Peripheral Peripheral VascularVascular Disease in Cardiac Disease in Cardiac

PatientsPatients

Jason Finkelstein, M.D.Jason Finkelstein, M.D.Cardiology FellowCardiology Fellow

Tulane University HSCTulane University HSC9/23/039/23/03

P A DP A D

Characterized by arterial stenosis and Characterized by arterial stenosis and occlusions in the peripheral arterial bedocclusions in the peripheral arterial bed

• Can be symptomatic or asymptomaticCan be symptomatic or asymptomatic

• Under diagnosed and under treated diseaseUnder diagnosed and under treated disease

• Patient and physician awareness is lowPatient and physician awareness is low

P V D P V D

• Ranges in severity from intermittent Ranges in severity from intermittent claudication to limb ischemiaclaudication to limb ischemia

• Patients have a decreased quality of life Patients have a decreased quality of life due to a reduction in walking distance due to a reduction in walking distance and speed leading to immobilityand speed leading to immobility

• Most cases of PAD are asymptomaticMost cases of PAD are asymptomatic

PrevalencePrevalence

• 27 million people in Europe and North 27 million people in Europe and North America have PAD (16% of the population America have PAD (16% of the population 55 yrs or older)55 yrs or older)– 10.5 million are symptomatic10.5 million are symptomatic– 16.5 million are asymptomatic16.5 million are asymptomatic

• Three recent programs have demonstrated Three recent programs have demonstrated high PAD detection rates when specific high PAD detection rates when specific populations were at risk for PAD were populations were at risk for PAD were screenedscreened

POPADAD studyPOPADAD study

• 8000 patients8000 patients

• 40 yrs or older with DM Type I or II40 yrs or older with DM Type I or II

• Had no clinical symptoms of arterial Had no clinical symptoms of arterial diseasedisease

• Results:Results:– 20.1% of patients had ABI < 0.920.1% of patients had ABI < 0.9

PAD Awareness & DetectionPAD Awareness & Detection

• Total of 6979 patientsTotal of 6979 patients• Ages 70 yrs or older or 50-69 with Ages 70 yrs or older or 50-69 with

diabetes or smoking historydiabetes or smoking history

• PAD was considered present if ABI< 0.9 or PAD was considered present if ABI< 0.9 or a h/x of limb revascularizationa h/x of limb revascularization

• CVD was defined as coronary, cerebral, or CVD was defined as coronary, cerebral, or aortic aneurysmal diseaseaortic aneurysmal disease

• Criqui, et al, JAMA 2001: 286; 1317-1324Criqui, et al, JAMA 2001: 286; 1317-1324

Results:Results:

• PAD was detected in 1865 pts ( 30%)PAD was detected in 1865 pts ( 30%)• 44% of these pts had newly diagnosed PAD only44% of these pts had newly diagnosed PAD only• 366 pts had newly diagnosed PAD and CVD (35%)366 pts had newly diagnosed PAD and CVD (35%)• Among pts with PVD, classic claudication was Among pts with PVD, classic claudication was

distinctly uncommondistinctly uncommon• PAD is relatively underdiagnosed by physiciansPAD is relatively underdiagnosed by physicians• PAD patients were less intensely treated than PAD patients were less intensely treated than

patients with CVDpatients with CVD

• Criqui et al, JAMA 2001 286. 1317-1324Criqui et al, JAMA 2001 286. 1317-1324

Natural History of PADNatural History of PAD

• Associated with significant mortality because of Associated with significant mortality because of association with coronary and cerebrovascular association with coronary and cerebrovascular events including death, MI, and strokeevents including death, MI, and stroke

• 6x more likely to die within 10 yrs than patients 6x more likely to die within 10 yrs than patients without PADwithout PAD

• 5 yr mortality rate in pts with claudication is about 5 yr mortality rate in pts with claudication is about 30%30%

• Continued use of smoking results in a two fold risk Continued use of smoking results in a two fold risk of mortalityof mortality

PrevalencePrevalence

• Severity of symptoms has been found to Severity of symptoms has been found to correlate with survivalcorrelate with survival– San Diego Artery studySan Diego Artery study

• Survival rates decreased with increasing severitySurvival rates decreased with increasing severity

• Another study showed that patients with Another study showed that patients with symptoms had a 22% survival rate over a symptoms had a 22% survival rate over a 15 yr period compared to a 78% survival 15 yr period compared to a 78% survival rate of pts w/o symptomsrate of pts w/o symptoms

• Belch et al, Arch Intern Med; April 2003; 884-892Belch et al, Arch Intern Med; April 2003; 884-892

Predictors of Mortality in Predictors of Mortality in PADPAD• 297 patients297 patients

– 213 had intermittent claudication213 had intermittent claudication– 84 had CLI defined by gangrene, ulcerations or persistent rest pain > 2 84 had CLI defined by gangrene, ulcerations or persistent rest pain > 2

weeksweeks– All subjects had ABI < 0.9All subjects had ABI < 0.9

• ResultsResults– Patients with CLI had a 1 yr death rate of 22%Patients with CLI had a 1 yr death rate of 22%– 3 yr survival was 52% compared to 86% in pts with intermittent 3 yr survival was 52% compared to 86% in pts with intermittent

claudicationclaudication– Data suggests that pts with advance PAD have widespread Data suggests that pts with advance PAD have widespread

arteriosclerotic diseasearteriosclerotic disease– CLI was a stronger predictor of death than a low ABICLI was a stronger predictor of death than a low ABI

Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60

ClaudicationClaudication

• Patients suffer from peripheral Patients suffer from peripheral atherosclerosisatherosclerosis

• Symptomatic deficiency in blood supply Symptomatic deficiency in blood supply to exercising muscle which is relieved by to exercising muscle which is relieved by restrest

• Largely a disorder of the elderlyLargely a disorder of the elderly• Only 1-2% of those ages 37-69 Only 1-2% of those ages 37-69 • Clinical history extremely importantClinical history extremely important

Risk FactorsRisk Factors

• Diabetes mellitusDiabetes mellitus– have worse arterial disease and poorer outcomes have worse arterial disease and poorer outcomes

than non-diabeticsthan non-diabetics

• Advanced ageAdvanced age

• HyperlipidemiaHyperlipidemia

• Cigarette smokingCigarette smoking

• HypertensionHypertension

Cardiac RiskCardiac Risk

• Pts with PVD have a 60% risk of CADPts with PVD have a 60% risk of CAD

• Up to 30 % of pts have correctable 3 Up to 30 % of pts have correctable 3 vessel disease with reduced LVEFvessel disease with reduced LVEF

• Patients with an ABI < 0.9 are twice Patients with an ABI < 0.9 are twice as likely to have CADas likely to have CAD

Clinical PresentationClinical Presentation

• Can vary from severe disabling discomfort at rest to a Can vary from severe disabling discomfort at rest to a bothersome pain of seemingly little consequencebothersome pain of seemingly little consequence

• Can present with buttock, thigh, calf or foot Can present with buttock, thigh, calf or foot claudication singly or in combinationclaudication singly or in combination

• Diminished pulses with occasional bruits over stenotic Diminished pulses with occasional bruits over stenotic lesionslesions

• Poor wound healing, unilateral cool extremity, shiny Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changesskin, hair loss, and nail changes

ClaudicationClaudication

• Calf Calf – Cramping in upper 2/3 usually due to SFA stenosisCramping in upper 2/3 usually due to SFA stenosis

• ThighThigh– Usually occlusion of the common femoral arteryUsually occlusion of the common femoral artery

• FootFoot– Occlusive disease of the tibial and peroneal vesselsOcclusive disease of the tibial and peroneal vessels

• Buttock and HipButtock and Hip– Aortoiliac occlusive disease (Lariche’s syndrome)Aortoiliac occlusive disease (Lariche’s syndrome)

Diagnostic testsDiagnostic tests• Ankle-brachial indexAnkle-brachial index

– Measures the resting and post exercise systolic BP in Measures the resting and post exercise systolic BP in both the ankle and armsboth the ankle and arms

– Normal > 1.0Normal > 1.0

– Below 0.9 has a 95 % sensitivity for detecting Below 0.9 has a 95 % sensitivity for detecting angiogram positive PVDangiogram positive PVD

– 0.4 to 0.9 suggests arterial obstruction0.4 to 0.9 suggests arterial obstruction• Highly predictive of morbidity and mortality of CV events Highly predictive of morbidity and mortality of CV events

linked to PADlinked to PAD

– Below 0.4 represents advanced ischemiaBelow 0.4 represents advanced ischemia

Diagnostic TestsDiagnostic Tests

• Segemental limb pressuresSegemental limb pressures– > 20 mmHg reduction significant> 20 mmHg reduction significant

• Duplex U/SDuplex U/S

• MRAMRA

• Conventional angiographyConventional angiography

AngiographyAngiography

• Indicated for:Indicated for:

– Defining vessel anatomyDefining vessel anatomy

– Evaluating therapyEvaluating therapy

– Documenting diseaseDocumenting disease

Long term survivalLong term survival

• 2, 296 patients reviewed from CASS found to have PAD2, 296 patients reviewed from CASS found to have PAD• Mean follow up period was 10.4 yrsMean follow up period was 10.4 yrs

• Pts with PAD had a higher frequency of CV risk factors Pts with PAD had a higher frequency of CV risk factors – HTN, DM, CHF, previous CABG, or smokedHTN, DM, CHF, previous CABG, or smoked

• Controlled for all independent risk factorsControlled for all independent risk factors• Vascular disease retained a highly significant correlation Vascular disease retained a highly significant correlation

with mortalitywith mortality– Pts had a 25% increased risk of dying at any time during Pts had a 25% increased risk of dying at any time during

followup ( p< 0.001)followup ( p< 0.001)

Eagle et al, JACC 1994;23:1091-5Eagle et al, JACC 1994;23:1091-5

Premature PADPremature PAD• 59 male patients with premature PAD59 male patients with premature PAD

• Age of onset < 45 yrs of ageAge of onset < 45 yrs of age

• PAD assessed by ABI and CAD assessed by PAD assessed by ABI and CAD assessed by exercise treadmill testing or coronary exercise treadmill testing or coronary angiogramangiogram

• Mean ABI was 0.65Mean ABI was 0.65

• Arteriography performed in 56/59 ptsArteriography performed in 56/59 pts

• Valentine et al, J of Vasc Surg (1994; 19; 668-674)Valentine et al, J of Vasc Surg (1994; 19; 668-674)

Premature PADPremature PAD

• 30 month period of the study30 month period of the study• 43 patients had significant CAD (73%)43 patients had significant CAD (73%)

– 17 pts had single vessel disease17 pts had single vessel disease– 4 pts had 2 vessel disease4 pts had 2 vessel disease– 22 pts had 3 vessel disease22 pts had 3 vessel disease

• 32 pts experienced an MI and 23 pts requires an 32 pts experienced an MI and 23 pts requires an intervention to help control anginaintervention to help control angina

• 8% mortality rate in the study8% mortality rate in the study

• Valentine et al, J Vasc Surg (1994; 19:668-674)Valentine et al, J Vasc Surg (1994; 19:668-674)

Management of PAD & CADManagement of PAD & CAD

• Close association of PAD and CADClose association of PAD and CAD• Pts with CAD undergoing PV surgery are at increased risk of Pts with CAD undergoing PV surgery are at increased risk of

early and late CV eventsearly and late CV events

• Coronary revasc. is likely to improve outcome but mortality Coronary revasc. is likely to improve outcome but mortality rate after CABG is not as good as in pts w/o PVDrate after CABG is not as good as in pts w/o PVD

• Recommends hemodynamic monitoringRecommends hemodynamic monitoring• Definitive guidelines are not availableDefinitive guidelines are not available

• Gersch et al, J am Coll Card; 1991;18:203-214Gersch et al, J am Coll Card; 1991;18:203-214

PVD and Role of CRPPVD and Role of CRP• 51 pts with PVD who underwent lower limb 51 pts with PVD who underwent lower limb

revasc. (screened 170 pts)revasc. (screened 170 pts)

• 24 month f/u period24 month f/u period

• 39 pts had PTA and 12 pts had bypass 39 pts had PTA and 12 pts had bypass surgerysurgery

• CRP levels were measured pre-opCRP levels were measured pre-op

All mortality, cardiac mortality and MI were All mortality, cardiac mortality and MI were considered major eventsconsidered major events

• Rossi et al, Circulation 2002; 105:800-803Rossi et al, Circulation 2002; 105:800-803

PVD and Role of CRPPVD and Role of CRP• 34% incidence of fatal and nonfatal MI over 2 yrs34% incidence of fatal and nonfatal MI over 2 yrs

• CRP > 9 predicted 60 % o f MI’s in pts undergoing lower limb CRP > 9 predicted 60 % o f MI’s in pts undergoing lower limb revasc. ( p <0.04)revasc. ( p <0.04)

• ConclusionConclusion

– CRP level in pts with PVD severe enough for revasc. may give CRP level in pts with PVD severe enough for revasc. may give incremental information about CV events and had a high predictive incremental information about CV events and had a high predictive valuevalue

– Pts may benefit from therapy modulating the immune responsePts may benefit from therapy modulating the immune response– More studies neededMore studies needed

– Rossi et al, Circulation; 2002; 105: 800-803Rossi et al, Circulation; 2002; 105: 800-803

PAD ManagementPAD Management• Anti-platelet agentsAnti-platelet agents

• Diabetic controlDiabetic control

• Smoking cessationSmoking cessation

• Anti-hypertensivesAnti-hypertensives

• Statin therapyStatin therapy

• Exercise rehabilitationExercise rehabilitation

• Revascularization/PTCA/stentingRevascularization/PTCA/stenting

RevascularizationRevascularization

• Indications for intervention (PTA)Indications for intervention (PTA)– Persistent limiting claudication that prevents patient Persistent limiting claudication that prevents patient

from performing daily activitiesfrom performing daily activities– Rest painRest pain– Tissue lossTissue loss– Patients who are poor surgical candidatesPatients who are poor surgical candidates

• Long term success of PTA depends on site and Long term success of PTA depends on site and length of the lesionlength of the lesion– Limited to focal, short segment occlusionsLimited to focal, short segment occlusions– No significant difference in outcome between PTA or No significant difference in outcome between PTA or

surgerysurgery

RevascularizationRevascularization

• Lesions might be better treated Lesions might be better treated surgically if:surgically if:– Long segmentsLong segments– Multi focal stenosesMulti focal stenoses– Long segment occlusionsLong segment occlusions– Eccentric, calcified lesionsEccentric, calcified lesions

ConclusionConclusion

• Need to increase awareness of PAD and its Need to increase awareness of PAD and its consequencesconsequences

• Improve the identification of patients with Improve the identification of patients with symptomatic PADsymptomatic PAD

• Initiate a screening protocol at high risk for Initiate a screening protocol at high risk for PADPAD

• Improve treatment rates for those who Improve treatment rates for those who have been diagnosedhave been diagnosed

• Increase the rates of early detection in Increase the rates of early detection in asymptomatic patientsasymptomatic patients

SummarySummary

• PAD is a powerful indicator of systemic PAD is a powerful indicator of systemic artherosclerosisartherosclerosis

• Mandates aggressive risk factor modification and Mandates aggressive risk factor modification and pharmacologic therapypharmacologic therapy

• Goal is to improve the functional capacity of our Goal is to improve the functional capacity of our patients and decrease morbidity and mortalitypatients and decrease morbidity and mortality

• Cardiologists need to take a more active role in Cardiologists need to take a more active role in treating PAD along with co-existing CADtreating PAD along with co-existing CAD

Case #1Case #1

• Mr. EG is a 52 yr old male with PMHx Mr. EG is a 52 yr old male with PMHx of HTN, tobacco abuse and CAD with of HTN, tobacco abuse and CAD with a 5 vessel CABG in June 2000a 5 vessel CABG in June 2000

– LIMA – LADLIMA – LAD– SVG to D1SVG to D1– SVG to OM1 & OM2SVG to OM1 & OM2– SVG to RCASVG to RCA

Case #1Case #1

• Last cath was in April of 2001 which showed Last cath was in April of 2001 which showed patent grafts and medical management was patent grafts and medical management was recommendedrecommended

• Now pt has recurrent chest pain on exertion < Now pt has recurrent chest pain on exertion < 1 block1 block

• Cardiolyte stress test revealed 1 mm ST Cardiolyte stress test revealed 1 mm ST depression and anterior ischemia. LVEF is depression and anterior ischemia. LVEF is 44%44%

Case # 2Case # 2

• Mr. JG is a 60 yr old male with PMHx of Mr. JG is a 60 yr old male with PMHx of severe tobacco abuse, AAA, PVD with severe tobacco abuse, AAA, PVD with ischemic rest pain, Right CEA, HTN, who ischemic rest pain, Right CEA, HTN, who presents with occasional atypical anginapresents with occasional atypical angina

• Persantine Cardiolyte stress test showed Persantine Cardiolyte stress test showed reversible anterior and septal ischemiareversible anterior and septal ischemia

Case # 2Case # 2

• TEE revealed normal LVEF with mild TEE revealed normal LVEF with mild inferobasal HKinferobasal HK

• Moderate to severe eccentric MRModerate to severe eccentric MR

• Physical exam revealed b/l carotid Physical exam revealed b/l carotid bruits and 2/6 SEMbruits and 2/6 SEM