PADDiagnosis and Management
Gerry Stansby
Newcastle upon Tyne, UK
Ischaemic stroke
Atherothrombosis affects many vascular beds
1. Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(Suppl 1): 1–6
2. Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234
These are expressions of a single extensive, progressive, unpredictable and deadly disease
Transient ischaemic attack
Myocardial infarction
Angina:StableUnstable
Peripheral arterial disease:Intermittent claudicationRest painGangreneNecrosis
Renovascular disease
Diabetes (type 2)Often considered vascular
equivalent to to a non-diabetic patient with previous MI2
Vascular Surgeons
Cardiologists (+cardiac surgeons)
General Practice
Care of the elderly
Stroke MedicineArteriopath
Diabetologists
Neurology
Renal Physicians
1. England and Wales, Office for National Statistics 2006 (www.heartstats.org)
Mortality (%)
The burden of atherothrombotic disease
Atherothrombosis* continues to be a leading cause of death1
*Atherothrombosis bar is an addition of burden for coronary heart disease (17.3%), cerebrovascular disease (9.9%) and peripheral arterial disease (no data)
27.3%
3.5%
14.0%
27.0%
0 5 10 15 20 25 30
Atherothrombosis*
Cancer
Respiratory
Injuries and poisoning
Clinically silentBegins in teenage years
Increasing age & risk factors
Stable anginaClaudication
PAD
MI / unstable anginaStroke / TIA
Critical limb ischaemiaCardiovascular death
Normal arteryFatty streakAtheroscleroticplaque
Plaque rupture & thrombosis
Development of atherothrombotic disease
Peripheral arterial disease should be treated as seriously as coronary heart disease when calculating cardiovascular risk
The underlying pathology is the same for each arterial bed
Patients with Type 2 diabetes are a high cardiovascular risk group
1. Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234
0
5
10
15
20
Prior MI (no diabetes)
7-yr incidence of cardiovascular events (%)
Type 2 diabetes (no prior MI)
MI(18.8%)
CV*Death
(15.9%)
Stroke(7.2%)
MI(20.2%)
Stroke(10.3%)
CV*Death
(15.4%)
*CV = cardiovascular
Edinburgh Artery Study.
Cross-sectional survey of 1592 subjects. (&aged 55-74)
Asymptomatic 15%
Symptomatic
4.5%
It’s Common!
20% die of MI
10% die of other causes
<5% amputation
5 years.
5 year fate of the claudicant (Dormandy et al)
11
22
33
44
55
<0.6<0.6 0.6-0.70.6-0.7 0.7-0.80.7-0.8 0.8-0.90.8-0.9 0.9-1.00.9-1.0 1.0-1.11.0-1.1 1.1-1.21.1-1.2 1.2-1.31.2-1.3 1.3-1.41.3-1.4 >1.4>1.4
FemaleFemale
MaleMale
Ankle Brachial Index
Base reference: ABI 1.0-1.4Base reference: ABI 1.0-1.4
Relative risk of Death
Relative Risks of All-Cause Mortality by Ankle Brachial Index in Relative Risks of All-Cause Mortality by Ankle Brachial Index in Men and Women in 12 cohort studiesMen and Women in 12 cohort studies
Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis.JAMA. 2008 Jul 9;300(2):197
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)
PADAnkle: Brachial Index
Ankle:Brachial Pressure Index
Highest pressure in foot (ankle)
Brachial systolic pressure
ABI<0.9 diagnostic for PAD
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 isthe ABI that stratifies the patient’s risk
DP: 160 mm HgPT: 154 mmHg
Right
156 mmHg
Left
160 mmHg
Diagnosis:
moderate PAD in left leg
ABI measurement
DP: 96 mmHgDP: 96 mmHgPT: 100 mm HgPT: 100 mm Hg
AGATHA: ABI is related to the site and extent of atherothrombosis
CAD35%
PAD10%
CVD20%
6%7%
15%26%
20%
33%
% with ABI ≤0.9
Type of arterial bed affected in the with-disease population (%) N=7099
Fowkes et al. EHJ 2006;27:861–867
CAD = coronary artery diseaseCVD = cerebrovascular diseasePAD = peripheral artery disease
7%
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
“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
•Blood Pressure
•Lipids
•Antiplatelets
•ACEI
•Diabetes•(Cilostazol)
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
Target = 140/85 Systolic Claudicants
<140
30.8%
140-160
33.1%
160-180
24.2%
180-200
8.5%
200+
3.4%
Data from PREPARED study.
SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE
Risk ratio and 95% CISTATIN PLACEBOBaselinefeature (10269) (10267) STATIN better STATIN worse
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(19.9%) (25.4%)
24%SE 2.6reduction(2P<0.00001)
0.4 0.6 0.8 1.0 1.2 1.4Heart Protection Study
Cholesterol (mmol / L)
Perc
ent
10.59.07.56.04.53.0
18
16
14
12
10
8
6
4
2
0
Mean 5.437StDev 1.238N 346
PREPARED study – cholesterol levels in claudicants
ACE inhibitors
Metabolic Syndrome
Difficult to define
Easy to spot
Exercise andAbsolute Claudication Distance
0
50
100
150
200
250
300
350
400
450
Baseline 3-month 6-month 9-month 12-month
Med
ian
Ab
solu
te C
lau
dic
atio
n D
ista
nce
o
n T
read
mill
Wal
kin
g (m
eter
s)
Supervised
Non-supervised
P < 0.001
North AmericaLatin America
Eastern Europe
Middle East
Asia (incl. Japan)
Australia
27,746
1,931
17,886
846
5,903
2,872
* up to 15 patients/site (up to 20 in the US)
Western Europe
REACH Registry: >67,000 patients from 5,473 sites* in 44 countries
5,048
5,656
JAMA 2006;295:180-9
Major endpoints as a function of single vs multiple and overlapping locations
Polyvascular diseaseSingle arterial bed
26.9(3)
7.4
4.0
1.8
3.6(3)
CAD + CVD + PAD
24.4(1)
7.0
4.8
1.3
1.8
CVD + PAD
23.3(3)
4.8(3)
1.3(3)
1.4
2.9(2)
CAD + PAD
20.0
6.4
3.7
1.6
2.0
CAD + CVD
22.018.2(3)10.0(3)13.312.8CV death/MI/ stroke/ hospitalisation*
6.02.34.5(3)3.13.4CV death/MI/ stroke
3.10.63.5(3)0.91.5Non-fatal stroke
1.51.00.5(3)1.41.2Non-fatal MI
1.5
CAD alone
1.5
Overall
1.2
PAD alone
2.4
Overall
1.4CV death
CVD alone
*TIA, unstable angina, other ischemic arterial event including worsening of peripheral arterial disease
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)
Critical Ischaemia=
Rest pain +/- gangrene or ulcersDoppler pressures < 50mmHg.>70% will need amputation if
nothing is done.Priority is revascularisationUrgent referral needed
Specialist referral:
Urgent: Critical ischaemia (rest pain, necrosis, gangrene).
Routine: Limiting symptoms, threatened
employment, diagnostic doubt
Refer to local guidelines
NEWCASTLE, NORTH TYNESIDE AND NORTHUMBERLAND GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH PERIPHERAL ARTERIAL DISEASE (PAD)
October 2008
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
Any Questions?Thank You For Listening
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