peripheral arterial disease physicians awareness program

Peripheral Arterial DiseasePeripheral Arterial Disease

Physicians Awareness ProgramPhysicians Awareness Program

3

ObjectivesObjectives

▪Increase the awareness of physicians (general practitioners, internists, cardiologists, and vascular surgeons) in Saudi Arabia about PAD

▪Educate physicians about the importance of risk reduction therapies, in order to close the care, knowledge and action gaps.

4

AgendaAgenda

Part I: Overview of Disease

▪ Atherothrombosis

▪ Epidemiology

▪ Management

Part II: Guidelines

▪ CV Risk Factor Reduction

( AHA/ACC, TASC II)

Part I – Overview of DiseasePart I – Overview of Disease

6

What is Atherosclerosis?What is Atherosclerosis?

Clogging, narrowing, and hardening of large and medium-sized arteries

7

What are the risk factors for Atherosclerosis?What are the risk factors for Atherosclerosis?

Non-Modifiable Risk Factors:Non-Modifiable Risk Factors: Male genderMale gender Advanced ageAdvanced age Family historyFamily history

Modifiable Risk Factors:Modifiable Risk Factors: Major Major SmokingSmoking HypertensionHypertension DiabetesDiabetes HyperlipidemiaHyperlipidemia

MinorMinor HomocystenemiaHomocystenemia ObesityObesity Hypercoaguable stateHypercoaguable state Physical inactivityPhysical inactivity

8

InflammationAccumulationof lipids

Normalartery

Smooth muscle cell progression,

plaque progression

Thrombus FormationThrombus Formation

Rupture of Fibrous Cap

Erosion of Endothelium

Erosion of Calcium Nodule

Intraplaque Hemorrhage

Pathophysiology of AtherothrombosisPathophysiology of Atherothrombosis

1. Munger MA et al. J Am Pharm Assoc. 2004;44(suppl 1):S5-S13.2. Libby P et al. Circulation. 2005;111:3481-3488.

AtherosclerosisAtherosclerosis +

Atherosclerosis leads to any number of four possible types of thrombus formation

9

Cerebrovascular disease

Coronary artery disease

Renal artery Diseases

Visceral arterial disease

Peripheral arterial disease• Intermittent claudication• Critical limb ischemia

Clinical Spectrum Clinical Spectrum

of Atherosclerosisof Atherosclerosis

10Munger MA et al. J Am Pharm Assoc. 2004;44(suppl 1):S5-S13.

Atherothrombosis: Atherothrombosis: Can Manifest in Multiple Vascular Beds Can Manifest in Multiple Vascular Beds

▪ Patients with atherothrombosis have thrombus formations that can manifest in multiple vascular beds throughout the body

▪ Atherothrombosis is a process that includes the following clinical consequences:

– Ischemic stroke, MI, and PAD

11

Atherothrombosis as a Cause of DeathAtherothrombosis as a Cause of Death“Burden of the disease”“Burden of the disease”

4.9%6.5%

9.1%

12.5%

19.1%

22.3%

0

5

10

15

20

25

Mo

rta

lity

(%

)

Athero-thrombosis

InfectiousDisease

Cancer Injuries PulmonaryDisease

AIDS

According to the World Health Organization in 2004 atherothrombosis* was the leading cause of death worldwide—more than AIDS and cancer combined1,2

According to the World Health Organization in 2004 atherothrombosis* was the leading cause of death worldwide—more than AIDS and cancer combined1,2

* Only includes ischemic heart disease and cerebrovascular disease.1. Bakhai A. Pharmacoeconomics. 2004;22(suppl 4):11-18.2. World Health Organization Report 2004. Available at: http://www.who.org. Accessed January 29, 2007.

Let’s Talk about Let’s Talk about PADPAD

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AsymptomaticAsymptomatic

SymptomaticSymptomatic

•Intermittent claudicationIntermittent claudication•Critical Limb IschemiaCritical Limb Ischemia Pain at restPain at rest Tissue lossTissue loss GangreneGangrene

How do patients with PAD present?How do patients with PAD present?

14


15

Symptomatic 10%

Asymptomatic 90%


16

Ankle Brachial IndexAnkle Brachial Index

17

Calculating the Ankle-Brachial IndexCalculating the Ankle-Brachial Index

Higher right ankle pressure (dorsalis pedis or posterior tibial pulse)

Higher arm pressure (of either arm)

=

Right leg ABIRight leg ABI Left leg ABILeft leg ABI

Higher left ankle pressure (dorsalis pedis or posterior tibial pulse)

Higher arm pressure (of either arm)

=

ABI InterpretationABI Interpretation≤≤0.90 is diagnostic of peripheral arterial disease0.90 is diagnostic of peripheral arterial disease

Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

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Role of ABI in PADRole of ABI in PAD

▪ Confirms the diagnosis of PAD

▪ Detects significant PAD in (sedentary) asymptomatic patients

▪ Used in the differential diagnosis of leg symptoms to identify a vascular etiology

▪ Identifies patients with reduced limb function (inability to walk defined distances or at usual walking speed)

▪ Provides key information on long-term prognosis– A 3–6-fold increased risk of CV mortality with an ABI <0.90

▪ Provides further risk stratification– A lower ABI indicating worse prognosis

– A Framingham risk score between 10%–20%

▪ Highly associated with coronary and cerebral artery disease


Epidemiology of PADEpidemiology of PAD

20

19.1% 19.8%

Prevalence was estimated using different methods1. Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Diehm C et al. Atherosclerosis. 2004;172:95-105. 3. Selvin E et al. NHANES. Circulation. 2004;110:738-743.4. Criqui MH et al. Circulation. 1985;71:510-515.5. Hirsch AT et al. JAMA. 2001;286:1317-1324.

Prevalence of PADPrevalence of PAD

14.5%

29.0%

11.7%

4.3%

PARTNERSPARTNERS55

Age >70, or between 50–69 with history of diabetes or smoking

San DiegoSan Diego44

Mean Age=66DiehmDiehm22

Age ≥65RotterdamRotterdam11

Age >55NHANESNHANES33

Age ≥70NHANESNHANES33

Age >40

European Data US Data

11.7%

Saudi Data

Pilot StudyPilot Study66

Age >45

6. Alshaekh et al. SMJ. 2007;28:412-414

21

Why it is important to recognize Why it is important to recognize patients with PAD? patients with PAD?

PAD is a marker of PAD is a marker of systemicsystemic atherosclerosis atherosclerosis

Patients with either symptomatic or Patients with either symptomatic or asymptomatic PAD generally have asymptomatic PAD generally have widespread widespread arterial diseasearterial disease

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CVD

16.6%CAD

44.6%8.4%

1.2%4.7%

1.6%

PAD

4.7%

The REACH Registry found overlapping manifestations of disease in patients with CAD, CVD, and PAD

The REACH Registry found overlapping manifestations of disease in patients with CAD, CVD, and PAD

sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.Bhatt DL et al. JAMA. 2006;295:180-189.

18.3% of patients in the REACH Registry did not have manifestations of atherothrombosis, but were included based on risk factors

18.3% of patients in the REACH Registry did not have manifestations of atherothrombosis, but were included based on risk factors

Peripheral Arterial Disease: Peripheral Arterial Disease: Prevalence of Polyvascular diseasePrevalence of Polyvascular disease

Peripheral Arterial Disease:Prevalence of Polyvascular Disease

Adapted from: Bhatt DL et al. JAMA. 2006;295(2):180-189.

Coronary disease

Cerebrovasculardisease

Peripheralarterial disease

16.6%

1.2% 4.7%

44.6%

1.6%

8.4%

4.7%

15.9%

~16% of patients had manifestations of

atherothrombosis in more than one arterial bed

23

Long term Risk of MI & StrokeLong term Risk of MI & Stroke

PAD places individuals at high short term risk of MI, Stroke & Death

24

Survival of Patients With PADSurvival of Patients With PADS

urv

ival

(%

)

Follow-up (years)

Controls

IC

CLI

0 5 10 150

20

40

60

80

100

CLI=critical limb ischemia.IC=intermittent claudication.Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

Life expectancy reduced 10 years in patients with

PAD

Mortality rate~ 25% at 5 years

~ 50% at 10 years~ 75% at 15 years

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Natural HistoryNatural History

Annual risk :

- Mortality 6.8%

- MI 2.0%

- Intervention 1.0%

- Amputation 0.4%

Ouriel K, Lancet 2001; 358: 1257-64.

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3.8

1.41.51.8

5.3

3.6

1.0

1.8

4.3

1.71.3

2.4

0

1

2

3

4

5

6

CV Death Nonfatal MI Nonfatal Stroke Death/MI/Stroke

CAD

CVD

PAD

sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.Rates adjusted for age and risk factors.Steg G. Oral presentation at American College of Cardiology. 2006. Available at: http://acc06online.acc.org/sessions.aspx?date=12. Accessed January 28, 2007.

Major Adverse Cardiac Events in Symptomatic Patients Major Adverse Cardiac Events in Symptomatic Patients With CAD, CVD, or PAD at 1 YearWith CAD, CVD, or PAD at 1 Year

Patients with PAD experienced high CV mortalityPatients with PAD experienced high CV mortality

% o

f P

atie

nts

REACH Registry

27

1.2

Single Arterial BedSingle Arterial Bed Polyvascular Disease CAD + CVD + PAD

CAD alone

OverallPAD alone Overall

CVD alone

26.9(‡)

7.4

4.0

1.8

3.6

22.018.2(§)10.0(†)13.312.8

6.02.34.5(†)3.13.4

3.10.63.5(†)0.91.5

1.51.00.5(†)1.41.2

1.51.5 2.41.4

Major End Points as a Function of Single vs Multiple Major End Points as a Function of Single vs Multiple and Overlapping Locationsand Overlapping Locations

sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry. The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.* TIA, unstable angina, other ischemic arterial event including worsening of peripheral arterial disease.

Steg G. Oral presentation at American College of Cardiology. 2006. Available at: http://acc06online.acc.org/sessions.aspx?date=12. Accessed January 28, 2007.

CV death / MI/ stroke/ hospitalization*

CV death / MI/ stroke

Non-fatal stroke

Non-fatal MI

CV death

REACH Registry

† P<0.001 (ref class: CAD alone)‡ P<0.001 (ref class: CAD + CVD)§ P<0.001 (ref class: PAD alone)

Risk doubles with polyvascular diseaseRisk doubles with polyvascular disease

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Relationship Between ABI and Relationship Between ABI and Fatal and Non-fatal CV eventsFatal and Non-fatal CV events

The lower the ABI the higher the 5-year risk of a cardiovascular event The lower the ABI the higher the 5-year risk of a cardiovascular event

Od

ds

of

MI,

Str

oke

or

CV

dea

th

Baseline ABI

1.4

0

40

35

30

25

20

15

10

5

1.21.00.80.60.40.20.0

45

Mehler PS et al. Circulation. 2003;107:753-756. Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75

29

All Cause Mortality as a All Cause Mortality as a Function of Baseline ABIFunction of Baseline ABI

Resnick HE et al. Circulation. 2004;109:733e739.Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

0

10

20

30

40

50

60

70

Baseline ABI

Pe

rce

nt

(%)

▪ PAD patients with an ABI ≤0.90 are at increased risk for cardiovascular events and all cause mortality as ABI decreases

▪ Patients with an ABI >1.40 have underlying diseases, such as diabetes, renal insufficiency or other diseases that cause vascular calcification, or the tibial vessels at the ankle to become non-compressible

<0.60 0.60–<0.70

0.70–<0.80

0.80–<0.90

0.90–<1.0

1.0–<1.10

1.40–<1.50

1.50 Incom-pressible

There appears to be an inverse correlation between mortality and ABI There appears to be an inverse correlation between mortality and ABI

Management of PADManagement of PAD

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What are the Goals of treating patients with PAD?What are the Goals of treating patients with PAD?

Relief symptomsRelief symptoms

Improve quality of lifeImprove quality of life

Limb salvageLimb salvage

Prolong survivalProlong survival

32

Strategies in treating patients with PADStrategies in treating patients with PAD

Improve Lower Limb CirculationImprove Lower Limb Circulation

Risk Factors Modification

33

Improve Lower Limb Circulation• Conservative (Exercise Program)Conservative (Exercise Program)• Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting- Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass


34


Risk Factors Modification• Diet and weight controlDiet and weight control• ExerciseExercise• Antiplatlets Antiplatlets • Hypertension controlHypertension control• Diabetes controlDiabetes control• Lipid controlLipid control• Smoking CessationSmoking Cessation

Part II – Guidelines for Risk Part II – Guidelines for Risk Factors ModificationFactors Modification

36

AHA/ACCAHA/ACC

37

AHA/ACC formatAHA/ACC format

38

Weight Management

Encourage weight reduction/maintenance

Balance of physical activity, caloric intake, and formal Balance of physical activity, caloric intake, and formal behavioral programsbehavioral programs

Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral Arterial Disease. J Am Coll Cardiol. 2006.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Goal:Goal: Body mass index:Body mass index: 18.5 to 24.9 kg/m² 18.5 to 24.9 kg/m²

Waist circumference:Waist circumference: men <40 inches men <40 inches

women < 35 incheswomen < 35 inches

39

Physical Activity

Moderate-intensity aerobic activity

Medically supervised programs for high risk



Goal: Goal:

30 minutes, 7 days per week (minimum 5 days/week)30 minutes, 7 days per week (minimum 5 days/week)

40

Smoking

Ask about smoking

Advise to quit

Counseling

Referal to special program

Pharmacotherapy



Goal: Goal:

Complete CessationComplete Cessation

41

Pharmacologic Risk Reduction Pharmacologic Risk Reduction StrategiesStrategies

ASA and other anti-platelet agentsASA and other anti-platelet agents

Hypertension ControlHypertension Control

Lipid ControlLipid Control

Diabetes ControlDiabetes Control

Angiotensin Converting Enzyme Inhibitors (ACE-I)Angiotensin Converting Enzyme Inhibitors (ACE-I)

42

Antiplatelet Therapy

Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.



▪ The Antithrombotic Trialists’ Collaboration involved 42 trials and 9716 patients with peripheral arterial disease.

▪ 23% reduction for adverse cardiovascular events, including myocardial infarction, stroke, or vascular death

43

Efficacy of Clopidogrel vs Aspirin in MI, Efficacy of Clopidogrel vs Aspirin in MI, Ischemic Stroke, or Vascular Death (N=19,185)Ischemic Stroke, or Vascular Death (N=19,185)11

Months of Follow-Up

Cu

mu

lati

ve

Eve

nt

Rat

e (%

)

0

4

8

12

16

Clopidogrel

Aspirin Overall Relative RiskReduction2

8.7%*

0 3 6 9 12 15 18 21 24 27 30 33 36

Aspirin

Clopidogrel

P=0.0452

* ITT analysis.1. CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.2. Clopidogrel Prescribing Information.

Median Follow-up=1.91 years

Study subjects had either recent MI, recent

ischemic stroke, or established peripheral

arterial disease.

CAPRIE

44

Outcomes by Subgroup AnalysisOutcomes by Subgroup Analysis

* CAPRIE: primary combined end point (myocardial infarction, ischemic stroke, vascular death): RRR 8.7% (P=0.045) for patients with PAD, post-myocardial infarction, post-ischemic stroke. CAPRIE subgroup analysis: for PAD patients the secondary end point, myocardial infarction, was reduced by 23.8% (RRR).

† Since the CAPRIE Trial was not powered to evaluate the efficacy of individual sub-groups, it is not clear whether the differences in RRR across qualifying conditions are real or a result of chance. CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.

-40 -30 -20 -10 0 10 20 30 40

PAD

All patients

Aspirin Better Clopidogrel Better

Mean & 95% CI

CAPRIE

Clopidogrel Reduced the Risk of MI/Ischemic Stroke/Cardiovascular Death in PAD Patients by 23.8%* Compared to ASA†

45

Antihypertensive Therapy

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.



46

Lipid Lowering Therapy

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.


▪ Cholesterol Treatment Trialists Coolaborators Meta-analysis data from 90 056 participants in 14 randomized trials of statins


(Lancet 2005; 366:1267-78)


47

Treatment of diabetes in individuals with lower extremity PAD by administration of glucose control therapies to reduce the hemoglobin A1C to less than 7% can be effective to reduce microvascular complications and potentially improve cardiovascular outcomes.


Diabetes Therapies


48

ACE inhibitors

ACE inhibitors is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.


▪ The HOPE study involved 9297 AS patients.


III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

49

TASC IITASC II

50

Goals of TASC IIGoals of TASC II

▪ Update and expand the consensus statement from 2000

▪ Maintain focus on peripheral arterial disease

▪ Make the document accessible to a wider audience – Including primary care physicians

▪ Reduce the length of the document

▪ Inclusion of Europe, North America, Asia, Africa, Australia


51

TASC II Participating SocietiesTASC II Participating Societies

▪ American College of Cardiology

▪ American Diabetes Association

▪ American Podiatric Medical Association

▪ Canadian Society for Vascular Surgeons

▪ Cardiovascular and Interventional Radiology Society of Europe

▪ CoCaLis collaboration

▪ European Society for Vascular Surgery

▪ International Diabetes Federation

▪ International Union of Angiology

▪ Interventional Radiology Society of Australasia

▪ Japanese College of Angiology

▪ Society for Cardiovascular Angiography and Intervention

▪ Society for Vascular Surgery

▪ Society of Interventional Radiology

▪ Society for Vascular Medicine & Biology

▪ Vascular Society of Southern Africa


52

TASC Grade DefinitionTASC Grade Definition

Grade Definition

A ▪ Based on the criterion of at least 1 randomized controlled clinical trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation

B ▪ Based on well-conducted clinical studies but no good quality randomized clinical trials on the topic of recommendation

C ▪ Based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities (ie, no applicable studies of good quality)

TASC II


53

PAD Patients Are at Increased PAD Patients Are at Increased Risk for CV Ischemic EventsRisk for CV Ischemic Events

PAD Patients ≥50 Years and Older Initial Presentation*

SymptomaticSymptomatic

~40% of Patients ~40% of Patients

AsymptomaticAsymptomatic

~60% of Patients ~60% of Patients

The majority of PAD patients remain highly

underdiagnosed

The majority of PAD patients remain highly

underdiagnosed

* Excluding patients with an initial presentation of critical limb ischemia.Adapted from Hirsch AT et al. Available at: www.acc.org. Accessed January 26, 2007.Adapted from Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

Up to 35% of PAD patients will have an MI/stroke or

die in the next 5 years

Up to 35% of PAD patients will have an MI/stroke or

die in the next 5 years

Limb MorbidityLimb Morbidity70%–80%70%–80%Stable claudication Stable claudication

10%–20%10%–20%Worsening claudicationWorsening claudication

5%–10%5%–10%Critical limb ischemiaCritical limb ischemia

MortalityMortality10%–15%10%–15%75% from CV causes75% from CV causes

5-year Outcomes5-year Outcomes

CV MorbidityCV Morbidity

20%20%Nonfatal CV event Nonfatal CV event (MI or stroke)(MI or stroke)

54

History and Physical Examination History and Physical Examination in Patients With Suspected PADin Patients With Suspected PAD

Grade Recommendations

B ▪ Individuals with risk factors for PAD, limb symptoms on exertion, or reduced limb function should undergo a vascular history to evaluate for symptoms of claudication or other limb symptoms that limit walking ability

B ▪ Patients at risk for PAD or patients with reduced limb function should also have a vascular examination evaluating peripheral pulses

B ▪ Patients with a history or examination suggestive of PAD should proceed to objective testing including an ABI


TASC II Guidelines – TASC II Guidelines – Ankle Brachial Index (ABI)Ankle Brachial Index (ABI)

56

Ankle-Brachial Index (ABI)Ankle-Brachial Index (ABI)

▪ The primary non-invasive screening test for PAD is the ankle-brachial index

▪ The American Diabetes Association recommends a screening with an ABI every 5 years in patients with diabetes

▪ The ABI should become a routine measurement in the primary care practice of medicine

TASC II


57

Grade ABI screening in the primary care setting

B ▪ All patients who have exertional leg symptoms

B ▪ All patients between the age of 50–69 and who have a cardiovascular risk factor (particularly diabetes or smoking)

B ▪ All patients age ≥70 years regardless of risk-factor status

C ▪ All patients with a Framingham risk score 10%–20%

TASC II

Ankle-Brachial Index (ABI)- Screening Ankle-Brachial Index (ABI)- Screening RecommendationsRecommendations


58

ABI for Assessing Systemic RiskABI for Assessing Systemic Risk

Secondary prevention†Secondary prevention†

• Evaluate the patient for symptoms of PAD

• Manage claudicationand CLI if present

• Evaluate the patient for symptoms of PAD

• Manage claudicationand CLI if present

High>20%High>20%

Low<10%Low

<10%

≤0.90≤0.90

Moderate20%–10%Moderate20%–10%

ABIABI

>0.90>0.90 Primary prevention*Primary prevention*

Cardiovascular 10-year risk score:

* Primary prevention=No antiplatelet therapy; LDL (low density lipoprotein) <130 mg/dL; appropriate blood pressure (<140/90 mmHg and <130/80 mmHg in diabetes/renal insufficiency).

† Secondary prevention=Prescribe antiplatelet therapy; LDL <100 mg/dL (<70 mg/dL in very high risk); appropriate blood pressure (<140/90 mmHg and <130/80 mmHg in diabetes/renal insufficiency).Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

TASC II

TASC-II Guidelines for Risk ReductionTASC-II Guidelines for Risk Reduction

60

TASC Guidelines Recommend TASC Guidelines Recommend CV Risk Reduction and Symptom ReliefCV Risk Reduction and Symptom Relief

Evidence Basis for Selected Treatment RecommendationsEvidence Basis for Selected Treatment Recommendations

CV Risk ReductionCV Risk Reduction Treatment for Claudication*Treatment for Claudication*

Recommendations Grade Recommendations Grade

Smoking cessation A Supervised exercise training

A

Statin therapy A

Antihypertensive therapy A

Glucose control therapy C

Folate supplementation B

Antiplatelet therapy A

* To improve symptoms and increase walking distance.Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75

61

Antiplatelet TherapyAntiplatelet Therapy

Grade Recommendations

A ▪ All symptomatic patients with or without a history of other cardiovascular disease should be prescribed an antiplatelet drug long term to reduce the risk of cardiovascular morbidity and mortality

A ▪ Aspirin is effective in patients with PAD who also have clinical evidence of other forms of cardiovascular disease (coronary or carotid)

C ▪ The use of aspirin in patients with PAD who do not have clinical evidence of other forms of cardiovascular disease can be considered

B ▪ Clopidogrel is effective in reducing cardiovascular events in a subgroup of patients with symptomatic PAD, with or without other clinical evidence of cardiovascular disease


62

So, Let’s wrap-up

63

Who should be screened for PAD?Who should be screened for PAD?

Age > 45 yearsAge > 45 years

Patients with Atherosclerotic risk factorsPatients with Atherosclerotic risk factors

64

What is the best way to screen?What is the best way to screen?

ABIABI

65

Summary of the Evidence

Goals

RecommendationClass of

recommendationLevel of evidence

Blood pressure

Systolic <140 mm Hg in all patients <130 mm Hg in diabetic patientsDiastolic <90 mm Hg in all patients <80 mm Hg in diabetic patients

I A

LDL-C LDL< 2.5 mmol/l in all patients I A

Diabetes HbA1c<7% in diabetic patients I B

Smoking Complete cessation in all patients I B

BMI 18.5-24.9 kg/m2 in all patients I B

66

Summary of the Evidence

Medications Recommendation

Class of recommendation

Level of evidence

Antiplatlets All patientsI A

Statins All patients I A

ACE inhibitors Symptomatic patientsAsymptomatic patients

I IIa

B B

67

Take home messageTake home message

▪ PAD is a marker for systemic atherosclerosis

▪ PAD is associated with increased risk of cardiovascular mortality and morbidity

▪ Majority of patients with PAD are asymptomatic

▪ Individuals with atherosclerotic risk factors should be screened for PAD (ABI measurement)

▪ Proven risk reduction therapy should be prescribed for patients with PAD

Thank Thank YouYou

peripheral arterial disease physicians awareness program

Documents

disease slide

pad slide

disease mortality

ankle brachial index

ischemic heart disease

pad present

body atherothrombosis

nonmodifiable risk factors