PADPADA Call to ActionA Call to Action
PAD: A Call to ActionPAD: A Call to Action
-- What is peripheral arterial disease What is peripheral arterial disease (PAD)? and why is it so dangerous? (PAD)? and why is it so dangerous?
-- Diagnosing PAD in the primary care Diagnosing PAD in the primary care settingsetting
-- The importance of aggressive riskThe importance of aggressive risk
management of PADmanagement of PAD
-- Evidence base for protecting Evidence base for protecting patients with PADpatients with PAD
Major manifestations of Major manifestations of atherothrombosis includeatherothrombosis include
Cerebrovascular diseaseCerebrovascular disease
Coronary artery diseaseCoronary artery disease
Renal artery stenosisRenal artery stenosis
Visceral arterial diseaseVisceral arterial disease
Peripheral arterial diseasePeripheral arterial disease– Intermittent claudicationIntermittent claudication– Critical limb ischemiaCritical limb ischemia
Prevalence of metabolic syndrome in each patient
group (%)
Prevalence of metabolic syndrome in each patient
group (%)
Cross-Sectional survey of 1,045 vascular disease patientsCross-Sectional survey of 1,045 vascular disease patients
40%40%
00
2020
4040
6060
CHDCHD
43%43% 45%45%
57%57%
StrokeStroke AAAAAA PADPAD
Olijhoek JK et al. Eur Heart J 2004; 25: 342-348.
Metabolic syndrome is more Metabolic syndrome is more common in PAD than in CHD or common in PAD than in CHD or
strokestroke
AAA = Abdominal Aortic Aneurysm
Prevalence of PAD increases Prevalence of PAD increases with agewith age
0
10
20
30
40
50
60
55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age group (y)
Figure adapted from Creager M, ed. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000.
1 Meijer WT et al. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.
2.Criqui MH et al. Circulation 1985; 71: 510-515.
Pat
ien
ts w
ith
PA
D (
%)
Pat
ien
ts w
ith
PA
D (
%)
Rotterdam Study (ABI Test <0.9)1 San Diego Study (PAD by noninvasive tests)2
Mortality is very high in patients Mortality is very high in patients with severe PADwith severe PAD
Relative 5-year mortality
1. Criqui MH. 1. Criqui MH. Vasc MedVasc Med 2001; 2001; 66 (suppl 1): 3–7. (suppl 1): 3–7.
2. McKenna M 2. McKenna M et alet al. . AtherosclerosisAtherosclerosis 1991; 1991; 8787: 119–28. : 119–28.
3. Ries LAG 3. Ries LAG et alet al. (eds). . (eds). SEER Cancer Statistics ReviewSEER Cancer Statistics Review, 1973–1997. US: National Cancer Institute; 2000., 1973–1997. US: National Cancer Institute; 2000.
Pat
ien
ts (
%)
0
5
10
15
20
25
30
35
40
45
50
Colon/rectalcancer1
Breast cancer1
SeverePAD2
Non-Hodgkin’slymphoma3
15
38
44
48
Resnick HE et al. Circulation 2004; 109: 733-739.
There is a strong two-way There is a strong two-way association between decreased ABI association between decreased ABI
and increased risk for and increased risk for cardiovascular deathcardiovascular death11
Baseline ABI*
Per
cen
t
0
20
40
60
<0.60 (n=25)
70
50
30
10
0.60-<0.70 (n
=21)
0.70-<0.80 (n
=40)
0.80-<0.90 (n
=130)
0.90-<1.0 (n
=195)
1.0-<1.10 (n
=980)
All-cause mortality
CVD Mortality
*Mean participant follow-up 8.3 years
Guidance for PAD diagnosisGuidance for PAD diagnosisSTEP 1STEP 1 Assess patient for risk factorsAssess patient for risk factors
– smokingsmoking– diabetesdiabetes– hypertension hypertension – age: men >55 years and women >65 years age: men >55 years and women >65 years – hyperlipidaemiahyperlipidaemia– history of cardiovascular diseasehistory of cardiovascular disease
Assess patient for leg symptomsAssess patient for leg symptoms– intermittent claudicationintermittent claudication– critical limb ischaemiacritical limb ischaemia
Tools: PAD checklist, Rose questionnaire, Tools: PAD checklist, Rose questionnaire, Edinburgh questionnaireEdinburgh questionnaire
STEP 2STEP 2 If suspicion of PAD, perform an ABI to If suspicion of PAD, perform an ABI to
confirm diagnosis using a hand-held confirm diagnosis using a hand-held DopplerDoppler
Only 1 in 10 patients with PAD Only 1 in 10 patients with PAD has classical symptoms of has classical symptoms of intermittent claudication intermittent claudication
Only 1 in 10 of these patients has classical
symptoms of intermittent claudication (IC)
1 in 5 people over 65
has PAD†
† ABI<0.9
Diehm C et al. Atherosclerosis 2004; 172; 95-105.
A screening ABI should be performed in patients A screening ABI should be performed in patients with with diabetesdiabetes
The American Diabetes Association The American Diabetes Association recommends screening for PAD in recommends screening for PAD in
patients with diabetespatients with diabetes
1. American Diabetes Association. Diabetes Care 2003; 26: 3333-3341.
2. Estes JM, Pomposelli FB Jr. Diabet Med 1996: 13: S43- S57.
Those <50 years of age who Those <50 years of age who have other risk factors have other risk factors associated with PADassociated with PAD
• SmokingSmoking• HypertensionHypertension• HyperlipidaemiaHyperlipidaemia• Duration of diabetes Duration of diabetes >10 years>10 years
Those >50 years of ageThose >50 years of age
• If normal an exercise If normal an exercise test should be test should be carried out carried out
• The ABI test The ABI test should be repeated should be repeated every 5 yearsevery 5 years
• Foot care is also important in diabetic patients as PAD is a major contributor to diabetic foot problems2
Risk factor management Risk factor management approach approach
Smoking cessationSmoking cessation
Weight reductionWeight reduction
Total cholesterol <175 mg/dL / <4.5 mmol/LTotal cholesterol <175 mg/dL / <4.5 mmol/L
LDL cholesterol <100 mg/dL / <2.6 mmol/LLDL cholesterol <100 mg/dL / <2.6 mmol/L
Glycosylated haemoglobin <7.0% Glycosylated haemoglobin <7.0%
Blood pressure (BP) <140/90 mm HgBlood pressure (BP) <140/90 mm Hg
– For patients with diabetes BP < 130/80mm HgFor patients with diabetes BP < 130/80mm Hg
Platelet inhibitionPlatelet inhibition
Hiatt WR. N Engl J Med 2001; 344: 1608-1621.
Key learning pointsKey learning points
Ensure aggressive and early Ensure aggressive and early risk management of patients risk management of patients who are at high risk but may who are at high risk but may be asymptomaticbe asymptomatic
Screen patients with diabetes Screen patients with diabetes >50 years of age, and those >50 years of age, and those <50 years of age who have <50 years of age who have additional risk factors additional risk factors associated with PADassociated with PAD
Only 1 in 10 patients withOnly 1 in 10 patients withPAD have typical PAD have typical claudicationclaudication11
Patients with diabetes are Patients with diabetes are at high risk of PADat high risk of PAD
It is important to improve It is important to improve the management of PAD tothe management of PAD toprotect patients from an protect patients from an increased risk of ischaemic increased risk of ischaemic eventsevents
REMEMBER ACTION
1. Diehm C et al. Atherosclerosis 2004; 172: 95-105.
Overall learning pointsOverall learning points PAD is a reliable warning sign that a patient is at high PAD is a reliable warning sign that a patient is at high risk for life threatening cardiovascular and risk for life threatening cardiovascular and cerebrovascular eventscerebrovascular events
PAD is easily overlooked by both patients and PAD is easily overlooked by both patients and physicians – assess whether patients presenting with physicians – assess whether patients presenting with symptoms or associated risk factors have PADsymptoms or associated risk factors have PAD
Treatments are available to protect the patients with Treatments are available to protect the patients with PAD from future MI or strokePAD from future MI or stroke
Help protect patients Help protect patients with PAD with PAD
from their increased from their increased risk of MI or strokerisk of MI or stroke