What is the management approach for vascular conditions, such as hypertension and atherosclerosis?

CHA₂DS₂-VASc Score: Vascular Disease Component

The "vascular disease" component of the CHA₂DS₂-VASc score includes prior myocardial infarction, peripheral arterial disease (PAD), or aortic plaque, and awards 1 point when present. 1

Definition and Scope

The vascular disease criterion encompasses:

• Prior myocardial infarction - documented history of MI 1
• Peripheral arterial disease - including lower extremity PAD, renal artery stenosis, mesenteric arterial disease, and abdominal aortic disease 1
• Aortic atherosclerotic plaque - significant plaque burden on imaging 1

Clinical Recognition of Peripheral Arterial Disease

Key Historical Features to Elicit

• Exertional leg symptoms - fatigue, aching, numbness, or pain in buttock, thigh, calf, or foot that is reproducibly provoked by walking and relieved by rest 1
• Rest pain - pain localized to lower leg or foot associated with recumbent position 1
• Non-healing wounds - poorly healing or non-healing wounds of legs or feet 1
• Postprandial abdominal pain - reproducibly provoked by eating and associated with weight loss (suggests mesenteric disease) 1

Essential Physical Examination Findings

• Pulse palpation - assess and document brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses using 0-3 scale (0=absent, 1=diminished, 2=normal, 3=bounding) 1
• Auscultation - listen for bruits over carotid, abdominal, flank, and femoral arteries 1
• Foot inspection - examine for hair loss, trophic skin changes, hypertrophic nails, ulcerations, and assess skin color and temperature 1
• Blood pressure measurement - measure in both arms and document any interarm asymmetry 1

Diagnostic Confirmation

Ankle-Brachial Index (ABI)

• ABI ≤0.90 confirms PAD diagnosis 1
• ABI 0.91-1.30 is normal; if PAD suspected clinically, perform exercise ABI 1
• ABI >1.30 suggests non-compressible vessels; use toe-brachial index or pulse volume recording 1

Additional Vascular Imaging

When revascularization is contemplated or diagnosis remains uncertain:

• Duplex ultrasound, CTA, or MRA - useful for anatomic assessment and severity determination 2
• Catheter angiography - provides definitive anatomic detail and allows simultaneous intervention 2

Management Implications for Stroke Prevention

Why Vascular Disease Matters in CHA₂DS₂-VASc

Patients with atherosclerotic vascular disease have:

• Coexistent coronary and cerebrovascular disease - PAD patients have markedly increased risk of MI and stroke 1
• Systemic atherosclerotic burden - disease in one vascular bed predicts disease elsewhere 1
• Higher thrombotic risk - prothrombotic state contributes to atherothrombotic events 3

Comprehensive Risk Factor Management

Blood Pressure Control:

• Target <140/90 mmHg for most patients with vascular disease 1
• Antihypertensive therapy is mandatory - use ACE inhibitors or ARBs as first-line agents 1
• More aggressive targets may be appropriate for specific high-risk subgroups 1

Lipid Management:

• Statin therapy for all patients - reduce LDL cholesterol below 100 mg/dL 1
• Intensive statin therapy after stroke - target LDL near or below 70 mg/dL 1
• Add bile acid sequestrants or niacin if statin alone insufficient 1

Antiplatelet Therapy:

• Aspirin is standard for patients with atherosclerotic vascular disease 1
• Consider in context of anticoagulation - when CHA₂DS₂-VASc score indicates need for anticoagulation, balance bleeding risk 1

Smoking Cessation:

• Mandatory intervention - smoking dramatically accelerates atherosclerosis progression 1
• Offer structured cessation programs with pharmacotherapy and behavioral support 1

Common Pitfalls to Avoid

• Missing asymptomatic PAD - many patients lack classic claudication but have functional impairment; perform ABI screening in at-risk populations 1
• Overlooking renal artery stenosis - present in 38% of patients with abdominal aortic aneurysm and 39% with PAD 1
• Underestimating cardiovascular risk - vascular disease patients have higher rates of cardiovascular death than limb events 1
• Inadequate risk factor control - achieving blood pressure and lipid targets requires aggressive, multi-drug regimens 1