stamford marriott stamford connecticut april 26 2008
Download
Skip this Video
Download Presentation
Stamford Marriott Stamford, Connecticut April 26, 2008

Loading in 2 Seconds...

play fullscreen
1 / 71

Stamford Marriott Stamford, Connecticut April 26, 2008 - PowerPoint PPT Presentation


  • 183 Views
  • Uploaded on

Stamford Marriott Stamford, Connecticut April 26, 2008. 2008. Symposia Series 1. 1. 1. Peripheral Arterial Disease: Keeping Pace With Current Diagnostic and Treatment Options. Randall M. Zusman, MD Associate Professor of Medicine Harvard Medical School

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Stamford Marriott Stamford, Connecticut April 26, 2008' - mabli


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
stamford marriott stamford connecticut april 26 2008
Stamford Marriott

Stamford, Connecticut

April 26, 2008

2008

Symposia Series 1

1

1

peripheral arterial disease keeping pace with current diagnostic and treatment options

Peripheral Arterial Disease: Keeping Pace With Current Diagnostic and Treatment Options

Randall M. Zusman, MD

Associate Professor of Medicine

Harvard Medical School

Director, Division of Hypertension and Vascular Medicine

Massachusetts General Hospital

Boston, Massachusetts

2

2

how many of your patients with cv risk do you test for pad
0How many of your patients with CV risk do you test for PAD?
  • 0%-24%
  • 25%-50%
  • 51%-75%
  • 76%-100%

Use your keypad to vote now!

faculty disclosure
Faculty Disclosure

Dr Zusman:advisory board/research grants/speakers bureau: Bristol-Myers Squibb Company, Daiichi Sankyo, Forest Pharmaceuticals, Inc., Novartis, Pfizer Inc., sanofi-aventis

4

4

learning objectives
Learning Objectives
  • State the clinical manifestations of PAD
  • Perform ankle-brachial index measurements in patients at risk for PAD
  • Describe medical treatments for improving leg symptoms in patients with PAD

PAD = peripheral arterial disease.

pad prevalence in the primary care office setting
PAD: Prevalence in the Primary Care Office Setting

NHANES1

Age >40

4.3%

The prevalence of PAD in primarycare clinics was almostin high-risk patients

San Diego2

Mean age = 66

11.7%

30%

NHANES1

Age ≥70

14.5%

Rotterdam3

Age >55

19.1%

Diehm4

Age ≥65

19.8%

PARTNERS5

Age >70, or between 50-69 with history of diabetes or smoking

29%

0%

5%

10%

15%

20%

25%

30%

35%

NHANES = National Health and Nutrition Examination Survey; PARTNERS = PAD Awareness, Risk, and Treatment

New Resources for Survival Program.

1. Selvin E, et al. Circulation. 2004;110:738-743; 2. Criqui MH, et al. Circulation.1985;71:510-515;

3. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192;

4. Diehm C, et al. Atherosclerosis. 2004;172:95-105; 5. Hirsch AT, et al. JAMA. 2001;286:1317-1324.

6

what is pad
What Is PAD?

Atherosclerotic occlusion of the arteries to the legs

PAD may be asymptomatic or present with atypical symptoms

Common, but often overlooked

Associated with significant morbidity and mortality

www.nhlbi.nih.gov/health/dci/Diseases/pad.

video clip predilation arteriogram bilateral iliac artery stenosis severe aortic atherosclerosis

VIDEO CLIP: Predilation Arteriogram—Bilateral Iliac Artery Stenosis Severe Aortic Atherosclerosis

Courtesy: Michael R. Jaff, DO

Director, Vascular Center

Massachusetts General Hospital

Boston, Massachusetts

pad scope of the problem
16

PAD affects 8-12 million Americans, second only to CHD*

Proportionately, for every 4 patients seen with CHD*, clinicians might expect to see approximately 3 patients with PAD

14

13

12

8-12

10

Prevalence (millions)

8

6

4

5.4

2

0

Stroke

PAD

CHD*

PAD: Scope of the Problem
  • Exact prevalence is unknown

*Includes MI and angina pectoris.

CHD = coronary heart disease; MI = myocardial infarction.

AHA. Heart Disease and Stroke Statistics—2008 Update. www.americanheart.org; Hiatt WR. N Engl J Med. 2001;344:1608-1621.

.

pad increases the risk of chd death by approximately
0PAD increases the risk of CHD death by approximately:
  • 1×-2×
  • 3×-4×
  • 5×-6×
  • 6×-7×
  • 7×-8×

Use your keypad to vote now!

pad increased risk of mortality
PAD: Increased Risk of Mortality

Patients with large-vessel PAD* are at ~6×the risk

of dying from

CHD compared

with patients without PAD

10.0

8.0

6.6

(2.9-14.9)

6.0

Relative Risk of Death (95% CI)

4.0

3.1

(1.9-4.9)

2.0

0.0

Death From CHD

All-Cause

Mortality

Cause of Death

*ABI ≤0.8.

ABI = ankle-brachial index.

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

patient profile
Patient Profile

58-year-old Latino male

Presents to the clinic after referral from emergency department where he was evaluated and discharged after an episode of chest pain

Coronary event ruled out by lab and diagnostic studies

Construction worker with no health benefits

Scenario #1

current history
Current History

Complains of fatigue and inability to maintain current productivity at the work site

Mild leg pain

Remembers being told his “sugar was a little high”

Reports he is not on any medications

Reports he does not drink alcohol

Smokes 1 pack/d x 30 years

physical examination
Physical Examination

Results

Height: 5 ft 9 in

Weight: 190 lb

BMI: 28.1 kg/m2

Waist circumference: 40 in

Blood pressure: 130/85 mm Hg

Pulse: 72 bpm

BMI = body mass index.

which element of the patient s history creates the highest index of suspicion for pad
0Which element of the patient’s history creates the highest index of suspicionfor PAD?
  • Age
  • Diabetes
  • Ethnicity
  • Hypertension
  • Smoking

Use your keypad to vote now!

pad common risk factors
PAD: Common Risk Factors*

◄Lesser risk

Greater risk ►

Diabetes

4.05

Smoking

2.55

Patients with diabetes are at a

4x higher risk

of developing symptomatic PAD versus the general population

Hypertension

1.51

Total cholesterol (10 mg/dL)

1.10

0 1 2 3 4 5 6

Age >40 years

*PAD diagnosis based on ABI <0.90.

Newman AB, et al. Circulation. 1993;88:837-845.

pad prevalence increases with age
PAD: Prevalence Increases With Age

Rotterdam Study (ABI <.9)

San Diego Study (PAD by noninvasive tests)

60

50

40

Patients With PAD (%)

30

20

10

0

55-59

60-64

65-69

70-74

75-79

80-84

85-89

Age Group (y)

Creager M, ed. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000.

san diego population study pad and ethnicity
San Diego Population StudyPAD and Ethnicity

Criqui MH, et al. Circulation. 2005;112:2703-2707.

reach scope of the problem cerebro and cardiovascular disease
REACHScope of the Problem: Cerebro- and Cardiovascular Disease

63% of PAD patients

had polyvascular* disease

N = 7013

Cerebro-vascular

Coronary

artery

14.2%

9.5%

39.4%

Peripheral artery

Polyvascular

disease

*PAD patients with polyvascular disease had concomitant symptomatic cerebrovascular disease and/or

CVD. REACH = REduction of Atherothrombosis for Continued Health.

CVD = cardiovascular disease.

Bhatt DL, et al. Presented at: ACC Scientific Session; March 6-9, 2005; Orlando, Fla.

what is the next step in assessing the patient for possible pad
0What is the next step in assessing the patient for possible PAD?
  • ABI testing
  • Differential diagnosis for leg pain
  • Lipid/endocrine panel
  • Vascular laboratory tests

Use your keypad to vote now!

pad intermittent claudication not always present
PAD: Intermittent Claudication Not Always Present

Patients With PAD

PARTNERS:

up to 90%*

of patients with PAD would be missed if healthcare providers relied solely on classic symptoms of intermittent claudication

Healthcare providers should routinely ask about atypical symptoms

*In patients with ABI ≤0.9.

Asymptomatic PAD

~40%

Symptomatic PAD

~60%

Typical Symptoms(Intermittent Claudication)

~10%

Exercise calf pain

Not present at rest

Relieved within 10 minutes by rest

Atypical Symptoms~50%

Occlusion may develop slowly, allowing collateral circulation to develop

AHA. Heart Disease and Stroke Statistics—2008 Update. www.americanheart.org;

Criqui MH, et al. Vasc Med. 1996;1:65-71; Hirsch AT, et al. JAMA. 2001;286:1317-1324.

pad diagnostic critical pathway
PAD: Diagnostic Critical Pathway

ABI Available

ABI Not Available

Clinical Evaluation:

History and Physical

Referral to Vascular Lab

  • Assessment of location/ severity is desired
  • Patients with poorly compressible vessels
  • Normal ABI where PAD suspicion is high

Vascular Lab Evaluation

  • Segmental pressures
  • Pulse volume recordings
  • Treadmill

PAD Diagnosis

PAD Diagnosis

Adapted from American Diabetes Association. Diabetes Care. 2003;26:3333-3341.

simple questions to ask your patient who has symptoms of pad
Simple Questions to Ask Your Patient Who Has Symptoms of PAD

Do you walk?

If you do not walk, why not?

Do you have pain in either leg when you walk?

How far can you walk?

How far do you walk without stopping?

What stops you when you are walking?

Have you had any poor or non-healing leg or foot wounds?

Olson KWP, et al. J Vasc Nurs. 2004;22:72-77.

pad physical evaluation differential diagnosis in patients with intermittent claudication
PAD: Physical Evaluation—Differential Diagnosis in Patients With Intermittent Claudication
  • Calf
    • Venous occlusion
    • Chronic compartment syndrome
    • Nerve root compression
    • Baker’s cyst
  • Hip/thigh/buttock
    • Hip arthritis
    • Spinal cord compression
  • Foot
    • Arthritis
    • Buerger disease

Adapted from Schmieder FA, et al. Am J Cardiol. 2001;87:3D-13D.

pad physical examination
PAD: Physical Examination

Additional examination by palpation and auscultation to detect abnormal aortic aneurysm or bruit

Gey DC, et al. Am Fam Physician. 2004;69:525-532.

physical examination results
Physical Examination Results

CV: RRR S1 and S2 with no murmurs or gallops

Chest: clear to A/P

Abdomen: rotund, but no pulsatile masses or distention

Vascular: no bruits; upper extremity pulses—normal limits

Lower extremity pulses reveal normal femoral bilaterally

Right popliteal, DP, and PT palpable

Left shows decreased popliteal, DP, and PT

Musculoskeletal: no evidence of foot ulceration or dependent rubor

Neurologic: sensory function intact in upper and lower extremities

DP = dorsalis pedis; PT = posterior tibial.

how often do you perform abis for patients who have a similar clinical profile
0How often do you perform ABIs for patients who have a similar clinical profile?
  • 0%-25%
  • 26%-50%
  • 51%-75%
  • 76%-100%

Use your keypad to vote now!

pad diagnostic critical pathway30
PAD: Diagnostic Critical Pathway

ABI Available

ABI Not Available

Clinical Evaluation:

History and Physical

Referral to Vascular Lab

  • Assessment of location/ severity is desired
  • Patients with poorly compressible vessels
  • Normal ABI where PAD suspicion is high

Vascular Lab Evaluation

  • Segmental pressures
  • Pulse volume recordings
  • Treadmill

PAD Diagnosis

PAD Diagnosis

Adapted from American Diabetes Association. Diabetes Care. 2003;26:3333-3341.

29

partners incorporating abi into primary care
PARTNERSIncorporating ABI Into Primary Care

358%

300%

Weekly Increase in ABI Use in Office

Monthly Increase in

ABI Use in Office

After Clinicians Participated in PARTNERS:

88%

Clinicians thought it feasible to incorporate ABI into daily practice

Mohler ER, et al. Vasc Med. 2004;9:253-260.

abi indications
ABI: Indications

American Diabetes Association. Diabetes Care. 2004;22:181-189.

concept of abi
Concept of ABI

Systolic blood pressure in the leg should be approximately the same as that in the arm

Leg Pressure

Therefore, the ratio of systolic blood pressure in the leg versus the arm should be approximately 1 or slightly higher

÷≈ 1

Arm Pressure

ABI is 95% sensitive and 99% specific for angiographically diagnosed PAD

Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049.

abi video

ABI Video

Vascular Disease Foundation

abi workshops

ABI Workshops

CME/CE–accredited demonstrations available

throughout the day

abi results
ABI Results
  • Diagnostic intervention
    • Evaluate vascular status ABI results
      • Right = 1.00
      • Left = 0.56
treatment rationale
Treatment Rationale

The lower the ABI, the greater the risk of cardiovascular events

Patients with critical leg ischemia—the most severe clinical manifestation of PAD—who have the lowest ABI values have an annual mortality of 25%

Hiatt WR. N Engl J Med. 2001;344:1608-1621.

patient consultation
Patient Consultation

You tell your patient he has:

PAD

A serious disease

The cause of his walking problem

A marker for the systemic disease atherosclerosis—and he is at risk for heart attack or stroke

appropriate management of this patient should be to
0Appropriate management of this patient should be to:
  • Treat symptoms
  • Reduce CV risk
  • Treat symptoms then address CV risk reduction
  • Simultaneously treat symptoms and reduce CV risk

Use your keypad to vote now!

slide41
PAD: 2-Pronged Management Strategy

Patient Management

Requires BOTH Approaches Simultaneously

Risk Reduction of Ischemic Events

  • Objective
    • Reduce risk of events causing morbidity and mortality
  • Control risk factors
  • Antiplatelet therapy (clopidogrel)

Treatment of Symptoms

  • Objective
    • Reduce symptoms to increase mobility, exercise tolerance, functional capacity
  • Exercise
  • Pharmacology therapy (cilostazol)
  • Selective use of interventional therapy

Kempczinski RF, et al. In: Rutherford RB, ed. Vascular Surgery. 1989; Clagett GP, et al. Chest. 1995;108:431S-443S; McDermott MM, et al. Surg Clin North Am. 1995;75:581-591.

slide42

Despite its prevalence and cardiovascular risk implications, only 25% of patients with PAD are undergoing treatment!

PAD: Undertreated

  • In a recent study of 1733 patients with known PAD:
    • 33% were taking a beta blocker
    • 29% were taking an ACE inhibitor
    • 31% were taking a statin
    • Of those with diabetes, only 46% had an A1C of <7%

ACE = angiotensin-converting enzyme.

AHA. Heart Disease and Stroke Statistics—2008 Update. www.americanheart.org; Rehring TF, et al. J Vasc Surg. 2005;41:816-822.

management plan risk reduction
Management Plan—Risk Reduction

Appropriate management includes:

Smoking cessation

Blood pressure control

Antiplatelet therapy

Exercise program

Order lipid/metabolic profiles

Follow-up in 1 month

pad aggressive risk factor modification smoking cessation
PAD: Aggressive Risk Factor Modification—Smoking Cessation

50

Varenicline (n = 344)

Bupropion SR (n = 342)

Placebo (n = 341)

45

40

35

Continuous Abstinence (%)

30

25

20

15

10

5

0

Week 9-24†

Week 9-12*

Week 9-52†

*Carbon monoxide level confirmed at clinic visits.

†Clinic and telephone visits.

Jorenby DE, et al. N Engl J Med. 2006;296:56-63.

44

meta analysis pad aggressive risk factor modification supervised exercise
Meta-AnalysisPAD: Aggressive Risk Factor Modification—Supervised Exercise

179%

122%

Percentage Increase

Distance to Maximal Claudication Pain

Distance to Onset of Claudication Pain

At 6 Months

AMA has published

a CPT code for supervised PAD rehabilitation (93668)2

Greatest improvement:

  • Sessions lasted >30 min
  • 3 sessions/week
  • Walk to near-maximal pain
  • >6-month program

CPT = current procedural terminology.

1. Gardner AW, et al. JAMA. 1995;274:975-980; 2. Kanjwal MK, et al. JK Practitioner. 2004;11:225-232.

hope pad aggressive risk factor modification antihypertensive therapy
HOPEPAD: Aggressive Risk Factor Modification—Antihypertensive Therapy

0.6

0.8

1.0

1.2

  • Benefit seen independent of antihypertensive effect

Relative Risk in Ramipril Group

HOPE Study Investigators. N Engl J Med. 2000;342:145-153.

which of the following would you recommend for the pharmacologic management of his pad
0Which of the following would you recommend for the pharmacologic management of his PAD?
  • Aspirin
  • Cilostazol
  • Clopidogrel
  • Pentoxifylline

Use your keypad to vote now!

antiplatelet therapy for pad
Antiplatelet Therapy for PAD

ACCP = American College of Chest Physicians; ASA = aspirin; CAPRIE = Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events;CCB = calcium channel blocker; CHF = chronic heart failure; GI = gastrointestinal; TTP = thrombotic thrombocytopenic purpura.

Adapted from Gey DC, et al. Am Fam Physician. 2004;69:525-532.

caprie clopidogrel versus asa mi ischemic stroke or vascular death
CAPRIEClopidogrel Versus ASA: MI, Ischemic Stroke, or Vascular Death

16

8.7%

Overall RRR

(P = .045)*

ASA

Clopidogrel

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.

ITT = intention to treat; RRR = relative risk reduction.

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

caprie safety profile
CAPRIESafety Profile

Although the risk of myelotoxicity with clopidogrel appears to be low, this possibility should be considered when a patient receiving clopidogrel has fever or another sign of infection.

  • Patients with a history of ASA intolerance were excluded from CAPRIE.

Data on file, Sanofi-Synthelabo Inc.; PLAVIX Prescribing Information. sanofi-aventis/Bristol-Myers Squibb Company; 2007.

tolerability profile
Tolerability Profile*

CAPRIE

*ASA-intolerant patients excluded; +≥2.5% of patients receiving clopidogrel.

Data on file, Sanofi-Synthelabo Inc.; PLAVIX Prescribing Information. Sanofi-aventis/Bristol-Myers Squibb Company; 2007.

laboratory results
Scenario #2Laboratory Results
  • Lipid panel
    • Total cholesterol: 276 mg/dL
    • LDL-C: 170 mg/dL
    • HDL-C: 29 mg/dL
    • Triglyceride: 280 mg/dL
  • A1C: 9.2%
  • FPG: 204 mg/dL
  • BUN: 19 mg/dL; creatinine: 1.2 mg/dL

BUN = blood urea nitrogen; FPG = fasting plasma glucose; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol.

pad aggressive risk factor modification diabetes and hyperlipidemia
PAD: Aggressive Risk Factor Modification—Diabetes and Hyperlipidemia

Gey DC, et al. Am Fam Physician. 2004;69:525-532; Hiatt WR. N Engl J Med. 2001;344:1608-1621; Norgren L, et al. J Vasc Surg. 2007;45:S5A-S67.

atherosclerosis risk in communities study pad a1c and diabetes
Atherosclerosis Risk in Communities Study PAD: A1C and Diabetes

A1C levels

1st tertile = <5.9%

2nd tertile = 6.0%-7.4%

3rd tertile = >7.5%

Log rank P value = .0006

0.06

0.05

0.04

Probability of PAD-Related Hospitalizations

0.03

0.02

0.01

0

0

2

4

6

8

10

Years of Follow-up

Selvin E, et al. Diabetes Care. 2006;29:877-882.

heart protection study pad aggressive risk factor modification lipids
Heart Protection Study PAD: Aggressive Risk Factor Modification—Lipids

0.4

0.6

0.8

1.0

1.2

1.4

Simvastatin Better

Placebo Better

.

HPS Collaborative Group. MRC/BHF. Lancet. 2002;360:7-22.

laboratory results56
Laboratory Results

Scenario #3

Lipid panel

  • Total cholesterol: 276 mg/dL
  • LDL-C: 170 mg/dL
  • HDL-C: 29 mg/dL
  • Triglyceride: 280 mg/dL

A1C: 9.2%

FPG: 204 mg/dL

BUN: 32 mg/dL; creatinine: 2.4 mg/dL

patient consultation57
Patient Consultation
  • Discuss with the patient that his renal function is deteriorating
    • Recommend renal consultation
  • Urinary albumin excretion test ordered
  • Consideration may be given to renal arteriogram
    • To determine presence of renal artery stenosis leading to diminished renal blood flow
pad when to refer
PAD: When to Refer
  • Primary care team is not confident making the diagnosis or lacks resources to make such a diagnosis
  • Patient has continued symptoms despite a reasonable trial and adherence to best medical therapy
  • Patient has critical limb ischemia (rest pain, gangrene, or ulceration)
pad diagnostic critical pathway59
PAD: Diagnostic Critical Pathway

ABI Available

ABI Not Available

Clinical Evaluation:

History and Physical

Referral to Vascular Lab

  • Assessment of location/ severity is desired
  • Patients with poorly compressible vessels
  • Normal ABI where PAD suspicion is high

Vascular Lab Evaluation

  • Segmental pressures
  • Pulse volume recordings
  • Treadmill

PAD Diagnosis

PAD Diagnosis

Adapted from American Diabetes Association. Diabetes Care. 2003;26:3333-3341.

vascular laboratory results segmental pressures
Vascular Laboratory Results: Segmental Pressures
  • Segmental pressures can help localize lesion
  • Considered abnormal when there is a

>20 mm Hg difference between adjacent segments within the same leg and between the original segment and the corresponding segment on the contralateral leg

Brachial Brachial artery

Upper thigh Proximal femoral artery

Lower thigh Distal femoral artery

Calf DP, PT, and proximal arteries

Ankle PT or DP artery

Holland T. Ostomy Wound Manage. 2002;48:38-40, 43-46, 48-49.

vascular laboratory test pulse volume recordings
Vascular Laboratory Test: Pulse Volume Recordings

Provides Segmental Waveform Analysis, a Qualitative Assessment of Blood Flow

UpperThigh

LowerThigh

Calf

Ankle

Normal

Normal tracingincludes initial systolic peak with a dicrotic wave on the down slope

PAD

Abnormal tracingcharacterized by a rounded systolic peak that is lower, as well as the lack of a dicrotic wave on the downslope

Data provided by Mark Creager, MD.

Holland T. Ostomy Wound Manage. 2002;48:38-40, 43-46, 48-49.

treadmill test function testing to aid diagnosis
Treadmill Test: Function Testing to Aid Diagnosis

Clinical Evaluation: History and Physical

Suspect PAD

Atypical Symptoms for PAD

ABI

Normal ABI With Typical Symptoms of Claudication

Treadmill Function Testing

  • Patients with claudication will normally display a drop in ankle pressure after exercise
  • May also be used to assess treatment efficacy and evaluate overall physical function

PAD Diagnosis

Adapted from American Diabetes Association. Diabetes Care. 2003;26:3333-3341.

positioning of dilating balloon
Positioning of Dilating Balloon

Courtesy: Michael R. Jaff, DO, Director, Vascular Center Massachusetts General Hospital, Boston, Mass.

63

video postprocedure restoration iliac vessel lumen

VIDEO: Postprocedure Restoration Iliac Vessel Lumen

Courtesy: Michael R. Jaff, DO

Director, Vascular Center

Massachusetts General Hospital

Boston, Massachusetts

pad in primary care underdiagnosed and undertreated
PAD in Primary Care: Underdiagnosed and Undertreated
  • Prevalence is high, yet clinician awareness of PAD and its diagnosis is relatively low
  • ABI can identify PAD
  • PAD is a reliable warning sign that a patient is at high risk for life-threatening cardiovascular and cerebrovascular events
  • Aggressive lifestyle changes and drug therapy can save lives

Hirsch AT, et al. JAMA. 2001;286:1317-1324.

will you use abi testing to diagnose patients at risk for pad
0Will you use ABI testing to diagnose patients at risk for PAD?
  • Extremely likely
  • Very likely
  • Somewhat likely
  • Not likely

Use your keypad to vote now!

stamford marriott stamford connecticut april 26 200871
Stamford Marriott

Stamford, Connecticut

April 26, 2008

2008

Symposia Series 1

71

71

ad