Management of Dyslipidemia in Patients with Peripheral Arterial

Disease: an update from Guidelines

Oman International Vascular Conference

Al-Bustan Palace Hotel

Muscat– Sultanate of Oman

12th- 14th March 2012

Khalid Al-Rasadi, MD

Event-free survival by PAD status at 5 years for 6880 patientsKaplan–Meier estimates showing all-cause mortality or

severe vascular events

Curt Diehm, Circulation November 24, 2009

Logistic Regression Estimates and Odds Ratios for Significant Risk Factors in the Intermittent Claudication Profile in Subjects Aged

45 to 84: Framingham Heart Study

Risk Factor Odds Ratio (95% CI) P

Male sex 1.7 (1.3, 2.1) .0001

Age (per 10 years) 1.5 (1.3, 1.6) .0001

High normal blood pressure1 1.3 (0.9, 1.8) .1384

Stage 1 hypertension1 1.5 (1.1, 2.0) .0091

Stage 2+ hypertension1 2.2 (1.7, 3.0) .0001

Diabetes 2.6 (2.0, 3.4) .0001

Cigarettes (per 10 cigarettes) 1.4 (1.3, 1.5) .0001

Cholesterol (per 40 mg/dL) 1.2 (1.1, 1.3) .0001

CHD 2.7 (2.2, 3.4) .0001

Circulation 1997; 96: 44–49.

Prevalence of and Risk Factors for Peripheral Arterial Disease in the United States : Results From the National Health and Nutrition Examination Survey,

1999 −2000

Circulation August 10, 2004

Values of plasma lipid and lipoprotein concentrations in male cases with PAD and

healthy controls

B.F. Mowat et al. : Atherosclerosis 131 (1997) 161–166

Lipoprotein(a) and PAD in a Community-Based Sample of Older Men and Women (the InCHIANTI Study)

Am J Cardiol 2010;105:1825–1830

Heart Protection Study: Vascular Heart Protection Study: Vascular Events by Baseline DiseaseEvents by Baseline Disease

Baseline featureSimvastatin (n=10,269)

Placebo (n=10,267)

Previous MI 1007 1255

Other CHD (not MI) 914 1234

No prior CHD

CVD 182 215

PVD 332 427

Diabetes 279 369

All patients2042

(19.9%)2606

(25.4%)

Collins R. Presented at AHA, Anaheim, California, 13 November 2001.

Risk ratio and 95% CI

Statin better

Statin worse

24 ± 2.6% (2P <0.00001)

0.4 0.6 0.8 1.0 1.2 1.4

The effect of intensified lipid-lowering therapy on long-term prognosis in patients with peripheral arterial disease (1374 patients,

followed for 6.4 ± 3.6 years)

J Vasc Surg 2007;45:936-43

0.0

1.0

2.0

hs-CRP and Risk of Developing PVD in hs-CRP and Risk of Developing PVD in Apparently Healthy MenApparently Healthy Men

Ridker PM et al. Circulation 1998;97:425-428.1998 Lippincott Williams & Wilkins.

None

hs-

CR

P (

mg

/dL)

IntermittentClaudication

Peripheral ArterySurgery

Patients with statin use had significantly less inflammatory activity in 515 patients with severe PAD

European Heart Journal (2004) 25, 742–748

Statin therapy improves cardiovascular outcome of patients with severe PAD

European Heart Journal (2004) 25, 742–748

Peripheral Arterial Disease (PAD)Peripheral Arterial Disease (PAD)

Studies of patients with atherosclerotic

PAD support the concept that PAD,

regardless of diagnosis by ABI, lower

limb blood flow studies, or clinical

symptoms, is a CHD risk equivalent

Guidelines for Lipid Management in PAD

Guideline source

LDL-C HDL-C Triglycerides

ACCF/AHA

Class 1: LDL <100 mg/dl, for all patients with PAD using HMG-CoA reductase inhibitor (statin)

Class 2a: LDL <70 mg/dl, for those at high risk of ischemic events

Class 2a: low HDL, consider treatment with

fibric acid derivative

Class 2a: elevated triglycerides, consider

treatment with fibric acid derivative

TASC II

LOE A: LDL <100 mg/dl, for all patients with PAD

LOE B: LDL <70 mg/dl, for patients with atherosclerosis in other territories

LOE A: statin drugs should be the primary agent used

LOE B: low HDL, consider treatment with

niacin or fibrates

LOE B: elevated triglycerides, consider treatment with fibrates

ESC

Class 1: LDL <2.5 mmol/l (100 mg/dl), for all patients with PAD

Class 1: Optimal LDL <1.8 mmol/l (<70 mg/dl)

Class 1: Goal >50% LDL reduction, if target level cannot be reached

Not addressed in guidelines

Not addressed in guidelines

Centralized pan-Middle East Survey on the undertreatment of hypercholesterolemia: Results from

the CEPHEUS Study in Arabian Gulf States

CEPHEUS, unpublished data

Lipid-lowering treatment in hypercholesterolaemic patients: the CEPHEUS Pan-Asian survey

European Journal of Cardiovascular Prevention & Rehabilitation 0(00) 1–14

Conclusion & Future Perspective

• Exciting advances have been made in the treatment of lower extremity PAD to reduce morbidity and mortality as well as to improve functional capacity.

• Continued investigation is needed to better understand the relationship between dyslipidemia, endothelial dysfunction, inflammation and hyperglycemia as they relate to an individual's exercise capacity and symptoms.

• Lastly, large clinical trials are needed to better understand the impact of statin therapy and resulting LDL reduction on exercise performance in patients with PAD.