Advances in the medical management of peripheral arterial disease
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Advances in the Medical Management of Peripheral Arterial Disease. Warner P. Bundens, MD, MS Associate Clinical Professor of Surgery Associate Clinical Professor of Family and Preventive Medicine School of Medicine University of California, San Diego La Jolla, California. ?.

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Advances in the medical management of peripheral arterial disease

Advances in theMedical Management of Peripheral Arterial Disease

Warner P. Bundens, MD, MS

Associate Clinical Professor of Surgery

Associate Clinical Professor of Family and Preventive Medicine

School of Medicine

University of California, San Diego

La Jolla, California


Key question

?

Key Question

How many of your patients with CV risk do

you test for peripheral arterial disease?

  • 0%-24%

  • 25%-50%

  • 51%-75%

  • 76%-100%

    Use your keypad to vote now!


Faculty disclosure
Faculty Disclosure

  • Dr Bundens: grants/research support:sanofi-aventis Group.


Learning objectives
Learning Objectives

  • Describe the prevalence and disease burden of PAD

  • State medical treatments for improving leg symptoms of the patient with PAD

  • Discuss interventions used to prevent systemic complications in the patient with PAD

PAD = peripheral arterial disease.


Peripheral arterial disease what is it
Peripheral Arterial Disease: What Is It?

PAD

PAOD

PAOD = peripheral arterial obstructive disease.


Lesions

ObstructedLumen

Plaque

What Is It?

Lesions


Who gets it
Who Gets It?

PAD: Risk Factors

  • Age

    • Uncommon: <50 years old

    • 50-70 years old

      • 10% overall

      • 20% with history of smoking or diabetes

    • >70 years old

      • 20%


Who gets it1
Who Gets It?

PAD: Risk Factors

  • Age

  • Diabetes 4×

  • Smoking 3.5×

    • Past or present

  • Hypertension 2×

  • Hyperlipidemia 0.1×


How do you diagnose it
How Do You Diagnose It?

PAD Symptoms

  • May be asymptomatic

  • Claudication


Claudication

Claudication

A Reproducible and

Consistent Symptom


Claudication1
Claudication

  • Muscular pain brought on by activity (walking) that is relieved by stopping that activity



Claudication3
Claudication

  • Muscular pain brought on by activity (walking) that is relieved by stopping that activity

    • Does not occur at rest

    • Is not brought on by standing


Other causes of leg pain pseudoclaudication
Other Causes of Leg Pain: “Pseudoclaudication”

  • Spinal stenosis

  • Nerve root compression

  • Arthritis/joint disease, especially the hip

  • Compartment syndrome

  • Venous claudication

  • Symptomatic Baker’s cyst


How do you diagnose it1
How Do You Diagnose It?

PAD Symptoms

  • May be asymptomatic

  • Claudication

  • Ischemic rest pain


Ischemic rest pain
Ischemic Rest Pain

  • Distal foot

  • Worse at night

  • Decreased by lowering foot


How do you diagnose it2
How Do You Diagnose It?

PAD Symptoms

  • May be asymptomatic

  • Claudication

  • Ischemic rest pain

  • Tissue loss, nonhealing lesions, gangrene



Not arterial

Not Arterial

Nocturnal Leg/Foot Cramps


Pad physical findings
PAD: Physical Findings

  • Pulses

  • Pallor

  • Dependent rubor

  • Thick nails

  • Hairlessness

  • Tissue loss/ulcer/gangrene


Pad physical findings1

PAD: Physical Findings

Poor Sensitivity and Specificity

for Mild-to-Moderate PAD


Pad an objective test

PAD: An Objective Test

Flow vs Pressure


Ohm s law
Ohm’s Law

Electrical: E = I·R

Voltage Drop = Current × Resistance

Fluids: P = F·R

Pressure Drop = Flow × Resistance



Office measurement of the ankle brachial index abi
Office Measurement ofthe Ankle-Brachial Index (ABI)

Supine

Patient

Right arm pressure

Left arm pressure

Pressure:

Posterior tibial

Anterior tibial

Pressure:

Posterior tibialAnterior tibial


Ankle pressure
Ankle Pressure

Patient Must Be Supine

Posterior Tibial Anterior Tibial


The abi

Ankle Systolic Pressure

Brachial Artery Systolic Pressure

ABI=

The ABI

  • Both ankle and brachial systolic pressures should be taken using a hand-held Doppler instrument

  • For arm and leg, use higher of 2 pressures


The abi1
The ABI

Right Arm 150 mm Hg

Right AT 68

Right PT 75

Left Arm 143

Left AT 120

Left PT 100

Right ABI = 75/150 = 0.50

Left ABI = 120/150 = 0.80

AT = anterior tibial; PT = posterior tibial.


What do the numbers mean
What Do the Numbers Mean?

ABI

  • Typical values

    • Normal = 1.25-0.9

    • Claudication = 1.0-0.3

    • Rest pain = <0.4

    • Tissue loss = <0.3


Abi 0 90
ABI <0.90

95% Sensitive and 99% Specific for PAD

?

TASC Working Group. J Vasc Surg. 2000;31(1 suppl):S1-S296.


Abi occasional gray areas

ABI 1.0-0.9

Most of these people have PAD

ABI >1.0

Most of these people do not have PAD

ABI: Occasional “Gray” Areas


Abi workshops
ABI Workshops

  • Demonstrations available throughout the day


Further noninvasive testing
Further Noninvasive Testing

  • Segmental pressures

  • Doppler waveforms

  • Exercise test


Lower extremity arterial exam

Further Testing

Lower Extremity Arterial Exam


Relative 5 year mortality rates

PAD Is a Bad Disease

Relative 5-Year Mortality Rates

*American Cancer Society. Cancer Facts and Figures,2000.

Criqui MH et al. N Engl J Med. 1992;326:381-386.



Key question1

?

Key Question

Without intervention, what percentage of

PAD patients will have an MI or stroke in

the next 5 years?

  • 10%

  • 25%

  • 50%

  • 75%

    Use your keypad to vote now!

MI = myocardial infarction.


Clinical outcomes in patients with pad
Clinical Outcomes in Patients With PAD

PAD Patient

Asymptomatic

50%

Intermittent claudication

40%

Critical leg ischemia

10%

Cardiovascular

morbidity/mortality

PAD outcomes

(5-year outcomes)

Stable claudication 73%

Worsening claudication 16%

Leg bypass surgery

7%

Major amputation 4%

Nonfatal events

(MI/stroke)

20%

Mortality 30%

Adapted from Weitz Jl. Circulation. 1996;94:3026-3049.


Pad and all cause mortality
PAD and All-Cause Mortality*

1.00

Normal subjectsAsymptomatic LV-PAD†Symptomatic LV-PAD†Severe symptomatic LV-PAD†

0.75

0.50

Survival

0.25

0.00

0

2

4

6

8

10

12

Year

*Kaplan-Meier survival curves based on mortality from all causes.

†Large-vessel PAD

Adapted from Criqui MH et al. N Engl J Med. 1992;326:381-386.


Diagnosis

Treatment

Diagnosis

2 Problems

Cardiovascular

Risk

Leg Symptoms

Claudication

Rest Pain

Tissue Loss


Cardiovascular risk

Treatment

Cardiovascular Risk

  • Stop smoking

    • Program

    • Toes vs cigarettes

  • Blood pressure control

    • 140/90 mm Hg

    • 130/80 mm Hg if patient has diabetes or renal disease

  • Lipid control

    • LDL <100 mg/dL

  • Diabetes control

    • HbA1C <7%

  • Antiplatelet medication

Hirsch A et al. J Am Coll Cardiol, 2006;47:1239-1312.



Key question2

?

Key Question

What is the proper daily dose of aspirin

for cardiovascular risk reduction?

  • 75 mg

  • 81 mg

  • 300 mg

  • 325 mg

    Use your keypad to vote now!


Antiplatelet medications1
Antiplatelet Medications

  • Aspirin 81 mg/d


Aspirin dosage

Antiplatelet Medications

Aspirin Dosage

Aspirin Dose No. Trials OR (%)

OR

500-1500 mg 34 19

160-325 mg 19 26

75-150 mg 12 32

<75 mg 3 13

Any aspirin 65 23

0

0.5

1.5

1.0

2.0

Antiplatelet Better

Antiplatelet Worse

OR = odds ratio.

Antithrombotic Trialists’ Collaboration. BMJ. 2002;324:71-86.


Aspirin dosage risk of major bleeding

Antiplatelet Medications

Aspirin Dosage: Risk of Major Bleeding

Clopidogrel

+ Aspirin

Placebo

+ Aspirin

Aspirin Dose

<100 mg 3.0% 1.9%

100-200 mg 3.4% 2.8%

>200 mg 4.9% 3.7%

CURE Trial. Circulation. 2003;108:1682-1687.


Antiplatelet medications2
Antiplatelet Medications

  • Aspirin

    • 81 mg

  • Clopidogrel

    • 75 mg


Caprie clopidogrel vs asa mi ischemic stroke or vascular death
CAPRIEClopidogrel vs ASA: MI, Ischemic Stroke, or Vascular Death

16

8.7%

Overall RRR

(P = .045)*

Clopidogrel

ASA

5.83%

12

5.32%

(N = 19,185)

8

Cumulative Event Rate (%)

Subjects had a recent MI, recent ischemic stroke, or symptomatic PAD

4

0

0

3

6

9

12

15

18

21

24

27

30

33

36

Months of Follow-up

Median follow-up = 1.91 years

*ITT analysis

ASA= aspirin; CAPRIE = Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events;

RRR = relative risk reduction.

CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.


Subgroup analysis

CAPRIE

Subgroup Analysis

No. Patients

Patient with stroke 6431

Patient with MI 6302

Patient with PAD 6452

All patients 19,185

-40

-30

-20

-10

0

10

20

30

40

ASA Better

Clopidogrel Better

Risk Reduction (%)

CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.


Leg problems

PAD Treatment

Leg Problems

  • Asymptomatic

    • No specific treatment

  • Claudication

    • Do nothing


Clinical outcomes in patients with pad1
Clinical Outcomes in Patients With PAD

PAD Patient

Asymptomatic

50%

Intermittent claudication

40%

Critical leg ischemia

10%

PAD outcomes

Cardiovascular

morbidity/mortality

(5-year outcomes)

Nonfatal events

(MI/stroke)

20%

Mortality 30%

Stable claudication 73%

Worsening claudication 16%

Leg bypass surgery

7%

Major amputation 4%

Adapted from Weitz Jl. Circulation. 1996;94:3026-3049.


Leg problems1

PAD Treatment

Leg Problems

  • Asymptomatic

  • Claudication

    • Do nothing

    • Walking program

      • Best are supervised

        • Few programs available

        • Rarely reimbursable by insurance

      • Most patients must do their own


Walking program

Claudication Treatment

Walking Program

  • Regular

    • At least 5×/week

  • Length

    • 40-60 min/d

  • Typical results

    • Doubling of walking distance each year

  • Excuses

    • Pain, hills, cold, heat, rain, etc.


Walking program1

Claudication Treatment

Walking Program

  • Additional benefits

    • Good for

      • Heart

      • Lungs

      • Weight loss

      • Muscles

    • See your neighborhood

    • See new areas

    • Their dog will love it (if they have one)


Walking program2

Claudication Treatment

Walking Program

  • Avoid negative walking programs

    • Disability parking

    • Wheelchairs

    • Motorized carts


Walking program3

Claudication Treatment

Walking Program

The Best Treatment, But Requires the Patient’s Commitment


Leg problems2

PAD Treatment

Leg Problems

  • Asymptomatic

  • Claudication

    • Walking program

    • Drugs: pentoxifylline; cilostazol


Cilostazol

PAD Treatment

Cilostazol

  • Not a cure

  • Average benefit

    • 65% increase in maximum walking distance at 6 months

  • Results not immediate

  • Exact mechanism unknown

  • Common side effects

    • Headache, diarrhea, ankle swelling, palpitations

  • Contraindicated in patients with a history of congestive heart failure

  • Reduce dosage indicated with some concomitant medications, eg, omeprazole, diltiazem


Leg problems3

PAD Treatment

Leg Problems

  • Asymptomatic

  • Claudication

    • Walking program

    • Drugs: pentoxifylline; cilostazol

    • Invasive: angioplasty/stenting; surgery


My approach recommendations
My Approach/Recommendations

  • Claudication

    • Walking program

    • Drug(s): cilostazol

    • Invasive: angioplasty/stenting; surgery


Leg problems4

PAD Treatment

Leg Problems

  • Asymptomatic

  • Claudication

  • Ischemic rest pain

    • Refer

  • Nonhealing wounds/ulcers/tissue loss

    • Refer


Critical limb ischemia

PAD Treatment

Critical Limb Ischemia

  • These patients need revascularization

    • Angioplasty/stenting

    • Surgery

  • If revascularization is not possible

    • May need amputation



Patient case study
Patient Case Study

  • Patient’s first visit to your practice because he is new to your area

  • 58-year-old, male

  • Occupation: “In sales”

  • Complaint: “My leg hurts.”

  • History of present illness

    • 6-month history of right calf pain with walking

      • Pain begins at ~60 yards; patient has to stop at ~100 yards

      • Pain goes away within 1 minute of stopping and standing

      • No pain at rest


Patient case study1
Patient Case Study

  • Medical history

    • Not on any medications

    • Once told his blood pressure was “a little high”

    • Doesn’t know his cholesterol or diabetes status

    • Has only sought medical care for acute problems in the past

  • Smoking history

    • Smokes 1-2 packs/d × 35 years


Patient case study2
Patient Case Study

  • Positive physical findings

    • Right arm systolic blood pressure: 160 mm Hg

    • Left arm systolic blood pressure: 152 mm Hg

    • Left carotid bruit

    • Absent right popliteal, PT, dorsalis pedis pulses

    • Right PT pressure: 80 mm Hg

    • Right AT pressure: 66 mm Hg

    • Left PT pressure: 135 mm Hg

    • Left AT pressure:140 mm Hg

AT = anterior tibial; PT = posterior tibial.


Patient case study3
Patient Case Study

  • Right ABI = 80/160 = 0.50

  • Left ABI = 140/160 = 0.88

  • Has abnormal ABIs: both legs

  • Only has symptoms in his right leg


Decision point

?

Decision Point

What etiology might account for unilateral

claudication?

  • Vascular disease limited to one leg

  • Bilateral vascular disease worse in one leg causing symptoms to appear earlier in one leg than another

  • Peripheral neuropathy due to diabetes

    Use your keypad to vote now!


Patient case study4
Patient Case Study

  • You tell the patient he has:

    • PAD

      • A serious disease

        • It is the cause of his walking problem

        • It is also a marker for the systemic disease atherosclerosis and he is at risk for heart attack or stroke

    • Probable hypertension


Decision point1

?

Decision Point

What test(s) would you consider now?

  • Lipid, glucose, repeat ABI

  • Lipid, glucose, segmental pressures

  • Lipid, glucose, carotid duplex, and repeat blood pressure

  • Segmental pressures

    Use your keypad to vote now!


Patient case study5
Patient Case Study

  • He needs further evaluation

    • Repeat blood pressure checks

    • Blood tests: lipid panel, glucose

    • Carotid duplex

  • He needs treatment for his cardiovascular risks


Patient case study6
Patient Case Study

  • Treatment for his cardiovascular risks

    • Stop smoking: teach him how or refer

    • Probable blood pressure control

    • Lipids?

    • Diabetes?

    • Antiplatelet therapy


Patient case study7
Patient Case Study

  • He says:

    • “I hear you. I know those things are important, but I came in here for this right calf pain I get with walking. What can we do about that? I had a neighbor who had ‘the balloon treatment’ and he was cured.”

  • You may be thinking:

    • “I’m trying to save his life.”

  • But unless you address his claudication, he may not come back and give you the chance

    • You may need to address the claudication first


Patient case study8
Patient Case Study

  • You describe the treatment options

    • Walking program

    • Drug(s): cilostazol

    • Invasive: angioplasty/stenting; surgery




Pce takeaways1
PCE Takeaways

  • PAD is a common disease

  • PAD is a serious disease

    • A marker for the systemic disease atherosclerosis

  • Diagnosis usually is not difficult

  • Management usually is straightforward


Key question3

?

Key Question

Will you use ABI testing to diagnose patients

at risk for PAD?

  • Not likely

  • Somewhat likely

  • Very likely

  • Extremely likely

    Use your keypad to vote now!


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