Medical Management of Peripheral Arterial Disease.

Peripheral arterial disease is a condition associated with high rates of cardiovascular morbidity and mortality, increased risk of adverse limb events, including development of critical limb ischemia and amputation, and also with decreased quality of life. This manuscript provides an overview of the medical management of patients with peripheral arterial disease. We discuss contemporary therapies that decrease major adverse cardiovascular and limb events among patients with peripheral arterial disease, and also therapies that improve the patient's ability to walk and quality of life in general.

Bleeding Risk Profile in Patients With Symptomatic Peripheral Artery Disease.

Purpose: To assess the bleeding risk profile using the HAS-BLED score in patients with symptomatic peripheral artery disease (PAD).

Methods: A post hoc analysis was performed using data from a series of 115 consecutive patients (mean age 72.4±11.

Buerger disease (thromboangiitis obliterans).

Buerger disease is a nonatherosclerotic vasculitis that is triggered by substantial exposure to tobacco. This disease usually affects small- and medium-sized arteries in the upper and lower extremities. All clinicians who take care of patients with peripheral arterial disease should know the clinical features and diagnostic evaluation of Buerger disease.

Noninvasive Testing in Peripheral Arterial Disease.

Most patients suspected of having peripheral arterial disease should undergo noninvasive vascular testing to confirm the diagnosis, and to determine the severity and extent of the disease. This article reviews practical aspects of commonly used noninvasive tests for lower extremity peripheral arterial disease, including the ankle-brachial index, segmental limb pressures, pulse volume recordings, duplex ultrasonography, computed tomography angiography, and magnetic resonance angiography.

Evaluation of the patient who presents with critical limb ischemia: diagnosis, prognosis, and medical management.

Patients with critical limb ischemia usually have severe atherosclerotic disease and are at a high risk of limb loss as well as major adverse cardiovascular events. The current article provides a description of the clinical presentation of patients with critical limb ischemia and also discusses the initial evaluation of these patients, including physical examination, use of noninvasive vascular tests, and other imaging modalities. An overview of the general management of these patients is also provided, including the identification of patients who benefit from revascularization or primary amputation, principles of wound care, and therapies for cardiovascular risk reduction.

Renal artery duplex ultrasound criteria for the detection of significant in-stent restenosis.

Objectives: To define velocity criteria by ultrasonography for the detection of hemodynamically significant (>60%) renal artery in-stent restenosis (ISR).

Background: The restenosis rate after renal artery stenting ranges between 10% and 20%. While duplex ultrasound criteria have been validated for native renal artery stenosis, there are no uniformly accepted validated criteria for stented renal arteries.

Ineligibility for anticoagulation in patients with atrial fibrillation.

Although anticoagulation therapy markedly reduces the risk of stroke in patients with atrial fibrillation, up to 50% of these patients are deemed ineligible for anticoagulation. In this manuscript we provide a framework to assess the net clinical benefit of anticoagulation in patients with atrial fibrillation with an increased risk of bleeding. We also review recent data related to the novel oral anticoagulants targeting thrombin or factor Xa, and discuss how the introduction of these agents raises the distinction between eligibility for vitamin K antagonist therapy specifically, and eligibility for anticoagulation in general.

Effect of caffeine on platelet inhibition by clopidogrel in healthy subjects and patients with coronary artery disease.

Background: Clopidogrel inhibits the platelet P2Y12 receptor, leading to increased intracellular cyclic AMP (cAMP) levels. Caffeine also causes a rise in platelet cAMP. We aimed to test the effect of acute caffeine administration on platelet inhibition by clopidogrel, in healthy volunteers and patients with coronary artery disease.

Platelet activation leads to activation and propagation of the complement system.

Inflammation and thrombosis are two responses that are linked through a number of mechanisms, one of them being the complement system. Various proteins of the complement system interact specifically with platelets, which, in turn, activates them and promotes thrombosis. In this paper, we show that the converse is also true: activated platelets can activate the complement system.

Tissue-factor-bearing microvesicles arise from lipid rafts and fuse with activated platelets to initiate coagulation.

Tissue factor (TF) circulates in plasma, largely on monocyte/macrophage-derived microvesicles that can bind activated platelets through a mechanism involving P-selectin glycoprotein ligand-1 (PSGL-1) on the microvesicles and P-selectin on the platelets. We found these microvesicles to be selectively enriched in both TF and PSGL-1, and deficient in CD45, suggesting that they arise from distinct membrane microdomains. We investigated the possibility that microvesicles arise from cholesterol-rich lipid rafts and found that both TF and PSGL-1, but not CD45, localize to lipid rafts in blood monocytes and in the monocytic cell line THP-1.

Effect of P-selectin on phosphatidylserine exposure and surface-dependent thrombin generation on monocytes.

Objective: Stimulation of monocytes with P-selectin induces the synthesis of an array of mediators of inflammation, as well as the expression of tissue factor (TF), the main initiator of coagulation. Because the membrane-bound reactions of coagulation are profoundly influenced by the presence of phosphatidylserine on the membranes of cells, factors that increase its expression may have an impact on coagulation.

Methods And Results: Using flow cytometry, we studied the effect of P-selectin on phosphatidylserine expression in blood monocytes and in the monocytic cells, THP-1.