1. Peripheral Arterial Disease
Physicians Awareness Program
Recommendations from the 2006 Trans-Atlantic Inter-Society (TASC) Guidelines for the Management of Peripheral Arterial Disease (PAD)

3. Objectives
Increase the awareness of physicians (general practitioners, internists, cardiologists, and vascular surgeons) in Saudi Arabia about PAD
Educate physicians about the importance of risk reduction therapies, in order to close the care, knowledge and action gaps.

4. Agenda Part I: Overview of Disease Atherothrombosis Epidemiology
Management
Part II: Guidelines
CV Risk Factor Reduction
( AHA/ACC, TASC II)
Part I: Overview of Disease
Atherothrombosis
Epidemiology
REACH Registry Overview
Part II: TASC II Guidelines and Clopidogrel Data
CV Risk Factor Reduction and Anti-platelet Therapy Recommendations
CAPRIE (& CAPRIE Sub-studies)

5. Part I – Overview of Disease
Part I – Overview of Diseases

6. What is Atherosclerosis?
Clogging, narrowing, and hardening of large and medium-sized arteries

7. What are the risk factors for Atherosclerosis?
Non-Modifiable Risk Factors:
Male gender
Advanced age
Family history
Modifiable Risk Factors:
Major
Smoking
Hypertension
Diabetes
Hyperlipidemia
Minor
Homocystenemia
Obesity
Hypercoaguable state
Physical inactivity

8. Pathophysiology of Atherothrombosis
MSL PAD Guidelines_B1-X0475_04.06
Pathophysiology of Atherothrombosis
Atherosclerosis +
Thrombus Formation
Rupture of Fibrous Cap
Smooth muscle cell progression,
plaque progression
Munger. J Am Pharm Assoc. Mar-Apr.2004/ p37/fig 1, c1/lines 13-18,c2/lines 1-7
Inflammation
Accumulation
of lipids
Libby.Circulation. Jun.2005/p3484/ c1/fig 3
Normal artery
Erosion of Endothelium
Erosion of Calcium Nodule
Atherothrombosis is a generalized and diffuse progressive process affecting multiple vascular beds. It is a condition that occurs when a thrombus forms over an unstable atherosclerotic plaque. Its clinical consequences include acute coronary syndrome (ACS*), ischemic stroke, and peripheral arterial disease.[1]
Atherosclerotic plaque initiation is aggravated by various cardiovascular risk factors and characterized by an accumulation of lipids and lipoproteins. The accumulation of lipids and lipoproteins contributes to oxidative stress which stimulates inflammatory factors, attracting inflammatory cells.[1]
Atherosclerotic plaque growth depends on several factors, including smooth muscle cell migration and division as well as extracellular matrix deposition. Migration of smooth muscle cells from the media into the layers of the arterial wall is facilitated by chemoattractants, primarily platelet-derived growth factor (PDGF) secreted from activated macrophages. Smooth muscle cells can also divide, contributing to the growth of the plaque. Smooth muscle cells also appear to undergo programmed cell death or apoptosis, possibly in response to inflammatory cytokines or T lymphocytes. Plaque evolution is a dynamic process, with the rate of plaque growth determined by the balance between smooth muscle cell proliferation and removal.[1]
Atherosclerosis can lead to any number of four possible types of thrombus formation. Rupture of fibrous cap causes approximately two thirds to three quarters of fatal coronary thromboses. Superficial erosion occurs in one fifth to one quarter of all cases of fatal coronary thromboses. Erosion of calcium nodule may also cause plaque disruption and thrombosis. In addition, friable microvessels in base of atherosclerotic plaque may rupture and cause intraplaque hemorrhage.[2]
Munger.J Am Pharm Assoc.Mar-Apr.2004/pS5/lines A11-A15, pS6/c1/ lines 1-2
Munger.J Am Pharm Assoc.Mar-Apr.2004/ p56/c2/ lines 19-30
Atherosclerosis leads to any number of four possible types of thrombus formation
Intraplaque Hemorrhage
Munger.J Am Pharm Assoc.Mar-Apr.2004/pS7/c1/ lines 13-18, c2/ lines 1-7
Munger MA et al. J Am Pharm Assoc. 2004;44(suppl 1):S5-S13.
Libby P et al. Circulation. 2005;111:
Libby.Circulation. Jun.2005/p3484/ c1/fig 3
* UA/non–Q-wave MI (also known as non–ST-segment elevation myocardial infarction).
Munger MA, Hawkins DW. Atherothrombosis: epidemiology, pathophysiology, and prevention. J Am Pharm Assoc. 2004;44(suppl 1):S5-S13.
Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation. 2005;111:

9. Clinical Spectrum of Atherosclerosis Intermittent claudication
Cerebrovascular disease
Coronary artery disease
Renal artery Diseases
Visceral arterial disease
Peripheral arterial disease
Intermittent claudication
Critical limb ischemia

10. Atherothrombosis: Can Manifest in Multiple Vascular Beds
MSL PAD Guidelines_B1-X0475_04.06
Atherothrombosis is a process that includes the following clinical consequences:
Ischemic stroke, MI, and PAD
Munger. J Am Pharm Assoc.Mar-Apr.2004/pS6/c1/ lines 1-2, c1/lines 8-12
Patients with atherothrombosis have thrombus formations that can manifest in multiple vascular beds throughout the body
Atherothrombosis is a generalized and diffuse progressive process that can manifest in multiple vascular beds. It is a condition that occurs when a thrombus forms over an unstable atherosclerotic plaque. The clinical consequences of atherothrombosis include ischemic stroke, MI, and peripheral arterial disease.
Munger. J Am Pharm Assoc.Mar-Apr.2004/pS6/c1/ lines 1-2, c1/lines 8-12
Munger MA et al. J Am Pharm Assoc. 2004;44(suppl 1):S5-S13.
Munger MA, Hawkins DW. Atherothrombosis: epidemiology, pathophysiology and prevention. J Am Pharm Assoc. 2004;44(suppl 1):S5-S13.

11. Atherothrombosis as a Cause of Death “Burden of the disease”
Speaker Training Webcast – 10/06
According to the World Health Organization in 2004 atherothrombosis* was the leading cause of death worldwide—more than AIDS and cancer combined1,2
Bakhai.Pharma coeconomics. 2004/p12/c1/ lines 21-27/fig 1
Mortality (%)
According to the World Health Organization, in 2004 atherothrombosis was the leading cause of death worldwide. Twenty-two percent of all deaths were attributed to atherothrombosis*, which was greater than the percentage of deaths from AIDS and cancer combined.[1,2]
Bakhai.Pharma coeconomics. 2004/p12/c1/ lines 21-27/fig 1
Athero- thrombosis
Infectious Disease
Cancer
Injuries
Pulmonary Disease
AIDS
* Only includes ischemic heart disease and cerebrovascular disease.
Bakhai A. Pharmacoeconomics. 2004;22(suppl 4):11-18.
World Health Organization Report Available at: Accessed January 29, 2007.
* Only includes ischemic heart disease and cerebrovascular disease.
Bakhai A. The burden of coronary, cerebrovascular and peripheral arterial disease. Pharmacoeconomics. 2004;22(suppl 4):11-18.
World Health Organization. The World Health Organization Report Available at: Accessed January 29, 2007.

12. Let’s Talk about PAD
Epidemiology

13. How do patients with PAD present?
Symptomatic
Intermittent claudication
Critical Limb Ischemia
Pain at rest
Tissue loss
Gangrene
Asymptomatic

14. How do patients with PAD present?

15. How do patients with PAD present?
Symptomatic
10%
Asymptomatic
90%

16. Ankle Brachial Index

17. Calculating the Ankle-Brachial Index
PAD Guidelines ODTC_USA.CLO _B1-X0456_04.06
Calculating the Ankle-Brachial Index
Right leg ABI
Left leg ABI
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS26/Fig C2
Higher right ankle pressure (dorsalis pedis or posterior tibial pulse)
Higher arm pressure
(of either arm) =
Higher left ankle pressure (dorsalis pedis or posterior tibial pulse)
Higher arm pressure
(of either arm) =
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS25/c2 lines 47-48
To find the right leg ABI, divide the higher right ankle pressure (DP or PT) by the higher arm blood pressure (either arm). To find the left leg ABI, divide the higher left ankle pressure (DP or PT pulse) by the higher arm pressure (either arm).
An ABI of ≤0.90 is diagnostic of PAD.
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS25/ c2 lines 47-48
ABI Interpretation
≤0.90 is diagnostic of peripheral arterial disease
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

18. Role of ABI in PAD Confirms the diagnosis of PAD
NEW
Role of ABI in PAD
Confirms the diagnosis of PAD
Detects significant PAD in (sedentary) asymptomatic patients
Used in the differential diagnosis of leg symptoms to identify a vascular etiology
Identifies patients with reduced limb function (inability to walk defined distances or at usual walking speed)
Provides key information on long-term prognosis
A 3–6-fold increased risk of CV mortality with an ABI <0.90
Provides further risk stratification
A lower ABI indicating worse prognosis
A Framingham risk score between 10%–20%
Highly associated with coronary and cerebral artery disease
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS26/c2/ lines 50-53,pS26/ c1/lines 1-12
Role of ABI in PAD
Confirms the diagnosis of PAD
Detects significant PAD in (sedentary) asymptomatic patients
Used in the differential diagnosis of leg symptoms to identify a vascular etiology
Identifies patients with reduced limb function (inability to walk defined distances or at usual walking speed)
Provides key information on long-term prognosis
A 3–6-fold increased risk of CV mortality with an ABI ≤0.90
Provides further risk stratification
A lower ABI indicating worse prognosis
A Framingham risk score between 10%–20%
Highly associated with coronary and cerebral artery disease
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS26/c2/ lines 50-53,pS26/ c1/lines 1-12
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

19. Epidemiology of PAD
Epidemiology

20. Age >70, or between 50–69 with history of diabetes or smoking
NEW – Adapted from PAD A Call to Action_USA.CLO _B1-X0318_11.05
Prevalence of PAD
Diehm.Athero sclerosis.Jul.2004/ p99/table 3
Hirsch.JAMA.Sep.2001/p1317/line A20
Selvin.Circulation.Aug.2004/p738/ lines A6-A8
Meijer.Arterio scler Thromb Vasc Biol.Feb.1998/ p188/c2/lines 9-11
US Data
European Data
Saudi Data
Criqui.Circulation. Mar.1985/p510/ lines A5-A7
Meijer.Arterio scler Thromb Vasc Biol.Feb.1998/ p188/c2/lines 9-11
Rotterdam included patients over the age of 55 and found a PAD prevalence of 19.1%.[1]
As part of the German Epidemiological Trial on Ankle Brachial Index (the getABI study), Diehm and colleagues studied patients age 65 and older and found an age-adjusted PAD prevalence of 19.8%.[2]
The National Health and Nutrition Survey (NHANES) found the prevalence of PAD among patients aged 40 years and over in the US was 4.3% [3]; for patients age 70 or older, the prevalence of PAD was 14.5%. [3]
San Diego included patients over the age of 60 and found a PAD prevalence of 11.7%.[4]
The PARTNERS program, conducted by Alan Hirsch and colleagues, included high-risk patients either over the age of 70, or between 50 to 69 with diabetes or a history of smoking. When common risk factors were included in the population, the prevalence of PAD was approximately one third of patients.[5]
Pilot study at KKUH of 471 patients over the age of 45 years using ABI and modified Rosi questionnaire, mean age 57 years [6]
Diehm.Athero sclerosis.Jul.2004/ p99/table 3
Diehm.Athero sclerosis.Jul.2004/ p99/table 3
Diehm2
Age ≥65
Rotterdam1
Age >55
Pilot Study6
Age >45
NHANES3
Age >40
San Diego4
Mean Age=66
NHANES3
Age ≥70
PARTNERS5
Age >70, or between 50–69 with history of diabetes or smoking
Criqui.Circulation. Mar.1985/p510/ lines A5-A7
Prevalence was estimated using different methods
Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:
Diehm C et al. Atherosclerosis. 2004;172:
3. Selvin E et al. NHANES. Circulation. 2004;110:
4. Criqui MH et al. Circulation. 1985;71:
5. Hirsch AT et al. JAMA. 2001;286:
Hirsch.JAMA.Sep. 2001/p1318/c2/ lines 1-8
6. Alshaekh et al. SMJ. 2007;28:
Meijer WT, Hoes AW, Rutgers D, Bots ML, Hofman A, Grobbee DE. Peripheral arterial disease in the elderly: the Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998;18:
Diehm C, Schuster A, Allenberg JR, et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis. 2004;172:
Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the national health and nutrition survey, Circulation. 2004;110:
Criqui MH, Fronek A, Barrett-Connor E, Klauber MR, Gabriel S, Goodman D. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71:
Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:

21. Why it is important to recognize patients with PAD?
PAD is a marker of systemic atherosclerosis
Patients with either symptomatic or asymptomatic PAD generally have widespread arterial disease

22. Peripheral Arterial Disease: Prevalence of Polyvascular disease
MSL PAD Guidelines_B1-X0475_04.06
Peripheral Arterial Disease: Prevalence of Polyvascular disease
The REACH Registry found overlapping manifestations of disease in patients with CAD, CVD, and PAD
Bhatt.JAMA.Jan. 2006/p184/fig 2
The REACH Registry is an international prospective observational registry with up to a 24-month follow-up. More than 69,000 patients with established coronary artery disease (CAD), cerebrovascular disease (CVD), or peripheral arterial disease (PAD), or those with at least three risk factors for atherothrombosis, were enrolled consecutively over 7 months, from December 2003 to June 2004, at over 5,000 sites in 44 countries in seven regions worldwide.
While over 69,000 patients were enrolled in the REACH Registry, baseline data were available for 67,888 patients. This slide depicts the patients entered into the REACH Registry who were symptomatic, including patients with CAD, PAD, and CVD. This does not include the 18.3% of patients in the REACH Registry who were included based on risk factors.
Bhatt.JAMA.Jan. 2006/p181/c1/ lines 25-34/p182/ c2/lines 11-12
18.3% of patients in the REACH Registry did not have manifestations of atherothrombosis, but were included based on risk factors
sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.
The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.
Bhatt DL et al. JAMA. 2006;295:
sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.
The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.
Bhatt DL, Steg GP, Ohman EM, et al for the REACH Registry Investigators. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295:

23. Long term Risk of MI & Stroke
PAD places individuals at high short term risk of
MI, Stroke & Death

24. Survival of Patients With PAD
New
Survival of Patients With PAD
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS14/c1/lines 29-32
Life expectancy reduced
10 years in patients with PAD
Mortality rate
~ 25% at 5 years
~ 50% at 10 years
~ 75% at 15 years
Survival (%)
Follow-up (years)
Controls IC
CLI 5 10 15 20 40 60 80
100
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS14/fig A8
This figure shows the survival of patients with varying degrees of PAD.
Patients with PAD typically have multiple cardiovascular risk factors, which place them at increased risk for cardiovascular events. For example, CAD (coronary artery disease) is the most common cause of death among patients with PAD (40%-60%).
The increased risk of cardiovascular events in patients with PAD correlates to the severity of the disease in the legs.
For claudicant patients, the mortality rate is, on average, 2.5-times higher than that of the age-matched, non-claudicant control population.
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS14/c1/lines 11-14
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS14/c1/lines 29-32,c2/lines 2-7
CLI=critical limb ischemia.
IC=intermittent claudication.
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

25. Natural History Annual risk : - Mortality 6.8% - MI 2.0%
- Intervention 1.0%
- Amputation 0.4%
Ouriel K, Lancet 2001; 358:

26. Patients with PAD experienced high CV mortality
REACH Registry
Major Adverse Cardiac Events in Symptomatic Patients With CAD, CVD, or PAD at 1 Year
MSL PAD Guidelines_B1-X0475_04.06
Patients with PAD experienced high CV mortality
Steg.REACH.ACC.AtlantaGa [Presentation]/p17
Steg.REACH.ACC. AtlantaGa [Presentation]/p11
% of Patients
The REACH Registry examined symptomatic patients with CAD, CVD, or PAD for major adverse cardiac events (MACE). After 1 year of observation, patients with PAD experienced the highest rate of CV death, when compared to patients with CAD* or CVD. 3.8% of patients with CAD, 5.3% of patients with CVD, and 4.3% of patients with PAD experienced the combined end point of death, MI, or stroke, respectively.
Steg.REACH.ACC.AtlantaGa [Presentation]/p20
sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.
The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.
Rates adjusted for age and risk factors.
Steg G. Oral presentation at American College of Cardiology Available at: Accessed January 28, 2007.
sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.
The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.
Rates adjusted for age and risk factors.
Steg G. Oral presentation at American College of Cardiology Available at: Accessed January 28, 2007.
Steg.REACH.ACC. AtlantaGa [Presentation]/p11

27. Risk doubles with polyvascular disease
REACH Registry
Major End Points as a Function of Single vs Multiple and Overlapping Locations
Speaker Training Meeting – IUA – Lisbon 6/06
Risk doubles with polyvascular disease
Single Arterial Bed
Polyvascular Disease
Steg.REACH. ACC.2006/p20
Overall
CAD alone
CVD alone
PAD alone
Overall
CAD CVD + PAD
CV death
1.5
1.5
1.4
1.2
2.4
3.6
Non-fatal MI
1.2
1.4
0.5(†)
1.0
1.5
1.8
Non-fatal stroke
1.5
0.9
3.5(†)
0.6
3.1
4.0
CV death / MI/ stroke
3.4
3.1
4.5(†)
2.3
6.0
7.4
Overall, patients with polyvascular disease are at approximately twice the risk of having an atherothrombotic event compared to patients with single arterial bed involvement.
Patients with polyvascular disease and CVD are at increased risk of having a nonfatal stroke than any other single atherothrombotic event.
Patients with CVD alone are at approximately three times the risk of having a nonfatal stroke than patients with CAD alone, or PAD alone.
Patients with atherothrombotic disease in all three vascular beds are at the greatest risk of a recurrent atherothrombotic event.
CV death / MI/ stroke/ hospitalization*
12.8
13.3
10.0(†)
18.2(§)
22.0
26.9(‡)
Steg.REACH. ACC.2006/p20
† P<0.001 (ref class: CAD alone)
‡ P<0.001 (ref class: CAD + CVD)
§ P<0.001 (ref class: PAD alone)
sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.
The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.
* TIA, unstable angina, other ischemic arterial event including worsening of peripheral arterial disease.
Steg G. Oral presentation at American College of Cardiology Available at: Accessed January 28, 2007.
sanofi-aventis and Bristol-Myers Squibb provide funding for the REACH Registry.
The REACH Registry includes patients with conditions for which clopidogrel may not be indicated.
Steg G. Oral presentation at American College of Cardiology Available at: Accessed January 28, 2007.

28. Relationship Between ABI and Fatal and Non-fatal CV events
NEW
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS14/c2 lines 22-24
The lower the ABI the higher the 5-year risk of a cardiovascular event
Odds of MI, Stroke or CV death
Baseline ABI
1.4 40 35 30 25 20 15 10 5
1.2
1.0
0.8
0.6
0.4
0.2
0.0 45
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS14/fig A9
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS14/ c2 lines 8-11
Several studies have demonstrated a strong correlation between ABI, as a measurement of the severity of PAD and mortality.
In a study of patients with type 2 diabetes, the adjusted odds of a cardiovascular event by ankle-brachial index demonstrated that the lower the ABI the higher the 5-year risk for a cardiovascular event (MI, stroke, or CV death).
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS14/c2 lines 22-24
Mehler PS et al. Circulation. 2003;107:
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75
Mehler PS, Coll JRE, Estacio R, Esler A, Schrier RW, Hiatt WR. Intensive Blood Pressure Control Reduces the Risk of Cardiovascular Events in Patients With Peripheral Arterial Disease and Type 2 Diabetes. Circulation. 2003;107:
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

29. All Cause Mortality as a Function of Baseline ABI
NEW
There appears to be an inverse correlation between mortality and ABI
PAD patients with an ABI ≤0.90 are at increased risk for cardiovascular events and all cause mortality as ABI decreases
Patients with an ABI >1.40 have underlying diseases, such as diabetes, renal insufficiency or other diseases that cause vascular calcification, or the tibial vessels at the ankle to become non-compressible
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS16/Fig B2
Patients with PAD, defined as an ABI≤0.90, are known to be at high risk for cardiovascular events. According to the figure, the mortality from all causes increases as ABI decreases.
The increased risk of mortality also appears to paradoxically increase at very high ABIs. In certain patient populations (eg, those with diabetes, renal insufficiency, or other diseases that cause vascular calcification), the tibial vessels at the ankle become non-compressible and can lead to a false elevation of the ankle pressure. In these patients, alternative non-invasive diagnostic tests should be employed to evaluate the patient for PAD.
An abnormal ABI is therefore an important tool for identifying high risk populations that require management with aggressive secondary prevention measures, including antiplatelet therapy.
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS16/Fig B2
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS26/ c1/lines 15-24
<0.60
0.60– <0.70
0.70– <0.80
0.80– <0.90
0.90– <1.0
1.0– <1.10
1.40– <1.50
1.50
Incom- pressible
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS15/c1/line 34, pS16/c1/lines 1-3
Resnick HE et al. Circulation. 2004;109:733e739.
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Resnick HE, Lindsay RS, Mcdermott MM, Devereux RB, Jones KL,Fabsitz RR, et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation. 2004;109:733e739.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

30. Management of PAD
Epidemiology

31. What are the Goals of treating patients with PAD?
Relief symptoms
Improve quality of life
Limb salvage
Prolong survival

32. Strategies in treating patients with PAD
Improve Lower Limb Circulation
Risk Factors Modification

33. Improve Lower Limb Circulation
Strategies in treating patients with PAD
Improve Lower Limb Circulation
Conservative (Exercise Program)
Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Surgical Bypass

34. Diet and weight control Exercise Antiplatlets Hypertension control
Strategies in treating patients with PAD
Risk Factors Modification
Diet and weight control
Exercise
Antiplatlets
Hypertension control
Diabetes control
Lipid control
Smoking Cessation

35. Part II – Guidelines for Risk Factors Modification
Part II – TASC Guidelines and Clopidogrel Data

36. NEW
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS5/c1 lines 13-28
AHA/ACC
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS5/c1 lines 13-28
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

37. AHA/ACC format

38. Arterial Disease. J Am Coll Cardiol. 2006.
Weight Management
Goal:
Body mass index: 18.5 to 24.9 kg/m²
Waist circumference: men <40 inches
women < 35 inches I
IIa
IIb
III B
Encourage weight reduction/maintenance
Balance of physical activity, caloric intake, and formal behavioral programs
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

39. Arterial Disease. J Am Coll Cardiol. 2006.
Physical Activity
Goal:
30 minutes, 7 days per week (minimum 5 days/week)
Moderate-intensity aerobic activity
Medically supervised programs for high risk I
IIa
IIb
III B
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

40. Arterial Disease. J Am Coll Cardiol. 2006.
Smoking
Goal:
Complete Cessation
Ask about smoking
Advise to quit
Counseling
Referal to special program
Pharmacotherapy I
IIa
IIb
III B
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

41. Pharmacologic Risk Reduction Strategies
ASA and other anti-platelet agents
Hypertension Control
Lipid Control
Diabetes Control
Angiotensin Converting Enzyme Inhibitors (ACE-I)

42. Arterial Disease. J Am Coll Cardiol. 2006.
Antiplatelet Therapy
The Antithrombotic Trialists’ Collaboration involved 42 trials and 9716 patients with peripheral arterial disease.
23% reduction for adverse cardiovascular events, including myocardial infarction, stroke, or vascular death
Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

43. Overall Relative Risk Reduction2
CAPRIE
Efficacy of Clopidogrel vs Aspirin in MI, Ischemic Stroke, or Vascular Death (N=19,185)1
Speaker Training Webcast – 10/06
Median Follow-up=1.91 years
Plavix PI.Aug.2006/ p1/c2/lines 1-2
8.7%*
Aspirin
Overall Relative Risk Reduction2 16
Plavix PI.Aug.2006/ p1/c2/fig 1
Clopidogrel 12
Aspirin
Event Rate (%)
Cumulative
P=0.0452 8
Clopidogrel
Study subjects had either recent MI, recent ischemic stroke, or established peripheral arterial disease.
The 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.[1]
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%[1] (P=0.045)[2] vs aspirin. An on-treatment analysis of the primary event cluster showed a relative risk reduction of 9.4%[1] (P=0.046).[3]
Although the statistical significance favoring clopidogrel 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 recent stroke. Thus, the difference between clopidogrel and placebo, although not measured directly, is substantial.[2]
The cumulative risk curves separated early and continued to diverge during the 3-year follow-up period.[1] 4
CAPRIE.Lancet. Nov.1996/p7/ table 4
CAPRIE.Lancet. Nov.1996/p8/ table 6
Plavix PI.Aug.2006/ p1/c2/lines 1-5 3 6 9 12 15 18 21 24 27 30 33 36
Months of Follow-Up
Plavix PI.Aug.2006/ p1/c2/lines 1-7
* ITT analysis.
CAPRIE Steering Committee. Lancet. 1996;348:
Clopidogrel Prescribing Information.
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-aventis U.S. LLC.
Data on file, sanofi-aventis.

44. Outcomes by Subgroup Analysis
CAPRIE
Speaker Training Webcast – 10/06
Outcomes by Subgroup Analysis
Clopidogrel Reduced the Risk of MI/Ischemic Stroke/Cardiovascular Death in PAD Patients by 23.8%* Compared to ASA† - 4 3 2 1
PAD
All patients
Mean & 95% CI
CAPRIE.Lancet. Nov.1996/p10/c2/ fig 4
In a post hoc analysis of the subgroup of patients with peripheral arterial disease (PAD) enrolled in the CAPRIE study, the average event rate per year in the clopidogrel group was 3.71% compared with 4.86% in the aspirin group, which amounted to a 23.8% relative risk reduction in the combined primary end point of ischemic stroke, MI, or vascular death (95% CI, 0.64 to 0.92, P=0.0028). The relative risk reduction for the other subgroups were 7.3% for stroke patients (P=0.26) and 3.7% for MI patients (P=0.66). Since the CAPRIE Trial was not powered to evaluate the efficacy of individual sub-groups, it is not clear whether the differences in RRR across qualifying conditions are real or a result of chance.
Since the CAPRIE Trial was not powered to evaluate the efficacy of individual sub-groups, it is not clear whether the differences in RRR across qualifying conditions are real or a result of chance.
CAPRIE.Lancet. Nov.1996/p10/ c1/lines
Aspirin Better
Clopidogrel Better
* CAPRIE: primary combined end point (myocardial infarction, ischemic stroke, vascular death): RRR 8.7% (P=0.045) for patients with PAD, post-myocardial infarction, post-ischemic stroke. CAPRIE subgroup analysis: for PAD patients the secondary end point, myocardial infarction, was reduced by 23.8% (RRR).
† Since the CAPRIE Trial was not powered to evaluate the efficacy of individual sub-groups, it is not clear whether the differences in RRR across qualifying conditions are real or a result of chance.
CAPRIE Steering Committee. Lancet. 1996;348:
CAPRIE Steering Committee. A randomized, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:

45. Antihypertensive Therapy
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.
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

46. Lipid Lowering Therapy
Cholesterol Treatment Trialists Coolaborators Meta-analysis data from participants in 14 randomized trials of statins
21% reduction for adverse cardiovascular events, including myocardial infarction, stroke, or vascular death
(Lancet 2005; 366: )
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.
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

47. Arterial Disease. J Am Coll Cardiol. 2006.
Diabetes Therapies
Treatment of diabetes in individuals with lower extremity PAD by administration of glucose control therapies to reduce the hemoglobin A1C to less than 7% can be effective to reduce microvascular complications and potentially improve cardiovascular outcomes. I
IIa
IIb
III B
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

48. Arterial Disease. J Am Coll Cardiol. 2006.
ACE inhibitors
The HOPE study involved 9297 AS patients.
25% reduction for adverse cardiovascular events, including myocardial infarction, stroke, or vascular death
ACE inhibitors is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD. I
IIa
IIb
III B B
Adapted from : ACC/AHA Guidelines for the Management of Patients With Peripheral
Arterial Disease. J Am Coll Cardiol

49. NEW
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS5/c1 lines 13-28
TASC II
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS5/c1 lines 13-28
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

50. Goals of TASC II Update and expand the consensus statement from 2000
NEW
Goals of TASC II
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS5/c1 lines 13-28
Update and expand the consensus statement from 2000
Maintain focus on peripheral arterial disease
Make the document accessible to a wider audience
Including primary care physicians
Reduce the length of the document
Inclusion of Europe, North America, Asia, Africa, Australia
Update and expand the consensus statement from 2000
Maintain focus on peripheral arterial disease
Make the document accessible to a wider audience
Including primary care physicians
Reduce the length of the document
Inclusion of Europe, North America, Asia, Africa, Australia
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS5/c1 lines 13-28
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

51. TASC II Participating Societies
NEW
TASC II Participating Societies
American College of Cardiology
American Diabetes Association
American Podiatric Medical Association
Canadian Society for Vascular Surgeons
Cardiovascular and Interventional Radiology Society of Europe
CoCaLis collaboration
European Society for Vascular Surgery
International Diabetes Federation
International Union of Angiology
Interventional Radiology Society of Australasia
Japanese College of Angiology
Society for Cardiovascular Angiography and Intervention
Society for Vascular Surgery
Society of Interventional Radiology
Society for Vascular Medicine & Biology
Vascular Society of Southern Africa
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS5/c2 lines 8-11
TASC II Participating Societies include:
American College of Cardiology
American College of Physicians
American Diabetes Association
American Podiatric Medical Association
Canadian Society for Vascular Surgeons
Cardiovascular and Interventional Radiology Society of Europe
CoCaLis collaboration
European Society for Vascular Surgery
International Diabetes Federation
International Union of Angiology
Interventional Radiology Society of Australasia
Japanese College of Angiology
Society for Cardiovascular Angiography and Intervention
Society for Vascular Surgery
Society of Interventional Radiology
Society for Vascular Medicine & Biology
Vascular Society of Southern Africa
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS5/c2 lines 8-11
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

52. A B C TASC Grade Definition Grade Definition
TASC II
NEW
TASC Grade Definition
Grade
Definition A
Based on the criterion of at least 1 randomized controlled clinical trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation B
Based on well-conducted clinical studies but no good quality randomized clinical trials on the topic of recommendation C
Based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities (ie, no applicable studies of good quality)
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS6/c1/ recommendations
TASC Grade Definition:
Based on the criterion of at least one randomized controlled clinical trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation (Grade A)
Based on well-conducted clinical studies but no good quality randomized clinical trials on the topic of recommendation (Grade B)
Based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities (ie, no applicable studies of good quality) (Grade C)
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS6/c1/ recommendations
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

53. PAD Patients Are at Increased Risk for CV Ischemic Events
NEW
PAD Patients ≥50 Years and Older Initial Presentation*
The majority of PAD patients remain highly underdiagnosed
Symptomatic
~40% of Patients
Asymptomatic
~60% of Patients
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS10/fig A3
5-year Outcomes
Limb Morbidity
70%–80% Stable claudication
10%–20% Worsening claudication
5%–10% Critical limb ischemia
CV Morbidity
20% Nonfatal CV event (MI or stroke)
Mortality
10%–15% 75% from CV causes
Up to 35% of PAD patients will have an MI/stroke or die in the next 5 years
The ACC/AHA 2006 guidelines for the management of patients with peripheral arterial disease summarized the different types of initial PAD patient presentations in a population 50 years of age and older. Approximately 40% are symptomatic versus ~60% are asymptomatic. Overall, the majority of PAD patients remain highly underdiagnosed.
PAD patients are at increased risk for CV ischemic events. Five-year outcomes for PAD patients 50 years of age or older include the following scenarios:
Limb Morbidity
70%–80% stable claudication
10%–20% worsening claudication
5%–10% critical limb ischemia
CV Morbidity
20% nonfatal CV event (MI or stroke)
Mortality
10%–15%
75% from CV causes
Over 35% of PAD patients will have an MI/Stroke or die in the next 5 years
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS10/fig A3
* Excluding patients with an initial presentation of critical limb ischemia.
Adapted from Hirsch AT et al. Available at: Accessed January 26, 2007.
Adapted from Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease [Lower Extremity, Renal, Mesenteric, and Abdominal Aortic]). Available at: Accessed January 26, 2007.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA and Fowkes FGR for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

54. History and Physical Examination in Patients With Suspected PAD
NEW
Grade
Recommendations B
Individuals with risk factors for PAD, limb symptoms on exertion, or reduced limb function should undergo a vascular history to evaluate for symptoms of claudication or other limb symptoms that limit walking ability
Patients at risk for PAD or patients with reduced limb function should also have a vascular examination evaluating peripheral pulses
Patients with a history or examination suggestive of PAD should proceed to objective testing including an ABI
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS25/c1/ recommendation 11
History and physical Examination in Patients with Suspected PAD
Individuals with risk factors for PAD, limb symptoms on exertion, or reduced limb function should undergo a vascular history to evaluate for symptoms of claudication or other limb symptoms that limit walking ability (Grade B)
Patients at risk for PAD or patients with reduced limb function should also have a vascular examination evaluating peripheral pulses (Grade B)
Patients with a history or examination suggestive of PAD should proceed to objective testing including an ABI (Grade B)
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS25/c1/ recommendation 11
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

55. TASC II Guidelines – Ankle Brachial Index (ABI)

56. Ankle-Brachial Index (ABI)
TASC II
NEW
Ankle-Brachial Index (ABI)
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS15/c2/ lines 8-11
The primary non-invasive screening test for PAD is the ankle-brachial index
The American Diabetes Association recommends a screening with an ABI every 5 years in patients with diabetes
The ABI should become a routine measurement in the primary care practice of medicine
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS8/c2/ lines 23-26
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS25/c2/lines 36-67
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS15/c2/ lines8-11
The primary non-invasive screening test for PAD is the ankle-brachial index
The American Diabetes Association recommends a screening with an ABI every 5 years in patients with diabetes
The ABI should become a routine measurement in the primary care practice of medicine
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS8/c2/ lines 23-26
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS25/c2/ lines36-67
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

57. Ankle-Brachial Index (ABI)- Screening Recommendations
TASC II
Ankle-Brachial Index (ABI)- Screening Recommendations
NEW
Grade
ABI screening in the primary care setting B
All patients who have exertional leg symptoms
All patients between the age of 50–69 and who have a cardiovascular risk factor (particularly diabetes or smoking)
All patients age ≥70 years regardless of risk-factor status C
All patients with a Framingham risk score 10%–20%
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS26/c2/ recommendation 12
Recommendations for ankle-brachial index screening in the primary care setting to detect peripheral arterial disease in the individual patient:
All patients who have exertional leg symptoms (Grade B)
All patients between the age of 50–69 and who have a cardiovascular risk factor (particularly diabetes or smoking) (Grade B)
All patients age ≥70 years regardless of risk-factor status (Grade B)
All patients with a Framingham risk score 10%–20% (Grade C)
Norgren.TASC II. Eur J Vasc Endovasc Surg. 2007/pS26/c2/ recommendation 12
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

58. ABI for Assessing Systemic Risk
TASC II
NEW
ABI for Assessing Systemic Risk
Cardiovascular 10-year risk score:
High >20%
Moderate 20%–10%
Low <10%
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS15/Fig B1
ABI
Secondary prevention†
≤0.90
>0.90
Primary prevention*
The ABI can be used for further risk stratification in patients with a Framingham risk score between 10%–20%, who are considered to have moderate cardiovascular 10-year risk scores.
Patients in this population with ABI≤0.90 are generally considered to be at an elevated risk for PAD, and should be managed with secondary prevention measures that include the use of an antiplatelet therapy, maintenance of low density lipoprotein levels <100 mg/dL, and a targeted blood pressure of 140/90 mmHg in patients without any other co-morbid states, and 130/80 mmHg in patients with diabetes or renal insufficiency.
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS26/c1/ lines 13-14
Evaluate the patient for symptoms of PAD
Manage claudication and CLI if present
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS15/Fig B1
* Primary prevention=No antiplatelet therapy; LDL (low density lipoprotein) <130 mg/dL; appropriate blood pressure (<140/90 mmHg and <130/80 mmHg in diabetes/renal insufficiency).
† Secondary prevention=Prescribe antiplatelet therapy; LDL <100 mg/dL (<70 mg/dL in very high risk); appropriate blood pressure (<140/90 mmHg and <130/80 mmHg in diabetes/renal insufficiency).
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

59. TASC-II Guidelines for Risk Reduction
TASC Guidelines Antiplatelet Therapy Recommendations

60. TASC Guidelines Recommend CV Risk Reduction and Symptom Relief
NEW
Evidence Basis for Selected Treatment Recommendations
CV Risk Reduction
Treatment for Claudication*
Recommendations
Grade
Smoking cessation A
Supervised exercise training
Statin therapy
Antihypertensive therapy
Glucose control therapy C
Folate supplementation B
Antiplatelet therapy
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS20/c2/ Recommendation 6, pS12/c2/ Recommendation 3, pS17/c1/ Recommendation 1, pS18/c1/ Recommendation 2, pS19/c2/ Recommendation 5, pS19/c1/ Recommendation 4
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS30/c1/ Recommendation 14, pS32/c2/ Recommendation 15
TASC Guidelines Recommend CV Risk Reduction and Symptom Relief
CV risk reduction:
Smoking cessation (Grade A)
Statin therapy (Grade A)
Antihypertensive therapy (Grade A)
Glucose control therapy (Grade C)
Folate supplementation (Grade B)
Antiplatelet therapy (Grade A)
Treatment for Claudication:
Supervised exercise training (Grade A)
Cilostazol (Grade A)
Naftidrofuryl (Grade A)
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS20/c2/ Recommendation 6, pS12/c2/ Recommendation 3, pS17/c1/ Recommendation 1, pS18/c1/ Recommendation 2, pS19/c2/ Recommendation 5, pS19/c1/ Recommendation 4
* To improve symptoms and increase walking distance.
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75
Norgren.TASC II.Eur J Vasc Endovasc Surg. 2007/pS30/c1/ Recommendation 14, pS32/c2/ Recommendation 15
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

61. Antiplatelet Therapy A
NEW
Antiplatelet Therapy
Grade
Recommendations A
All symptomatic patients with or without a history of other cardiovascular disease should be prescribed an antiplatelet drug long term to reduce the risk of cardiovascular morbidity and mortality
Aspirin is effective in patients with PAD who also have clinical evidence of other forms of cardiovascular disease (coronary or carotid) C
The use of aspirin in patients with PAD who do not have clinical evidence of other forms of cardiovascular disease can be considered B
Clopidogrel is effective in reducing cardiovascular events in a subgroup of patients with symptomatic PAD, with or without other clinical evidence of cardiovascular disease
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS20/c2/Recommendation 6
TASC Recommendations for Antiplatelet Therapy
All symptomatic patients with or without a history of other cardiovascular disease should be prescribed an antiplatelet drug long term to reduce the risk of cardiovascular morbidity and mortality (Grade A)
Aspirin is effective in patients with PAD who also have clinical evidence of other forms of cardiovascular disease (coronary or carotid) (Grade A)
Clopidogrel is effective in reducing cardiovascular events in a subgroup of patients with symptomatic PAD, with or without other clinical evidence of cardiovascular disease (Grade B)
The use of aspirin in patients with PAD who do not have clinical evidence of other forms of cardiovascular disease can be considered (Grade C)
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS20/c2/Recommendation 6
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

62. So, Let’s wrap-up

63. Who should be screened for PAD?
NEW
Who should be screened for PAD?
Age > 45 years
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS6/c1/ recommendations
Patients with Atherosclerotic risk factors
TASC Grade Definition:
Based on the criterion of at least one randomized controlled clinical trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation (Grade A)
Based on well-conducted clinical studies but no good quality randomized clinical trials on the topic of recommendation (Grade B)
Based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities (ie, no applicable studies of good quality) (Grade C)
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS6/c1/ recommendations
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

64. What is the best way to screen?
NEW
What is the best way to screen?
ABI
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS6/c1/ recommendations
TASC Grade Definition:
Based on the criterion of at least one randomized controlled clinical trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation (Grade A)
Based on well-conducted clinical studies but no good quality randomized clinical trials on the topic of recommendation (Grade B)
Based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities (ie, no applicable studies of good quality) (Grade C)
Norgren.TASC II.Eur J Vasc Endovasc Surg.2007/pS6/c1/ recommendations
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, and Fowkes FGR, for the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

65. Summary of the Evidence Class of recommendation
Goals
Recommendation
Class of recommendation
Level of evidence
Blood pressure
Systolic
<140 mm Hg in all patients
<130 mm Hg in diabetic patients
Diastolic
<90 mm Hg in all patients
<80 mm Hg in diabetic patients I A
LDL-C
LDL< 2.5 mmol/l in all patients
Diabetes
HbA1c<7% in diabetic patients B
Smoking
Complete cessation in all patients
BMI
kg/m2 in all patients

66. Summary of the Evidence Class of recommendation
Medications
Recommendation
Class of recommendation
Level of evidence
Antiplatlets
All patients I A
Statins
ACE inhibitors
Symptomatic patients
Asymptomatic patients
IIa B

67. Take home message PAD is a marker for systemic atherosclerosis
PAD is associated with increased risk of cardiovascular mortality and morbidity
Majority of patients with PAD are asymptomatic
Individuals with atherosclerotic risk factors should be screened for PAD (ABI measurement)
Proven risk reduction therapy should be prescribed for patients with PAD

68. Thank You