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Park Florio Hotel & Magaggiari Hotel Resort October 24th-27th, 2009

18° MEETING OF THE EUROPEAN CHAPTER OF THE INTERNATIONAL UNION OF ANGIOLOGY JOINT WITH THE XIX ANNUAL MEETING OF THE MEDITERRANEAN LEAGUE OF ANGIOLOGY AND VASCULAR SURGERY. Park Florio Hotel & Magaggiari Hotel Resort October 24th-27th, 2009.

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Park Florio Hotel & Magaggiari Hotel Resort October 24th-27th, 2009

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  1. 18° MEETING OF THE EUROPEAN CHAPTER OF THE INTERNATIONAL UNION OF ANGIOLOGY JOINT WITH THE XIX ANNUAL MEETING OF THE MEDITERRANEAN LEAGUE OF ANGIOLOGY AND VASCULAR SURGERY Park Florio Hotel & Magaggiari Hotel Resort October 24th-27th, 2009

  2. JOINT SYMPOSIUM WITH THE WG ON PERIPHERAL CIRCULATION OF THE ITALIAN SOCIETY OF CARDIOLOGY ON CLINICAL IMPORTANCE OF EARLY DETECTION OF PRECLINICAL ATSCHAIRMEN: N. ANGELIDES (NICOSIA, CYPRUS) - E. BASTOUNIS (ATHENS, GREECE) – F. FEDELE (ROME, ITALY) Park Florio Hotel & Magaggiari Hotel Resort October 27th, 2009 – 12.00-13.20 HALL A

  3. University of Palermo Faculty of Medicine and Surgery Department of Internal Medicine and Cardiovascular Diseases Chair of Cardiovascular Diseases, post-graduate School of Cardiology, Master of Vascular Diseases, Master of Echocardiography, Center for the Early Diagnosis of Preclinical and Multifocal Atherosclerosis and for the Secondary Prevention, Division of Cardiology University Hospital “P. Giaccone” of the University of Palermo Director: prof. Salvatore Novo ANKLE BRACHIAL PRESSURE INDEX (ABI) Salvatore NOVO

  4. The PARTNERS Program:PAD Awareness, Risk, and Treatment: New Resources for SurvivalRegional Coordinating Centers Seattle Minneapolis Ann Arbor Denver New York Pittsburgh Boston St. Louis Chicago (2) Toledo Philadelphia (2) Cleveland Baltimore Washington, DC Winston-Salem Knoxville Stanford La Jolla Phoenix Los Angeles Miami New Orleans Clearwater Dallas Oklahoma City

  5. Inclusion and Exclusion Criteria • Target populations with atherosclerotic RF • Age > 70 years (62%) • Younger individuals (50-69 years) with RF, smoking (18%), diabetes (10%), both (10%) Hirsh AT, Hiatt WR et al., Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care. JAMA 2001; 286: 1317-24

  6. METHODS • Recruitment between June and October 1999, 29 cities, 320 primary care practice, to assess: 6979 “at risk” pts • ABI measurement and standard questionnaire used • PAD confirmed if ABI =< 0.90, or a previous diagnosis of PAD or a prior limb revascularization procedure • CVD defined by history of angina, previous AMI, CABG, PTCA, AAA repair, TIA or Stroke or endarterectomy Hirsh AT, Hiatt WR et al., Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care. JAMA 2001; 286: 1317-24

  7. RESULTS • 6369 evaluable patients • 29% of patients with PAD • 13% with PAD only • 16% with both PAD and CVD • 24% with CVD only • 47% had neither PAD or CVD Hirsh AT, Hiatt WR et al., Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care. JAMA 2001; 286: 1317-24

  8. Position Statement on the use of the ABI in Patients with PAD A Consensus Statement developed by the Standards Division of the Society of International Radiology (SIR) ABI helps to define the severity and successfully screens for hemodinamically significant disease. An ABI < 0.90, without I.C., identify patients with asymptomatic PAD Sacks D et al. J Vasc Interv Radiol 2003 1,2 1 ABI 0,8 0,6 0,4 0,2 0 Normal ( ABI > 1,1) Claudication (range from 0,3 to 0,9) Rest pain or severe occlusive disease (< 0.3)

  9. PREVALENCE OF CHD ACCORDING TO THE VALUE OF ABI Cardiovascular Health Study (n=4400 patients with six years follow-up): a) 10% with normal ABI, b) 30% if ABI < 0.95, c) 50% if ABI < 0.75 Newman AB et al., Circulation 1993; 88: 837-45

  10. PREVALENCE OF > 50 % CAROTID STENOSIS ACCORDING TO ABI Severity of Carotid Stenosis ABI < 50% > 50% 75% 25% > 0.8 57% 43% 0.6-0.79 61% 39% 0.4-0.59 41% 59% < 0.4 Kendall  < 0.001 Cinà CS et al. J Vasc Surg 2002; 36, 75

  11. ANKLE-BRACHIAL BLOOD PRESSURE IN ELDERLY MEN AND THE RISK OF STROKE Abbott RD et al., J Clin Epidemiol 2001; 54: 973-978.

  12. OCCURRENCE OF CHD AND CVD ACCORDING TO AN ABI VALUE < 0.90 IN THE ARIC STUDY (15106 pts 45-64 y) Odds ratios for CHD: 3.0-3.4 in men 3.5-4.5 in women Odds ratios for CVD: 4.2-4.9 in men Significantly greater prevalence of coronary plaques, asymptomatic carotid plaques, and increased carotid IMT ABI LEVELS < 0.9 SUGGEST GENERALIZED ATHEROSCLEROSIS Zheng ZJ et al. Atherosclerosis 1997

  13. LIFE-TABLE CURVES FOR FATAL CARDIOVASCULAR EVENTS ABPI > 0.85 ABPI 0.4-0.85 Survival (%) ABPI < 0.4 Year McKenna M et al Atherosclerosis 1991; 87: 119-128

  14. 2.5 2.0 1.5 1.0 0.0 0.2 0.4 0.6 0.8 1.0 ABI ABI: INVERSE RELATIONSHIP WITH 5-YEAR RISK OF CV EVENTS AND DEATH 10.2% relative risk increaseper 0.1 decrease in ABI (p = 0.041) Risk relative to ABI Dormandy JA, Creager MA. Cerebrovasc Dis 1999; 9 (Suppl 1): 128 (Abstr 4)

  15. Aim: to assess the prognostic importance of PAD as evaluated by ABI and the impact of Ramipril on the prevention of major CV events in PAD patients included in the HOPE Study. Methods: Patients were randomized to treatment with Ramipril or Placebo and follewed for 4.5 years. ABI was measured, mainly by digital palpation of the foot pulse, at baseline in 8986 patients. Ostergren J et al. Eur Heart J 2004; 25; 17-24

  16. RESULTS FROM HOPE The ABI was a strong predictor of morbidity and mortality during the follow-up even in patients with no clinical symptoms of PAD Ostergren J et al. Eur Heart J 2004; 25, 17-24

  17. RESULTS FROM HOPE Ostergren J et al.Eur Heart J 2004; 25; 17-24 Ramipril reduced the risk of clinical outcomes in those with a clinical history of PAD as well in the patients with subclinical PAD

  18. ABI COMBINED WITH FRAMINGHAM RISK SCORE TO PREDICT CV EVENTS AND MORTALITY JAMA 2008; 300: 197-208

  19. Results: In addition to the known associations of the ABI with stroke, MI, PAD and CV death, an ABI < 0.9 also predicts an increase in serum creatinine over time. Low Ankle-Brachial Index Associated With Creatinine Level Over Time Objective:To define whether a low ABI predict a decline in renal function Methods:The Authors examined the association between ABI and change in serum creatinine level over time evaluating serum creatinine and ABI at baseline and also 3 years later). O’Hare A M et al. Arch Intern Med 2005, 165:1481-5

  20. Sensitivity and Specificity of the ABI to predict future cardiovascular outcomes Sensivity Specificity CORONARY ARTERY DESEASE 16,5 % 92,7% STROKE 16,0% 92,2% CARDIOVASCULAR DEATH 41,0% 87,9% The specificity of a low ABI to predict future CV outcomes is high , but its sensitivy is low. So, the ABI should become part of the vascular risk assessment among selected individuals. Doobay A V et al. ATVB 2005; 25: 1463-9

  21. TASC 2 (2005) - Recommendation 12 Indications to perform a measurement of the ABI • Individuals with a history, or physical examination, suggestive of PAD [B] • Patients at risk for PAD (between the age of 50–69 with history of diabetes or smoking, or anyone over 70 years) [A] • Patients with a Framingham risk score of 10% - 20% in 10 years [B]

  22. TASC 2 (2005) - Recommendation 13: Alternative measures to diagnose PAD when the ABI is elevated When the ABI is greater than 1.40 and PAD is suspected, then patients should have the measurement of either a toe pressure to calculate theTBI or a Doppler velocity wave form analysis [B].

  23. Relationship of High and Low ABI to All-Cause CV Mortality The STRONG HEART STUDY Diabetes, albuminuria and hypertension occurred with greater frequency among person with low and high ABI compared with those with normal ABI. The association between high ABI and CVD mortality was similar to that of low ABI and CVD mortality. The Authors concluded that the upper limit of normal ABI should not exceed 1.40 ABI Risk for all-cause of mortality Risk for CVD mortality < 0.9 (low) 1.69 (1.34 to 2.14) 2.52 (1.74 to 3.64) > 1.4 (high) 1.77 (1.48 to 2.13) 2.09 (1.49 to 2.94) Resnick H E et al. Circulation 2004; 109:733-739

  24. LOW ABI IS A STRONG PREDICTOR OF CARDIOVASCULAR MORTALITY • Reduced ABI is a significant independent predictor of Cerebro-Vascular and Coronary Mortality • Age-adjusted relative risks for 10-year CV and coronary mortality are higher in those with ABI < 0.9 • The risk of CV death increases with decreasing ABI • ABI measurements are inexpensive, simple and non-invasive • ABI measurement is still underutilized and can be usefully incorporated in risk assessment and screening programmes as suggested in the recommendations of the TASC 2 Consensus Document to be published at the end of 2007 Kornitzer M et al. Angiology 1995; 46: 211–9 - McKenna M et al. Atherosclerosis 1991; 87: 119–28 Dormandy JA et al. J Cardiovasc Surg 1989; 30: 50–7

  25. Despite the tremendous effort of looking into new CV risk markers to design new CV trials and study CV outcome of new drugs, one should recognize that a reduced ABI even in asymptomatic patients as one of the inclusion criteria could be an important help in the increase of CV risk. In times of major health care budget burden, ABI can be utilized with little or no additional costs to further stratify patients into risk categories who may benefit to a greater extente by preventive treatments. Duprez D. Eur Heart J 2004; 25: 1-2

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