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 Peripheral arterial disease:

Intermittent claudication Rest pain Gangrene Necrosis 1.

2.

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

Angina:

Stable Unstable

Renovascular disease Diabetes (type 2)

Often considered vascular equivalent to to a non-diabetic patient with previous MI

2

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

The burden of atherothrombotic disease

Atherothrombosis* continues to be a leading cause of death 1

Injuries and poisoning 3.5% Respiratory 14.0% Cancer 27.0% Atherothrombosis* 27.3% 0 5 10 15 Mortality (%) 20 25 30

*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)

Development of atherothrombotic disease Stable angina Stroke / TIA Clinically silent PAD 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

Patients with Type 2 diabetes are a high cardiovascular risk group 7-yr incidence of cardiovascular events (%) MI (18.8%) Stroke (7.2%)

20

MI (20.2%) CV* Death (15.9%)

15 10

Stroke (10.3%) CV* Death (15.4%)

5 0

Prior MI (no diabetes)

1. Adapted from Haffner SM et al.

N Engl J Med

1998;339:229-234

Type 2 diabetes (no prior MI)

*CV = cardiovascular

Edinburgh Artery Study.

Cross-sectional survey of 1592 subjects. (  &  aged 55-74)

Symptomatic 4.5%

It’s Common!

Asymptomatic 15%

20% die of MI 10% die of other causes

5 years.

<5% amputation

5 year fate of the claudicant (Dormandy et al)

3 Relative risk of Death 2 4 5 Relative Risks of All-Cause Mortality by Ankle Brachial Index in Men and Women in 12 cohort studies Female 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

1 <0.6

0.6-0.7

0.7-0.8

0.8-0.9

0.9-1.0

1.0-1.1

Ankle Brachial Index Base reference: ABI 1.0-1.4

1.1-1.2

1.2-1.3

1.3-1.4

>1.4

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)

PAD Ankle: Brachial Index

Ankle:Brachial Pressure Index

Highest pressure in foot (ankle) Brachial systolic pressure

ABI<0.9 diagnostic for PAD

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 Diagnosis: moderate PAD in left leg DP: 160 mm Hg PT: 154 mmHg Left 160 mmHg DP: 96 mmHg PT: 100 mm Hg

AGATHA: ABI is related to the site and extent of atherothrombosis % with ABI ≤0.9

20% CAD = coronary artery disease CVD = cerebrovascular disease PAD = peripheral artery disease PAD 10% 7% 6% 7% 26% 33% 15% CAD 35% CVD 20%

Type of arterial bed affected in the with-disease population (%) N=7099

Fowkes et al. EHJ 2006;27:861 –867

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

“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.

PAD: Medical Therapy

•Blood Pressure •Lipids •Antiplatelets •ACEI •Diabetes •(Cilostazol)

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.

Blood Pressure Control

Target = 140/85 Systolic Claudicants Data from PREPARED study.

<140 140-160 160-180 180-200 200+ 30.8% 33.1% 24.2% 8.5% 3.4%

STATIN worse SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE Baseline feature Previous MI Other CHD (not MI) No prior CHD CVD PVD Diabetes STATIN (10269) 1007 452 182 332 279 ALL PATIENTS 2042 (19.9%) Heart Protection Study PLACEBO (10267) 1255 597 Risk ratio and 95% CI STATIN better STATIN worse 215 427 369 2606 (25.4%) 0.4

0.6

0.8

1.0

1.2

1.4

24%SE 2.6

reduction (2P<0.00001)

4 2 0 10 8 6 18 16 14 12 PREPARED study – cholesterol levels in claudicants 3.0

4.5

6.0

7.5

Cholesterol (mmol / L)

9.0

10.5

Mean StDev N 5.437

1.238

346

ACE inhibitors

Metabolic Syndrome Difficult to define Easy to spot

Exercise and Absolute Claudication Distance

450 400 350 300 250 200 150 100 50 0 Supervised P < 0.001

Non-supervised Baseline 3-month 6-month 9-month 12-month

REACH Registry: >67,000 patients from 5,473 sites* in 44 countries

27,746 North America Latin America Western Europe Eastern Europe Middle East Asia (incl. Japan) Australia 1,931

* up to 15 patients/site (up to 20 in the US)

17,886 846 5,656 5,903 5,048 2,872

JAMA 2006;295:180-9

Major endpoints as a function of single vs multiple and overlapping locations CV death Non-fatal MI Non-fatal stroke CV death/MI/ stroke CV death/MI/ stroke/ hospitalisation *

Overall 1.5

1.2

1.5

Single arterial bed CAD alone 1.5

1.4

0.9

CVD alone 1.4

0.5

(3) 3.5

(3) PAD alone 1.2

1.0

0.6

3.4

12.8

3.1

13.3

4.5

10.0

(3) (3) 2.3

18.2

(3) Overall 2.4

1.5

Polyvascular disease CAD + CVD CAD + PAD CVD + PAD 2.0

1.6

2.9

1.4

(2) 1.8

1.3

CAD + CVD + PAD 3.6

(3) 1.8

3.1

3.7

1.3

(3) 4.8

4.0

6.0

22.0

6.4

20.0

4.8

23.3

(3) (3) 7.0

24.4

(1) 7.4

26.9

(3)

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

Critical Ischaemia=



Rest pain +/- gangrene or ulcers



Doppler pressures < 50mmHg.



>70% will need amputation if nothing is done.



Priority is revascularisation



Urgent referral needed

Specialist referral:

 Urgent: Critical ischaemia (rest pain, necrosis, gangrene).

 Routine: Limiting symptoms, threatened employment, diagnostic doubt  Refer to local guidelines

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

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

Thank You For Listening Any Questions?