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Amjad AlMahameed, MD Director, Vascular Medicine Research

Medical Management of Claudication: Just Walk it Off!!. Amjad AlMahameed, MD Director, Vascular Medicine Research Associate Staff, Section of Vascular Medicine Department of Cardiovascular Medicine Cleveland Clinic Foundation. Objectives.

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Amjad AlMahameed, MD Director, Vascular Medicine Research

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  1. Medical Management of Claudication: Just Walk it Off!! Amjad AlMahameed, MD Director, Vascular Medicine Research Associate Staff, Section of Vascular Medicine Department of Cardiovascular Medicine Cleveland Clinic Foundation

  2. Objectives • Recognize the magnitude of PAD as a public health problem • Review best management strategies • Reflect on future prospects

  3. Other Cardiovascular Morbidity/Mortality Nonfatal CV Event MI/Stroke/other 20% 5 year Mortality 30% Cardiovascular Cause 75% Serious, but “not so bad overall”…. Natural History of Intermittent Claudication Population > 55 y/o Intermittent Claudication (5%) Peripheral Vascular Outcomes Stable Claudication 50-75% Worsening Claudication 17-25% Lower Ext Bypass 7% Major Amputation 4% Adapted from Weitz JI et al, Circulation 1996, 94:3026 and TASC Working Group J Vasc Surg 2000;31:(suppl 1) S1-296

  4. PAD Survival* as a Factor of Clinical Severity 100 Normal Subjects 75 Asymptomatic LV-PAD† Survival (% of patients) 50 Symptomatic LV-PAD† 25 Severe Symptomatic LV-PAD† 0 0 2 4 6 8 10 12 Year *Kaplan-Meier survival curves based on mortality from all causes.†Large-vessel PAD. Criqui MH et al. N Engl J Med. 1992;326:381-386.

  5. event event event event The diagnosis of established atherosclerosis in a patient, or identifying that a patient is high risk for atherosclerosis is an: EVENT

  6. Treatment Goals in PAD Improve Functional Status Save the Limb Prevent Atherosclerosis Progression Reduce Cardiac & Cerebrovascular Morbidity/Mortality • Improve symptoms • Improve QOL • Improve exercise • capacity Decrease the need for revascularization • Systemic Therapy • “Ongoing research” Record nonfatal events (MI/CVA) Weitz JI et al. Circulation 1996; 94: 3026

  7. Repeated advice Nicotine replacement Rx +/- Bupropion Behavioral therapy: smoking cessation classes and support groups Cessation leads to a reduction in 10 year mortality from 54% to 18% Rest pain developed in 0% of quitters compared 16% of continued smokers at seven years Smoking Cessation Strategies Benefits

  8. CAPRIE: Clopidogrel in Diabetes 38 21 25 21.5% 9 20 Clopidogrel 17.7% 17.7% Aspirin 15.6% 15 Annual event rate (%) 12.7% 11.8% Events* prevented/ 1000 patients over Aspirin 10 5 0 Nondiabetic All diabetic patients Insulin-treated * Events=vascular death, MI, stroke, or re-hospitalization for ischemia or bleeding. Bhatt DL, et al. Am J Cardiol. 2002;90:625-628.

  9. All pts should be on a statin to achieve a 25% reduction in cholesterol Additional treatment may be needed if HDL is low or TG are high Remember that HDL and TG (+/- usCRP) are becoming therapeutic targets RR=0.81(0.72 to 0.87) for major vascular events (MI, CVA, or revascularization) Improved leg functioning, pain-free walking distance, and community-based physical activity independent of cholesterol level Statin Therapy Strategies Benefits of Statin Rx

  10. 50 40 30 20 10            0 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 Intensive BP therapy in PAD Odds of MI, Stroke, or Vascular Death  Moderate Rx Intensive Rx             Baseline ABI

  11. ACE-I: HOPE Study 0.6 0.8 1.0 1.2 Relative Risk in Ramipril Group HOPE Study Investigators N Eng J Med, 2000, 342:143

  12. Increasing Walking Distance

  13. Meta Analysis # 1 49 publications, > 600 pts Statistically significant increase in: - Initial claudication distance: 139 meters - Absolute claudication distance: 176 meters Meta analysis # 2: 33 publications Statistically significant increase in: - Initial claudication distance: 179% from 125.9 +/- 57.3 m to 351.2 +/- 188.7 m - Absolute claudication distance: 122% (from 325.8 +/- 148.1 m to 723.3 +/- 591.5 m) Treatment of IC with Exercise Program CONCLUSIONS--The optimal exercise program for improving claudication pain distances in patients with peripheral arterial disease uses intermittent walking to near-maximal pain during a program of at least 6 months. Such a program should be part of the standard medical care for patients with intermittent claudication. JAMA. 1995 Sep 27;274(12):975-80. Archives of Intern Med 1999, 159: 337

  14. Relative Efficacy of Hospital vs. Home-Based Exercise Training (Regensteiner Angiology, 1997, 48:291) Improvement in: Supervised (N = 10) Unsupervised (N = 10) Peak walking time 137% 5% Pin free walking time 26% 150% Peak O2 consumption 19% 9% Physical functioning 38% 16% Walking distance 77% 42% (P<0.05) Functional status evaluated by Walking Impairment Questionnaire (WIQ) and the Medical Outcomes Study SF-20 questionnaire (MOS).

  15. Indications for Angiography in patients with PAD • Rest pain • Non-healing ulcers • Lifestyle-limiting claudication

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