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PAD Diagnosis and Management. Gerry Stansby Newcastle upon Tyne, UK . Atherothrombosis affects many vascular beds. These are expressions of a single extensive, progressive, unpredictable and deadly disease . Ischaemic stroke. Transient ischaemic attack. Myocardial infarction. Angina:

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pad diagnosis and management

PADDiagnosis and Management

Gerry Stansby

Newcastle upon Tyne, UK

atherothrombosis affects many vascular beds
Atherothrombosis affects many vascular beds

These are expressions of a single extensive, progressive, unpredictable and deadly disease

Ischaemic stroke

Transient ischaemic attack

Myocardial infarction

Angina:

Stable

Unstable

Renovascular disease

Peripheral arterial disease:

Intermittent claudication

Rest pain

Gangrene

Necrosis

Diabetes (type 2)

Often considered vascular equivalent to to a non-diabetic patient with previous MI2

  • Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(Suppl 1): 1–6
  • Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234
slide3

Cardiologists (+cardiac surgeons)

Vascular Surgeons

Stroke Medicine

Arteriopath

General Practice

Neurology

Care of the elderly

Diabetologists

Renal Physicians

the burden of atherothrombotic disease

Atherothrombosis* continues to be a leading cause of death1

The burden of atherothrombotic disease

Mortality (%)

*Atherothrombosis bar is an addition of burden for coronary heart disease (17.3%), cerebrovascular disease (9.9%) and peripheral arterial disease (no data)

1. England and Wales, Office for National Statistics 2006 (www.heartstats.org)

development of atherothrombotic disease
Development of atherothrombotic disease

Atheroscleroticplaque

Plaque rupture & thrombosis

Normal artery

Fatty streak

MI / unstable angina

Stroke / TIA

Critical limb ischaemia

Cardiovascular death

Stable angina

Claudication

PAD

Clinically silent

Begins in teenage years

Increasing age & risk factors

The underlying pathology is the same for each arterial bed

Peripheral arterial disease should be treated as seriously as coronary heart disease when calculating cardiovascular risk

patients with type 2 diabetes are a high cardiovascular risk group
Patients with Type 2 diabetes are a high cardiovascular risk group

7-yr incidence of

cardiovascular events (%)

20

MI

(20.2%)

MI

(18.8%)

15

CV*

Death

(15.9%)

CV*

Death

(15.4%)

10

Stroke

(10.3%)

Stroke

(7.2%)

5

0

Type 2 diabetes

(no prior MI)

Prior MI

(no diabetes)

*CV = cardiovascular

1. Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234

slide8

Edinburgh Artery Study.

Cross-sectional survey of 1592 subjects. (&aged 55-74)

Symptomatic 4.5%

It’s Common!

Asymptomatic 15%

slide9

5 years.

<5% amputation

20% die of MI

10% die of other causes

5 year fate of the claudicant (Dormandy et al)

slide10

Relative Risks of All-Cause Mortality by Ankle Brachial Index in Men and Women in 12 cohort studies

5

Female

4

Male

Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis.

JAMA. 2008 Jul 9;300(2):197

3

Relative risk of Death

2

1

<0.6

0.6-0.7

0.7-0.8

0.8-0.9

0.9-1.0

1.0-1.1

1.1-1.2

1.2-1.3

1.3-1.4

>1.4

Ankle Brachial Index

Base reference: ABI 1.0-1.4

intermittent claudication key questions
Intermittent claudication? Key questions.
  • Does this pain ever occur standing still or sitting? (No)
  • Is it worse if you walk uphill or hurry? (Yes)
  • What happens to it if you stand still? (It goes away)
  • Where do you get the pain or discomfort? (Claudication pain is typically in the calf, atypically in the buttock or thigh – not in foot or toes)
ankle brachial pressure index
Ankle:Brachial Pressure Index

Highest pressure in foot (ankle)

Brachial systolic pressure

ABI<0.9 diagnostic for PAD

slide14

ABI measurement

  • Brachial Systolic blood pressure
    • Right: 156/88 mmHg
    • Left: 160/92 mmHg
    • Right leg:

DP: 160 mmHg

PT: 154 mmHg

160/160 = 1.00

    • Left leg:

DP: 96 mmHg

PT: 100 mmHg

100/160 = 0.63

The lowest ABI between both legs is

the ABI that stratifies the patient’s risk

Right

156 mmHg

Left

160 mmHg

DP: 96 mmHg

PT: 100 mm Hg

Diagnosis: moderate PAD in left leg

DP: 160 mm Hg

PT: 154 mmHg

agatha abi is related to the site and extent of atherothrombosis
AGATHA: ABI is related to the site and extent of atherothrombosis

20%

33%

26%

% with ABI ≤0.9

CAD = coronary artery disease

CVD = cerebrovascular disease

PAD = peripheral artery disease

CAD

35%

7%

PAD

10%

7%

15%

6%

CVD

20%

Type of arterial bed affected in the with-disease population (%) N=7099

Fowkes et al. EHJ 2006;27:861–867

management of claudication
Management of claudication.
  • Mostly conservative -risk factors
  • If diagnosis certain no tests are needed
  • Intervene only if there is a major impairment of Quality of Life
slide17

“Assessing risk for coronary heart disease: beyond Framingham”.

Am Heart J. 2003 Oct;146(4):572-80.

Cobb FR, Kraus WE, Root M, Allen JD.

pad medical therapy
PAD: Medical Therapy
  • Blood Pressure
  • Lipids
  • Antiplatelets
  • ACEI
  • Diabetes
  • (Cilostazol)
anti platelet therapy
Anti-Platelet therapy
  • Well established role in CHD/Stroke prevention
  • PAD patients have very active platelets
  • 25% fewer events/death on an antiplatelet agent
  • Aspirin or clopidogrel.
blood pressure control

Systolic

Claudicants

<140

30.8%

140-160

33.1%

160-180

24.2%

180-200

8.5%

200+

3.4%

Blood Pressure Control

Target = 140/85

Data from PREPARED study.

slide21

SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE

STATIN worse

Baseline

STATIN

PLACEBO

Risk ratio and 95% CI

feature

(10269)

(10267)

STATIN better

STATIN worse

Previous MI

1007

1255

Other CHD (not MI)

452

597

No prior CHD

CVD

182

215

PVD

332

427

Diabetes

279

369

ALL PATIENTS

2042

2606

24%

SE 2.6

reduction

(19.9%)

(25.4%)

(2P<0.00001)

0.4

0.6

0.8

1.0

1.2

1.4

Heart Protection Study

slide25

Metabolic Syndrome

Difficult to define

Easy to spot

exercise and absolute claudication distance
Exercise andAbsolute Claudication Distance

450

400

350

Supervised

300

250

P < 0.001

Median Absolute Claudication Distance

on Treadmill Walking (meters)

200

Non-supervised

150

100

50

0

Baseline

3-month

6-month

9-month

12-month

reach registry 67 000 patients from 5 473 sites in 44 countries
REACH Registry: >67,000 patients from 5,473 sites* in 44 countries

5,656

17,886

27,746

5,048

5,903

846

North America

1,931

Latin America

Western Europe

2,872

Eastern Europe

Middle East

Asia (incl. Japan)

Australia

JAMA 2006;295:180-9

* up to 15 patients/site (up to 20 in the US)

major endpoints as a function of single vs multiple and overlapping locations

Single arterial bed

Polyvascular disease

Overall

CAD alone

CVD alone

PAD alone

Overall

CAD + CVD

CAD + PAD

CVD + PAD

CAD + CVD + PAD

CV death

1.5

1.5

1.4

1.2

2.4

2.0

2.9(2)

1.8

3.6(3)

Non-fatal MI

1.2

1.4

0.5(3)

1.0

1.5

1.6

1.4

1.3

1.8

Non-fatal stroke

1.5

0.9

3.5(3)

0.6

3.1

3.7

1.3(3)

4.8

4.0

CV death/MI/ stroke

3.4

3.1

4.5(3)

2.3

6.0

6.4

4.8(3)

7.0

7.4

CV death/MI/ stroke/ hospitalisation*

12.8

13.3

10.0(3)

18.2(3)

22.0

20.0

23.3(3)

24.4(1)

26.9(3)

Major endpoints as a function of single vs multiple and overlapping locations

1 p<0.05; 2 p<0.01; 3 p<0.001 (ref class: CAD alone)

1 p<0.05; 2 p<0.01; 3 p<0.001 (ref class: CAD + CVD)

*TIA, unstable angina, other ischemic arterial event including worsening of peripheral arterial disease

critical ischaemia
Critical Ischaemia=
  • Rest pain +/- gangrene or ulcers
  • Doppler pressures < 50mmHg.
  • >70% will need amputation if nothing is done.
  • Priority is revascularisation
  • Urgent referral needed
specialist referral
Specialist referral:
  • Urgent: Critical ischaemia (rest pain, necrosis, gangrene).
  • Routine: Limiting symptoms, threatened employment, diagnostic doubt
  • Refer to local guidelines
slide31

NEWCASTLE, NORTH TYNESIDE AND NORTHUMBERLAND GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH PERIPHERAL ARTERIAL DISEASE (PAD)

October 2008

members of the group
Members of the group
  • Dr Jane Skinner, Consultant Community Cardiologist, Newcastle upon Tyne Hospitals NHS Foundation Trust
  • Professor Gerry Stansby, Professor of Vascular Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust
  • Dr Mike Scott, GP, Newcastle upon Tyne
  • Mrs Margaret King, Programme Co-ordinator, Community Cardiac Care, Newcastle PCT
  • Mrs Lisa English, Community Cardiology Co-ordinator, North Tyneside PCT
  • Mr Glyn Trueman, Formulary Pharmacist, Newcastle Hospitals
  • Ms Zahra Irranejad, Lead Pharmaceutical Advisor, North of Tyne PCTs (represented by Lindsay White)
  • Ms Sheila Dugdill, Peripheral Arterial Nurse Specialist, Freeman Hospital
  • Mrs Susan Turner, Pharmaceutical Advisor (commissioning), NHS North of Tyne
  • Mrs Alice Wincup, Cardiac rehabilitation nurse, Northumberland Care Trust