Discussion Week 2: Peripheral Artery Disease Case Study – Comprehensive Assessment and Management Plan

Assignment Brief: Creating a PAD Case Study for Advanced Practice Nursing

Create a case study (already created and attached) Review the primary diagnosis and the reason for the clinic visit.

Reason: Peripheral artery disease (PAD)
Reason for today’s clinic visit: The client has noticed more frequent pain and cramping in their bilateral lower legs, especially when they try to walk for any length of time. The pain seems to go away with rest.

Answer the initial and response prompts below with explanation and detail, providing complete references for all citations. Use this week’s Explore pages, relevant CPGs, and additional scholarly sources (including the course text) to create your case example. You may list case information in bullets or complete sentences.

In your discussion post, present the client, include holistic assessment findings and diagnostic results aligning with the primary diagnosis and a management plan incorporating pharmacological and non-pharmacological treatment.

Include the following sections:

1. Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
2. Integration of Evidence: Integrate relevant scholarly sources as defined by program expectations: Cite a scholarly source.
3. Professionalism in Communication: Communicate with minimal errors in English grammar, spelling, syntax, and punctuation.
4. Reference Citation: Use current APA format to format citations and references and is free of errors.

Please add AI and Similarity report.

5. Assigned Primary Diagnosis: PAD
6. Client Name: Erica Smith
7. Date of Birth: 6/8/1962
8. Chief Complaint: cramping, pain in legs during exercise
9. History of Present Illness: 64 y.o female with history of htn, hyperlipidemia and 30 pack smoking hx. who presents with a 6 month hx of progressing, aching, calf pain and tightness. pain occurring bilaterally but is constant in the right calf. Discomfort is triggered by walking or climbing stairs. it resolves within 3-5 minutes of rest. Denies sudden onset of severe limb pain, numbness, tinging or weakness. Reports no pain at rest or while laying down. On review of systems he notes skin is shiny on his lower les and had become more dry with decreased hair growth on shins. he denies any open sores, ulcers, or non-healing wounds on his feet or toes.
10. Physical Exam
11. Height: 5ft 4in
12. Weight: 160lbs
13. BMI: 27.5
14. Blood pressure: 134/82 mmHg
15. Heart rate: 74 bpm
16. Respiratory rate: 16
17. Oxygen saturation: 98% on room air
18. Temperature: 98.4F
19. Past Medical History (PMH) (Include at least three significant pieces of the client’s past medical history)
20. Hypertension
21. Hyperlipidemia
22. Smoker
23. Allergies (Include any drug allergies and the client’s typical reaction)
24. NKDA
25. Medications (Based on the client’s PMH, list at least three current medications, including dose, route, and frequency)
26. Atorvastatin 40mg Oral once at bedtime
27. Lisinopril 10mg Oral once daily in the morning
28. Aspirin 81mg Oral Once daily

2. Social History (MUST include status of tobacco, ETOH, and drug use [e.g., usage, type, quantity, using or non-using] AND include at least two other significant social history elements, e.g., marital status, living conditions, social support, etc.)
3. Current daily Smoker – 35 pack-year smoking history. mild interest in quitting
4. Social alcohol drinking 1-2 glasses of wine on weekends
5. Lives in a 2 story family home with husband
6. Diagnostics (To assist the FNP with diagnosing the client’s primary problem, list at least three expected diagnostic findings, which may include priority laboratory findings, diagnostic imaging, etc.)
7. Diagnostic Test: Lipid panel
   Expected finding: Elevated total cholesterol
8. Diagnostic Test: Ankle-Brachial Index with segmental pressures.
   Expected finding ABI 0.65 on the right and 0.72 on the left confirming arterial insufficiency.
9. Diagnostic Test: Arterial Duplex Ultrasound
   Expected finding Hemodynamically significant stenosis (> 50% narrowing) in the right superficial femoral artery.
10. Diagnostic Test: Hemoglobin A1C
    Expected finding 7.2% reflecting below ideal level.
11. Current Management Plan (List two priority non-pharmacological and two priority pharmacological interventions for this client based on assessment and diagnostic findings and CPG recommendations to allow the FNP to treat the assigned diagnosis.)
12. Non-pharmacological interventions
13. Supervised Exercise Therapy
14. Behavioral smoking cessation counseling
15. Pharmacological interventions
16. Escalate to high-intensity statin therapy to 80mg Lipitor
17. Add Rivaroxaban (Xarelto) to antiplatelet therapy

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Sample Answer Excerpt: Erica Smith’s PAD Case Study Analysis

Erica Smith, a 64-year-old female with a 35-pack-year smoking history, hypertension, and hyperlipidemia, presents with classic intermittent claudication symptoms consistent with peripheral artery disease. Her progressive calf pain triggered by walking and relieved with rest, combined with physical examination findings of shiny, dry skin and decreased hair growth on her lower extremities, strongly supports the diagnosis of lower extremity PAD. The 2024 ACC/AHA/Multisociety PAD Guideline emphasizes that PAD remains a significantly underdiagnosed and undertreated public health issue affecting approximately 10 to 12 million people in the United States over age 40. Diagnostic testing confirms the clinical suspicion, with an ankle-brachial index of 0.65 on the right and 0.72 on the left, both below the diagnostic threshold of 0.90 that indicates arterial insufficiency. Additionally, her elevated A1C of 7.2% reveals previously unidentified prediabetes, a critical risk amplifier that the 2024 guideline identifies as a key factor requiring aggressive management.

The management plan for Ms. Smith must address both her modifiable risk factors and her symptomatic disease burden. The 2024 ACC/AHA guideline provides a Class 1 recommendation for high-intensity statin therapy in all patients with PAD, with an aim of achieving a ≥50% reduction in low-density lipoprotein cholesterol levels. Escalating her atorvastatin from 40mg to 80mg daily aligns with this evidence-based recommendation. Furthermore, the COMPASS trial demonstrated that low-dose rivaroxaban (2.5 mg twice daily) combined with aspirin significantly reduces major adverse cardiovascular events in patients with PAD compared with aspirin alone. The 2024 ACC/AHA guideline now includes this dual pathway inhibition as a Class 1 recommendation for patients with symptomatic PAD without high bleeding risk. Non-pharmacological interventions remain equally vital, with supervised exercise therapy representing an essential, evidence-based strategy to reduce claudication symptoms and improve functional outcomes. Smoking cessation counseling must be prioritized given her significant pack-year history, as continued tobacco exposure directly accelerates disease progression and increases amputation risk.

Why This Matters in Practice

Peripheral artery disease is frequently overlooked in primary care settings, yet it carries significant morbidity and mortality risks. Family nurse practitioners occupy a critical position in early identification and comprehensive management of PAD, as they can implement both lifestyle interventions and evidence-based pharmacotherapy. Ms. Smith’s case illustrates the importance of a holistic approach that addresses the interconnected risk factors of smoking, hyperlipidemia, hypertension, and glycemic control. The 2024 ACC/AHA guideline represents the first comprehensive update since 2016, providing clinicians with new evidence-based recommendations including the addition of low-dose rivaroxaban to antiplatelet therapy. Early diagnosis and appropriate management can significantly reduce the risk of major adverse cardiovascular events, amputation, and mortality while improving functional status and quality of life.

Research, Writing, Citation, and Referencing Guide

When developing this case study response, students should prioritize the following evidence-based resources to support their clinical reasoning:

• The 2024 ACC/AHA/Multisociety Guideline for the Management of Lower Extremity Peripheral Artery Disease, published in Circulation and the Journal of the American College of Cardiology, provides the most current comprehensive recommendations for PAD diagnosis and treatment. The guideline can be accessed at https://doi.org/10.1161/CIR.0000000000001251.
• The 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases offer complementary European perspectives on PAD management. Available at https://doi.org/10.1093/eurheartj/ehae179.
• Peer-reviewed literature on statin therapy in PAD, including the meta-analysis by Sagris et al. demonstrating that high-intensity statins are associated with a 36% reduction in all-cause mortality compared to low-intensity statins.
• Studies on the COMPASS and VOYAGER PAD trials supporting dual pathway inhibition with low-dose rivaroxaban and aspirin.

Students should integrate at least 2–3 in-text citations per substantive paragraph, ensuring that citations flow naturally within the analysis rather than being mechanically appended. The 2024 ACC/AHA guideline should serve as the foundational reference, supplemented by recent peer-reviewed articles that provide additional context and evidence for specific interventions.

Frequently Asked Questions

What ankle-brachial index value confirms a diagnosis of peripheral artery disease?
An ankle-brachial index (ABI) below 0.90 confirms the diagnosis of lower extremity peripheral artery disease. Ms. Smith’s ABI values of 0.65 on the right and 0.72 on the left are both significantly below this threshold, indicating hemodynamically significant arterial stenosis. The 2023 Intersocietal Guidelines on PAD in the Diabetic Foot note that while ABI serves as an effective initial screening tool, its limitations in patients with diabetes or incompressible arteries must be recognized.

Why is high-intensity statin therapy recommended for all patients with PAD?
High-intensity statin therapy, defined as atorvastatin ≥40mg or rosuvastatin ≥20mg, is indicated for all patients with PAD based on a Class 1, Level of Evidence A recommendation from the 2024 ACC/AHA guideline. Statins provide both lipid-lowering effects and pleiotropic benefits including improved endothelial function, reduced inflammation, and stabilization of atherosclerotic plaques. Research demonstrates that high-intensity statins are associated with a 36% reduction in all-cause mortality compared to low-intensity statins in patients with PAD.

What are the key non-pharmacological interventions for managing intermittent claudication?
Supervised exercise therapy represents the cornerstone non-pharmacological intervention for symptomatic PAD, effectively reducing claudication symptoms and improving functional outcomes. The 2024 ACC/AHA guideline strongly supports supervised exercise programs as a Class 1 recommendation. Smoking cessation counseling is equally critical, as continued tobacco use directly accelerates disease progression and increases the risk of major adverse limb events. Dietary modifications, weight management, and blood pressure control constitute additional essential lifestyle interventions.

How does dual pathway inhibition benefit patients with PAD?
Dual pathway inhibition with low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (75–100 mg daily) has been shown in the COMPASS and VOYAGER PAD trials to significantly reduce major adverse cardiovascular events, including cardiovascular death, myocardial infarction, and stroke, compared with aspirin alone. The 2024 ACC/AHA guideline now includes this regimen as a Class 1 recommendation for patients with symptomatic PAD without high bleeding risk. This represents the first new Class 1 recommendation for an antithrombotic regimen in PAD in nearly two decades.

What diagnostic tests should be ordered when PAD is suspected?
The initial diagnostic evaluation for suspected PAD should include an ankle-brachial index with segmental pressures, which provides objective evidence of arterial insufficiency. Arterial duplex ultrasound can identify the specific location and severity of stenosis. Laboratory testing should include a lipid panel to assess for dyslipidemia and hemoglobin A1C to screen for diabetes or prediabetes. The 2024 ACC/AHA guideline emphasizes the importance of comprehensive risk factor assessment, including evaluation for PAD-related risk amplifiers such as diabetes, smoking, older age, and depression.

This case study response should demonstrate mastery of the most current evidence-based guidelines for peripheral artery disease management. The 2024 ACC/AHA/Multisociety PAD Guideline (Gornik et al., 2024) represents the authoritative source for clinical recommendations, superseding previous 2016 guidance. Students should also reference the 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases (Mazzolai et al., 2024) to provide a comprehensive international perspective. When discussing pharmacotherapy, the COMPASS trial data supporting dual pathway inhibition with rivaroxaban and aspirin should be cited. For non-pharmacological interventions, the evidence base for supervised exercise therapy and smoking cessation should be drawn from recent systematic reviews and meta-analyses.

References

Gornik, H. L., Aronow, H. D., Goodney, P. P., Arya, S., Brewster, L. P., Byrd, L., Chandra, V., Drachman, D. E., Eaves, J. M., Ehrman, J. K., Evans, J. N., Getchius, T. S. D., Gutiérrez, J. A., Hawkins, B. M., Hess, C. N., Ho, K. J., Jones, W. S., Kim, E. S. H., Kinlay, S., … Wilkins, L. R. (2024). 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 149(24), e1313–e1410. https://doi.org/10.1161/CIR.0000000000001251

Mazzolai, L., Teixido-Tura, G., Lanzi, S., Cavallaro, M., & Belch, J. (2024). 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. European Heart Journal, 45(36), 3538–3700. https://doi.org/10.1093/eurheartj/ehae179

Sagris, M., Theofilis, P., Antonopoulos, A. S., Oikonomou, E., Simantiris, S., Papastamos, C., Tsioufis, K., & Tousoulis, D. (2023). Association of statin dose with amputation and survival in patients with peripheral artery disease. Atherosclerosis, 370, 1–8.

Sullivan, S. D., & Hammad, T. A. (2023). Medical management of peripheral artery disease. Seminars in Interventional Radiology, 40(2), 119–128.

Fowkes, F. G. R., Aboyans, V., Fowkes, F. J. I., McDermott, M. M., Sampson, U. K. A., & Criqui, M. H. (2017). Peripheral artery disease: Epidemiology and global perspectives. Nature Reviews Cardiology, 14(3), 156–170.

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Compose a comprehensive PAD case study analysis for Discussion Week 2, examining Erica Smith’s presentation of intermittent claudication with bilateral lower extremity pain, incorporating holistic assessment findings, diagnostic results, and evidence-based pharmacological and non-pharmacological management strategies aligned with the 2024 ACC/AHA guidelines in a 500–750 word discussion post.

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Next Assignment: Week 3 – Diabetes and Cardiovascular Risk Management

Course Code: NURS 6540 – Advanced Practice Nursing in Primary Care
Assignment: Discussion Week 3 – Case Study Analysis: Managing Type 2 Diabetes with Cardiovascular Complications

Assignment Description: Create a case study of a patient with type 2 diabetes who presents with microvascular and macrovascular complications. Include a comprehensive assessment of glycemic control, blood pressure management, lipid optimization, and screening for cardiovascular disease. Discuss the role of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing cardiovascular risk in patients with diabetes. Develop a management plan incorporating lifestyle modifications, pharmacological interventions, and appropriate referral strategies. Support your analysis with current clinical practice guidelines from the American Diabetes Association and the American College of Cardiology.

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