Transcript THE ARTERIAL SYSTEM

Why Are We Invloved in the Detection
and Treatment of Peripheral Artery
Disease？
HU Dayi
Major Clinical Manifestations
of Atherothrombosis
Ischemic
stroke
Myocardial
infarction
Renal artery
stenosis
Transient ischemic
attack
Angina
Atherosclerotic
nephrology
Peripheral arterial
disease:
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•
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Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.
Intermittent claudication
Rest Pain
Gangrene
Necrosis
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.
Risk of a Second Vascular Event
Increased risk vs general population (%)
Original event
Myocardial infarction
Stroke
Myocardial infarction
5–7 x greater risk1
3–4 x greater risk2
(includes death)
(includes TIA)
2–3 x greater risk2
9 x greater risk3
Stroke
(includes angina and
sudden death*)
Peripheral arterial disease
4 x greater risk4
2–3 x greater risk3
(includes only fatal MI and
other CHD death†)
(includes TIA)
*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.
Why A PAD Guideline?
• To enhance the quality of patient care
• Increasing recognition of the importance
atherosclerotic lower extremity PAD:
of
– 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
Natural History of PAD
Age > 50 years
Cardiovascular
Morbidity /
Mortality
Limb
Morbidity
Stable
Claudication
70-80%
Worsening
Claudication
10-20%
Critical
Limb
Ischemia
1-2%
Nonfatal CV
Events
20%
CV Causes
75%
Mortality
15-30%
Non CV Causes
25%
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.
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
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.
The Ankle-Brachial Index
ABI =
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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
Lipid Lowering and Antihypertensive Therapy
II IIa IIb
IIb III
III
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.
I IIa IIb III
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.
Antihypertensive Drug
II IIa IIb
IIb III
III
Beta-adrenergic blocking drugs are effective
antihypertensive agents and are not
contraindicated in patients with PAD.
I IIa IIb III
The use of angiotensin-converting enzyme
inhibitors is reasonable for symptomatic patients
with lower extremity PAD to reduce the risk of
adverse cardiovascular events
Antiplatelet Therapy
I IIa IIb III
Antiplatelet therapy is indicated to reduce the risk of myocardial
infarction, stroke, or vascular death in individuals with
atherosclerotic lower extremity PAD.
I IIa IIb III
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.
II IIa IIb
IIb III
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.