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PAD Diagnosis and Management

PAD Diagnosis and Management. Gerry Stansby Newcastle upon Tyne, UK . Atherothrombosis affects many vascular beds. These are expressions of a single extensive, progressive, unpredictable and deadly disease . Ischaemic stroke. Transient ischaemic attack. Myocardial infarction. Angina:

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PAD Diagnosis and Management

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  1. PADDiagnosis and Management Gerry Stansby Newcastle upon Tyne, UK

  2. Atherothrombosis affects many vascular beds These are expressions of a single extensive, progressive, unpredictable and deadly disease Ischaemic stroke Transient ischaemic attack Myocardial infarction Angina: Stable Unstable Renovascular disease Peripheral arterial disease: Intermittent claudication Rest pain Gangrene Necrosis Diabetes (type 2) Often considered vascular equivalent to to a non-diabetic patient with previous MI2 • Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(Suppl 1): 1–6 • Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234

  3. Cardiologists (+cardiac surgeons) Vascular Surgeons Stroke Medicine Arteriopath General Practice Neurology Care of the elderly Diabetologists Renal Physicians

  4. Atherothrombosis* continues to be a leading cause of death1 The burden of atherothrombotic disease Mortality (%) *Atherothrombosis bar is an addition of burden for coronary heart disease (17.3%), cerebrovascular disease (9.9%) and peripheral arterial disease (no data) 1. England and Wales, Office for National Statistics 2006 (www.heartstats.org)

  5. Development of atherothrombotic disease Atheroscleroticplaque Plaque rupture & thrombosis Normal artery Fatty streak MI / unstable angina Stroke / TIA Critical limb ischaemia Cardiovascular death Stable angina Claudication PAD Clinically silent Begins in teenage years Increasing age & risk factors The underlying pathology is the same for each arterial bed Peripheral arterial disease should be treated as seriously as coronary heart disease when calculating cardiovascular risk

  6. Patients with Type 2 diabetes are a high cardiovascular risk group 7-yr incidence of cardiovascular events (%) 20 MI (20.2%) MI (18.8%) 15 CV* Death (15.9%) CV* Death (15.4%) 10 Stroke (10.3%) Stroke (7.2%) 5 0 Type 2 diabetes (no prior MI) Prior MI (no diabetes) *CV = cardiovascular 1. Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234

  7. Edinburgh Artery Study. Cross-sectional survey of 1592 subjects. (&aged 55-74) Symptomatic 4.5% It’s Common! Asymptomatic 15%

  8. 5 years. <5% amputation 20% die of MI 10% die of other causes 5 year fate of the claudicant (Dormandy et al)

  9. Relative Risks of All-Cause Mortality by Ankle Brachial Index in Men and Women in 12 cohort studies 5 Female 4 Male Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008 Jul 9;300(2):197 3 Relative risk of Death 2 1 <0.6 0.6-0.7 0.7-0.8 0.8-0.9 0.9-1.0 1.0-1.1 1.1-1.2 1.2-1.3 1.3-1.4 >1.4 Ankle Brachial Index Base reference: ABI 1.0-1.4

  10. 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)

  11. PADAnkle: Brachial Index

  12. Ankle:Brachial Pressure Index Highest pressure in foot (ankle) Brachial systolic pressure ABI<0.9 diagnostic for PAD

  13. ABI measurement • 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 is the ABI that stratifies the patient’s risk Right 156 mmHg Left 160 mmHg DP: 96 mmHg PT: 100 mm Hg Diagnosis: moderate PAD in left leg DP: 160 mm Hg PT: 154 mmHg

  14. AGATHA: ABI is related to the site and extent of atherothrombosis 20% 33% 26% % with ABI ≤0.9 CAD = coronary artery disease CVD = cerebrovascular disease PAD = peripheral artery disease CAD 35% 7% PAD 10% 7% 15% 6% CVD 20% Type of arterial bed affected in the with-disease population (%) N=7099 Fowkes et al. EHJ 2006;27:861–867

  15. 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

  16. “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.

  17. PAD: Medical Therapy • Blood Pressure • Lipids • Antiplatelets • ACEI • Diabetes • (Cilostazol)

  18. 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.

  19. Systolic Claudicants <140 30.8% 140-160 33.1% 160-180 24.2% 180-200 8.5% 200+ 3.4% Blood Pressure Control Target = 140/85 Data from PREPARED study.

  20. SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE STATIN worse Baseline STATIN PLACEBO Risk ratio and 95% CI feature (10269) (10267) STATIN better 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 24% SE 2.6 reduction (19.9%) (25.4%) (2P<0.00001) 0.4 0.6 0.8 1.0 1.2 1.4 Heart Protection Study

  21. PREPARED study – cholesterol levels in claudicants

  22. ACE inhibitors

  23. Metabolic Syndrome Difficult to define Easy to spot

  24. Exercise andAbsolute Claudication Distance 450 400 350 Supervised 300 250 P < 0.001 Median Absolute Claudication Distance on Treadmill Walking (meters) 200 Non-supervised 150 100 50 0 Baseline 3-month 6-month 9-month 12-month

  25. REACH Registry: >67,000 patients from 5,473 sites* in 44 countries 5,656 17,886 27,746 5,048 5,903 846 North America 1,931 Latin America Western Europe 2,872 Eastern Europe Middle East Asia (incl. Japan) Australia JAMA 2006;295:180-9 * up to 15 patients/site (up to 20 in the US)

  26. Single arterial bed Polyvascular disease Overall CAD alone CVD alone PAD alone Overall CAD + CVD CAD + PAD CVD + PAD CAD + CVD + PAD CV death 1.5 1.5 1.4 1.2 2.4 2.0 2.9(2) 1.8 3.6(3) Non-fatal MI 1.2 1.4 0.5(3) 1.0 1.5 1.6 1.4 1.3 1.8 Non-fatal stroke 1.5 0.9 3.5(3) 0.6 3.1 3.7 1.3(3) 4.8 4.0 CV death/MI/ stroke 3.4 3.1 4.5(3) 2.3 6.0 6.4 4.8(3) 7.0 7.4 CV death/MI/ stroke/ hospitalisation* 12.8 13.3 10.0(3) 18.2(3) 22.0 20.0 23.3(3) 24.4(1) 26.9(3) Major endpoints as a function of single vs multiple and overlapping locations 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) *TIA, unstable angina, other ischemic arterial event including worsening of peripheral arterial disease

  27. Critical Ischaemia= • Rest pain +/- gangrene or ulcers • Doppler pressures < 50mmHg. • >70% will need amputation if nothing is done. • Priority is revascularisation • Urgent referral needed

  28. Specialist referral: • Urgent: Critical ischaemia (rest pain, necrosis, gangrene). • Routine: Limiting symptoms, threatened employment, diagnostic doubt • Refer to local guidelines

  29. NEWCASTLE, NORTH TYNESIDE AND NORTHUMBERLAND GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH PERIPHERAL ARTERIAL DISEASE (PAD) October 2008

  30. 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

  31. Thank You For Listening

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