Atherothrombosis Management in Practice – Clinical Cases

Clinical Case One

Clinical Case One

Patient:

• JM: male, 50 years old

• Occupation: postman

clinical case one

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

Diagnosis

What is your diagnosis?

clinical case one

2. Peripheral neuropathy

3. Venous disease

4. Intermittent claudication

5. Sciatic pain (sciatic nerve compression)

6. None of the above

1. Arthritis of the hip

Physical Examination (I)

On presentation:

• General status: excellent

• Heart and lungs: no abnormalities

• BP: 138/88 mmHg

• Pulse: regular 88/min

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Electrocardiogram (ECG)

clinical case one

• ECG Q-waves suggest an old inferior infarction

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

Investigation (I)

What is your next step in light of JM’s condition?

clinical case one

2. Measure ankle pressure

3. Duplex scan arteries of the lower limbs

4. Perform contrast arteriography

1. Reassure JM: nothing else to be done

Pressure gradients:

• Left ankle 80/138 (index = 0.58)

• Right ankle 104/138 (index = 0.75)

Investigation (II)

clinical case one

What treatment does JM require now?

2. Drug therapy

3. Exercise training

4. Drugs and training

1. No treatment

5. Interventional treatment (PTA, vascular surgery)

4. Some other treatment

Treatment (I)

Which medication would you consider?

clinical case one

2. Dipyridamole

3. Ticlopidine

4. Clopidogrel

5. Cilostazol

6. One of pentoxifylline, buflomedil, or naftidrofuryl

1. ASA

7. A combination of drugs

8. Some other drug

Follow-up (I)

On discharge:

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

clinical case one

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

Investigation (III)

How would you approach the TIA problem?

clinical case one

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

1. Duplex scan of the carotid arteries

Imaging Results (I)

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Right carotid:

Imaging Results (II)

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Left carotid:

Imaging Results (III)

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Velocity pattern:

Treatment (II)

How would you treat the TIA?

clinical case one

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

1. Endarterectomy

Follow-up (II)

1 year later:

• JM is doing fine

• Minor claudication remains

• No neurologic symptoms

• Clopidogrel 75 mg o.d.

clinical case one

Clinical Case Two

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

Background

clinical case two

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)

Physical Examination (I)

clinical case two

On presentation:

• Height: 5’ 8" (1.72 m)

• Weight: 186 lb (84.4 kg)

• BP: 164/100 mmHg

• Pulse: 84 bpm

• Left carotid bruit

Physical Examination (II)

clinical case two

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

Laboratory results:

Investigation (I)

clinical case two

• 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]

• Liver function tests: normal

• Hct: 48%

• White blood cells: 5,300/µL

• Platelets: 190,000/µL

Laboratory results:

Investigation (II)

clinical case two

• In summary, KK has systemic atherothrombosis

• He has multiple clinical manifestations of this problem and multiple risk factors, including:

Diagnosis

What are the relevant diagnoses?

clinical case two

– coronary artery disease (prior MI)

– peripheral arterial disease

– hypertension

– Type II diabetes mellitus

– carotid bruit (asymptomatic)

– hypercholesterolemia

Investigation (III)

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

2. Segmental pressure measurements

3. Pulse-volume recording

1. Magnetic resonance arteriogram

4. Duplex ultrasound of the leg

5. Contrast arteriogram

clinical case two

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)

Investigation (IV)

Segmental systolic pressure measurements:

clinical case two

Investigation (V)

Which test is NOT indicated at this time?

2. Dipyridamole MIBI

3. Cardiac catheterization

1. Treadmill exercise test

4. Carotid ultrasound

5. Abdominal ultrasound

clinical case two

• Risk factor modification – treatments include:

Treatment (I)

What treatment should be initiated to reduce potential cardiovascular events?

• Antiplatelet therapy – treatments include:

clinical case two

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

– ASA– clopidogrel

Treatment (II)

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

2. PTA

3. Vascular surgery

1. Exercise rehabilitation

4. Cilostazol

5. Naftidrofuryl

clinical case two

6. Pentoxifylline

• Intensified diabetes Rx, so that HbA1C < 7%

• Statin Rx

• No renal artery stenosis, therefore hypertension managed with pharmacotherapy

• Smoking cessation program

• Clopidogrel 75 mg o.d.

• Exercise rehabilitation program

Treatment (III)

Treatment strategy:

clinical case two

Follow-up

After 3 months:

clinical case two

• KK able to walk distance of half a mile

Clinical Case Three

Clinical Case Three

Patient:

• VM: male, 62 years old

• Occupation: retired

clinical case three

Background:

• Diabetes and hypertension

• No smoking

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 (< 5 min) right facial numbness, 2 weeks prior to presentation

clinical case three

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

Referral

clinical case three

Physical Examination (I)

clinical case three

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

Physical Examination (II)

clinical case three

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

Medication

clinical case three

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

• 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

Laboratory results:

Investigation (I)

clinical case three

• Normal sinus rhythm at 70

• Left ventricular hypertrophy

• Small inferior Qs

ECG:

Investigation (II)

• Mild cardiomegaly

Chest X-ray:

Treatment (I)

What is your next step?

2. Urgent bypass surgery

3. Urgent bypass surgery, plus transmyocardial revascularization

4. Referral for heart transplantation

1. Urgent angioplasty

clinical case three

5. None of the above, need more information

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

Diagnosis (I)

2. Gout

3. Claudication

4. Spinal stenosis

1. Arthritis

5. None of the above

clinical case three

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

Diagnosis (II)

2. Stroke

3. Seizure

4. Neuropathy

1. Transient ischemic attack (TIA)

5. None of the above

clinical case three

What are the appropriate studies to order?

Investigation (III)

2. Echocardiography (ECHO)

3. Pulse volume recordings (PVRs)

4. Answer 1 and 2

1. Carotid ultrasound

5. Answers 1, 2 and 3

clinical case three

Investigation (IV)

• 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

Non-invasive studies:

clinical case three

What is VM’s heart failure most likely to be due to?

Diagnosis (III)

2. Mitral regurgitation

3. Diastolic dysfunction

4. All of the above

1. Systolic dysfunction

5. None of the above

clinical case three

Treatment (II)

How should VM’s carotid stenosis be addressed?

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

1. Urgent carotid endarterectomy

clinical case three

Do the normal PVRs exclude the diagnosis of PAD?

Diagnosis (IV)

2. No

1. Yes

clinical case three

Left renal artery stenosis

clinical case three

Investigation (V)

Right renal artery stenosis

Invasive studies:

clinical case three

Investigation (VI)

Left SFA stenosis LICA stenosis

Invasive studies:

Investigation (VII)

Analysis:

clinical case three

• Abnormal angiography was performed revealing:

– bilateral renal artery stenosis

– left SFA stenosis

– 95% LICA stenosis

Treatment (III)

What is the appropriate management strategy?

clinical case three

3. Carotid stenting

4. All of the above

5. None of the above

1. Bilateral renal artery stenting

2. Superficial femoral artery PTA

What is the appropriate management strategy?

clinical case three

• VM underwent stenting:

– left and right renal arteries

– left SFA

– carotid (following evaluation by multidisciplinary team)

Treatment (IV)

Left renal artery stent

clinical case three

Follow-up (I)

Right renal artery stent

Invasive management:

Left superficial femoral artery stent

clinical case three

Follow-up (II)

Invasive management:

Treatment (V)

What is the most appropriate medical management?

2. Starting clopidogrel

3. Starting a statin

4. Starting an ACE inhibitor

5. All of the above

1. Continuation of ASA

clinical case three

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

Treatment (VII)

Lifestyle program:

• Maintain a log book of blood glucose values

• Start walking program

Additional interventions proposed:

• LICA stenting with emboli protection

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LICA stent

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Follow-up (III)

On discharge:

• Successful LICA stent

• Uneventful discharge on following day

clinical case three

Discussion

Clinical Case Four

Clinical Case Four

Patient:

• FB: male, 64 years old

clinical case four

Presenting complaint:

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

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

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

Physical Examination (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

Investigation (I)

Investigation (II)

clinical case four

Laboratory results:

• Liver function tests: normal

• Blood urea nitrogen: normal

• Hct: 47%

• White blood cells: 6,300/μL

• Platelets: 250,000/μL

Diagnosis

• In summary, FB has multi-system atherosclerosis

• He has multiple clinical manifestations of this problem and multiple risk factors, including:

clinical case four

What are the relevant diagnoses?

– hypercholesterolemia

– hypertension

– coronary artery disease (prior MI)

– cerebrovascular disease (prior stroke and new transient ishemic attack [TIA])

– overweight

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?

clinical case four

2. Magnetic resonance (MR) scan

3. Contrast arteriogram

1. Computed tomography (CT) scan

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CT scan

Investigation (IV)

Investigation (V)

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

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

1. Ultrasound of the cervical arteries

clinical case four

clinical case four

MR angiogram

Investigation (VI)

Investigation (VII)

Which of the following tests should be considered to further evaluate FB’s heart and aorta, as sources of embolism?

2. Conventional echocardiogram

3. Transesophageal echocardiogram (TEE)

4. TEE with bubble contrast

5. Contrast aortogram

6. All of the above

1. Holter monitor

7. Answers 1 and 2

8. All except 5

clinical case four

9. None of the above

Treatment (I)

What is the appropriate treatment for this patient?

clinical case four

2. Antihypertension Rx

3. Statin Rx

4. Antiplatelet therapy

1. Smoking cessation program

5. All of the above

Treatment (II)

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

2. Clopidogrel

3. ASA

4. ASA and dipyridamole

1. Ticlopidine

clinical case four

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.