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Peripheral Vascular Disease in Cardiac Patients. Jason Finkelstein, M.D. Cardiology Fellow Tulane University HSC 9/23/03. P A D. Characterized by arterial stenosis and occlusions in the peripheral arterial bed Can be symptomatic or asymptomatic Under diagnosed and under treated disease

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peripheral vascular disease in cardiac patients

Peripheral Vascular Disease in Cardiac Patients

Jason Finkelstein, M.D.

Cardiology Fellow

Tulane University HSC

9/23/03

p a d
P A D

Characterized by arterial stenosis and occlusions in the peripheral arterial bed

  • Can be symptomatic or asymptomatic
  • Under diagnosed and under treated disease
  • Patient and physician awareness is low
p v d
P V D
  • Ranges in severity from intermittent claudication to limb ischemia
  • Patients have a decreased quality of life due to a reduction in walking distance and speed leading to immobility
  • Most cases of PAD are asymptomatic
prevalence
Prevalence
  • 27 million people in Europe and North America have PAD (16% of the population 55 yrs or older)
    • 10.5 million are symptomatic
    • 16.5 million are asymptomatic
  • Three recent programs have demonstrated high PAD detection rates when specific populations were at risk for PAD were screened
popadad study
POPADAD study
  • 8000 patients
  • 40 yrs or older with DM Type I or II
  • Had no clinical symptoms of arterial disease
  • Results:
    • 20.1% of patients had ABI < 0.9
pad awareness detection
PAD Awareness & Detection
  • Total of 6979 patients
  • Ages 70 yrs or older or 50-69 with diabetes or smoking history
  • PAD was considered present if ABI< 0.9 or a h/x of limb revascularization
  • CVD was defined as coronary, cerebral, or aortic aneurysmal disease
  • Criqui, et al, JAMA 2001: 286; 1317-1324
results
Results:
  • PAD was detected in 1865 pts ( 30%)
  • 44% of these pts had newly diagnosed PAD only
  • 366 pts had newly diagnosed PAD and CVD (35%)
  • Among pts with PVD, classic claudication was distinctly uncommon
  • PAD is relatively underdiagnosed by physicians
  • PAD patients were less intensely treated than patients with CVD
  • Criqui et al, JAMA 2001 286. 1317-1324
natural history of pad
Natural History of PAD
  • Associated with significant mortality because of association with coronary and cerebrovascular events including death, MI, and stroke
  • 6x more likely to die within 10 yrs than patients without PAD
  • 5 yr mortality rate in pts with claudication is about 30%
  • Continued use of smoking results in a two fold risk of mortality
prevalence9
Prevalence
  • Severity of symptoms has been found to correlate with survival
    • San Diego Artery study
      • Survival rates decreased with increasing severity
  • Another study showed that patients with symptoms had a 22% survival rate over a 15 yr period compared to a 78% survival rate of pts w/o symptoms
  • Belch et al, Arch Intern Med; April 2003; 884-892
predictors of mortality in pad
Predictors of Mortality in PAD
  • 297 patients
    • 213 had intermittent claudication
    • 84 had CLI defined by gangrene, ulcerations or persistent rest pain > 2 weeks
    • All subjects had ABI < 0.9
  • Results
    • Patients with CLI had a 1 yr death rate of 22%
    • 3 yr survival was 52% compared to 86% in pts with intermittent claudication
    • Data suggests that pts with advance PAD have widespread arteriosclerotic disease
    • CLI was a stronger predictor of death than a low ABI

Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60

claudication
Claudication
  • Patients suffer from peripheral atherosclerosis
  • Symptomatic deficiency in blood supply to exercising muscle which is relieved by rest
  • Largely a disorder of the elderly
  • Only 1-2% of those ages 37-69
  • Clinical history extremely important
risk factors
Risk Factors
  • Diabetes mellitus
    • have worse arterial disease and poorer outcomes than non-diabetics
  • Advanced age
  • Hyperlipidemia
  • Cigarette smoking
  • Hypertension
cardiac risk
Cardiac Risk
  • Pts with PVD have a 60% risk of CAD
  • Up to 30 % of pts have correctable 3 vessel disease with reduced LVEF
  • Patients with an ABI < 0.9 are twice as likely to have CAD
clinical presentation
Clinical Presentation
  • Can vary from severe disabling discomfort at rest to a bothersome pain of seemingly little consequence
  • Can present with buttock, thigh, calf or foot claudication singly or in combination
  • Diminished pulses with occasional bruits over stenotic lesions
  • Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changes
claudication15
Claudication
  • Calf
    • Cramping in upper 2/3 usually due to SFA stenosis
  • Thigh
    • Usually occlusion of the common femoral artery
  • Foot
    • Occlusive disease of the tibial and peroneal vessels
  • Buttock and Hip
    • Aortoiliac occlusive disease (Lariche’s syndrome)
diagnostic tests
Diagnostic tests
  • Ankle-brachial index
    • Measures the resting and post exercise systolic BP in both the ankle and arms
    • Normal > 1.0
    • Below 0.9 has a 95 % sensitivity for detecting angiogram positive PVD
    • 0.4 to 0.9 suggests arterial obstruction
      • Highly predictive of morbidity and mortality of CV events linked to PAD
    • Below 0.4 represents advanced ischemia
diagnostic tests17
Diagnostic Tests
  • Segemental limb pressures
    • > 20 mmHg reduction significant
  • Duplex U/S
  • MRA
  • Conventional angiography
angiography
Angiography
  • Indicated for:
    • Defining vessel anatomy
    • Evaluating therapy
    • Documenting disease
long term survival
Long term survival
  • 2, 296 patients reviewed from CASS found to have PAD
  • Mean follow up period was 10.4 yrs
  • Pts with PAD had a higher frequency of CV risk factors
    • HTN, DM, CHF, previous CABG, or smoked
  • Controlled for all independent risk factors
  • Vascular disease retained a highly significant correlation with mortality
    • Pts had a 25% increased risk of dying at any time during followup ( p< 0.001)

Eagle et al, JACC 1994;23:1091-5

premature pad
Premature PAD
  • 59 male patients with premature PAD
  • Age of onset < 45 yrs of age
  • PAD assessed by ABI and CAD assessed by exercise treadmill testing or coronary angiogram
  • Mean ABI was 0.65
  • Arteriography performed in 56/59 pts
  • Valentine et al, J of Vasc Surg (1994; 19; 668-674)
premature pad21
Premature PAD
  • 30 month period of the study
  • 43 patients had significant CAD (73%)
    • 17 pts had single vessel disease
    • 4 pts had 2 vessel disease
    • 22 pts had 3 vessel disease
  • 32 pts experienced an MI and 23 pts requires an intervention to help control angina
  • 8% mortality rate in the study
  • Valentine et al, J Vasc Surg (1994; 19:668-674)
management of pad cad
Management of PAD & CAD
  • Close association of PAD and CAD
  • Pts with CAD undergoing PV surgery are at increased risk of early and late CV events
  • Coronary revasc. is likely to improve outcome but mortality rate after CABG is not as good as in pts w/o PVD
  • Recommends hemodynamic monitoring
  • Definitive guidelines are not available
  • Gersch et al, J am Coll Card; 1991;18:203-214
pvd and role of crp
PVD and Role of CRP
  • 51 pts with PVD who underwent lower limb revasc. (screened 170 pts)
  • 24 month f/u period
  • 39 pts had PTA and 12 pts had bypass surgery
  • CRP levels were measured pre-op

All mortality, cardiac mortality and MI were considered major events

  • Rossi et al, Circulation 2002; 105:800-803
pvd and role of crp24
PVD and Role of CRP
  • 34% incidence of fatal and nonfatal MI over 2 yrs
  • CRP > 9 predicted 60 % o f MI’s in pts undergoing lower limb revasc. ( p <0.04)
  • Conclusion
    • CRP level in pts with PVD severe enough for revasc. may give incremental information about CV events and had a high predictive value
    • Pts may benefit from therapy modulating the immune response
    • More studies needed
    • Rossi et al, Circulation; 2002; 105: 800-803
pad management
PAD Management
  • Anti-platelet agents
  • Diabetic control
  • Smoking cessation
  • Anti-hypertensives
  • Statin therapy
  • Exercise rehabilitation
  • Revascularization/PTCA/stenting
revascularization
Revascularization
  • Indications for intervention (PTA)
    • Persistent limiting claudication that prevents patient from performing daily activities
    • Rest pain
    • Tissue loss
    • Patients who are poor surgical candidates
  • Long term success of PTA depends on site and length of the lesion
    • Limited to focal, short segment occlusions
    • No significant difference in outcome between PTA or surgery
revascularization27
Revascularization
  • Lesions might be better treated surgically if:
    • Long segments
    • Multi focal stenoses
    • Long segment occlusions
    • Eccentric, calcified lesions
conclusion
Conclusion
  • Need to increase awareness of PAD and its consequences
  • Improve the identification of patients with symptomatic PAD
  • Initiate a screening protocol at high risk for PAD
  • Improve treatment rates for those who have been diagnosed
  • Increase the rates of early detection in asymptomatic patients
summary
Summary
  • PAD is a powerful indicator of systemic artherosclerosis
  • Mandates aggressive risk factor modification and pharmacologic therapy
  • Goal is to improve the functional capacity of our patients and decrease morbidity and mortality
  • Cardiologists need to take a more active role in treating PAD along with co-existing CAD
case 1
Case #1
  • Mr. EG is a 52 yr old male with PMHx of HTN, tobacco abuse and CAD with a 5 vessel CABG in June 2000
    • LIMA – LAD
    • SVG to D1
    • SVG to OM1 & OM2
    • SVG to RCA
case 138
Case #1
  • Last cath was in April of 2001 which showed patent grafts and medical management was recommended
  • Now pt has recurrent chest pain on exertion < 1 block
  • Cardiolyte stress test revealed 1 mm ST depression and anterior ischemia. LVEF is 44%
case 2
Case # 2
  • Mr. JG is a 60 yr old male with PMHx of severe tobacco abuse, AAA, PVD with ischemic rest pain, Right CEA, HTN, who presents with occasional atypical angina
  • Persantine Cardiolyte stress test showed reversible anterior and septal ischemia
case 240
Case # 2
  • TEE revealed normal LVEF with mild inferobasal HK
  • Moderate to severe eccentric MR
  • Physical exam revealed b/l carotid bruits and 2/6 SEM