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Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease ？

Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease ？. HU Dayi. Major Clinical Manifestations of Atherothrombosis. Ischemic stroke. Transient ischemic attack. Myocardial infarction. Angina. Renal artery stenosis. Atherosclerotic nephrology.

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Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease ？

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  1. Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease？ HU Dayi

  2. Major Clinical Manifestations of Atherothrombosis Ischemic stroke Transient ischemic attack Myocardial infarction Angina Renal artery stenosis Atheroscleroticnephrology • Peripheralarterial • disease: • Intermittent claudication • Rest Pain • Gangrene • Necrosis Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.

  3. NCEP ATP III: Evaluation—CAD Risk Equivalents • Diabetes • Atherosclerotic disease • Peripheral artery disease • Abdominal aortic aneurysm • Symptomatic carotid artery disease • CAD 10-year risk >20% Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.

  4. Increased risk vs general population (%) Myocardial infarction Stroke Original event 5–7 x greater risk1 (includes death) Myocardial infarction 3–4 x greater risk2 (includes TIA) Stroke 2–3 x greater risk2 (includes angina and sudden death*) 9 x greater risk3 2–3 x greater risk3 (includes TIA) Peripheral arterial disease 4 x greater risk4 (includes only fatal MI and other CHD death†) Risk of a Second Vascular Event *Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD) †Includes only fatal MI and other CHD death; does not include non-fatal MI 1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9. 3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63. 4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.

  5. Why A PAD Guideline? • To enhance the quality of patient care • Increasing recognition of the importance of atherosclerotic lower extremity PAD: • High prevalence • High cardiovascular risk • Poor quality of life • Improved ability to detect and treat renal artery disease • Improved ability to detect and treat AAA • The evidence base has become increasingly robust, so that a data-driven care guideline is now possible

  6. Natural History of PAD Age > 50 years Cardiovascular Morbidity / Mortality Limb Morbidity Mortality 15-30% Stable Claudication 70-80% Critical Limb Ischemia 1-2% Nonfatal CV Events 20% Worsening Claudication 10-20% CV Causes 75% Non CV Causes 25%

  7. Quality of Life in Patients with PAD • Individuals with asymptomatic lower extremity PAD have a worse quality of life and limb function than an age-matched cohort • The quality of life for patients with severe CLI can be worse than that of patients with terminal cancer McDermott MM, J Am Geriatr Soc 2002;50:238-46. Dormandy JA, J Vasc Surg 2000;31(1 pt 2):S1-S296.

  8. Defining a Population “At Risk” for Lower Extremity PAD • Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) • Age 50 to 69 years and history of smoking or diabetes • Age 70 years and older • Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain • Abnormal lower extremity pulse examination • Known atherosclerotic coronary, carotid, or renal artery disease

  9. Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication 1 in 5 people over 65 has PAD† Only 1 in 10 of these patients has classical symptoms of intermittent claudication (IC) † ABI<0.9 Diehm C et al. Atherosclerosis 2004; 172; 95-105.

  10. The Ankle-Brachial Index ABI = Lower extremity systolic pressure Brachial artery systolic pressure • The ankle-brachial index is 95% sensitive and 99% specific for PAD • Establishes the PAD diagnosis • Identifies a population at high risk of CV ischemic events • “Population at risk” can be clinically & epidemiologically defined: • Exertional leg symptoms, non-healing wounds, age > 70, age > 50 years with a history of smoking or diabetes. • Toe-brachial index (TBI) useful in individuals with non-compressible pedal pulses Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34; Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14

  11. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Lipid Lowering and Antihypertensive Therapy Treatment with an HMG coenzyme-A reductase inhibitor (statin) medication is indicated for all patients with peripheral arterial disease to achieve a target LDL cholesterol of less than 100 mg/dl. Antihypertensive therapy should be administered to hypertensive patients with lower extremity PAD to a goal of less than 140/90 mmHg (non-diabetics) or less than 130/80 mm/Hg (diabetics and individuals with chronic renal disease) to reduce the risk of myocardial infarction, stroke, congestive heart failure, and cardiovascular death.

  12. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I A B Antihypertensive Drug Beta-adrenergic blocking drugs are effective antihypertensive agents and are not contraindicated in patients with PAD. The use of angiotensin-converting enzyme inhibitors is reasonable for symptomatic patients with lower extremity PAD to reduce the risk of adverse cardiovascular events

  13. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Antiplatelet Therapy Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD. Aspirin, in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD. Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

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