Beth ABRAMSON, Toronto Sonia ANAND, Hamilton Tom FORBES, London Anil GUPTA ,Brampton

1. Beth ABRAMSON, Toronto Sonia ANAND, Hamilton Tom FORBES, London Anil GUPTA ,Brampton Ken HARRIS, London Vic HUCKELL, Vancouver Asad JUNAID, Winnipeg Tom LINDSAY, Toronto Finlay McALISTER, Edmonton Andre ROUSSIN, Montreal Jacqueline SAW, Vancouver Koon TEO, Hamilton A. G TURPIE, Hamilton Subodh VERMA, Toronto Canadian Cardiovascular Society Consensus Conference 2005:Peripheral Arterial DiseaseB. L. Abramson V. Huckell Co-Chairs

2. Goals of the CCS Consensus Process • to put Peripheral Arterial Disease on the radar screen • to ensure better treatment, to reduce both morbidity and mortality in the patient with vascular disease • to foster discussion regarding newer models to deliver care across disciplines • to serve as a guide to the busy clinician

3. CCS Consensus Conference 05 • Involved a broad range of specialists caring for the PAD patient • In Collaboration with the Can. Society of Vascular Surgeons • Executive Summary: C. J. Cardiol 05; 21(2)997-1006 • Complementary to larger AHA/ACC, TASC • Practical focus for our membership - thoracic and abdominal aortic disease, renal arterial disease discussed • Current version will not discuss: carotid disease, digital disease, pulmonary arterial disease, erectile dysfunction, venous disease

4. QUALITY OF EVIDENCE AND CLASSIFICATION OF RECOMMENDATIONS Quality of Evidence 1 Evidence obtained from at least one properly randomized controlled trial or one large epidemiological study 2 Evidence based on at least one non-randomized cohort comparison or multi-centre study, chronological series or extra ordinary results from large non-randomized studies. 3 Opinions of respective authorities, based on clinical experience, descriptive studies or reports of expert committees. Classification and Recommendations A Evidence sufficient for universal use (usually based on RCTs) B Evidence acceptable for widespread use, evidence less robust, but based on randomized clinical trials. C Evidence not based on randomized clinical trials.

5. PAD - Epidemiology • PAD is often asymptomatic, under-diagnosed, under-recognized, and under-treated • 16% of North America and Europe has PAD, correlating to 27 million people • Of these 16.5 million are asymptomatic • Little contemporary epidemiological data for the prevalence of PAD in Canada but it likely represents 4% of the population over age 40 A. Gupta

6. PAD - Epidemiology A. Gupta

7. PATHOPHYSIOLOGY OF ATHEROSCLEROSIS • a systemic and generalized disorder of the arterial tree • involves a close interplay between endothelial dysfunction and inflammation, which in turn may modify the vascular responses to oxidative stress, and platelet-endothelial interaction • when compensatory mechanisms fail, complications of atherosclerosis such as stenosis, plaque ulceration, embolization and thrombosis appear S. Verma

8. PAD Risk Factors: K. Teo

9. AORTIC ANEURYSMS • Aortic aneurysms are silent killers. • They develop mostly in patients over the age 60 • 90% of all abdominal aortic aneurysms (AAA) occur below the renal arteries • incidence of 4-5% in the general population • Survival rates for aortic rupture depend upon the aneurysm location and the population examined • Mortality rates can be as low as 40% • Series that take into account pre hospital deaths show mortality rates up to 90%. T. Lindsay

10. RecommendationsAneurysm Screening T. Lindsay

11. RecommendationsAAA Follow-up Based on Initial Size T. Lindsay

12. ATHEROSCLEROTIC RENAL ARTERY STENOSIS (RAS) • The incidence of renal arterial disease is up to 45% in those with acute, severe or refractory HT • PAD patients are at high risk of RAS • Patients with moderate or severe hypertension and otherwise unexplained pulmonary edema are much more likely to have either bilateral renal arterial disease or arterial stenosis of a solitary functioning kidney A. Junaid

13. Main Indications for Investigation • Uncontrolled Hypertension despite maximum dosing of 3 HT medications & Creatinine < 300 • Rapid (within weeks to months) otherwise unexplained decline in renal function and serum Cr. < 300 mol/l • Otherwise unexplained recurrent flash pulmonary edema A. Junaid

14. Recommendations:Atherosclerotic RAS Management A. Junaid

15. Screening & Diagnosis

16. PAD Diagnosis A. Roussin

17. PAD Diagnosis continued A. Roussin

18. RecommendationsMedical Therapies to Reduce Cardiovascular Events in PAD

19. RecommendationsMedical Therapies to Reduce Cardiovascular Events in PAD S. Anand, A. Turpie

20. Choice of Anti-Platelet Agent Given Current Evidence S. Anand, A. Turpie

21. NON-MEDICAL MANAGEMENT • The vast majority of patients with claudication, are best treated conservatively • Surgical or interventional approaches should be considered in patients whose claudication prevents them from meeting their work and everyday responsibilities and with very poor quality of life • Those with limb threatening ischemia suffer from such symptoms as rest pain, gangrene, non-healing ulcers or sores, and diabetic foot infections • These patients should be urgently referred for consideration of revascularization procedures T. Forbes, K. Harris

22. Non-Medical Management of Chronic Limb Ischemia T. Forbes, K. Harris

23. Percutaneous Interventions – Clinical Indications J. Saw

24. PERIOPERATIVE RISK ASSESSMENT FOR VASCULAR SURGERY • General internists and cardiologists are frequently asked to perform preoperative assessments on patients who are scheduled for vascular surgery. • The purpose should not be to “clear” someone for surgery, but rather to evaluate the severity and stability of the medical conditions and optimize their management before surgery. • The preoperative assessment should be seen as a venue for the provision of risk estimates to the surgeon, patient, and anaesthetist which can be used to inform decision making. F. McAlister

25. PERIOPERATIVE RISK ASSESSMENT THREE PRINICPLES • the approach should be appropriate to the situation i.e. -tailored evaluation with a surgical emergency • preoperative coronary revascularization should not be done to try to reduce surgical risk, but rather should only be considered in patients who would warrant revascularization for medical reasons independent of the proposed operation • the preoperative approach should be tempered by the patient’s overall health status F. McAlister

26. Additional Highlights • Screening and Diagnosis • – A. Roussin, MD • Medical Management • – S. Anand, MD • Perioperative Risk Assessment • – B. Abramson, MD • A National Call to Action • - V. Huckell MD

27. CCS PAD 2005 CONSENSUSScreening and Diagnosis • Taking a directed history for symptoms of PAD. • A validated questionnaire, such as the Edinburgh Questionnaire, can help diagnose arterial claudication in patients suspected of suffering from PAD • Grade 1A recommendation

28. CCS PAD 2005 CONSENSUSScreening and Diagnosis • Performing a directed examination focusing on physical findings that have been proven useful to detect PAD as defined as an ABI < 0.9 • Grade 1A recommendation

29. CCS PAD 2005 CONSENSUSScreening and Diagnosis • Ordering an ABI to help diagnose arterial claudication in patients suspected of claudication. • An ABI below 0.9 is diagnostic of PAD with values below 0.4 associated with severe disease • Grade 1A recommendation

30. CCS PAD 2005 CONSENSUSScreening and Diagnosis • Ordering an ABI to diagnose PAD in asymptomaticpatients with arterial bruits or diminished pulses • Grade 1A recommendation

31. CCS PAD 2005 CONSENSUSScreening and Diagnosis • Considering an ABI to diagnose PAD in patients with a high cardiovascular risk, particularly patients over the age of 40 with smoking or diabetes. • Femoral bruits are specific (95%) for PAD and reduced pulses are quite sensitive (±70%) for PAD but the ABI will still detect PAD in a fair number of patients with a normal physical exam • Grade 1B recommendation

32. CCS PAD 2005 CONSENSUSScreening and Diagnosis • Considering Segmental pressures, Duplex scanning and Treadmill testing in conjunction with a vascular specialist • Grade 3C recommendation

33. PAD Investigation and ImagingMost useful methods in 2005 • Ankle-Brachial Index (ABI) to confirm PAD • Duplex for screening in view of further investigation • Claudication & normal creatinine • Consider CT-Angio • Claudication & diabetes or renal failure • Consider MR-Angio • Critical ischemia • Consider MR-Angio

34. #1: Smoking Cessation • Top Priority reduces CV events and improves claudication • Doctors make an impact*** • Single most powerful preventive intervention inclinical practice

35. # 2: Antiplatelet Tx Reduces CV Events in PAD Patients (Grade 1A) Lifelong Antiplatelet Therapy is Indicated in All PAD Patients

36. # 3: Statins (Grade 1A) • Reduce CV death, MI, and stroke in PAD patients • May improve walking distance in intermittent claudication

37. # 4: ACE Inhibitors (Grade 1A) • Blood Pressure Lowering • Reduction in clinical events over and above BP Lowering (HOPE)

38. PAD 4046 22.0 No PAD 5251 14.3 The HOPE Study: PAD Subgroup Analysis No. of Patients Incidence of Composite Outcome in Placebo Group 0.8 1.0 1.2 0.6 Relative Risk in Ramipril Group The Heart Outcomes Prevention and Evaluation Study Investigators N. Engl. J. Med. 2000; 342: 145-153

39. Supervised Exercise to improve Claudication (1A) • Cochrane Meta-analysis (only RCT’s) • 10 trials, 250 Patients • Exercise increased maximum walking time by 6.51 min (95% CI: 4.36-8.66] • Prescription: 3 sessions x 30 minutes per week Leng, Cochrane Database

40. PERIOPERATIVE RISK ASSESSMENT FOR VASCULAR SURGERY Proposed Algorithm:

41. Need for noncardiac vascular surgery Emergent PROCEED TO OPERATION Elective Revascularization or favourable result on coronary evaluation within 2 years? Yes and asymptomatic since No (or new symptoms) • Cancel/Delay surgery • Treat modifiable conditions & re-evaluate • Consider cath if revasc. would be appropriate for reasons independent of planned OR ANY MAJOR RISK PREDICTOR: MI within 4 weeks CCS Class III/IV or unstable angina Decompensated CHF Severe valvular disease High grade AV block Symptomatic vent. arrhythmias Uncontrolled ventricular response Yes Not Low Risk No ANY INTERMEDIATE RISK PREDICTOR: MI > 4 weeks ago CCS class I or II angina Compensated heart failure Diabetes Mellitus, Renal insufficiency Cerebrovascular disease Yes Noninvasive Testing Low Risk No Functional capacity < 1-2 blocks walking PLUS ANY MINOR RISK PREDICTOR: Age >70 years Rhythm other than sinus Abnormal ECG (LVH, LBBB, ST-T) BP > 180/110 mm Hg Yes PROCEED TO OPERATION No

42. Patient scheduled for elective vascular surgery and non-invasive testing indicated Exercise ECG Stress Test Resting ECG normal? Yes Yes Patient able to exercise? No No Non-exercise Stress Test Exercise perfusion imaging History of bronchospasm, second degree AV block, theophylline dependence, or valvular dysfunction? Yes History of ventricular arrhythmias, uncontrolled hypertension, or resting hypotension? No No Yes Dipyridamole myocardial perfusion scintigraphy Dobutamine Stress Echo Other

43. PAD An (inter) national(inter) organ (inter) specialty disease

44. A national call to action

45. Critical issues • Increase awareness of PAD and its consequences

46. Increase Awareness of PAD and Its Consequences • Ischemic burden • Dissemination of clinical definition • Prediction of CVD and CAD • Vascular disease foundations and networks • Vascular societies

47. Critical issues • Increase awareness of PAD and its consequences • Improve the identification of patients with symptomatic PAD

48. Improve the identification of patients with symptomatic PAD • Public awareness campaigns • Patient and physician education

49. Critical issues • Increase awareness of PAD and its consequences • Improve the identification of patients with symptomatic PAD • Initiate a screening protocol for patients at high risk for PAD

50. Initiate a screening protocol for patients at high risk for PAD • Review traditional risk factors • Examine peripheral pulses • Consider ABI