1. PAD Diagnosis and Management Gerry Stansby Newcastle upon Tyne, UK

2. Ischaemic stroke Atherothrombosis affects many vascular beds 1.Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(Suppl 1): 1–6 2.Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234 These are expressions of a single extensive, progressive, unpredictable and deadly disease Transient ischaemic attack Myocardial infarction Angina: Stable Unstable Peripheral arterial disease: Intermittent claudication Rest pain Gangrene Necrosis Renovascular disease Diabetes (type 2) Often considered vascular equivalent to to a non-diabetic patient with previous MI 2

3. Vascular Surgeons Cardiologists (+cardiac surgeons) General Practice Care of the elderly Stroke Medicine Arteriopath Diabetologists Neurology Renal Physicians

4. 1. England and Wales, Office for National Statistics 2006 (www.heartstats.org) Mortality (%) The burden of atherothrombotic disease Atherothrombosis* continues to be a leading cause of death 1 *Atherothrombosis bar is an addition of burden for coronary heart disease (17.3%), cerebrovascular disease (9.9%) and peripheral arterial disease (no data)

5. Clinically silent Begins in teenage years Increasing age & risk factors Stable angina Claudication PAD MI / unstable angina Stroke / TIA Critical limb ischaemia Cardiovascular death Normal artery Fatty streak Atherosclerotic plaque Plaque rupture & thrombosis Development of atherothrombotic disease Peripheral arterial disease should be treated as seriously as coronary heart disease when calculating cardiovascular risk The underlying pathology is the same for each arterial bed

7. Patients with Type 2 diabetes are a high cardiovascular risk group 1. Adapted from Haffner SM et al. N Engl J Med 1998;339:229-234 0 5 10 15 20 Prior MI (no diabetes) 7-yr incidence of cardiovascular events (%) Type 2 diabetes (no prior MI) MI (18.8%) CV* Death (15.9%) Stroke (7.2%) MI (20.2%) Stroke (10.3%) CV* Death (15.4%) *CV = cardiovascular

8. Edinburgh Artery Study. Cross-sectional survey of 1592 subjects. (  &  aged 55-74) Asymptomatic 15% Symptomatic 4.5% It’s Common!

9. 20% die of MI 10% die of other causes <5% amputation 5 years. 5 year fate of the claudicant (Dormandy et al)

10. 1 2 3 4 5 <0.60.6-0.70.7-0.80.8-0.90.9-1.01.0-1.11.1-1.21.2-1.31.3-1.4>1.4 Female Male Ankle Brachial Index Base reference: ABI 1.0-1.4 Relative risk of Death Relative Risks of All-Cause Mortality by Ankle Brachial Index in Men and Women in 12 cohort studies Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008 Jul 9;300(2):197

11. 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)

12. PAD Ankle: Brachial Index

13. Ankle:Brachial Pressure Index Highest pressure in foot (ankle) Brachial systolic pressure ABI<0.9 diagnostic for PAD

14. 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 patient’s risk DP: 160 mm Hg PT: 154 mmHg Right 156 mmHg Left 160 mmHg Diagnosis: moderate PAD in left leg ABI measurement DP: 96 mmHg PT: 100 mm Hg

15. AGATHA: ABI is related to the site and extent of atherothrombosis CAD 35% PAD 10% CVD 20% 6% 7% 15% 26% 20% 33% % with ABI ≤0.9 Type of arterial bed affected in the with-disease population (%) N=7099 Fowkes et al. EHJ 2006;27:861–867 CAD = coronary artery disease CVD = cerebrovascular disease PAD = peripheral artery disease 7%

16. 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

17. “Assessing risk for coronary heart disease: beyond Framingham”. Am Heart J. 2003 Oct;146(4):572-80. Cobb FR, Kraus WE, Root M, Allen JD.

18. PAD: Medical Therapy Blood Pressure Lipids Antiplatelets ACEI Diabetes (Cilostazol)

19. 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.

20. Blood Pressure Control Target = 140/85 SystolicClaudicants <140 30.8% 140-160 33.1% 160-180 24.2% 180-200 8.5% 200+ 3.4% Data from PREPARED study.

21. SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE Risk ratio and 95% CISTATINPLACEBOBaseline feature (10269)(10267)STATIN betterSTATIN worse Previous MI10071255 Other CHD (not MI)452597 No prior CHD CVD182215 PVD332427 Diabetes279369 ALL PATIENTS20422606 (19.9%)(25.4%) 24%SE 2.6 reduction (2P<0.00001) 0.40.60.81.01.21.4 Heart Protection Study

22. PREPARED study – cholesterol levels in claudicants

23. ACE inhibitors

25. Metabolic Syndrome Difficult to define Easy to spot

26. Exercise and Absolute Claudication Distance 0 50 100 150 200 250 300 350 400 450 Baseline3-month6-month9-month12-month Median Absolute Claudication Distance on Treadmill Walking ( meters ) Supervised Non-supervised P < 0.001

27. North America Latin America Eastern Europe Middle East Asia (incl. Japan) Australia 27,746 1,931 17,886 846 5,903 2,872 * up to 15 patients/site (up to 20 in the US) Western Europe REACH Registry: >67,000 patients from 5,473 sites* in 44 countries 5,048 5,656 JAMA 2006;295:180-9

28. Major endpoints as a function of single vs multiple and overlapping locations Polyvascular diseaseSingle arterial bed 26.9 (3) 7.4 4.0 1.8 3.6 (3) CAD + CVD + PAD 24.4 (1) 7.0 4.8 1.3 1.8 CVD + PAD 23.3 (3) 4.8 (3) 1.3 (3) 1.4 2.9 (2) CAD + PAD 20.0 6.4 3.7 1.6 2.0 CAD + CVD 22.018.2 (3) 10.0 (3) 13.312.8 CV death/MI/ stroke/ hospitalisation * 6.02.34.5 (3) 3.13.4 CV death/MI/ stroke 3.10.63.5 (3) 0.91.5 Non-fatal stroke 1.51.00.5 (3) 1.41.2Non-fatal MI 1.5 CAD alone 1.5 Overall 1.2 PAD alone 2.4 Overall 1.4CV death CVD alone *TIA, unstable angina, other ischemic arterial event including worsening of peripheral arterial disease 1 p<0.05; 2 p<0.01; 3 p<0.001 (ref class: CAD alone) 1 p<0.05; 2 p<0.01; 3 p<0.001 (ref class: CAD + CVD)

29. Critical Ischaemia= Rest pain +/- gangrene or ulcers Doppler pressures < 50mmHg. >70% will need amputation if nothing is done. Priority is revascularisation Urgent referral needed

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

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

32. 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

34. Thank You For Listening