Presentation on theme: "Advances in the Medical Management of Peripheral Arterial Disease"— Presentation transcript:
1Advances in the Medical Management of Peripheral Arterial Disease Warner P. Bundens, MD, MSAssociate Clinical Professor of SurgeryAssociate Clinical Professor of Family and Preventive MedicineSchool of MedicineUniversity of California, San DiegoLa Jolla, California
2? Key Question How many of your patients with CV risk do you test for peripheral arterial disease?0%-24%25%-50%51%-75%76%-100%Use your keypad to vote now!
4Learning Objectives Describe the prevalence and disease burden of PAD State medical treatments for improving leg symptoms of the patient with PADDiscuss interventions used to prevent systemic complications in the patient with PADPAD = peripheral arterial disease.
5Peripheral Arterial Disease: What Is It? PADPAODPAOD = peripheral arterial obstructive disease.
25Office Measurement of the Ankle-Brachial Index (ABI) SupinePatientRight arm pressureLeft arm pressureOffice Measurement of the ABIThe ankle–brachial index (or ABI) is the ratio of systolic blood pressure in the ankle to systolic blood pressure in the arm. This measurement tool permits clinicians to both objectively detect PAD and assess its severity. The ABI is a simple, inexpensive, and reliable indicator of limb perfusion, and can be done in the office. It requires a 5-7 MHz Doppler ultrasound probe rather than a stethoscope to ensure accuracy and facilitate measurement of the ankle blood pressure.ABI measurements should be performed during the examination of any patient who is considered to be at risk for PAD or who complains of exertional leg pain. The measurement is made by using the Doppler device to identify appropriate arteries. Using a standard BP cuff, the systolic pressure is taken in both ankles at the dorsalis pedis (DP) and posterior tibial (PT) arteries and at the brachial arteries in both arms.Pressure:Posterior tibialAnterior tibialPressure:Posterior tibial Anterior tibial
26Ankle PressurePatient Must Be SupinePosterior Tibial Anterior Tibial
27Ankle Systolic Pressure Brachial Artery Systolic Pressure The ABIAnkle Systolic PressureBrachial Artery Systolic PressureABI =Both ankle and brachial systolic pressures should be taken using a hand-held Doppler instrumentFor arm and leg, use higher of 2 pressuresUnderstanding the ABIThe ABI is considered the “gold standard” for determining the presence of PAD and assessing its severity. It is determined by dividing the higher of the two systolic blood pressures at each ankle by the higher of the two systolic blood pressures in each arm. The ankle pressures may be obtained over either the dorsalis pedis or the posterior tibial artery.The ABI boasts a 95% sensitivity and 99% specificity for diagnosing PAD. Indeed, the Doppler ankle systolic pressure has been shown to correlate closely with direct intraarterial recordings. For this reason, the ABI is considered the most useful noninvasive test available for epidemiologic studies of PAD. It should be remembered, however, that the ABI assesses PAD, not intermittent claudication.
28The ABI Right Arm 150 mm Hg Right AT 68 Right PT 75 Left Arm 143 Left ATLeft PTRight ABI = 75/150 = 0.50Left ABI = 120/150 = 0.80AT = anterior tibial; PT = posterior tibial.
29What Do the Numbers Mean? ABITypical valuesNormal =Claudication =Rest pain = <0.4Tissue loss = <0.3
30? ABI <0.90 95% Sensitive and 99% Specific for PAD TASC Working Group. J Vasc Surg. 2000;31(1 suppl):S1-S296.
31ABI: Occasional “Gray” Areas Most of these people have PADABI >1.0Most of these people do not have PAD
32ABI WorkshopsDemonstrations available throughout the day
33Further Noninvasive Testing Segmental pressuresDoppler waveformsExercise test
34Lower Extremity Arterial Exam Further TestingLower Extremity Arterial Exam
35Relative 5-Year Mortality Rates PAD Is a Bad DiseaseRelative 5-Year Mortality Rates*American Cancer Society. Cancer Facts and Figures, 2000.Criqui MH et al. N Engl J Med. 1992;326:
37? Key Question Without intervention, what percentage of PAD patients will have an MI or stroke inthe next 5 years?10%25%50%75%Use your keypad to vote now!MI = myocardial infarction.
38Clinical Outcomes in Patients With PAD PAD PatientAsymptomatic50%Intermittent claudication40%Critical leg ischemia10%Cardiovascularmorbidity/mortalityPAD outcomes(5-year outcomes)Clinical Outcomes in Patients with PADAlthough PAD follows the same course in patients with vascular disease as it does in the general population, the percentage of affected individuals is higher. As noted here, half of all affected patients >55 years old are asymptomatic, whereas 40% experience intermittent claudication and 10% have critical leg ischemia. Five years after diagnosis, nearly three quarters of all claudicants remain symptomatically stable. A much smaller percentage (16%) experience worsening symptoms, and in 11% the situation deteriorates to the point where bypass surgery or amputation is needed.While PAD itself is not generally life-threatening, there is a high associated morbidity and mortality from CVD and cerebrovascular disease. Five years after diagnosis, 20% of affected persons will have had a nonfatal stroke or MI and another 20% to 30% will have died from such events.Stable claudication 73%Worsening claudication 16%Leg bypass surgery7%Major amputation 4%Nonfatal events(MI/stroke)20%Mortality 30%Adapted from Weitz Jl. Circulation. 1996;94:
39PAD and All-Cause Mortality* 1.00Normal subjects Asymptomatic LV-PAD† Symptomatic LV-PAD† Severe symptomatic LV-PAD†0.75Survival0.500.250.0024681012Year*Kaplan-Meier survival curves based on mortality from all causes.†Large-vessel PADAdapted from Criqui MH et al. N Engl J Med. 1992;326:
40Diagnosis Treatment 2 Problems Cardiovascular Leg Symptoms Risk ClaudicationRest PainTissue Loss
41Cardiovascular Risk Treatment Stop smoking Program Toes vs cigarettes Blood pressure control140/90 mm Hg130/80 mm Hg if patient has diabetes or renal diseaseLipid controlLDL <100 mg/dLDiabetes controlHbA1C <7%Antiplatelet medicationHirsch A et al. J Am Coll Cardiol, 2006;47:
48CAPRIE Clopidogrel vs ASA: MI, Ischemic Stroke, or Vascular Death 168.7%Overall RRR(P = .045)*ClopidogrelASA5.83%125.32%(N = 19,185)8Cumulative Event Rate (%)Subjects had a recent MI, recent ischemic stroke, or symptomatic PAD4The primary outcome analysis in CAPRIE was based on the composite end point of MI, ischemic stroke, or vascular death among all randomized patients (intent-to-treat analysis). Only the first occurrence of these outcomes was counted. The total number of patients randomized was 9,599 for clopidogrel bisulfate and 9,586 for aspirin.Results from the CAPRIE trial demonstrated that clopidogrel had a lower event rate per year compared with aspirin, 5.32% vs 5.83%, respectively, which resulted in an overall risk reduction of 8.7% (P=0.045) vs aspirin. An on-treatment analysis of the primary event cluster showed a relative risk reduction of 9.4% (P=0.046).Although the statistical significance favoring clopidogrel bisulfate (Plavix®) over aspirin was marginal (P=0.045, based on overall incidence of primary outcome events: 9.78% for clopidogrel vs 10.64% for aspirin), and represents the result of a single trial that has not been replicated, the comparator drug, aspirin, is itself effective (vs placebo) in reducing cardiovascular events in patients with recent MI or stroke. Thus, the difference between clopidogrel and placebo, although not measured directly, is substantial.The cumulative risk curves separated early and continued to diverge during the 3-year follow-up period.CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:Plavix® (clopidogrel bisulfate) Prescribing Information. Sanofi-Synthelabo Inc.Data on file, Sanofi-Synthelabo Inc.369121518212427303336Months of Follow-upMedian follow-up = 1.91 years*ITT analysisASA= aspirin; CAPRIE = Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events;RRR = relative risk reduction.CAPRIE Steering Committee. Lancet. 1996;348:
49Subgroup Analysis CAPRIE No. Patients Patient with stroke 6431 Patient with MI 6302Patient with PAD 6452All patients 19,185CAPRIE=clopidogrel vs. ASA in patients at risk of ischemic events. Subgroup analysis.75 mg clopidogrel vs. 325 ASA. Entry –recent MI, stroke, or PAD. Endpoint MI, stroke, or other vascular death.-40-30-20-1010203040ASA BetterClopidogrel BetterRisk Reduction (%)CAPRIE Steering Committee. Lancet. 1996;348:
50Leg Problems Asymptomatic No specific treatment Claudication PAD TreatmentLeg ProblemsAsymptomaticNo specific treatmentClaudicationDo nothing
51Clinical Outcomes in Patients With PAD PAD PatientAsymptomatic50%Intermittent claudication40%Critical leg ischemia10%PAD outcomesCardiovascularmorbidity/mortality(5-year outcomes)Clinical Outcomes in Patients with PADAlthough PAD follows the same course in patients with vascular disease as it does in the general population, the percentage of affected individuals is higher. As noted here, half of all affected patients >55 years old are asymptomatic, whereas 40% experience intermittent claudication and 10% have critical leg ischemia. Five years after diagnosis, nearly three quarters of all claudicants remain symptomatically stable. A much smaller percentage (16%) experience worsening symptoms, and in 11% the situation deteriorates to the point where bypass surgery or amputation is needed.While PAD itself is not generally life-threatening, there is a high associated morbidity and mortality from CVD and cerebrovascular disease. Five years after diagnosis, 20% of affected persons will have had a nonfatal stroke or MI and another 20% to 30% will have died from such events.Nonfatal events(MI/stroke)20%Mortality 30%Stable claudication 73%Worsening claudication 16%Leg bypass surgery7%Major amputation 4%Adapted from Weitz Jl. Circulation. 1996;94:
52Leg Problems Asymptomatic Claudication Do nothing Walking program PAD TreatmentLeg ProblemsAsymptomaticClaudicationDo nothingWalking programBest are supervisedFew programs availableRarely reimbursable by insuranceMost patients must do their own
53Walking Program Regular At least 5×/week Length 40-60 min/d Claudication TreatmentWalking ProgramRegularAt least 5×/weekLength40-60 min/dTypical resultsDoubling of walking distance each yearExcusesPain, hills, cold, heat, rain, etc.
54Walking Program Additional benefits Good for Heart Lungs Weight loss Claudication TreatmentWalking ProgramAdditional benefitsGood forHeartLungsWeight lossMusclesSee your neighborhoodSee new areasTheir dog will love it (if they have one)
56The Best Treatment, But Requires the Patient’s Commitment Claudication TreatmentWalking ProgramThe Best Treatment, But Requires the Patient’s Commitment
57Leg Problems Asymptomatic Claudication Walking program PAD TreatmentLeg ProblemsAsymptomaticClaudicationWalking programDrugs: pentoxifylline; cilostazol
58Cilostazol PAD Treatment Not a cure Average benefit 65% increase in maximum walking distance at 6 monthsResults not immediateExact mechanism unknownCommon side effectsHeadache, diarrhea, ankle swelling, palpitationsContraindicated in patients with a history of congestive heart failureReduce dosage indicated with some concomitant medications, eg, omeprazole, diltiazem
59Leg Problems PAD Treatment Asymptomatic Claudication Walking program Drugs: pentoxifylline; cilostazolInvasive: angioplasty/stenting; surgery
60My Approach/Recommendations ClaudicationWalking programDrug(s): cilostazolInvasive: angioplasty/stenting; surgery
61Leg Problems Asymptomatic Claudication Ischemic rest pain Refer PAD TreatmentLeg ProblemsAsymptomaticClaudicationIschemic rest painReferNonhealing wounds/ulcers/tissue loss
62Critical Limb Ischemia PAD TreatmentCritical Limb IschemiaThese patients need revascularizationAngioplasty/stentingSurgeryIf revascularization is not possibleMay need amputation
64Patient Case StudyPatient’s first visit to your practice because he is new to your area58-year-old, maleOccupation: “In sales”Complaint: “My leg hurts.”History of present illness6-month history of right calf pain with walkingPain begins at ~60 yards; patient has to stop at ~100 yardsPain goes away within 1 minute of stopping and standingNo pain at rest
65Patient Case Study Medical history Not on any medications Once told his blood pressure was “a little high”Doesn’t know his cholesterol or diabetes statusHas only sought medical care for acute problems in the pastSmoking historySmokes 1-2 packs/d × 35 years
66Patient Case Study Positive physical findings Right arm systolic blood pressure: 160 mm HgLeft arm systolic blood pressure: 152 mm HgLeft carotid bruitAbsent right popliteal, PT, dorsalis pedis pulsesRight PT pressure: 80 mm HgRight AT pressure: 66 mm HgLeft PT pressure: 135 mm HgLeft AT pressure:140 mm HgAT = anterior tibial; PT = posterior tibial.
67Patient Case Study Right ABI = 80/160 = 0.50 Left ABI = 140/160 = 0.88 Has abnormal ABIs: both legsOnly has symptoms in his right leg
68? Decision Point What etiology might account for unilateral claudication?Vascular disease limited to one legBilateral vascular disease worse in one leg causing symptoms to appear earlier in one leg than anotherPeripheral neuropathy due to diabetesUse your keypad to vote now!
69Patient Case Study You tell the patient he has: PAD A serious disease It is the cause of his walking problemIt is also a marker for the systemic disease atherosclerosis and he is at risk for heart attack or strokeProbable hypertension
70? Decision Point What test(s) would you consider now? Lipid, glucose, repeat ABILipid, glucose, segmental pressuresLipid, glucose, carotid duplex, and repeat blood pressureSegmental pressuresUse your keypad to vote now!
71Patient Case Study He needs further evaluation Repeat blood pressure checksBlood tests: lipid panel, glucoseCarotid duplexHe needs treatment for his cardiovascular risks
72Patient Case Study Treatment for his cardiovascular risks Stop smoking: teach him how or referProbable blood pressure controlLipids?Diabetes?Antiplatelet therapy
73Patient 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 chanceYou may need to address the claudication first
74Patient Case Study You describe the treatment options Walking program Drug(s): cilostazolInvasive: angioplasty/stenting; surgery