Canadian Cardiovascular Society Consensus Conference 2005:
Peripheral Arterial Disease
B. L. Abramson V. Huckell Co-Chairs• Beth ABRAMSON, Toronto
• Sonia ANAND, Hamilton
• Tom FORBES, London
• Anil GUPTA ,Brampton
• Ken HARRIS, London
• Vic HUCKELL, Vancouver
• Asad JUNAID, Winnipeg
• Tom LINDSAY, Toronto
• Finlay McALISTER, Edmonton
• Andre ROUSSIN, Montreal
• Jacqueline SAW, Vancouver
• Koon TEO, Hamilton
• A. G TURPIE, Hamilton
• Subodh VERMA, Toronto
Goals of the CCS Consensus Process
• to put Peripheral Arterial Disease on the radar screen
• to ensure better treatment, to reduce both morbidity and mortality in the patient with vascular disease
• to foster discussion regarding newer models to deliver care across disciplines
• to serve as a guide to the busy clinician
CCS Consensus Conference 05
• Involved a broad range of specialists caring for the PAD patient
• In Collaboration with the Can. Society of Vascular Surgeons
• Executive Summary: C. J. Cardiol 05; 21(2)997-1006
• Complementary to larger AHA/ACC, TASC
• Practical focus for our membership - thoracic and abdominal
aortic disease, renal arterial disease discussed
• Current version will not discuss:
carotid disease, digital disease, pulmonary arterial disease,
erectile dysfunction, venous disease
QUALITY OF EVIDENCE AND CLASSIFICATION OF RECOMMENDATIONS
Quality of Evidence 1 Evidence obtained from at least one properly randomized
controlled trial or one large epidemiological study2 Evidence based on at least one non-randomized cohort
comparison or multi-centre study, chronological series or extra ordinary results from large non-randomized studies.
3 Opinions of respective authorities, based on clinical experience, descriptive studies or reports of expert committees.
Classification and RecommendationsA Evidence sufficient for universal use (usually based on RCTs)B Evidence acceptable for widespread use, evidence less robust, but
based on randomized clinical trials.C Evidence not based on randomized clinical trials.
A. Gupta
PAD - Epidemiology• PAD is often asymptomatic, under-diagnosed,
under-recognized, and under-treated
• 16% of North America and Europe has PAD, correlating to 27 million people
• Of these 16.5 million are asymptomatic
• Little contemporary epidemiological data for the prevalence of PAD in Canada but it likely represents 4% of the population over age 40
PAD - Epidemiology
A. Gupta
PATHOPHYSIOLOGY OF ATHEROSCLEROSIS
• a systemic and generalized disorder of the arterial tree
• involves a close interplay between endothelial dysfunction and inflammation, which in turn may modify the vascular responses to oxidative stress, and platelet-endothelial interaction
• when compensatory mechanisms fail, complications of atherosclerosis such as stenosis, plaque ulceration, embolization and thrombosis appear
S. Verma
PAD Risk Factors: Recommendations Grade1 All individuals with symptomatic or
asymptomatic PAD should be assessed for all modifiable risk factors.
1A
2 Identified risk factors should be managed appropriately in order to reduce the risk of (a) adverse cardiovascular events, and (b) progression of the PAD.
1A1B
3 Individuals should be advised to quit smoking and have regular walking programs to:(a) reducing overall cardiovascular risk, and (b) improving symptoms of the PAD.
1A1B
K. Teo
AORTIC ANEURYSMS• Aortic aneurysms are silent killers.
• They develop mostly in patients over the age 60
• 90% of all abdominal aortic aneurysms (AAA) occur below the renal arteries
• incidence of 4-5% in the general population
• Survival rates for aortic rupture depend upon the aneurysm location and the population examined
• Mortality rates can be as low as 40%
• Series that take into account pre hospital deaths show mortality rates up to 90%.
T. Lindsay
RecommendationsAneurysm Screening
Grade
1 Men age 65-74 1A
2 Women aged 65 who have cardiovascular disease and positive family history of AAA
3C
3 Men aged 50 and above with a positive family history
3C
T. Lindsay
Initial size Grade
<3.0 cm Repeat ultrasound follow-up in 3-5 years
1A
3.1-3.5cm Repeat ultrasound in 3 years 1A
3.6-3.9 cm Repeat ultrasound in 2 years 1A
4.0-4.5 cm Repeat ultrasound in 1 year 1A
4.6 cm or > Referral to Vascular Surgeon and repeat ultrasound every 3-6 months
1A
If > 1cm growth in 1 year
Referral to Vascular Surgeon 1A
RecommendationsAAA Follow-up Based on Initial Size
T. Lindsay
ATHEROSCLEROTIC RENAL ARTERY STENOSIS (RAS)
• The incidence of renal arterial disease is up to
45% in those with acute, severe or refractory HT
• PAD patients are at high risk of RAS
• Patients with moderate or severe hypertension and
otherwise unexplained pulmonary edema are
much more likely to have either bilateral renal
arterial disease or arterial stenosis of a solitary
functioning kidney
A. Junaid
Main Indications for Investigation
• Uncontrolled Hypertension despite maximum
dosing of 3 HT medications & Creatinine < 300
• Rapid (within weeks to months) otherwise
unexplained decline in renal function and
serum Cr. < 300 mol/l
• Otherwise unexplained recurrent flash
pulmonary edema
A. Junaid
Recommendations: Atherosclerotic RAS Management
Revascularization should be attempted with perc. balloon angioplasty & stenting
Grade
1 In patients with >70% luminal compromise of one or both renal arteries and uncontrolled hypertension (BP>140/90) despite the use of 3 medications at maximum dose.
I B
2 Patients with recurrent episodes of flash pulmonary edema and no other readily identifiable cause and greater than 70% stenosis of at least one renal artery.
II C
3 For preservation of renal function in patients with either bilateral renal artery stenosis/stenosis supplying a single functioning kidney who have a rapid decline in renal function and creatinine < 300 mol/l
II C
A. Junaid
Screening & Diagnosis
PAD DiagnosisRecommendation Grade
Taking a directed history for symptoms of PAD. A validated questionnaire, such as the Edinburgh Questionnaire, can help diagnose arterial claudication in patients suspected of suffering from PAD.
1A
Performing a directed examination focusing on physical findings that have been proven useful to detect PAD as defined as an ABI < 0.9
1A
Ordering an ABI to help diagnose arterial claudication in patients suspected of claudication. An ABI below 0.9 is diagnostic of PAD with values below 0.4 associated with severe disease.
1A
Ordering an ABI to diagnose PAD in asymptomatic patients with arterial bruits or diminished pulses
1A
A. Roussin
PAD Diagnosis continued
Recommendation Grade
Consider: an ABI to diagnose PAD in patients with a high CV risk, esp. patients over the age of 40 with smoking or diabetes. Femoral bruits are specific (95%) for PAD and reduced pulses are quite sensitive (±70%) for PAD but the ABI will still detect PAD in a fair number of patients with a normal physical exam
1B
A. Roussin
RecommendationsMedical Therapies to Reduce
Cardiovascular Events in PAD
RecommendationsMedical Therapies to Reduce
Cardiovascular Events in PAD
Class of Agents Grade
1 Statins 1A2 ACE Inhibitors 1A3 Oral Hypoglycemics or
Insulin2B
4 Antiplatelet 1A
S. Anand, A. Turpie
Choice of Anti-Platelet Agent Given Current Evidence
Agent Recommendation Grade
Aspirin Lifelong aspirin therapy, 75-325mg/d, in comparison to no antiplatelet therapy in patients with or without clinically manifest coronary or cerebrovascular disease
1A
Clopidogrel Clopidogrel in comparison to no antiplatelet therapy
1A
Ticlopidine Aspirin or Clopidogrel recommended over ticlopidine
1B
S. Anand, A. Turpie
NON-MEDICAL MANAGEMENT• The vast majority of patients with claudication, are
best treated conservatively• Surgical or interventional approaches should be
considered in patients whose claudication prevents them from meeting their work and everyday responsibilities and with very poor quality of life
• Those with limb threatening ischemia suffer from such symptoms as rest pain, gangrene, non-healing ulcers or sores, and diabetic foot infections
• These patients should be urgently referred for consideration of revascularization procedures
T. Forbes, K. Harris
Non-Medical Management of Chronic Limb Ischemia
Recommendation Grade
1 The majority of claudicants should undergo risk factor modification, medical management and a walking program rather than revascularization
1B
2 Only those who suffer from severely limiting claudication should be considered for revascularization
1B
3 Patients with critical limb ischemia should be considered for revascularization
1A
4 An aortobifemoral bypass grafting offers superior long term patency compared to extraanatomic bypasses as an inflow procedure.
2B
T. Forbes, K. Harris
Percutaneous Interventions – Clinical Indications
Recommendation Grade
(where technically feasible)
Severe intermittent claudication that interferes with work or lifestyle despite pharmacologic and exercise therapies
2 C
Chronic critical limb ischemia (rest pain, non-healing ulcer, gangrene)
2 C
J. Saw
PERIOPERATIVE RISK ASSESSMENT FOR VASCULAR SURGERY
• General internists and cardiologists are frequently asked to perform preoperative assessments on patients who are scheduled for vascular surgery.
• The purpose should not be to “clear” someone for surgery, but rather to evaluate the severity and stability of the medical conditions and optimize their management before surgery.
• The preoperative assessment should be seen as a venue for the provision of risk estimates to the surgeon, patient, and anaesthetist which can be used to inform decision making.
F. McAlister
PERIOPERATIVE RISK ASSESSMENT THREE PRINICPLES
1. the approach should be appropriate to the situation i.e. -tailored evaluation with a surgical emergency
2. preoperative coronary revascularization should not be done to try to reduce surgical risk, but rather should only be considered in patients who would warrant revascularization for medical reasons independent of the proposed operation
3. the preoperative approach should be tempered by the patient’s overall health status F. McAlister
Additional Highlights
• Screening and Diagnosis
• – A. Roussin, MD
• Medical Management
• – S. Anand, MD
• Perioperative Risk Assessment
• – B. Abramson, MD
• A National Call to Action• - V. Huckell MD
CCS PAD 2005 CONSENSUSScreening and Diagnosis
• Taking a directed history for symptoms of PAD.
• A validated questionnaire, such as the Edinburgh Questionnaire, can help diagnose arterial claudication in patients suspected of suffering from PAD
Grade 1A recommendation
CCS PAD 2005 CONSENSUSScreening and Diagnosis
• Performing a directed examination focusing on physical findings that have been proven useful to detect PAD as defined as an ABI < 0.9
Grade 1A recommendation
CCS PAD 2005 CONSENSUSScreening and Diagnosis
• Ordering an ABI to help diagnose arterial claudication in patients suspected of claudication.
• An ABI below 0.9 is diagnostic of PAD with values below 0.4 associated with severe disease
Grade 1A recommendation
CCS PAD 2005 CONSENSUSScreening and Diagnosis
• Ordering an ABI to diagnose PAD in asymptomatic patients with arterial bruits or diminished pulses
Grade 1A recommendation
CCS PAD 2005 CONSENSUSScreening and Diagnosis
• Considering an ABI to diagnose PAD in patients with a high cardiovascular risk, particularly patients over the age of 40 with smoking or diabetes.
• Femoral bruits are specific (95%) for PAD and reduced pulses are quite sensitive (±70%) for PAD but the ABI will still detect PAD in a fair number of patients with a normal physical exam
Grade 1B recommendation
CCS PAD 2005 CONSENSUSScreening and Diagnosis
• Considering Segmental pressures, Duplex scanning and Treadmill testing in conjunction with a vascular specialist
Grade 3C recommendation
PAD Investigation and ImagingMost useful methods in 2005
• Ankle-Brachial Index (ABI) to confirm PAD
• Duplex for screening in view of further
investigation
• Claudication & normal creatinine• Consider CT-Angio
• Claudication & diabetes or renal failure• Consider MR-Angio
• Critical ischemia• Consider MR-Angio
#1: Smoking Cessation
• Top Priority reduces CV events and improves claudication
• Doctors make an impact***
• Single most powerful Single most powerful preventive intervention inpreventive intervention in clinical practiceclinical practice
# 2: Antiplatelet Tx Reduces CV Events in PAD Patients (Grade 1A)
184 RCT's 140,000vascular patients
MI 30% stroke 30% mortality 16%
39 RCT's 9000 patientswith PAD
21% RRR in CV death,MI, stroke
Lifelong Antiplatelet Therapy is Indicated in All PAD Patients
# 3: Statins (Grade 1A)
• Reduce CV death, MI, and stroke in PAD patients
• May improve walking distance in intermittent claudication
# 4: ACE Inhibitors (Grade 1A)
• Blood Pressure Lowering
• Reduction in clinical events over and above BP Lowering (HOPE)
The HOPE Study: PAD Subgroup Analysis
0.6 0.8 1.0 1.2
PAD 4046 22.0
No PAD 5251 14.3
No. of Patients
Incidence of Composite Outcome
in Placebo Group
The Heart Outcomes Prevention and Evaluation Study Investigators N. Engl. J. Med. 2000; 342: 145-153
Relative Risk in Ramipril Group
Supervised Exercise to improve Claudication (1A)
• Cochrane Meta-analysis (only RCT’s) • 10 trials, 250 Patients • Exercise increased maximum walking
time by 6.51 min (95% CI: 4.36-8.66]
• Prescription: 3 sessions x 30 minutes per week
Leng, Cochrane Database
PERIOPERATIVE RISK ASSESSMENT FOR
VASCULAR SURGERY
Proposed Algorithm:
Need for noncardiac vascular surgeryPROCEED TO OPERATION
1. Cancel/Delay surgery2. Treat modifiable conditions & re-
evaluate3. Consider cath if revasc. would be
appropriate for reasons independent of planned OR
PROCEED TO OPERATION
Noninvasive Testing
Not Low Risk
Emergent
Elective
Yes and asymptomatic since
Yes
No (or new symptoms)
No
No
Yes
Yes
No
Functional capacity < 1-2 blocks walkingPLUS ANY MINOR RISK PREDICTOR:
Age >70 yearsRhythm other than sinus
Abnormal ECG (LVH, LBBB, ST-T)BP > 180/110 mm Hg
ANY MAJOR RISK PREDICTOR:MI within 4 weeks
CCS Class III/IV or unstable anginaDecompensated CHF
Severe valvular diseaseHigh grade AV block
Symptomatic vent. arrhythmiasUncontrolled ventricular response
Low Risk
ANY INTERMEDIATE RISK PREDICTOR:MI > 4 weeks ago
CCS class I or II anginaCompensated heart failure
Diabetes Mellitus, Renal insufficiencyCerebrovascular disease
Revascularization or favourable result on coronary evaluation within 2 years?
Resting ECG normal?
History of ventricular arrhythmias, uncontrolled hypertension, or resting
hypotension?
History of bronchospasm, second degree AV block, theophylline
dependence, or valvular dysfunction?
Exercise ECG Stress Test
Exercise perfusion imaging
Dipyridamole myocardial perfusion
scintigraphy Other
Dobutamine Stress Echo
No
No
Yes Yes
No
Yes
No Yes
Patient scheduled for elective vascular surgery and non-invasive testing
indicated
Patient able to exercise?
Non-exercise Stress Test
An (inter) national(inter) organ
(inter) specialty disease
PAD
A national call to action
Critical issues
1. Increase awareness of PAD and its consequences
• Ischemic burden• Dissemination of clinical definition• Prediction of CVD and CAD• Vascular disease foundations and
networks• Vascular societies
Increase Awareness of PAD
and Its Consequences
Critical issues
1. Increase awareness of PAD and its consequences
2. Improve the identification of patients with symptomatic PAD
Improve the identification of patients with symptomatic PAD
• Public awareness campaigns• Patient and physician education
Critical issues
1. Increase awareness of PAD and its consequences
2. Improve the identification of patients with symptomatic PAD
3. Initiate a screening protocol for patients at high risk for PAD
Initiate a screening protocol for patients at high risk for PAD
• Review traditional risk factors• Examine peripheral pulses• Consider ABI
Critical issues
4. Improve treatment rates among patients diagnosed with symptomatic PAD
Improve treatment rates among patients diagnosed with symptomatic PAD
• Life style modification• Intensive risk reduction interventions• Antiplatelet therapy
Critical issues
4. Improve treatment rates among patients diagnosed with symptomatic PAD
5. Increase the rates of early detection among the asymptomatic population
Increase the rates of early detection among the asymptomatic population
• Review patients with multiple risk factors
• Clinical examination where indicated
Critical issues
4. Improve treatment rates among patients diagnosed with symptomatic PAD
5. Increase the rates of early detection among the asymptomatic population
6. Develop national implementation strategies for guidelines and consensus conferences
Develop national implementation strategies for guidelines and consensus conferences
• Prevention of atherothrombotic disease network
• ACC / AHA guidelines• Vascular societies
• Quebec Vascular Society• Atlantic Vascular Society• Western Vascular Society
• Vascular biology working groups
Develop national implementation strategies for guidelines and consensus conferences
• Publication of the consensus conference
• CCS visiting professor series• Dedicated website(s)• Enduring materials
• Physician handouts• Patient handouts