1. Peripheral Vascular Disease in Cardiac Patients
Jason Finkelstein, M.D.
Cardiology Fellow
Tulane University HSC
9/23/03

2. P A D
Characterized by arterial stenosis and occlusions in the peripheral arterial bed
Can be symptomatic or asymptomatic
Under diagnosed and under treated disease
Patient and physician awareness is low

3. P V D
Ranges in severity from intermittent claudication to limb ischemia
Patients have a decreased quality of life due to a reduction in walking distance and speed leading to immobility
Most cases of PAD are asymptomatic

4. Prevalence
27 million people in Europe and North America have PAD (16% of the population 55 yrs or older)
10.5 million are symptomatic
16.5 million are asymptomatic
Three recent programs have demonstrated high PAD detection rates when specific populations were at risk for PAD were screened

5. POPADAD study 8000 patients 40 yrs or older with DM Type I or II
Had no clinical symptoms of arterial disease
Results:
20.1% of patients had ABI < 0.9

6. PAD Awareness & Detection
Total of 6979 patients
Ages 70 yrs or older or with diabetes or smoking history
PAD was considered present if ABI< 0.9 or a h/x of limb revascularization
CVD was defined as coronary, cerebral, or aortic aneurysmal disease
Criqui, et al, JAMA 2001: 286;

7. Results: PAD was detected in 1865 pts ( 30%)
44% of these pts had newly diagnosed PAD only
366 pts had newly diagnosed PAD and CVD (35%)
Among pts with PVD, classic claudication was distinctly uncommon
PAD is relatively underdiagnosed by physicians
PAD patients were less intensely treated than patients with CVD
Criqui et al, JAMA

8. Natural History of PAD
Associated with significant mortality because of association with coronary and cerebrovascular events including death, MI, and stroke
6x more likely to die within 10 yrs than patients without PAD
5 yr mortality rate in pts with claudication is about 30%
Continued use of smoking results in a two fold risk of mortality

9. Prevalence
Severity of symptoms has been found to correlate with survival
San Diego Artery study
Survival rates decreased with increasing severity
Another study showed that patients with symptoms had a 22% survival rate over a 15 yr period compared to a 78% survival rate of pts w/o symptoms
Belch et al, Arch Intern Med; April 2003;

10. Predictors of Mortality in PAD
297 patients
213 had intermittent claudication
84 had CLI defined by gangrene, ulcerations or persistent rest pain > 2 weeks
All subjects had ABI < 0.9
Results
Patients with CLI had a 1 yr death rate of 22%
3 yr survival was 52% compared to 86% in pts with intermittent claudication
Data suggests that pts with advance PAD have widespread arteriosclerotic disease
CLI was a stronger predictor of death than a low ABI
Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:

11. Claudication Patients suffer from peripheral atherosclerosis
Symptomatic deficiency in blood supply to exercising muscle which is relieved by rest
Largely a disorder of the elderly
Only 1-2% of those ages 37-69
Clinical history extremely important

12. Risk Factors Diabetes mellitus Advanced age Hyperlipidemia
have worse arterial disease and poorer outcomes than non-diabetics
Advanced age
Hyperlipidemia
Cigarette smoking
Hypertension

13. Cardiac Risk Pts with PVD have a 60% risk of CAD
Up to 30 % of pts have correctable 3 vessel disease with reduced LVEF
Patients with an ABI < 0.9 are twice as likely to have CAD

14. Clinical Presentation
Can vary from severe disabling discomfort at rest to a bothersome pain of seemingly little consequence
Can present with buttock, thigh, calf or foot claudication singly or in combination
Diminished pulses with occasional bruits over stenotic lesions
Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changes

15. Claudication Calf Thigh Foot Buttock and Hip
Cramping in upper 2/3 usually due to SFA stenosis
Thigh
Usually occlusion of the common femoral artery
Foot
Occlusive disease of the tibial and peroneal vessels
Buttock and Hip
Aortoiliac occlusive disease (Lariche’s syndrome)

16. Diagnostic tests Ankle-brachial index
Measures the resting and post exercise systolic BP in both the ankle and arms
Normal > 1.0
Below 0.9 has a 95 % sensitivity for detecting angiogram positive PVD
0.4 to 0.9 suggests arterial obstruction
Highly predictive of morbidity and mortality of CV events linked to PAD
Below 0.4 represents advanced ischemia

17. Diagnostic Tests Segemental limb pressures Duplex U/S MRA
> 20 mmHg reduction significant
Duplex U/S
MRA
Conventional angiography

18. Angiography Indicated for: Defining vessel anatomy Evaluating therapy
Documenting disease

19. Long term survival
2, 296 patients reviewed from CASS found to have PAD
Mean follow up period was 10.4 yrs
Pts with PAD had a higher frequency of CV risk factors
HTN, DM, CHF, previous CABG, or smoked
Controlled for all independent risk factors
Vascular disease retained a highly significant correlation with mortality
Pts had a 25% increased risk of dying at any time during followup ( p< 0.001)
Eagle et al, JACC 1994;23:1091-5

20. Premature PAD 59 male patients with premature PAD
Age of onset < 45 yrs of age
PAD assessed by ABI and CAD assessed by exercise treadmill testing or coronary angiogram
Mean ABI was 0.65
Arteriography performed in 56/59 pts
Valentine et al, J of Vasc Surg (1994; 19; )

21. Premature PAD 30 month period of the study
43 patients had significant CAD (73%)
17 pts had single vessel disease
4 pts had 2 vessel disease
22 pts had 3 vessel disease
32 pts experienced an MI and 23 pts requires an intervention to help control angina
8% mortality rate in the study
Valentine et al, J Vasc Surg (1994; 19: )

22. Management of PAD & CAD Close association of PAD and CAD
Pts with CAD undergoing PV surgery are at increased risk of early and late CV events
Coronary revasc. is likely to improve outcome but mortality rate after CABG is not as good as in pts w/o PVD
Recommends hemodynamic monitoring
Definitive guidelines are not available
Gersch et al, J am Coll Card; 1991;18:

23. PVD and Role of CRP
51 pts with PVD who underwent lower limb revasc. (screened 170 pts)
24 month f/u period
39 pts had PTA and 12 pts had bypass surgery
CRP levels were measured pre-op
All mortality, cardiac mortality and MI were considered major events
Rossi et al, Circulation 2002; 105:

24. PVD and Role of CRP 34% incidence of fatal and nonfatal MI over 2 yrs
CRP > 9 predicted 60 % o f MI’s in pts undergoing lower limb revasc. ( p <0.04)
Conclusion
CRP level in pts with PVD severe enough for revasc. may give incremental information about CV events and had a high predictive value
Pts may benefit from therapy modulating the immune response
More studies needed
Rossi et al, Circulation; 2002; 105:

25. PAD Management Anti-platelet agents Diabetic control Smoking cessation
Anti-hypertensives
Statin therapy
Exercise rehabilitation
Revascularization/PTCA/stenting

26. Revascularization Indications for intervention (PTA)
Persistent limiting claudication that prevents patient from performing daily activities
Rest pain
Tissue loss
Patients who are poor surgical candidates
Long term success of PTA depends on site and length of the lesion
Limited to focal, short segment occlusions
No significant difference in outcome between PTA or surgery

27. Revascularization Lesions might be better treated surgically if:
Long segments
Multi focal stenoses
Long segment occlusions
Eccentric, calcified lesions

35. Conclusion Need to increase awareness of PAD and its consequences
Improve the identification of patients with symptomatic PAD
Initiate a screening protocol at high risk for PAD
Improve treatment rates for those who have been diagnosed
Increase the rates of early detection in asymptomatic patients

36. Summary PAD is a powerful indicator of systemic artherosclerosis
Mandates aggressive risk factor modification and pharmacologic therapy
Goal is to improve the functional capacity of our patients and decrease morbidity and mortality
Cardiologists need to take a more active role in treating PAD along with co-existing CAD

37. Case #1
Mr. EG is a 52 yr old male with PMHx of HTN, tobacco abuse and CAD with a 5 vessel CABG in June 2000
LIMA – LAD
SVG to D1
SVG to OM1 & OM2
SVG to RCA

38. Case #1
Last cath was in April of 2001 which showed patent grafts and medical management was recommended
Now pt has recurrent chest pain on exertion < 1 block
Cardiolyte stress test revealed 1 mm ST depression and anterior ischemia. LVEF is 44%

39. Case # 2
Mr. JG is a 60 yr old male with PMHx of severe tobacco abuse, AAA, PVD with ischemic rest pain, Right CEA, HTN, who presents with occasional atypical angina
Persantine Cardiolyte stress test showed reversible anterior and septal ischemia

40. Case # 2 TEE revealed normal LVEF with mild inferobasal HK
Moderate to severe eccentric MR
Physical exam revealed b/l carotid bruits and 2/6 SEM