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
— cardio-met (@cardiomet_CE) April 13, 2021
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.
— cardio-met (@cardiomet_CE) April 13, 2021
5) With what you know now, should antiplatelet therapy be initiated?
— cardio-met (@cardiomet_CE) April 13, 2021
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
7) Very similar number of events prevented as major bleeds caused. No difference in mortality. If there is a benefit, it is very small.
— cardio-met (@cardiomet_CE) April 13, 2021
9) AAA enrolled 3350 M/W screened for PAD and found no benefit with ASA. pic.twitter.com/wkc6RsaC0U
— cardio-met (@cardiomet_CE) April 13, 2021
11) So, is ASA unnecessary in ASX PAD?
— cardio-met (@cardiomet_CE) April 13, 2021
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. pic.twitter.com/P5nFiQMjij
— cardio-met (@cardiomet_CE) April 13, 2021
15) The walking limitation has been there for more than a year and makes her worried about going shopping and leaving the house.
— cardio-met (@cardiomet_CE) April 13, 2021
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.
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.
— cardio-met (@cardiomet_CE) April 13, 2021
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
— cardio-met (@cardiomet_CE) April 13, 2021
21) The WAVE trial of ASA +/- warfarin (Am Heart J. 2006 Jan;151(1):1-9. doi: 10.1016/j.ahj.2005.03.021) showed no benefit of adding warfarin . . . pic.twitter.com/loquP1NgT3
— cardio-met (@cardiomet_CE) April 14, 2021
23) Clopidogrel did not improve outcomes in PAD in CHARISMA (Eur Heart J 2009 Jan;30(2):192-201) and apixaban has not been studied in PAD.
— cardio-met (@cardiomet_CE) April 14, 2021
25) In the 7470 PAD patients in COMPASS, ASA 81 mg + Riva 2.5 mg BID reduced CV Death, MI, and CVA compared to ASA 81 mg alone. The trial was stopped early for efficacy. pic.twitter.com/Fcols4sruu
— cardio-met (@cardiomet_CE) April 14, 2021
27) OK, back to our patient, who is unsure of taking more meds but promises to think about it.
— cardio-met (@cardiomet_CE) April 14, 2021
29) What should we prescribe first to increase her walking the most?
— cardio-met (@cardiomet_CE) April 14, 2021
30) Of those 4 choices, supervised exercise therapy has the most potent improvement in walking distance. From the CLEVER trial (J Am Coll Cardiol. 2015 Mar 17; 65(10): 999–1009): pic.twitter.com/GfUc9PCIY0
— cardio-met (@cardiomet_CE) April 14, 2021
32) It should also be noted that revascularization makes patients feel better despite a smaller increase in walking distance. This suggests benefits of each have different mechanisms.
— cardio-met (@cardiomet_CE) April 14, 2021
34) She returns to the office after SET has completed. She has doubled her walking distance to 2 blocks, but still feels limited and unable to accomplish most out-of-the house routine tasks. She wants to know if there is anything else that you can do.
— cardio-met (@cardiomet_CE) April 14, 2021
36) Cast your vote and return tomorrow for the answer and the link to your FREE #CME/CE. You're almost there. Follow us for the best accredited tweetorials in #cardiometabolic medicine! @naomihamburg @gerhardherman @sahilparikhmd @jrunmd @sahersabri @maureenkohi @dougdrachmanmd
— cardio-met (@cardiomet_CE) April 14, 2021
38) In the ERASE trial (JAMA 2015 Nov 10;314(18):1936-44), the addition of endovascular revascularization further improved walking distance beyond SET and may represent a good addition to therapy when SET alone does not restore enough functional capacity. pic.twitter.com/vWtXivkKmq
— cardio-met (@cardiomet_CE) April 15, 2021
40) Which of the following therapies will improve limb outcomes after endovascular revascularization for PAD?
— cardio-met (@cardiomet_CE) April 15, 2021
42) In contrast, the addition of arterial dose rivaroxaban was studied in the VOYAGER trial (N Engl J Med 2020; 382:1994-2004).
— cardio-met (@cardiomet_CE) April 15, 2021
44) The addition of Riva 2.5 mg BID reduced the primary outcome of ALI, vascular major amputation, MI, CVA, and CV death. It also reduced unplanned recurrent revasc and hospitalization for a coronary or peripheral thrombotic event. pic.twitter.com/jU6GnJCy2Z
— cardio-met (@cardiomet_CE) April 15, 2021
46) The role of clopidogrel in patients undergoing limb revascularization is unclear and a data-free space. It certainly increases bleeding, but efficacy remains unclear. Large RCTs are needed.
— cardio-met (@cardiomet_CE) April 15, 2021
47) That's it! You made it! Free CE/CME! Now go to https://t.co/elhUS5pPRA and claim your credit from @academiccme! I am @JoshuaBeckmanMD. Follow @cardiomet_CE for more tweetorials! #PAD #medtwittter #cardiotwitter @MedTweetorials
— cardio-met (@cardiomet_CE) April 15, 2021