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PVD and HYPERTENSION

PVD and HYPERTENSION. Presenter: Dr. Dov Gavish. Best Marker of Susceptibility to CHD prevalent arterial disease. CHD risk equivalents. NCEP ATP III. Cerebrovascular disease Coronary artery disease Renal artery stenosis Visceral arterial disease Peripheral arterial disease

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PVD and HYPERTENSION

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  1. PVD and HYPERTENSION Presenter: Dr. Dov Gavish

  2. Best Marker of Susceptibility to CHD prevalent arterial disease CHD risk equivalents NCEP ATP III

  3. Cerebrovascular disease • Coronary artery disease • Renal artery stenosis • Visceral arterial disease • Peripheral arterial disease • Intermittent claudication • Critical limb ischemia Major manifestations of atherothrombosis

  4. Overlap of Vascular Disease in Patients With Atherothrombosis CAPRIE Aronow & Ahn Cerebral Disease Coronary Disease Cerebral Disease Coronary Disease 25% 7% 30% 15% 13% 33% 8% 3% 4% 12% 5% 14% 19% 12% PAD PAD PAD, peripheral artery disease.41% of pad have coronary and or cerebral on dg Adapted from TransAtlantic Inter-Society Consensus Group. J Vasc Surg. 2000;31:S16.

  5. PAD:Prevalence (NHANES)

  6. Risk factors for PAD • Gender (male) • Age • Smoking • Hypertension • Diabetes • Hyperlipidaemia • Fibrinogen • Homocysteinaemia PAD Atherosclerosis Atherothrombosis Ischaemic stroke Myocardial infarction Murabito JM et al. Circulation 1997;96:44–49; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:2910–2913;Malinow MR et al. Circulation 1989;79:1180–1188; Brigden ML. Postgrad Med 1997;101:249–262.

  7. Risk factors for PAD Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Alcohol 0.75 1 2 3 4 5 6 Relative Risk Newman AB et al. Circulation 1993; 88: 837-845. TASC Working Group. J Vasc Surg 2000; 31 (1, pt 2): S1-S288. Djousse PM et al. Circulation 2000; 102: 3092-3097.

  8. REACH • מתוך מאגר נתוני ה • גורמי סיכון ב7013 חולים עם מחלת כלי דם הקפית

  9. קיום מחלת כלי דם הקפית מגביר מאד סיכוי לארוע לבבי או מוחי 50 Men Women 40 Concurrent cardiovascular disease (MI, CABG, stroke or stroke surgery) 30 Percentage of group 20 10 0 Yes No Yes No PAD Criqui MH et al. Vasc Med 1997;2:221–226.

  10. 1. Ouriel K. Lancet 2001; 358: 1257–64. סיבות המוות יותר בעיות לב מאשר בעיות גפה PAD • Causes of death: • 55% coronary artery disease • 10% cerebrovascular disease • 25% non-vascular • < 10% other vascular 100 80 60 Patients (%) Survival 40 Myocardial Infarction 20 Intervention Amputation 0 0 1 2 3 4 5 6 7 8 9 10 Time (years)

  11. Peripheral Arterial Disease(PAD) A marker for myocardial infarction and ischaemic stroke

  12. Relative 5-year PAD mortality rates versus other common pathologies 100 86 90 80 70 60 50 38 Patients (%) 40 28 30 18 15 20 10 0 Breast cancer1 Hodgkin's PAD2 Colon and Lung cancer1 disease1 rectal cancer1 1American Cancer Society. Cancer Facts and Figures – 1997. 2Kampozinski RF, Bernhard VM. In: Vascular Surgery (Rutherford RB, ed). Philadelphia, PA: WB Saunders: 1989;chap 53.

  13. PAD תמותה תוך 10 שנים בהתאם להסתמנות הקלינית 1.00 Normal 0.75 Asymptomatic 0.50 Survival Symptomatic 0.25 Severe symptomatic 0.00 0 2 4 6 8 10 12 Time (years) Criqui MH et al. N Engl J Med 1992;326:381–386.

  14. פי כמה גדל הסיכון בחולי מחלת כלי דם הקפיים *

  15. Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication 1 in 5 people over 65 has PAD† Only 1 in 10 of these patients has classical symptoms of intermittent claudication (IC) † ABI<0.9 Diehm C et al. Atherosclerosis 2004; 172; 95-105.

  16. 5-year natural history of PAD 100 patientswith claudication who do notseek medical advice 100 patients with asymptomatic PAD 100 patients diagnosedwith claudication Local Events Systemic Events Worsening claudication25 patients 10 to 20 non-fatal MIs or strokes PLUS Surgical revascularization 10 patients 30 deaths: • CHD 15 • Other cardiovascular and cerebrovascular 5 • Non-cardiovascular 10 Major amputation 2 patients Dormandy JA. Hosp Update 1991;April:314–318.

  17. ד"ר דב גבישמחלקה פנימית אבית חולים וולפסון לחצים בין קרסול לזרוע כמדד לחומרתטרשת העורקים

  18. Slide 19

  19. 2.5 2.0 1.5 1.0 0.0 0.2 0.4 0.6 0.8 1.0 ABPI ABPI – inverse relationship with 5-year risk of cardiovascular events and death 10.2% relative risk increaseper 0.1 decrease in ABPI (p = 0.041) Risk relative to ABPI Dormandy JA, Creager MA. Cerebrovasc Dis 1999;9(Suppl 1):1–128 (Abstr 4).

  20. ABI: Predictive value

  21. PVD ABI in HOPE

  22. פרויקט אגאתה בישראל • 20 מחלקות פנימיות בארץ • 600 חולים עם גורמי סיכון,מחלה ידועה וגיל מבוגר. • בדיקת לחצים קרסול זרוע והערכת טיפול וגורמי סיכון קיימים. • השוואת טיפול מונע לפני ואחרי הבדיקה. • הערכת כדאיות ביצוע הבדיקה כשגרה בחולים דומים לצורך קביעת מדיניות טיפול נכונה.

  23. Effect of Statins in PAD

  24. Effect of inflammation and statins on outcome of PVD patients

  25. Effect of Ramipril by ABI

  26. Platelet thrombus Platelets adhering to subendothelial space Platelets Endothelial cells Subendothelial space הפעלת טסיות שלב חשוב בהתפתחות טרשת Normal platelets Activated platelets Platelet aggregation Adapted from: Ferguson JJ. The Physiology of Normal Platelet Function. In: Ferguson JJ. Chronos N, Harrington RA (Eds). Antiplatelet Therapy in Clinical Practice. London: Martin Dunitz; 2000: 15–35.

  27. אגרגציה בנוכחות טרשת הקפית SPA at 3 min in patients with carotid disease, AAA, and lower limb PAD compared to normal controls. There was higher baseline SPA in patients with lower-limb PAD (p<0.01) or AAA (p<0.05) compared to normal controls. Robless PA, Okonko D, Lintott P, et al.Eur J Vasc Endovasc Surg 2003;25:16-22

  28. PAD אגרגציה מוגברת בחולי SPA-, ADP-, and collagen-induced platelet aggregation in control and lower limb PAD patients. There was significantly higher collagen-induced aggregation in lower-limb PAD patients compared to normal controls (p<0.01). Robless PA, Okonko D, Lintott P, et al.Eur J Vasc Endovasc Surg 2003;25:16-22

  29. CAPRIE – efficacy profile of clopidogrel 8.7% relative risk reduction, p = 0.043 160 Event rate per year 120 Placebo3 * 7.7% Event rate/1000 patients/year 77 80 Aspirin1 5.8% 19 24 58 Clopidogrel1 5.3% 53 40 * extrapolated curve 3 Based on the APTC findings,2 in a population similar to CAPRIE, for each 1000 patients treated per year, aspirin can be expected to prevent 19 events and clopidogrel, 24.1 0 0 3 6 9 12 15 18 21 24 27 30 33 36 Time from Randomization (Months) 1CAPRIE Steering Committee. Lancet 1996;348:1329–1339. 2Antiplatelet Trialists' Collaboration. BMJ 1994;308:81–106. 3Fisher LD. J Am Coll Cardiol 1998;31(Suppl A):49A.

  30. Patients with PAD are at risk of MI, ISand death CAPRIE data Cerebrovascularoutcome Coronaryoutcome 6 5.2 5.1 5 4.2 3.6 4 Clopidogrel 3 3-year cumulative event rate (%) Aspirin 2 1 0 Patients qualifying for CAPRIE on the basis of PAD Dormandy JA, Creager MA. Cerebrovasc Dis 1999;9(Suppl 1):1–128 (Abstr 4).

  31. Summary – 1 • PAD is a marker of atherosclerosis in the coronary and cerebral arteries • PAD is often underestimated and underdiagnosed, and requires proper diagnosis: • ABPI is a non-invasive, easily performed measurement that reliably predicts ischaemic risk in PAD patients • Risk factors need to be managed: smoking cessation, regular exercise training • Antiplatelet therapy is a key component of treatment

  32. Risk factor management approach • Smoking cessation • Weight reduction • Total cholesterol <175 mg/dL / <4.5 mmol/Lor <150 mg% • LDL cholesterol <100 mg/dL / <2.6 mmol/L or <70mg% • Glycosylated hemoglobin <7.0% • Blood pressure (BP) <140/90 mm Hg • For patients with diabetes(or all) BP < 130/80mm Hg • Platelet inhibition Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

  33. Symptomatic Treatment • Exercise1 • Smoking cessation2 • Pharmacologic therapy • Selective use ofinterventional therapy3 • Risk Reduction of Ischemic Events3 • Smoking • Hyperlipidemia • Hypertension • Diabetes • Antiplatelet therapy2 Two complementary objectives for PAD management 1. McDermott MM, McCarthy W. Surg Clin North Am 1995; 75: 581–591. 2. Clagett GP, Krupski WC. Chest 1995; 108 (4 suppl): 431S–443S. 3. Kempczinski RF, Bernhard VM. In: Rutherford RB, ed. Vascular Surgery. 1989: chapt 53.

  34. Management of PADpatients • Lifestyle modification • Smoking cessation • Regular exercise training • Diet • Pharmacological treatment • Antiplatelet therapy • Control risk factors (e.g. hypertension, blood glucose) • Vasodilators for symptomatic relief?

  35. Summary – 2 • Clopidogrel provides increased benefit over aspirin for secondary prevention in atherothrombotic patients, including those with diagnosed PAD • Reduces the risk of all major events(IS, MI, vascular death) • Offers better gastrointestinal safety and tolerabilityin comparison with aspirin

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