Atherothrombosis Management in Practice Clinical Cases

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Atherothrombosis Management in Practice
Clinical Cases
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Clinical Case One
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Clinical Case One

• Patient
• JM male, 50 years old
• Occupation postman

• Presenting complaint
• Last 6 months left calf pain on walking 300 m
  (two blocks)
• Pain is relieved by rest
• No pain at rest
• No other complaints

clinical case one
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Diagnosis

• What is your diagnosis?

1. Arthritis of the hip
2. Peripheral neuropathy
3. Venous disease
4. Intermittent claudication
5. Sciatic pain (sciatic nerve compression)
6. None of the above
clinical case one
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Physical Examination (I)

• On presentation
• General status excellent
• Heart and lungs no abnormalities
• BP 138/88 mmHg
• Pulse regular 88/min

clinical case one
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Electrocardiogram (ECG)

• ECG Q-waves suggest an old inferior infarction

clinical case one
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Physical Examination (II)

• Right limb
• Bruit over right femoral artery
• Artery pulsations present, including in foot
  arteries
• Left limb
• Bruit over left femoral artery
• Femoral artery pulsations present in groin
• No pulsations in popliteal or distal pulses

clinical case one
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Investigation (I)

• What is your next step in light of JMs
  condition?

1. Reassure JM nothing else to be done
2. Measure ankle pressure
3. Duplex scan arteries of the lower limbs
4. Perform contrast arteriography
clinical case one
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Investigation (II)

• Pressure gradients
• Left ankle 80/138 (index 0.58)
• Right ankle 104/138 (index 0.75)

What treatment does JM require now?
1. No treatment
2. Drug therapy
3. Exercise training
4. Drugs and training
5. Interventional treatment (PTA, vascular
surgery)
4. Some other treatment
clinical case one
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Treatment (I)

• Which medication would you consider?

1. ASA
2. Dipyridamole
3. Ticlopidine
4. Clopidogrel
5. Cilostazol
6. One of pentoxifylline, buflomedil, or
naftidrofuryl
7. A combination of drugs
8. Some other drug
clinical case one
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Follow-up (I)

• On discharge
• Training program and low-dose ASA (100 mg o.d.)

• 4 months later
• Claudication improved but did not disappear
• JM developed a transient ischemic attack (TIA)
  with weakness in the left arm
• Bruit heard over right carotid artery

clinical case one
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Investigation (III)

• How would you approach the TIA problem?

1. Duplex scan of the carotid arteries
2. Invasive arteriography
3. Nuclear magnetic resonance (NMR) angiography
4. Brain computed tomography (CT) scan
5. Duplex and brain CT scans
6. None of these
clinical case one
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Imaging Results (I)
Right carotid
clinical case one
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Imaging Results (II)
Left carotid
clinical case one
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Imaging Results (III)
Velocity pattern
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Treatment (II)

• How would you treat the TIA?

1. Endarterectomy
2. Angioplasty and, if appropriate, stenting of
the right carotid artery
3. Continue ASA therapy alone
4. Replace ASA with clopidogrel
5. Prescribe a combination of ASA and clopidogrel
6. None of these
clinical case one
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Follow-up (II)

• 1 year later
• JM is doing fine
• Minor claudication remains
• No neurologic symptoms
• Clopidogrel 75 mg o.d.

clinical case one
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Clinical Case Two
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Clinical Case Two

• Patient
• KK male, 58 years old
• Presenting complaint
• My right calf cramps whenever I walk a quarter
  of a mile uphill
• Symptom present 2 months

clinical case two
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Background
KK medical history

• Myocardial infarction (MI) at age 53
• Hypertension 8 years
• Type II diabetes mellitus 4 years.
• KK smoked 2 packs/day for 35 years
• Medications include captopril and glyburide
  (glibenclamide)

clinical case two
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Physical Examination (I)

• On presentation
• Height 5 8" (1.72 m)
• Weight 186 lb (84.4 kg)
• BP 164/100 mmHg
• Pulse 84 bpm
• Left carotid bruit

clinical case two
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Physical Examination (II)

• On presentation
• Lungs clear to palpation and auscultation
• Heart S4, no murmurs
• Abdomen right lower quadrant bruit, no masses
• Extremities
• diminished right femoral pulse
• absent right popliteal and pedal pulses
• normal left femoral, popliteal, and pedal pulses

clinical case two
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Investigation (I)
Laboratory results

• Glucose 204 mg/dL 11.3 mmol/L
• HbA1C 9.8
• Total cholesterol 272 mg/dL 7.0 mmol/L
• Low-density lipoprotein (LDL) cholesterol 184
  mg/dL 4.7 mmol/L
• High-density lipoprotein (HDL) cholesterol 38
  mg/dL 0.9 mmol/L
• Triglycerides 250 mg/dL 2.8 mmol/L

clinical case two
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Investigation (II)
Laboratory results

• Liver function tests normal
• Hct 48
• White blood cells 5,300/µL
• Platelets 190,000/µL

clinical case two
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Diagnosis
What are the relevant diagnoses?

• In summary, KK has systemic atherothrombosis
• He has multiple clinical manifestations of this
  problem and multiple risk factors, including

• peripheral arterial disease

• coronary artery disease (prior MI)

• carotid bruit (asymptomatic)

• hypertension

• Type II diabetes mellitus

• hypercholesterolemia

clinical case two
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Investigation (III)

• Which one of the following tests should be
  considered to further evaluate PAD?

1. Magnetic resonance arteriogram
2. Segmental pressure measurements
3. Pulse-volume recording
4. Duplex ultrasound of the leg
5. Contrast arteriogram
clinical case two
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Investigation (IV)
Segmental systolic pressure measurements
Right (mmHg) Left (mmHg) Arm
164 160 Upper thigh 144 170 Lower
thigh 142 168 Calf 110 166 Ankle 88 164
Ankle-brachial 0.51 1.00index (ABI)
clinical case two
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Investigation (V)

• Which test is NOT indicated at this time?

1. Treadmill exercise test
2. Dipyridamole MIBI
3. Cardiac catheterization
4. Carotid ultrasound
5. Abdominal ultrasound
clinical case two
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Treatment (I)

• What treatment should be initiated to reduce
  potential cardiovascular events?

• Risk factor modification treatments include

• smoking cessation
• statin
• fibric acid derivative
• insulin/oral hypoglycemic agent
• antihypertensive agent

• Antiplatelet therapy treatments include

• ASA
• clopidogrel

clinical case two
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Treatment (II)

• What is the most effective initial strategy to
  relieve symptoms of claudication?

1. Exercise rehabilitation
2. PTA
3. Vascular surgery
4. Cilostazol
5. Naftidrofuryl
6. Pentoxifylline
clinical case two
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Treatment (III)

• Treatment strategy

• Intensified diabetes Rx, so that HbA1C lt 7
• Statin Rx
• No renal artery stenosis, therefore hypertension
  managed with pharmacotherapy
• Smoking cessation program
• Clopidogrel 75 mg o.d.
• Exercise rehabilitation program

clinical case two
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Follow-up
After 3 months

• KK able to walk distance of half a mile

clinical case two
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Clinical Case Three
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Clinical Case Three

• Patient
• VM male, 62 years old
• Occupation retired

• Background
• Diabetes and hypertension
• No smoking

clinical case three
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History

• VM medical history
• CABG in 1985
• Several episodes of hospitalization for
  congestive heart failure in the past few months
• Left knee pain with walking, relieved with
  stopping
• No chest pain or dyspnea with exertion
• Episode (lt 5 min) right facial numbness, 2 weeks
  prior to presentation

clinical case three
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Referral

• Referral details
• Lateral ischemia with NSVT at a low workload on
  thallium stress test
• 100 proximal occlusion of the LAD, Lat Cx and
  RCA on cardiac catheterization
• Patent grafts, but severe diffuse disease beyond
  touchdown of the three grafts
• 75 stenosis beyond the anastomosis of the SVG to
  Lat Cx

clinical case three
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Physical Examination (I)

• On referral
• BP 170/95 mmHg
• Heart rate 78 bpm
• Respiratory rate 12 bpm
• Corpulence mildly obese
• Head, eye, nose and throat (HEENT) bilateral
  carotid bruits
• Lungs clear to auscultation

clinical case three
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Physical Examination (II)

• On referral
• Heart regular rhythm and rate, no S3, 2/6 HSM at
  apex
• Abdomen no bruits, and no pulsatile mass
• Extremities distal pulses 2 bilateral
• Neurologic exam intact in detail

clinical case three
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Medication

• Current
• Furosemide 100 mg o.d.
• Nifedipine XL 90 mg o.d.
• Atenolol 100 mg o.d.
• Isosorbide mononitrate 120 mg o.d.
• ASA 325 mg o.d.
• Glipizide XL 10 mg o.d.

Allergies Penicillin, captopril, and shellfish
clinical case three
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Investigation (I)
Laboratory results

• Blood urea nitrogen 22 mg/dL
• Creatinine 1.3 mg/dL
• Glucose 278 mg/dL
• Hemoglobin 14 g/dl
• Low-density lipoprotein (LDL) cholesterol 140
  mg/dL
• High-density lipoprotein (HDL) cholesterol 40
  mg/dL

clinical case three
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Investigation (II)
ECG

• Normal sinus rhythm at 70
• Left ventricular hypertrophy
• Small inferior Qs

clinical case three
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Treatment (I)

• What is your next step?

1. Urgent angioplasty
2. Urgent bypass surgery
3. Urgent bypass surgery, plus transmyocardial
revascularization
4. Referral for heart transplantation
5. None of the above, need more information
clinical case three
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Diagnosis (I)

• In this case, what are the symptoms of knee pain
  most likely be consistent with?

1. Arthritis
2. Gout
3. Claudication
4. Spinal stenosis
5. None of the above
clinical case three
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Diagnosis (II)

• What is the most likely cause of the right facial
  numbness?

1. Transient ischemic attack (TIA)
2. Stroke
3. Seizure
4. Neuropathy
5. None of the above
clinical case three
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Investigation (III)

• What are the appropriate studies to order?

1. Carotid ultrasound
2. Echocardiography (ECHO)
3. Pulse volume recordings (PVRs)
4. Answer 1 and 2
5. Answers 1, 2 and 3
clinical case three
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Investigation (IV)
Non-invasive studies

• ECHO
• LVH with diastolic dysfunction
• LVEF of 45 with 2 mitral regurgitation
• moderate/lateral hypokinesis
• Head CT and PVRs at rest
• normal
• Carotid ultrasound
• severe stenosis of the LICA

clinical case three
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Diagnosis (III)

• What is VMs heart failure most likely to be due
  to?

1. Systolic dysfunction
2. Mitral regurgitation
3. Diastolic dysfunction
4. All of the above
5. None of the above
clinical case three
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Treatment (II)

• How should VMs carotid stenosis be addressed?

1. Urgent carotid endarterectomy
2. Urgent carotid angiography
3. Increasing the dose of ASA
4. Replacing ASA with clopidogrel
5. Answers 2 and 4
6. All of the above
clinical case three
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Diagnosis (IV)

• Do the normal PVRs exclude the diagnosis of PAD?

1. Yes
2. No
clinical case three
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Investigation (V)
Invasive studies
Left renal artery stenosis
Right renal artery stenosis
clinical case three
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Investigation (VI)
Invasive studies
Left SFA stenosis
LICA stenosis
clinical case three
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Investigation (VII)
Analysis

• Abnormal angiography was performed revealing
• bilateral renal artery stenosis
• left SFA stenosis
• 95 LICA stenosis

clinical case three
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Treatment (III)

• What is the appropriate management strategy?

1. Bilateral renal artery stenting
2. Superficial femoral artery PTA
3. Carotid stenting
4. All of the above
5. None of the above
clinical case three
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Treatment (IV)

• What is the appropriate management strategy?

• VM underwent stenting
• left and right renal arteries
• left SFA
• carotid (following evaluation by
  multidisciplinary team)

clinical case three
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Follow-up (I)
Invasive management
Left renal artery stent
Right renal artery stent
clinical case three
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Follow-up (II)
Invasive management
Left superficial femoral artery stent
clinical case three
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Treatment (V)

• What is the most appropriate medical management?

1. Continuation of ASA
2. Starting clopidogrel
3. Starting a statin
4. Starting an ACE inhibitor
5. All of the above
clinical case three
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Treatment (VI)

• On discharge
• ASA 325 mg o.d.
• Clopidogrel 75 mg o.d.
• Atorvastatin 10 mg o.d.
• Ramipril 2.5 mg o.d. (increased after BP
  evaluation at 1 week)
• Diuretic discontinued
• Nitrate continued (with possibility of future
  dose increase)
• Beta blocker continued (with possibility of
  future dose increase)

clinical case three
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Treatment (VII)

• Lifestyle program
• Maintain a log book of blood glucose values
• Start walking program
• Additional interventions proposed
• LICA stenting with emboli protection

clinical case three
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Follow-up (III)
On discharge

• Successful LICA stent
• Uneventful discharge on following day

LICA stent
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Discussion
clinical case three
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Clinical Case Four
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Clinical Case Four

• Patient
• FB male, 64 years old

• Presenting complaint
• "My right side went weak and numb for 10 minutes,
  and my speech was slurred. This happened about
  five hours ago"

clinical case four
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Background

• FB medical history
• Smoked 1 pack/day for 40 years
• Hypertension 10 years
• Myocardial infarction (MI) at age 58
• Minor stroke at age 60, while taking ASA
• Medications include
• ASA
• atenolol
• captopril
• ticlopidine tried following his stroke, but was
  discontinued because of persistent diarrhea

clinical case four
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Physical Examination (I)

• On presentation
• Height 6 0" (1.83 m)
• Weight 196 lb (89.0 kg)
• BP 154/88 mmHg
• Pulse 68 bpm and regular
• Carotid arteries no bruits
• Heart no murmurs
• Neurologic post stroke 4 years ago
• slight left-sided clumsiness and hyperreflexia
• dysarthria
• otherwise, normal

clinical case four
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Investigation (I)

• Laboratory results
• Glucose 94 mg/dL 5.2 mmol/L
• Total cholesterol 200 mg/dL 5.2 mmol/L
• Low-density lipoprotein (LDL) cholesterol 135
  mg/dL 3.5 mmol/L
• High-density lipoprotein (HDL) cholesterol 30
  mg/dL 0.8 mmol/L
• Triglycerides 250 mg/dL 2.8 mmol/L

clinical case four
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Investigation (II)

• Laboratory results
• Liver function tests normal
• Blood urea nitrogen normal
• Hct 47
• White blood cells 6,300/µL
• Platelets 250,000/µL

clinical case four
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Diagnosis
What are the relevant diagnoses?

• In summary, FB has multi-system atherosclerosis
• He has multiple clinical manifestations of this
  problem and multiple risk factors, including

• hypertension

• hypercholesterolemia

• overweight

• coronary artery disease (prior MI)

• cerebrovascular disease (prior stroke and new
  transient ishemic attack TIA)

clinical case four
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Investigation (III)

• What is the most appropriate diagnostic test, to
  exclude a small intracerebral hemorrhage, a brain
  tumor, or other brain disease masquerading as a
  TIA?

1. Computed tomography (CT) scan
2. Magnetic resonance (MR) scan
3. Contrast arteriogram
clinical case four
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Investigation (IV)
CT scan
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Investigation (V)

• Which test(s) are appropriate to further evaluate
  this patient's cerebral circulation?

1. Ultrasound of the cervical arteries
2. Magnetic resonance arteriography (MRA) of the
cervical arteries
3. Ultrasound or MRA of the cervical and
intracranial arteries
4. Intra-arterial contrast arteriography
5. All of the above
clinical case four
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Investigation (VI)
MR angiogram
clinical case four
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Investigation (VII)

• Which of the following tests should be considered
  to further evaluate FBs heart and aorta, as
  sources of embolism?

1. Holter monitor
2. Conventional echocardiogram
3. Transesophageal echocardiogram (TEE)
4. TEE with bubble contrast
5. Contrast aortogram
6. All of the above
7. Answers 1 and 2
8. All except 5
9. None of the above
clinical case four
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Treatment (I)

• What is the appropriate treatment for this
  patient?

1. Smoking cessation program
2. Antihypertension Rx
3. Statin Rx
4. Antiplatelet therapy
5. All of the above
clinical case four
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Treatment (II)

• Which of the following antiplatelet therapies is
  the most appropriate in this case?

1. Ticlopidine
2. Clopidogrel
3. ASA
4. ASA and dipyridamole
clinical case four
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Disclaimer

• These clinical patient cases represent model
  cases, expressing the views of the authors, only.
  All patients should be evaluated based upon their
  personal clinical history.
• The slide kit has been prepared for medical and
  scientific purposes, and cannot be considered as
  an inducement to use clopidogrel in
  non-registered indications.
• Neither Sanofi-Synthélabo nor Bristol-Myers
  Squibb recommends the use of clopidogrel in any
  manner inconsistent with that described in the
  full prescribing information.