PAD Diagnosis and Management

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PADDiagnosis and Management

• Gerry Stansby
• Newcastle upon Tyne, UK

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Atherothrombosis affects many vascular beds
These are expressions of a single extensive,
progressive, unpredictable and deadly disease
Ischaemic stroke
Transient ischaemic attack
Myocardial infarction
Angina Stable Unstable
Renovascular disease
Peripheral arterial disease Intermittent
claudication Rest pain Gangrene Necrosis
Diabetes (type 2) Often considered vascular
equivalent to to a non-diabetic patient with
previous MI2

1. Adapted from Drouet L. Cerebrovasc Dis 2002
   13(Suppl 1) 16
2. Adapted from Haffner SM et al. N Engl J Med
   1998339229-234

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Cardiologists (cardiac surgeons)
Vascular Surgeons
Stroke Medicine
Arteriopath
General Practice
Neurology
Care of the elderly
Diabetologists
Renal Physicians
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The burden of atherothrombotic disease
Mortality ()
Atherothrombosis bar is an addition of burden
for coronary heart disease (17.3),
cerebrovascular disease (9.9) and peripheral
arterial disease (no data)
1. England and Wales, Office for National
Statistics 2006 (www.heartstats.org)
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Development of atherothrombotic disease
Atheroscleroticplaque
Plaque rupture thrombosis
Normal artery
Fatty streak
MI / unstable angina Stroke / TIA Critical limb
ischaemia Cardiovascular death
Stable angina Claudication PAD
Clinically silent
Begins in teenage years
Increasing age risk factors
The underlying pathology is the same for each
arterial bed
Peripheral arterial disease should be treated as
seriously as coronary heart disease when
calculating cardiovascular risk
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Patients with Type 2 diabetes are a high
cardiovascular risk group
7-yr incidence of cardiovascular events ()
20
MI (20.2)
MI (18.8)
15
CV Death (15.9)
CV Death (15.4)
10
Stroke (10.3)
Stroke (7.2)
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0
Type 2 diabetes (no prior MI)
Prior MI (no diabetes)
CV cardiovascular
1. Adapted from Haffner SM et al. N Engl J Med
1998339229-234
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Edinburgh Artery Study. Cross-sectional survey
of 1592 subjects. (??aged 55-74)

Symptomatic 4.5
Its Common!
Asymptomatic 15
9
5 years.
lt5 amputation
20 die of MI 10 die of other causes
5 year fate of the claudicant (Dormandy et al)
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Relative Risks of All-Cause Mortality by Ankle
Brachial Index in Men and Women in 12 cohort
studies
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Female
4
Male
Ankle brachial index combined with Framingham
Risk Score to predict cardiovascular events and
mortality a meta-analysis. JAMA. 2008 Jul
9300(2)197
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Relative risk of Death
2
1
lt0.6
0.6-0.7
0.7-0.8
0.8-0.9
0.9-1.0
1.0-1.1
1.1-1.2
1.2-1.3
1.3-1.4
gt1.4
Ankle Brachial Index
Base reference ABI 1.0-1.4
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Intermittent claudication? Key questions.

• Does this pain ever occur standing still or
  sitting? (No)
• Is it worse if you walk uphill or hurry? (Yes)
• What happens to it if you stand still? (It goes
  away)
• Where do you get the pain or discomfort?
  (Claudication pain is typically in the calf,
  atypically in the buttock or thigh not in foot
  or toes)

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PADAnkle Brachial Index
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AnkleBrachial Pressure Index

• Highest pressure in foot (ankle)
• Brachial systolic pressure

ABIlt0.9 diagnostic for PAD
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ABI measurement

• Brachial Systolic blood pressure
• Right 156/88 mmHg
• Left 160/92 mmHg
• Right leg
• DP 160 mmHg
• PT 154 mmHg
• 160/160 1.00
• Left leg
• DP 96 mmHg
• PT 100 mmHg
• 100/160 0.63
• The lowest ABI between both legs is
• the ABI that stratifies the patients risk

Right 156 mmHg
Left 160 mmHg
DP 96 mmHg PT 100 mm Hg
DP 160 mm Hg PT 154 mmHg
Diagnosis moderate PAD in left leg
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AGATHA ABI is related to the site and extent of
atherothrombosis
with ABI 0.9
CAD coronary artery disease CVD
cerebrovascular disease PAD peripheral artery
disease
CAD 35
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PAD 10
7
15
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CVD 20
Type of arterial bed affected in the with-disease
population () N7099
Fowkes et al. EHJ 200627861867
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Management of claudication.

• Mostly conservative -risk factors
• If diagnosis certain no tests are needed
• Intervene only if there is a major impairment of
  Quality of Life

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Assessing risk for coronary heart disease
beyond Framingham. Am Heart J. 2003
Oct146(4)572-80. Cobb FR, Kraus WE, Root M,
Allen JD.
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PAD Medical Therapy

• Blood Pressure
• Lipids
• Antiplatelets
• ACEI
• Diabetes
• (Cilostazol)

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Anti-Platelet therapy

• Well established role in CHD/Stroke prevention
• PAD patients have very active platelets
• 25 fewer events/death on an antiplatelet agent
• Aspirin or clopidogrel.

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Blood Pressure Control

• Target 140/85

Data from PREPARED study.
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SIMVASTATIN VASCULAR EVENT by PRIOR DISEASE
STATIN worse
Risk ratio and 95 CI
STATIN
PLACEBO
Baseline
feature
(10269)
(10267)
STATIN better
STATIN worse
Previous MI
1007
1255
Other CHD (not MI)
452
597
No prior CHD


CVD
182
215
PVD
332
427
Diabetes
279
369
ALL PATIENTS
2042
2606
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SE 2.6
reduction
(19.9)
(25.4)
(2Plt0.00001)
0.4
0.6
0.8
1.0
1.2
1.4
Heart Protection Study
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PREPARED study cholesterol levels in claudicants

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ACE inhibitors
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Metabolic Syndrome Difficult to define Easy to
spot
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Exercise andAbsolute Claudication Distance
450
400
350
Supervised
300
250
P lt 0.001
Median Absolute Claudication Distance
on Treadmill Walking (meters)
200
Non-supervised
150
100
50
0
Baseline
3-month
6-month
9-month
12-month
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REACH Registry gt67,000 patients from 5,473
sites in 44 countries
5,656
17,886
27,746
5,048
5,903
846
North America
1,931
Latin America
Western Europe
2,872
Eastern Europe
Middle East
Asia (incl. Japan)
Australia
JAMA 2006295180-9
up to 15 patients/site (up to 20 in the US)
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Major endpoints as a function of single vs
multiple and overlapping locations
1 plt0.05 2 plt0.01 3 plt0.001 (ref class CAD
alone)
1 plt0.05 2 plt0.01 3 plt0.001 (ref class CAD
CVD)
TIA, unstable angina, other ischemic arterial
event including worsening of peripheral arterial
disease
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Critical Ischaemia

• Rest pain /- gangrene or ulcers
• Doppler pressures lt 50mmHg.
• gt70 will need amputation if nothing is done.
• Priority is revascularisation
• Urgent referral needed

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Specialist referral

• Urgent Critical ischaemia (rest pain, necrosis,
  gangrene).
• Routine Limiting symptoms, threatened
  employment, diagnostic doubt
• Refer to local guidelines

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• NEWCASTLE, NORTH TYNESIDE AND NORTHUMBERLAND
  GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF
  PATIENTS WITH PERIPHERAL ARTERIAL DISEASE (PAD)
•  
• October 2008

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Members of the group

• Dr Jane Skinner, Consultant Community
  Cardiologist, Newcastle upon Tyne Hospitals NHS
  Foundation Trust
• Professor Gerry Stansby, Professor of Vascular
  Surgery, Newcastle upon Tyne Hospitals NHS
  Foundation Trust
• Dr Mike Scott, GP, Newcastle upon Tyne
• Mrs Margaret King, Programme Co-ordinator,
  Community Cardiac Care, Newcastle PCT
• Mrs Lisa English, Community Cardiology
  Co-ordinator, North Tyneside PCT
• Mr Glyn Trueman, Formulary Pharmacist, Newcastle
  Hospitals
• Ms Zahra Irranejad, Lead Pharmaceutical Advisor,
  North of Tyne PCTs (represented by Lindsay White)
• Ms Sheila Dugdill, Peripheral Arterial Nurse
  Specialist, Freeman Hospital
• Mrs Susan Turner, Pharmaceutical Advisor
  (commissioning), NHS North of Tyne
• Mrs Alice Wincup, Cardiac rehabilitation nurse,
  Northumberland Care Trust

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Thank You For Listening