peripheral arterial disease · rx •ramipril •amlodipine •metformin examination: ......
TRANSCRIPT
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Peripheral Arterial Disease
A Case study
By Dr Chris Arden
Presented by Dr Ivan Benett
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Case study
• Ralph is a 58 year old male
• exertional left calf discomfort at 200 yards
• symptoms occur reproducibly with exertion and relieved by rest
• PH: • DM
• HTN
• Smoker 5/day
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Rx • Ramipril • Amlodipine • Metformin
Examination:
• palpable femoral pulses without bruits,
diminished popliteal and distal pulse on left, and no positional colour changes, skin intact
Case study
How do we establish a diagnosis of PAD and assess severity?
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Clinical Presentation
• Asymptomatic
• Atypical symptoms
• Intermittent claudication
• Critical limb ischemia
– Rest Pain
– Ulceration
– Necrosis/Gangrene
• Acute limb ischemia
The Spectrum of Manifestations of PAD
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Classification of Preipheral Arterial Disease severity
Rutherford Stage Symptoms Fontaine stage Symptoms
0 Asymptomatic I Asymptomatic
1 Claudication - mild II Intermittent Claudication
2 Claudication - moderate
IIa IC >200m
3 Claudication - severe IIb IC <200m
4 Rest Pain IV Rest pain
5 Minor tissue loss V Necrosis or gangrene
6 Major tissue loss
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Typical vs Atypical Symptoms
in Patients With Symptomatic PAD
Other nonspecific leg symptoms that
may be indicative of PAD
Typical Symptoms1
Intermittent claudication
• Exertional calf pain that
– causes the patient to
stop walking
– resolves within 10 minutes
of rest
Atypical Symptoms1
• Exertional leg pain that
– may involve areas other than
the calves
– may not stop the patient from
walking
– may not resolve within
10 minutes of rest
33%2
>50%2
1. McDermott MM et al. JAMA. 2001;286:1599-1606.
2. Hiatt WR. N Engl J Med. 2001;344:1608-1621.
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Examination of the peripheral vascular system
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Auscultation
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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.
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Pathophysiology
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Common Sites of Claudication
Obstruction in
Aorta or
iliac artery
Femoral artery
or branches
Popliteal artery
or distal
Ischaemia in
Buttock, hip,
thigh
Thigh,
calf
Calf, ankle,
foot
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Independent Risk Factors for PAD
Relative Risk vs the General Population
Reduced Increased
Diabetes
Smoking
Hypertension
Dyslipidaemia
4.05
2.55
1.51
1.10
PAD diagnosis based on ABI <0.90.
Newman AB, et al. Circulation. 1993;88:837-845
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Diagnostic Tests
≥1.0 — Normal
0.81-0.90 — Mild Obstruction
0.41-0.80 — Moderate Obstruction
≤0.40 — Severe Obstruction
How to Perform and
Calculate the ABI
How to Perform and
Calculate the ABI
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Treadmill test
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He is sent for ABI/PVR and arterial duplex revealing ABI 0.5 on left with femoral-popliteal involvement
Why sould we care about his diagnosis of PAD?
Case study
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Mortality is very high in patients with severe PAD
Relative 5-year mortality
Pati
en
ts (
%)
0
5
10
15
20
25
30
35
40
45
50
Colon/rectal
cancer1
Breast
cancer1
Severe
PAD2
Non-Hodgkin’s
lymphoma3
15
38 44
48
1. Criqui MH. Vasc Med 2001; 6 (suppl 1): 3–7.
2. McKenna M et al. Atherosclerosis 1991; 87: 119–28.
3. Ries LAG et al. (eds). SEER Cancer Statistics Review, 1973–1997. US: National Cancer Institute; 2000.
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There is a strong two-way association between decreased ABI and increased risk for
cardiovascular death
All-cause mortality
CVD Mortality
Perc
en
t
Baseline ABI*
*Mean participant follow-up 8.3 years Resnick HE et al. Circulation 2004; 109: 733-739.
70
60
50
40
30
20
10
0
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What should we be thinking about in his treatment?
Case study
Smoking cessation
Weight reduction
Total cholesterol <4.5 mmol/L
LDL cholesterol <2.6 mmol/L
HbA1c < 53 mmol/mol
Blood pressure (BP) <140/90 mm Hg
– For patients with diabetes BP < 130/80mm Hg
Anti-platelet therapy
Risk factor management approach
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Effect of Smoking Cessation on Survival in PAD
131 Patients Followed After Bypass Graft or Lumbar Sympathectomy Surgery
0 1 2 3 4 5
0
20
40
60
80
100
Australian Census
Tobacco Abstinence
Continued Tobacco UsersCu
mu
lati
ve
Su
rviv
al
(%)
Years Postoperative
Faulkner et al. Med J Aust 1983;1:217.
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Treatment of PAD Effect of Exercise Training Meta-analysis of 21 Studies
80
60
40
20
0
100
120
140
160
180
200
Ch
ange
in T
read
mill
Wal
kin
g D
ista
nce
(%
)
Onset of Claudication Pain
Maximal Claudication Pain
Exercise Training
Control
Gardner AW. JAMA. 1995;274:975-980.
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Exercise for PAD?
Offer supervised exercise training should be the initial treatment
• 30-45 minute sessions • 3 or more times per week • At least 12 weeks
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Effect of Antiplatelet Therapy on Cardiovascular Events in PAD
• 42 clinical trials
• 9,214 patients with PAD
• 23% reduction in serious adverse vascular events (P=0.004)
• Benefits similar among PAD subtypes (intermittent claudication, peripheral grafting, and peripheral angioplasty)
Antithrombotic Trialists’ Collaboration. BMJ. 2002;324:71-86.
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Recommendations for Antiplatelet and Antithrombotic Drugs
• Antiplatelet therapy is indicated to reduce the risk of MI, stroke, and vascular death in symptomatic PAD
• Aspirin 75mg daily is recommended as an effective antiplatelet therapy
• Clopidogrel (75 mg per day) is recommended as an alternative antiplatelet therapy to aspirin
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Risk Reduction with ACE-inhibitors, Statins,
and Antiplatelet Therapy in PAD
No. of Patients
(>9000)
(>6000)
(4051)
(2701)
APTC*
CAPRIE*
HOPE*
HPS*
0 1 2 3 4 5 6 7
Event Rate (% per year)
APTC Antiplatelet Trialists’ Collaboration. BMJ. 1994;308:81-106.
CAPRIE Steering Committee. Lancet. 1996;348:1329-1339.
HOPE Study Investigators. N Engl J Med. 2000;342:145-153.
Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22.
Placebo 6.0%
Aspirin 4.9% Clopidogrel 3.7%
Placebo 4.4%
Ramipril 3.4% P < 0.001
Placebo 6.1% Simvastatin 4.9% P < 0.001
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You put him on Atorvastatin 40mg and Aspirin
75mg daily and advised to perform interval
exercise training but claudication remains at 100
meters
After three months his symptoms are no better.
What should we consider next?
Case study
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Treatment Approach to Intermittent Claudication
Assess severity of claudication
Mild to moderate claudication
Exercise & drug therapy
Symptoms improve
Symptoms debilitating
Continue present therapy
Severe claudication
Localise lesion
Aortoiliac or femoral dz
Popliteal-tibial dz
Consider percutaneous intervention
Exercise & drug therapy unless
debilitating
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Angiography – occlusion of left popliteal artery with collaterals
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Occlusion managed by angioplasty
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Left popliteal artery after angioplasty
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Occlusion of right common Iliac Artery before and after stent
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Revascularization for Aorto-Iliac Arterial Disease
Aortofemoral Bypass
• Primary patency at 5 years of 81-85%
1
• Perioperative mortality 5-8%1
• Reserved for severe diffuse disease cases2
• Indicated for Rutherford class 32
1. Raptis S. et al. Eur. J. Vasc. Endovasc. Sur. 1995; 9: 97-102
2. Rosenfield K and Isner JM. Chap 97 in Textbook of Cardiovascular Medicine 1998
Percutaneous Intervention
• Patency at 5 years of 65-80%1
• Perioperative mortality 0.1%1
• Treatment of choice3
• Indicated for Rutherford class 22
1. Becker GJ et al. Radiology 1989;170:921-940
2. Belli A-M et al. Clin Radiol 1990;41:380-3
3. Rosenfield K and Isner JM. Chap97 in Textbook of Cardiovascular Medicine 1998
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Summary of PAD and Management
• PAD is common and has a significant impact upon cardiovascular outcomes
• Treatment of PAD, even asymptomatic, should focus on risk factor modification/risk reduction
• Treatment of intermittent claudication should include exercise therapy, drug therapy and selective use of revascularization
• Treatment for critical limb ischemia warrants aggressive efforts at revascularization, including surgery, to reduce the risk of amputation
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Overall learning points
PAD is a reliable warning sign that a patient is at high risk for life threatening cardiovascular and cerebrovascular events
PAD is easily overlooked by both patients and clinicians – assess whether patients presenting with symptoms or
associated risk factors have PAD
Treatments are available to protect the patients with PAD from future MI or stroke
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