Study Questions: Chapter 11 Chapter 11: Peripheral Artery Disease: Medical Treatment and Risk Reduction Strategies TRACIE C. COLLINS, MD, MPH Study Questions : Chapter 11 * 1.) What are the most important risk factors for PAD? Diabetes mellitus and obesity Obesity and hypertension Cigarette smoking and dyslipidemia Diabetes mellitus and cigarette smoking Show answerThe correct answer is 4, Diabetes mellitus and cigarette smoking. Diabetes mellitus and smoking are associated with PAD progression and limb loss. They are the 2 most important risk factors for PAD. * 2.) What is the expected percentage improvement in peak exercise performance in patients with claudication treated with supervised walking therapy? 10% 25% 150% 100% Show answerThe correct answer is 3, 150%. Based on several trials, supervised walking therapy improves maximal walking distance 150%. * 3.) Based on results from the CLaudication: Exercise Versus Endoluminal Revascularization (CLEVER) trial, which of the following therapies is superior in improving quality of life for patients with aortoiliac occlusive disease? Statin therapy Stent revascularization Supervised walking therapy Open revascularization Show answerThe correct answer is 2, Stent revascularization. In the CLEVER trial, in patients with claudication due to aortoiliac peripheral artery disease, both supervised exercise and stent revascularization improved maximal walking distance more than optimal medical care alone. While supervised exercise led to greater improvement in maximal walking distance as compared to stent revascularization, quality of life and free-living step activity were improved more with stent revascularization. * 4.) Which of the following treatments is most efficacious for smoking cessation in patients with PAD? Motivational interviewing Health education counseling Varenicline Bupropion Show answerThe correct answer is 3, Varenicline. In a randomized, double-blind, clinical trial conducted at 19 US centers from June 19, 2003, to April 22, 2005, 1025 healthy smokers (10 cigarettes/day) were randomized to receive brief counseling and varenicline at 1 mg twice per day (n=352), bupropion sustained-release at 150 mg twice per day (n=329), or placebo (n=344). Four-week abstinence rates with varenicline were 44%, as compared to 17.7% for placebo (P<0.001) and 29.5% for bupropion (P<0.001). * 5.) A 62-year-old waste management worker was recently diagnosed with PAD based on exertional calf symptoms at 3 blocks, and an ankle-brachial index of 0.80 and 0.72 of the right and left leg, respectively. His symptoms limit his ability to work. He has the following risk-factor profile: a 25-pack-year smoking history; hypertension, with an office blood pressure of 142/98, on hydrochlorothiazide; and hyperlipidemia, with an LDL 110, on simvastatin, 20 mg daily. He has normal renal function and a normal ejection fraction. In addition to smoking cessation, which of the following is a reasonable next step in his management? Refer to surgical bypass Refer for walking therapy Refer for endovascular stenting Start pentoxifylline Show answerThe correct answer is 2, Refer for walking therapy. The patient would benefit from efficacious medical therapy prior to consideration for invasive therapy. Thus, the best choice as an initial option is to start a supervised walking program.