Page 115 - fbkCardioDiabetes_2017

Cardio Diabetes Medicine 2017 91

lower than 130/80 mm/hg. Among the antihyperten- EXERCISE PROGRAMS
sive agents ACEI should be a preferred agent.
A supervised exercise program has confirmed im-
provement in symptoms of claudication. Meta anal-
STATINS ysis of RCTs showed that a supervised exercise
As per the NCEP ATP III guidelines PAD is considered causes an increase in walking time by 6.5 minutes.
as a CAD risk equivalent. The TASC II and AHA/ACC This applies even to asymptomatic PAD patients. An
recommends statins to all patients with PAD irrespec- exercise rehabilitation program includes the use of
tive of their LDL levels and the LDL target level is < a motorized treadmill to allow monitoring of patients
100 mg/dl. However the more aggressive target level claudication. The patient attends 3 sessions per week
of < 70 mg/dl is recommended only for patients with of 45-60 minutes for more than 3 months under the
lower extremity PAD at high risk of ischemic events supervision of an exercise physiologist, nurse, or
including those with concomitant CAD. physical therapist, who monitors the patients claudi-
cation threshold and cardiovascular limitation.
ANTIPLATELET THERAPY
Official guidelines have continued to recommend an- PHARMACOLOGY THERAPY FOR
tiplatelet therapy to decrease the risk of MI, stroke INTERMITTENT CLAUDICATION
or vascular death in patients of lower extremity PAD. CILASTAZOL: Cilastazol a phosphodiesterase-3 in-
Doses of 75 to 325 mg/day are generally recom- hibitor is the most effective medication to improve
mended. Clopidogrel 75 mg/day is an effective al- claudication and should be the first line-medical ther-
ternative therapy and compared with aspirin in PAD apy for treatment of lower extremity PAD. It has vaso-
subgroup of CAPRIE trial showed a relative risk re- dilator effects, antiplatelet effect and ant proliferative
duction of 24% for MACE, compared to aspirin. There activity. Cilastazol therapy gives a 50.7% improvement
is no role for dual antiplatelet therapy aspirin and in maximal walking distance versus placebo in 20
clopidogrel for PAD. However based on new studies weeks. Though it improves walking distance it does
there is insufficient evidence to firmly recommend not reduce all cause mortality. AHA/ACC and TASC
use of aspirin or clopidogrel in all patients with PAD. II supports the use of 100 mg Cilastazole twice a day
as the first line treatment to improve symptoms. Side

Fig.5: (A) Trans-Atlantic inter -society Consensus II Classifications for (A) Aortaliac and (B) Femoro-
popliteal peripheral Arterial Disease

Cardio Diabetes Medicine