Hg=


66 mm Hg

120 mm Hg=


Calculating the ABICalculating the ABIExample CalculationExample Calculation

66 mm Hg

120 mm Hg


= 0.50 = 0.55


60 mm Hg

120 mm Hg


ABI InterpretationABI Interpretation

≤ ≤ 0.90 is diagnostic of peripheral arterial 0.90 is diagnostic of peripheral arterial diseasedisease

ABI Limitations

Possible false negatives in patients with noncompressible arteries, such as some diabetics and elderly individuals

Insensitive to very mild occlusive disease and iliac occlusive disease

Not well correlated with functional ability and should be considered in conjunction with activity history or questionnaires

Interpreting the Ankle–Brachial Index

Adapted from Hirsch AT. Family Practice Recertification. 2000;22:6-12.

ABI Interpretation

0.90–1.30

Normal

0.70–0.89

Mild

0.40–0.69

Moderate

0.40 Severe

>1.30 Noncompressible vessels

Referring to the Vascular Lab

Caveats for referral to vascular labCaveats for referral to vascular lab

• Assessment of the location and severity is desired

• Patients with poorly compressible vessels • Normal ABI where there is high suspicion of

PAD

Vascular Lab EvaluationVascular Lab Evaluation

•Segmental pressures •Pulse volume recordings•Treadmill

PAD DiagnosisPAD Diagnosis

Indications for Referral for Vascular Specialty Care

Lifestyle-disabling claudication (refractory to exercise or pharmacotherapy)

Rest pain Tissue loss

Severity

of

ischemia

Summary

PAD is a common atherosclerotic disease associated with risk of cardiovascular ischemic events and significant functional disability

PAD can be effectively assessed in the primary care setting by primary care nurses

The ankle brachial index is an effective and efficient measurement tool for diagnosis of PAD

Early detection of PAD allows for appropriate disease management and decreased likelihood of ischemic events and disease progression

The Graying of U.S. Society

Seniors 12.4 percent of the population

Baby boomers will number 75 million

2030– 20 percent will be over age 65– 1/2 population > age 40

Nurse Competence in Aging Imperatives Moving to an aging society 85+ population > 8.9 million in

2030 Older adults

– Utilize 50% of hospital days – 45% of the direct care – primary patient population of most

specialty nurses. Geriatric preparation significantly

improve health care to older adults.

Classifying the Elderly

ages 65 to 74 - the young old ages 75 to 84 - the middle old ages 85 and older - the old old

Impact of Aging

↑risk of health ↑co-morbidities ↑ disabilities ↑dementia ↑seniors with chronic illness

requiring care ↓quality of life

Age Related Changes

Cardiac Pulmonary Renal Gastrointestinal CNS Integument

Cardiac Function

Coronary artery blood flow – decreases 35% between ages 20

and 60. Cardiac output decreases Systolic and diastolic murmurs There is a decrease in cardiac

responsiveness rate with exercise.

Cardiovascular Function and Aging

Central and peripheral circulation decreases

Aerobic capacity decreases about 1% per year

Maximum heart rate decreases about 1 beat per year

Maximum stroke volume decreases Maximum cardiac output decreases Peripheral blood flow decreases

Physiological Changes to the Body with Aging

Heart muscle– Contractile strength and efficiency decreases – Left ventricular wall thickens

Heart valves – fibrotic and sclerotic

SA node and AV tracts – Infiltrated by fibrous tissue.

Aortic and mitral valves– Calcify

Changes in Blood Vessels

Veins and arteries – dilate and stretch – decreased strength and elasticity.

Peripheral arteries – Tortuous – Less resilient.

Aorta and large arteries – stiffen

Aorta – may lengthen and become tortuous.

Blood Pressure Changes

Systolic blood pressure – May rise disproportionately higher than

diastolic. Changes in the cardiovascular system

– Direct effects on other organs. Hypertension

– Atherosclerotic changes in blood vessels – May result in the loss of vision, renal

Strength Changes With Aging

Maximal strength decreases

Muscle mass decreases

Total number and size of

muscle fibers decreases

Nervous system response slows

Exercise and the Elderly

1996 report 30% of the elderly exercise regularly.

Results in decreased risk for a number of chronic and debilitating illnesses.

US Department of Health and Human Services

Assess– Motivation. – Level of activity that a person is capable of

doing,– Help him/ her to understand how to change

Health Care for the Elderly

Include– health promotion, – disease prevention, – health maintenance

Anatomical and physiological changes – cardiovascular respiratory– Genitourinary endocrine – Neurological skin– musculoskeletal

peripheral arterial disease education and abi training for vascular nurses presented by the society...

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