Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease?

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• Why Are We Invloved in the Detection and
  Treatment of Peripheral Artery Disease?

HU Dayi
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Major Clinical Manifestations of Atherothrombosis
Ischemic stroke
Transient ischemic attack
Myocardial infarction
Angina
Renal artery stenosis
Atherosclerotic nephrology

• Peripheral arterial
• disease
• Intermittent claudication
• Rest Pain
• Gangrene
• Necrosis

Adapted from Drouet L. Cerebrovasc Dis 2002
13(suppl 1) 16.
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NCEP ATP III EvaluationCAD Risk Equivalents

• Diabetes

• Atherosclerotic disease
• Peripheral artery disease
• Abdominal aortic aneurysm
• Symptomatic carotid artery disease
• CAD 10-year risk gt20

Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486.
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Risk of a Second Vascular Event
Sudden death defined as death documented within
1 hour and attributed to coronary heart disease
(CHD) Includes only fatal MI and other CHD
death does not include non-fatal MI
1. Adult Treatment Panel II. Circulation 1994
89133363. 2. Kannel WB. J Cardiovasc Risk 1994
1 3339. 3. Wilterdink JI, Easton JD. Arch
Neurol1992 49 85763. 4. Criqui MH et al. N
Engl J Med 1992 326 3816.
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Why A PAD Guideline?

• To enhance the quality of patient care
• Increasing recognition of the importance of
  atherosclerotic lower extremity PAD
• High prevalence
• High cardiovascular risk
• Poor quality of life
• Improved ability to detect and treat renal artery
  disease
• Improved ability to detect and treat AAA
• The evidence base has become increasingly robust,
  so that a data-driven care guideline is now
  possible

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Natural History of PAD Age gt 50 years
Cardiovascular Morbidity / Mortality
Limb Morbidity
Mortality 15-30
Worsening Claudication 10-20
Critical Limb Ischemia 1-2
Nonfatal CV Events 20
Stable Claudication 70-80
CV Causes 75
Non CV Causes 25
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Quality of Life in Patients with PAD

• Individuals with asymptomatic lower extremity PAD
  have a worse quality of life and limb function
  than an age-matched cohort
• The quality of life for patients with severe CLI
  can be worse than that of patients with terminal
  cancer

McDermott MM, J Am Geriatr Soc 200250238-46.
Dormandy JA, J Vasc Surg 200031(1 pt 2)S1-S296.
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Defining a Population At Risk for Lower
Extremity PAD

• Age less than 50 years with diabetes, and one
  additional risk factor (e.g., smoking,
  dyslipidemia, hypertension, or hyperhomocysteinemi
  a)
• Age 50 to 69 years and history of smoking or
  diabetes
• Age 70 years and older
• Leg symptoms with exertion (suggestive of
  claudication) or ischemic rest pain
• Abnormal lower extremity pulse examination
• Known atherosclerotic coronary, carotid, or renal
  artery disease

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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)
ABIlt0.9
Diehm C et al. Atherosclerosis 2004 172 95-105.
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The Ankle-Brachial Index

• Lower extremity systolic pressure
• Brachial artery systolic pressure

ABI

• The ankle-brachial index is 95 sensitive and 99
  specific for PAD
• Establishes the PAD diagnosis
• Identifies a population at high risk of CV
  ischemic events
• Population at risk can be clinically
  epidemiologically defined

• Exertional leg symptoms, non-healing wounds, age
  gt 70, age gt 50 years with a history of smoking or
  diabetes.
• Toe-brachial index (TBI) useful in individuals
  with non-compressible pedal pulses

Lijmer JG. Ultrasound Med Biol 199622391-8
Feigelson HS. Am J Epidemiol 1994140526-34
Baker JD. Surgery 198189134-7 Ouriel K. Arch
Surg 19821171297-13 Carter SA. J Vasc Surg
200133708-14
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Lipid Lowering and Antihypertensive 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.
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.
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Antihypertensive Drug
Beta-adrenergic blocking drugs are effective
antihypertensive agents and are not
contraindicated in patients with PAD.
The use of angiotensin-converting enzyme
inhibitors is reasonable for symptomatic patients
with lower extremity PAD to reduce the risk of
adverse cardiovascular events
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Antiplatelet Therapy
Antiplatelet therapy is indicated to reduce the
risk of myocardial infarction, stroke, or
vascular death in individuals with
atherosclerotic lower extremity PAD.
Aspirin, in daily doses of 75 to 325 mg, is
recommended as safe and effective antiplatelet
therapy to reduce the risk of myocardial
infarction, stroke, or vascular death in
individuals with atherosclerotic lower extremity
PAD.
Clopidogrel (75 mg per day) is recommended as an
effective alternative antiplatelet therapy to
aspirin to reduce the risk of myocardial
infarction, stroke, or vascular death in
individuals with atherosclerotic lower extremity
PAD.
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