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Advances in the Medical Management of Peripheral Arterial Disease Warner P. Bundens, MD, MS Associate Clinical Professor of Surgery Associate Clinical.

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Presentation on theme: "Advances in the Medical Management of Peripheral Arterial Disease Warner P. Bundens, MD, MS Associate Clinical Professor of Surgery Associate Clinical."— Presentation transcript:

1 Advances in the Medical Management of Peripheral Arterial Disease Warner P. Bundens, MD, MS Associate Clinical Professor of Surgery Associate Clinical Professor of Family and Preventive Medicine School of Medicine University of California, San Diego La Jolla, California

2 Key Question How many of your patients with CV risk do you test for peripheral arterial disease? 1. 0%-24% 2. 25%-50% 3. 51%-75% 4. 76%-100% Use your keypad to vote now! ?

3 Faculty Disclosure  Dr Bundens: grants/research support: sanofi-aventis Group.

4 Learning Objectives  Describe the prevalence and disease burden of PAD  State medical treatments for improving leg symptoms of the patient with PAD  Discuss interventions used to prevent systemic complications in the patient with PAD PAD = peripheral arterial disease.

5 Peripheral Arterial Disease: What Is It? PAD PAOD PAOD = peripheral arterial obstructive disease.

6 Lesions What Is It? Obstructed Lumen Plaque

7 Who Gets It? PAD: Risk Factors  Age  Uncommon: <50 years old  years old 10% overall 20% with history of smoking or diabetes  >70 years old 20%

8 Who Gets It? PAD: Risk Factors  Age  Diabetes 4×  Smoking 3.5×  Past or present  Hypertension 2×  Hyperlipidemia 0.1×

9 How Do You Diagnose It? PAD Symptoms  May be asymptomatic  Claudication

10 Claudication A Reproducible and Consistent Symptom

11 Claudication  Muscular pain brought on by activity (walking) that is relieved by stopping that activity

12 Claudication

13  Muscular pain brought on by activity (walking) that is relieved by stopping that activity  Does not occur at rest  Is not brought on by standing

14 Other Causes of Leg Pain: “Pseudoclaudication” ►Spinal stenosis ►Nerve root compression ►Arthritis/joint disease, especially the hip ►Compartment syndrome ►Venous claudication ►Symptomatic Baker’s cyst

15 How Do You Diagnose It? PAD Symptoms  May be asymptomatic  Claudication  Ischemic rest pain

16 Ischemic Rest Pain  Distal foot  Worse at night  Decreased by lowering foot

17 How Do You Diagnose It? PAD Symptoms  May be asymptomatic  Claudication  Ischemic rest pain  Tissue loss, nonhealing lesions, gangrene

18 Arterial Ulcer/Gangrene

19 Not Arterial Nocturnal Leg/Foot Cramps

20 PAD: Physical Findings  Pulses  Pallor  Dependent rubor  Thick nails  Hairlessness  Tissue loss/ulcer/gangrene

21 PAD: Physical Findings Poor Sensitivity and Specificity for Mild-to-Moderate PAD

22 PAD: An Objective Test Flow vs Pressure

23 Ohm’s Law Electrical: E = I·R Voltage Drop = Current × Resistance Fluids: P = F·R Pressure Drop = Flow × Resistance

24 Ohm’s Law

25 Office Measurement of the Ankle-Brachial Index (ABI) Right arm pressure Pressure: Posterior tibial Anterior tibial Pressure: Posterior tibial Anterior tibial Left arm pressure Supine Patient

26 Ankle Pressure Posterior Tibial Anterior Tibial Patient Must Be Supine

27 The ABI  Both ankle and brachial systolic pressures should be taken using a hand-held Doppler instrument  For arm and leg, use higher of 2 pressures Ankle Systolic Pressure Brachial Artery Systolic Pressure ABI =

28 The ABI Right Arm 150 mm Hg Right AT 68 Right PT 75 Left Arm 143 Left AT 120 Left PT 100 Right ABI = 75/150 = 0.50Left ABI = 120/150 = 0.80 AT = anterior tibial; PT = posterior tibial.

29 What Do the Numbers Mean? ABI  Typical values  Normal =  Claudication =  Rest pain = <0.4  Tissue loss = <0.3

30 ABI < % Sensitive and 99% Specific for PAD TASC Working Group. J Vasc Surg. 2000;31(1 suppl):S1-S296.

31 ABI: Occasional “Gray” Areas  ABI  Most of these people have PAD  ABI >1.0  Most of these people do not have PAD

32 ABI Workshops  Demonstrations available throughout the day

33 Further Noninvasive Testing  Segmental pressures  Doppler waveforms  Exercise test

34 Lower Extremity Arterial Exam Further Testing

35 Relative 5-Year Mortality Rates *American Cancer Society. Cancer Facts and Figures, Criqui MH et al. N Engl J Med. 1992;326: PAD Is a Bad Disease

36 WHY ?

37 Key Question Without intervention, what percentage of PAD patients will have an MI or stroke in the next 5 years? 1.10% 2.25% 3.50% 4.75% Use your keypad to vote now! ? MI = myocardial infarction.

38 Clinical Outcomes in Patients With PAD Adapted from Weitz Jl. Circulation. 1996;94: PAD Patient PAD outcomes Nonfatal events (MI/stroke) 20% Mortality 30% Worsening claudication 16% Leg bypass surgery 7% Major amputation 4% Stable claudication 73% (5-year outcomes) Intermittent claudication 40% Critical leg ischemia 10% Asymptomatic 50% Cardiovascular morbidity/mortality

39 PAD and All-Cause Mortality* *Kaplan-Meier survival curves based on mortality from all causes. † Large-vessel PAD Adapted from Criqui MH et al. N Engl J Med. 1992;326: Year Survival Normal subjects Asymptomatic LV-PAD † Symptomatic LV-PAD † Severe symptomatic LV-PAD †

40 Diagnosis 2 Problems Cardiovascular Risk Leg Symptoms Claudication Rest Pain Tissue Loss Treatment

41 Cardiovascular Risk  Stop smoking  Program  Toes vs cigarettes  Blood pressure control  140/90 mm Hg  130/80 mm Hg if patient has diabetes or renal disease  Lipid control  LDL <100 mg/dL  Diabetes control  HbA 1 C <7%  Antiplatelet medication Treatment Hirsch A et al. J Am Coll Cardiol, 2006;47:

42 Antiplatelet Medications  Aspirin

43 Key Question What is the proper daily dose of aspirin for cardiovascular risk reduction? mg mg mg mg Use your keypad to vote now! ?

44  Aspirin 81 mg/d Antiplatelet Medications

45 Aspirin Dosage OR = odds ratio. Antithrombotic Trialists’ Collaboration. BMJ. 2002;324: mg mg mg <75 mg 3 13 Any aspirin Antiplatelet BetterAntiplatelet Worse Aspirin Dose No. Trials OR (%) OR Antiplatelet Medications

46 Aspirin Dosage: Risk of Major Bleeding Placebo + Aspirin Clopidogrel + Aspirin <100 mg 3.0% 1.9% mg 3.4% 2.8% >200 mg 4.9% 3.7% Aspirin Dose CURE Trial. Circulation. 2003;108: Antiplatelet Medications

47  Aspirin  81 mg  Clopidogrel  75 mg Antiplatelet Medications

48 8.7% Overall RRR (P =.045)* Months of Follow-up Cumulative Event Rate (%) Clopidogrel ASA Median follow-up = 1.91 years 5.32% 5.83% Subjects had a recent MI, recent ischemic stroke, or symptomatic PAD (N = 19,185) *ITT analysis ASA= aspirin; CAPRIE = Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events; RRR = relative risk reduction. CAPRIE Steering Committee. Lancet. 1996;348: CAPRIE Clopidogrel vs ASA: MI, Ischemic Stroke, or Vascular Death

49 Subgroup Analysis CAPRIE Steering Committee. Lancet. 1996;348: Risk Reduction (%) ASA BetterClopidogrel Better Patient with stroke6431 Patient with MI6302 Patient with PAD6452 All patients19,185 No. Patients CAPRIE

50 Leg Problems  Asymptomatic  No specific treatment  Claudication  Do nothing PAD Treatment

51 Clinical Outcomes in Patients With PAD Adapted from Weitz Jl. Circulation. 1996;94: PAD Patient Cardiovascular morbidity/mortality Worsening claudication 16% Leg bypass surgery 7% Major amputation 4% Nonfatal events (MI/stroke) 20% Mortality 30% Critical leg ischemia 10% Asymptomatic 50% Stable claudication 73% (5-year outcomes) Intermittent claudication 40% PAD outcomes

52 Leg Problems  Asymptomatic  Claudication  Do nothing  Walking program  Best are supervised –Few programs available –Rarely reimbursable by insurance Most patients must do their own PAD Treatment

53 Walking Program  Regular  At least 5×/week  Length  min/d  Typical results  Doubling of walking distance each year  Excuses  Pain, hills, cold, heat, rain, etc. Claudication Treatment

54 Walking Program  Additional benefits  Good for Heart Lungs Weight loss Muscles  See your neighborhood  See new areas  Their dog will love it (if they have one) Claudication Treatment

55 Walking Program  Avoid negative walking programs  Disability parking  Wheelchairs  Motorized carts Claudication Treatment

56 Walking Program The Best Treatment, But Requires the Patient’s Commitment Claudication Treatment

57 Leg Problems  Asymptomatic  Claudication  Walking program  Drugs: pentoxifylline; cilostazol PAD Treatment

58 Cilostazol  Not a cure  Average benefit  65% increase in maximum walking distance at 6 months  Results not immediate  Exact mechanism unknown  Common side effects  Headache, diarrhea, ankle swelling, palpitations  Contraindicated in patients with a history of congestive heart failure  Reduce dosage indicated with some concomitant medications, eg, omeprazole, diltiazem PAD Treatment

59  Asymptomatic  Claudication  Walking program  Drugs: pentoxifylline; cilostazol  Invasive: angioplasty/stenting; surgery Leg Problems PAD Treatment

60 My Approach/Recommendations  Claudication  Walking program  Drug(s): cilostazol  Invasive: angioplasty/stenting; surgery

61 Leg Problems  Asymptomatic  Claudication  Ischemic rest pain  Refer  Nonhealing wounds/ulcers/tissue loss  Refer PAD Treatment

62 Critical Limb Ischemia  These patients need revascularization  Angioplasty/stenting  Surgery  If revascularization is not possible  May need amputation PAD Treatment

63 Case Study

64 Patient Case Study  Patient’s first visit to your practice because he is new to your area  58-year-old, male  Occupation: “In sales”  Complaint: “My leg hurts.”  History of present illness  6-month history of right calf pain with walking Pain begins at ~60 yards; patient has to stop at ~100 yards Pain goes away within 1 minute of stopping and standing No pain at rest

65 Patient Case Study  Medical history  Not on any medications  Once told his blood pressure was “a little high”  Doesn’t know his cholesterol or diabetes status  Has only sought medical care for acute problems in the past  Smoking history  Smokes 1-2 packs/d × 35 years

66 Patient Case Study  Positive physical findings  Right arm systolic blood pressure: 160 mm Hg  Left arm systolic blood pressure: 152 mm Hg  Left carotid bruit  Absent right popliteal, PT, dorsalis pedis pulses  Right PT pressure: 80 mm Hg  Right AT pressure: 66 mm Hg  Left PT pressure: 135 mm Hg  Left AT pressure:140 mm Hg AT = anterior tibial; PT = posterior tibial.

67 Patient Case Study  Right ABI = 80/160 = 0.50  Left ABI = 140/160 = 0.88  Has abnormal ABIs: both legs  Only has symptoms in his right leg

68 Decision Point What etiology might account for unilateral claudication? 1. Vascular disease limited to one leg 2. Bilateral vascular disease worse in one leg causing symptoms to appear earlier in one leg than another 3. Peripheral neuropathy due to diabetes Use your keypad to vote now! ?

69 Patient Case Study  You tell the patient he has:  PAD A serious disease –It is the cause of his walking problem –It is also a marker for the systemic disease atherosclerosis and he is at risk for heart attack or stroke  Probable hypertension

70 Decision Point What test(s) would you consider now? 1. Lipid, glucose, repeat ABI 2. Lipid, glucose, segmental pressures 3. Lipid, glucose, carotid duplex, and repeat blood pressure 4. Segmental pressures Use your keypad to vote now! ?

71 Patient Case Study  He needs further evaluation  Repeat blood pressure checks  Blood tests: lipid panel, glucose  Carotid duplex  He needs treatment for his cardiovascular risks

72 Patient Case Study  Treatment for his cardiovascular risks  Stop smoking: teach him how or refer  Probable blood pressure control  Lipids?  Diabetes?  Antiplatelet therapy

73 Patient Case Study  He says:  “I hear you. I know those things are important, but I came in here for this right calf pain I get with walking. What can we do about that? I had a neighbor who had ‘the balloon treatment’ and he was cured.”  You may be thinking:  “I’m trying to save his life.”  But unless you address his claudication, he may not come back and give you the chance You may need to address the claudication first

74 Patient Case Study  You describe the treatment options  Walking program  Drug(s): cilostazol  Invasive: angioplasty/stenting; surgery

75 Q & A

76 PCE Takeaways

77  PAD is a common disease  PAD is a serious disease  A marker for the systemic disease atherosclerosis  Diagnosis usually is not difficult  Management usually is straightforward

78 Key Question Will you use ABI testing to diagnose patients at risk for PAD? 1. Not likely 2. Somewhat likely 3. Very likely 4. Extremely likely Use your keypad to vote now! ?


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