PADDiagnosis and Management

Gerry Stansby

Newcastle upon Tyne, UK

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:StableUnstable

Peripheral arterial disease:Intermittent claudicationRest painGangreneNecrosis

Renovascular disease

Diabetes (type 2)Often considered vascular

equivalent to to a non-diabetic patient with previous MI2

Vascular Surgeons

Cardiologists (+cardiac surgeons)

General Practice

Care of the elderly

Stroke MedicineArteriopath

Diabetologists

Neurology

Renal Physicians

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 death1

*Atherothrombosis bar is an addition of burden for coronary heart disease (17.3%), cerebrovascular disease (9.9%) and peripheral arterial disease (no data)

27.3%

3.5%

14.0%

27.0%

0 5 10 15 20 25 30

Atherothrombosis*

Cancer

Respiratory

Injuries and poisoning

Clinically silentBegins in teenage years

Increasing age & risk factors

Stable anginaClaudication

PAD

MI / unstable anginaStroke / TIA

Critical limb ischaemiaCardiovascular death

Normal arteryFatty streakAtheroscleroticplaque

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

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

Edinburgh Artery Study.

Cross-sectional survey of 1592 subjects. (&aged 55-74)

Asymptomatic 15%

Symptomatic

4.5%

It’s Common!

20% die of MI

10% die of other causes

<5% amputation

5 years.

5 year fate of the claudicant (Dormandy et al)

11

22

33

44

55

<0.6<0.6 0.6-0.70.6-0.7 0.7-0.80.7-0.8 0.8-0.90.8-0.9 0.9-1.00.9-1.0 1.0-1.11.0-1.1 1.1-1.21.1-1.2 1.2-1.31.2-1.3 1.3-1.41.3-1.4 >1.4>1.4

FemaleFemale

MaleMale

Ankle Brachial Index

Base reference: ABI 1.0-1.4Base reference: ABI 1.0-1.4

Relative risk of Death

Relative Risks of All-Cause Mortality by Ankle Brachial Index in Relative Risks of All-Cause Mortality by Ankle Brachial Index in Men and Women in 12 cohort studiesMen 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

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)

PADAnkle: Brachial Index

Ankle:Brachial Pressure Index

Highest pressure in foot (ankle)

Brachial systolic pressure

ABI<0.9 diagnostic for PAD

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 isthe ABI that stratifies the patient’s risk

DP: 160 mm HgPT: 154 mmHg

Right

156 mmHg

Left

160 mmHg

Diagnosis:

moderate PAD in left leg

ABI measurement

DP: 96 mmHgDP: 96 mmHgPT: 100 mm HgPT: 100 mm Hg

AGATHA: ABI is related to the site and extent of atherothrombosis

CAD35%

PAD10%

CVD20%

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 diseaseCVD = cerebrovascular diseasePAD = peripheral artery disease

7%

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

“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.

PAD: Medical Therapy

•Blood Pressure

•Lipids

•Antiplatelets

•ACEI

•Diabetes•(Cilostazol)

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.

Blood Pressure Control

Target = 140/85 Systolic Claudicants

 <140

 30.8%

 

 140-160

 33.1%

 160-180

 24.2%

 180-200

 8.5%

 200+

 3.4%

 Data from PREPARED study.

SIMVASTATIN: VASCULAR EVENT by PRIOR DISEASE

Risk ratio and 95% CISTATIN PLACEBOBaselinefeature (10269) (10267) STATIN better STATIN worse

STATIN worse

Previous MI 1007 1255

Other CHD (not MI) 452 597

No prior CHD

CVD 182 215

PVD 332 427

Diabetes 279 369

ALL PATIENTS 2042 2606(19.9%) (25.4%)

24%SE 2.6reduction(2P<0.00001)

0.4 0.6 0.8 1.0 1.2 1.4Heart Protection Study

Cholesterol (mmol / L)

Perc

ent

10.59.07.56.04.53.0

18

16

14

12

10

8

6

4

2

0

Mean 5.437StDev 1.238N 346

PREPARED study – cholesterol levels in claudicants

ACE inhibitors

Metabolic Syndrome

Difficult to define

Easy to spot

Exercise andAbsolute Claudication Distance

0

50

100

150

200

250

300

350

400

450

Baseline 3-month 6-month 9-month 12-month

Med

ian

Ab

solu

te C

lau

dic

atio

n D

ista

nce

o

n T

read

mill

Wal

kin

g (m

eter

s)

Supervised

Non-supervised

P < 0.001

North AmericaLatin 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

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)13.312.8CV death/MI/ stroke/ hospitalisation*

6.02.34.5(3)3.13.4CV death/MI/ stroke

3.10.63.5(3)0.91.5Non-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)

Critical Ischaemia=

Rest pain +/- gangrene or ulcersDoppler pressures < 50mmHg.>70% will need amputation if

nothing is done.Priority is revascularisationUrgent referral needed

Specialist referral:

Urgent: Critical ischaemia (rest pain, necrosis, gangrene).

Routine: Limiting symptoms, threatened

employment, diagnostic doubt

Refer to local guidelines

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

 

October 2008

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

Any Questions?Thank You For Listening