Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD....

Transcript of Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD....

Management ofPeripheral Arterial

Disease

Daniel Char, MD

Disclosures:None

I AM NOT A CARDIOLOGIST

Page 7: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 8: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 9: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 10: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 11: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 12: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 13: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Yoshimitsu Soga et al. JCIN 2014;7:1444-1449

Page 14: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Yoshimitsu Soga et al. JCIN 2014;7:1444-1449

Page 15: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 16: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

70% 2-year survival

Page 17: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication

Page 18: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 19: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 20: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 21: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 22: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 23: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 24: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Jeffrey S. Berger, and Joseph A. Ladapo JACC 2017;69:2293-2300

Page 25: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Randomized 27,395 patients with stable atherosclerotic disease:1. Rivaroxaban 2.5 mg BID and ASA 100 mg QD2. Rivaroxaban 5 mg BID3. ASA 100 mg QD

Page 26: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

CV Death, stroke, MI:Rivaroxaban + ASA. v. ASA

4.1% v 5.4%

Page 27: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 28: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

7,470 PAD patientsMajor Adverse Limb Events:Rivaroxaban + ASA v. ASA

1.5% v 2.6%

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Major Bleeding:Rivaroxaban + ASA v. ASA

3.1% v 1.9%

Page 31: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Concerns:Did not specifically emphasize aggressive use of secondary prevention therapies to lower blood

pressure and cholesterol

Page 32: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Concerns:Cost

Over $400 per month

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Concerns:1.3% absolute risk reduction in composite outcomes

v.Increased risk of bleeding

Page 34: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Concerns:Composite endpoints: Number Needed to Treat 70

MALE: Number Needed to Treat 175

Page 35: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 36: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 37: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 38: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 39: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 40: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

I’m a rather brilliant vascular surgeon. Perhaps Icould help you with your claudication.

Page 41: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 42: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Page 43: Management of Peripheral Arterial Disease · Peripheral Arterial Disease Daniel Char, MD. Disclosures: None. I AM NOT A CARDIOLOGIST . Yoshimitsu Soga et al. JCIN 2014;7:1444-1449.

Conclusions:1. Peripheral Arterial Disease is Bad2. Cholesterol management is good3. Exercise is good4. Intervention and exercise better5. Addition of rivaroxaban ?