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CVD Critical Pathways Group 2006 Teleconferences

2. Faculty. Christopher P. Cannon, MDAssociate Professor of MedicineHarvard Medical SchoolSenior Investigator, TIMI Study GroupAssociate Physician, Cardiovascular DivisionBrigham and Women's HospitalBoston, Massachusetts. . . 3. Disclosure Statement. The Network for Continuing Medical Educati

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CVD Critical Pathways Group 2006 Teleconferences

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    1. 1 CVD Critical Pathways Group 2006 Teleconferences

    2. 2 Faculty Christopher P. Cannon, MD Associate Professor of Medicine Harvard Medical School Senior Investigator, TIMI Study Group Associate Physician, Cardiovascular Division Brigham and Women’s Hospital Boston, Massachusetts

    3. 3 Disclosure Statement The Network for Continuing Medical Education requires that CME faculty disclose, during the planning of an activity, the existence of any personal financial or other relationships they or their spouses/partners have with the commercial supporter of the activity or with the manufacturer of any commercial product or service discussed in the activity.

    4. 4 Faculty Disclosure Statement Christopher P. Cannon, MD, has served as a consultant to AstraZeneca Pharmaceuticals LP, Bristol-Myers Squibb Company, GlaxoSmithKline, Guilford Pharmaceuticals, Merck/Schering-Plough Pharmaceuticals, Pfizer Inc, sanofi-aventis, Schering-Plough Corporation, and Vertex Pharmaceuticals Inc. He has also received research support from AstraZeneca Pharmaceuticals LP, Bristol-Myers Squibb Company, Merck & Co., Inc., and sanofi-aventis. The team from Maricopa Medical Center reports no such relationships.

    5. 5 Applying the New ACC/AHA Guidelines for Peripheral Arterial Disease

    6. 6 Polling Question #1 All of the time Most of the time Occasionally Never

    7. 7 Peripheral Arterial Disease (PAD) Defined as the presence of a stenosis or occlusion in the aorta or arteries of the limbs Usually caused by atherosclerosis Associated with an increased risk of cardiovascular and cerebrovascular events, including death, MI, and stroke May impair walking ability and threaten the limb

    8. 8 Overlap of Atherosclerotic Disease

    9. 9 PAD Clinical Presentations

    10. 10 PAD Survival Curve

    11. 11 ACC/AHA 2006 PAD Management Guidelines Clinical Presentation: Asymptomatic A history of walking impairment, claudication, ischemic rest pain, and/or nonhealing wounds is recommended as a required component of a standard review of systems for adults 50 years and older who have atherosclerosis risk factors and for adults 70 years and older.

    12. 12 ACC/AHA 2006 PAD Management Guidelines Clinical Presentation: Asymptomatic Individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ankle-brachial index (ABI) so that therapeutic interventions known to diminish their increased risk of myocardial infarction (MI), stroke, and death may be offered.

    13. 13 Claudication and Mortality

    14. 14 ACC/AHA 2006 PAD Management Guidelines Clinical Presentation: Claudication Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the ankle-brachial index (ABI).

    15. 15 Association Between Ankle-Brachial Index (ABI) and Mortality

    16. 16 ACC/AHA 2006 PAD Management Guidelines Diagnostic Methods: Ankle-Brachial Index (ABI) The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with exertional leg symptoms, with nonhealing wounds, who are 70 years and older, or who are 50 years and older with a history of smoking or diabetes.

    17. 17 Risk Factors for PAD

    18. 18 Effect of Smoking Cessation on Survival in Patients With PAD

    19. 19 ACC/AHA 2006 PAD Management Guidelines CV Risk Reduction: Smoking Cessation Individuals with lower extremity PAD who smoke cigarettes or use other forms of tobacco should be advised by each of their clinicians to stop smoking and should be offered comprehensive smoking cessation interventions, including behavior modification therapy, nicotine replacement therapy, or bupropion.

    20. 20 Heart Protection Study: Vascular Event by Prior Disease

    21. 21 ACC/AHA 2006 PAD Management Guidelines CV Risk Reduction: Lipid-Lowering Drugs Treatment with a hydroxymethyl glutaryl coenzyme-A reductase inhibitor (statin) medication is indicated for all patients with PAD to achieve a target low-density lipoprotein (LDL) cholesterol level of less than 100 mg per dL. Treatment with a statin medication to achieve a target LDL-C level of less than 70 mg per dL is reasonable for patients with lower extremity PAD at very high risk of ischemic events.

    22. 22 Intensive BP Therapy in PAD: The ABCD Trial

    23. 23 ACC/AHA 2006 PAD Management Guidelines CV Risk Reduction: Antihypertensive Drugs Antihypertensive therapy should be administered to hypertensive patients with lower extremity PAD to achieve a goal of less than 140 mm Hg systolic over 90 mm Hg diastolic (nondiabetics) or less than 130 mm Hg systolic over 80 mm Hg diastolic (diabetics and individuals with chronic renal disease) to reduce the risk of MI, stroke, congestive heart failure, and cardiovascular death.

    24. 24 UKPDS: Intensive Blood Glucose Control vs Conventional Treatment in Patients With Type 2 Diabetes

    25. 25 ACC/AHA 2006 PAD Management Guidelines CV Risk Reduction: Diabetes Therapies Treatment of diabetes in individuals with lower extremity PAD by administration of glucose control therapies to reduce the hemoglobin A1C to less than 7% can be effective to reduce microvascular complications and potentially improve cardiovascular outcomes.

    26. 26 Antithrombotic Trialists’ Collaboration: MI, Stroke, CV Death in Patients With PAD Category APT CTRL Reduction (%) Intermittent 6.4% 7.9% 23±9 claudication Peripheral artery 5.4% 6.5% 22±16 bypass graft Peripheral 2.5% 3.6% 29±35 angioplasty All high-risk patients 22±2 (P<.001)

    27. 27 ACC/AHA 2006 PAD Management Guidelines CV Risk Reduction: Antiplatelet Therapy Antiplatelet therapy is indicated to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

    28. 28 CAPRIE Study

    29. 29 CAPRIE Study

    30. 30 ACC/AHA 2006 PAD Management Guidelines CV Risk Reduction: Antiplatelet Therapy Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of MI, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

    31. 31 Meta-Analysis of Exercise Training in Claudication

    32. 32 Relative Efficacy of Supervised vs Unsupervised Exercise Training

    33. 33 ACC/AHA 2006 PAD Management Guidelines Exercise and Lower Extremity PAD Rehabilitation A program of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication.

    34. 34 Effect of Cilostazol on Walking Distance in Patients With Claudication

    35. 35 Effect of Cilostazol vs Pentoxifylline on Walking Distance in Patients With Claudication

    36. 36 ACC/AHA 2006 PAD Management Guidelines Medical and Pharmacological Treatment for Claudication Cilostazol (100 mg orally 2 times per day) is indicated as an effective therapy to improve symptoms and increase walking distance in patients with lower extremity PAD and intermittent claudication (in the absence of heart failure).

    37. 37 Lower-Extremity Occlusive Disease Catheter-based Revascularization Angioplasty (balloon, subintimal) Stents (stainless steel, nitinol) Covered stents (Dacron, PTFE) Rotational atherectomy Other interventions (cryoplasty, brachytherapy) Surgical Reconstruction Aortic bifemoral bypass Infrainguinal bypass (vein, PTFE)

    38. 38 Indications for Revascularization Lifestyle-interfering intermittent claudication Limb-threatening ischemia Ischemic rest pain Nonhealing ulceration Gangrene

    39. 39 ACC/AHA 2006 PAD Management Guidelines Endovascular Intervention of Intermittent Claudication Endovascular procedures are indicated for individuals with a vocational or lifestyle-limiting disability due to intermittent claudication when clinical features suggest a reasonable likelihood of symptomatic improvement with endovascular intervention and (a) there has been an inadequate response to exercise or pharmacological therapy and/or (b) there is a very favorable risk-benefit ratio (eg, focal aortoiliac occlusive disease).

    40. 40 ACC/AHA 2006 PAD Management Guidelines Thrombolysis for Acute and Chronic Limb Ischemia Catheter-based thrombolysis is an effective and beneficial therapy and is indicated for patients with acute limb ischemia (Rutherford categories 1 and IIa) of less than 14 days’ duration.

    41. 41 ACC/AHA 2006 PAD Management Guidelines Critical Limb Ischemia and Treatment for Limb Salvage Parenteral administration of prostaglandin E-1 (PGE-1) or iloprost for 7 to 28 days may be considered to reduce ischemic pain and facilitate ulcer healing in patients with CLI, but its efficacy is likely to be limited to a small percentage of patients.

    42. 42

    43. 43 Polling Question #2 We are currently on the same item We have since moved to the next checkbox on the checklist We have progressed by more than one item on the checklist ACS pathways are up-to-date and regularly followed

    44. 44 Progress Checklist: Immediate Goals

    45. 45 Progress Checklist: Short-term Goals/Activities

    46. 46 Progress Checklist: Long-term Goals/Activities

    47. 47 Question-and-Answer Session

    48. 48 Concluding Remarks Christopher P. Cannon, MD Next Program Highlights From the American College of Cardiology 2006 Annual Scientific Session Gregg C. Fonarow, MD Wednesday, March 22, 2006 3:00 PM Eastern Time (12:00 Noon Pacific Time)

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