Pranav M. Patel, MD, FACC, FSCAIDirector, Cardiac Catheterization Lab

University of California, IrvineDivision of Cardiology

Peripheral Artery Disease (PAD): Diagnosis and Management

Acknowledgments

Consultant : Sanofi-Aventis, Terumo, Daiichi Sankayo

ACC/AHA (www.americanheart.org and www.acc.org) website

http://www.americanheart.org/�

What is P.A.D.? Peripheral Arterial Disease (P.A.D.) is a common

yet serious disease. P.A.D. occurs when extra cholesterol and fat

circulating in the blood collects in the walls of the arteries that supply blood to your limbs.

P.A.D. can affect your quality of life, make walking difficult, or worse, increase your risk of heart attack, stroke, leg amputation, and even death.

A National Public Awareness Campaign from the P.A.D. Coalition and the National Heart, Lung, and Blood Institute

Why should you learn about P.A.D.?

P.A.D. affects 8 to 12 million people within the U.S., especially those over age 50.

Early diagnosis and treatment of P.A.D. can help to… Prevent disability and restore your mobility Stop the disease from progressing Lower your risk for heart attack, heart disease,

and stroke

Peripheral Arterial Disease

Ness J, Aronow WS. J Am Geriatric Soc. 1999;47:1255-1256.

Overlap of Atherosclerotic Disease

Patients with one manifestation often havecoexistent disease in other vascular beds

CoronaryArtery

DiseaseCerebrovascular

Disease

Peripheral Arterial Disease6%

16%40%

11% 3%

15%

9%

38% overlap of 2 vascular beds

N= 1802 patientsMean age = 80 yrs (60-102)

How do you know if you have P.A.D.?

Most people with P.A.D. do not have the typical signs and symptoms of the disease.

People who do experience symptoms often fail to report them because they think they are a natural part of aging.

What are the signs and symptoms of P.A.D.?

Claudication—fatigue, heaviness, tiredness, cramping in the leg muscles (buttocks, thigh, or calf) that occurs during activities such as walking or climbing stairs

The pain or discomfort goes away once the activity is stopped or during rest.

What causes P.A.D.?

Plaque builds up on artery walls, blocking flow of blood to the arteries of the limbs, often the legs.

The cause of plaque buildup is unknown in most cases.

However, there are some conditions and habits that raise your chance of developing P.A.D.

Are you at risk for P.A.D.? Are you over age 50? Do you smoke or used to smoke? Do you have diabetes? Do you have high blood pressure? Do you have high blood cholesterol? Do you have a personal history of vascular disease,

heart attack, or stroke? Are you African American?

0% 5% 10% 15% 20% 25% 30% 35%

29%

11.7%

19.8%

19.1%

14.5%

4.3%

Prevalence of PAD

PARTNERS5Aged >70 years, or 50–69 years with a history diabetes or smoking

San Diego2Mean age 66 years

Diehm4Aged 65 years

Rotterdam3Aged >55 years

NHANES1Aged 70 years

NHANES1Aged >40 years

NHANES=National Health and Nutrition Examination Study; PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program].1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743.2. Criqui MH, et al. Circulation. 1985;71:510-515.3. Diehm C, et al. Atherosclerosis. 2004;172:95-105. 4. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 5. Hirsch AT, et al. JAMA. 2001;286:1317-1324.

In a primary care population defined by age and common risk factors,

the prevalence of PAD was approximately one in

three patients

29% of Patients in a Target Population Were Diagnosed With PAD Using An Office-Based ABI

Patients diagnosed with PADPAD onlyPAD and CVD

PARTNERS: Prevalence of PAD and Other CVD in Primary Care Practices

29%44%

56%

ABI=ankle-brachial index; CVD=cardiovascular disease.

Hirsch, AT et al. JAMA. 2001;286:1317-24.

1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Criqui MH, et al. Circulation. 1985;71:510-515.

Rotterdam Study (ABI

Gender Differences in the Prevalence of PAD

Adapted from Diehm C. Atherosclerosis. 2004;172:95-105 with permission from Elsevier.

Prev

alen

ce (%

)

Women

Men

6880 Consecutive Patients (61% Female) in 344 Primary Care Offices

85Age (years)

18

Ethnicity and PAD:The San Diego Population Study

NHW Black Hispanic Asian0123456789

10

Frac

tion

of P

opul

atio

n W

ith P

AD

(%)

NHW = Non-hispanic white. Reprinted with permission from Criqui, et al. Circulation. 2005:112:2703-07.

More signs and symptoms of P.A.D. Cramping or pain in the legs and/or feet at rest that

often disturbs sleep Sores or wounds on toes, feet, or legs that heal

slowly, poorly, or not at all Color changes in the skin of the feet, including

paleness or blueness A lower temperature in one leg compared to the

other leg Poor nail growth and decreased hair growth on toes

and legs

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Relative Risk

Smoking

Diabetes

Hypertension

Hypercholesterolemia

Hyperhomocysteinemia

C-Reactive Protein

Reduced Increased

Risk Factors for PAD

1 2 3 4 5 60

Cardiologists and PADRationale

Coexistence of CAD & PAD Common risk factors & modification Expertise in clinical evaluation of the patient Expertise in risk factor adjustment Interest in longitudinal follow-up and global

approach to patients disease

At risk for P.A.D.? Then…

Discuss this concern with your health care provider. Ask your health care provider if you should be

screened or tested for P.A.D.

Think you may be at risk? Ask your health care provider…

Does my medical history put me at higher risk for P.A.D.?

Which screening tests or exams are right for me? If I have P.A.D., what steps should I take to treat it? What steps can I take to reduce my risk for heart

attack and stroke?

Physical Exam Findings of PAD

Limb examination (and comparison with the opposite limb) includes: Absent or diminished femoral or pedal pulses (especially after exercising

the limb) Pulse intensity - 0: absent, 1: diminished, 2: normal , 3: bounding

Arterial bruits Hair loss Poor nail growth (brittle nails) Dry, scaly, atrophic skin Dependent rubor Pallor with leg elevation after 1 minute at 60 degrees (normal color

should return in 10 to 15 seconds; longer than 40 seconds indicates severe ischemia)

Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene

Lesho EP, et al. Am Fam Physician. 2004;69:525-533.

The Physical Exam Should BePerformed With Patient’s Pants/Shoes Off

More questions for your health care provider…

What is my blood sugar level? If I have diabetes, what should I do about it?

What is my blood pressure? Do I need to do anything about it?

What are my cholesterol numbers? Do I need to do anything about them?

What can I do to quit smoking?

The First Tool to Establish the PAD Diagnosis:A Standardized Physical Examination

Pulse assessment0 = absent1 = weak

2 = present (easily found)

http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_diagnosis.html

ABI Procedure = Ankle/Brachial Index

Exercise ABI Testing

Confirms the PAD diagnosis

Assesses the functional severity of claudication

May “unmask” PAD when resting the ABI is normal

Aids differentiation of intermittent claudication vs. pseudoclaudication diagnoses

Magnetic Resonance Angiography (MRA)

MRA has virtually replaced contrast arteriography for PAD diagnosis

No ionizing radiation Non-iodine–based intravenous contrast medium ~10% of patients cannot utilize MRA because of:

− Claustrophobia− Pacemaker/implantable cardioverter-

defibrillator− Obesity

• Gadolinium use in individuals with an eGFR

Computed Tomographic Angiography (CTA)

Requires iodinated contrast

Requires ionizing radiation

Produces excellent arterial picture

RightFem-Pop

BPG

CTA DSA(Pre-PTA)

LeftSFA

Stenosis

The overall goals for treating P.A.D.

Reducing the risk for heart attack and stroke Reducing any symptoms Improving quality of life and mobility

Two main treatment approaches1. Reduce cardiovascular risk

Get help to quit smoking Lower blood pressure Lower LDL (bad) cholesterol Manage diabetes Take anti-platelet medicines such as aspirin or

clopidogrel Follow a healthy eating plan

Two main treatment approaches

2. Relieve leg pain symptoms Get regular exercise Special PAD exercise program Medicines are available to improve

walking ability Special procedures or surgery, if needed

PAD: Prevention is Key

Risk Factors for PADNonmodifiable

Age Sex Family History (Race)

Modifiable

Cigarette smoking Diabetes mellitus Hypertension Dyslipidemia Inflammatory Markers

(CRP) Hyperviscosity Hypercoagulability Hyperhomocysteminemia Chronic renal

insufficiency

Effect of Smoking Cessation on Survival

0

20

40

60

80

100

0 1 2 3 4 5

Australian censusTobacco abstinenceContinued tobacco use

Years Postoperative

Faulkner KW, et al. Med J Aust. 1983;1:217-219.

133 Patients observed after bypass graft or lumbar sympathectomyC

umul

ativ

e Su

rviv

al (%

)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Intensive Antihypertensive Therapy in PAD: The ABCD Trial

0

10

20

30

40

Moderate treatment n = 227

Odd

s of

MI,

Stro

ke

or V

ascu

lar D

eath

Baseline ABI

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3

Intensive treatment n = 227*enalapril or nisoldipine

Reprinted with permission from Mehler, et al. Circulation. 2003;107;753-756.

Effects of Exercise Training on Claudication

Gardner AW, Poehlman ET. JAMA. 1995;274:975-980.

Exercise Training

Control

200

0

20

40

60

80

100

120

140

160

180

Onset of Claudication Pain

Maximal Claudication Pain

Chan

ge in

Tre

adm

ill W

alki

ng

Dis

tanc

e (%

)

Meta-analysis of 21 Studies

*

*

* P < 0.05

How can I reduce my risk for P.A.D.?

Don’t smoke/quit smoking. If you have diabetes, high blood pressure, and/or

high cholesterol, talk to your health care provider about how to manage your condition.

Eat a healthy diet full of fruits, vegetables, and whole grains.

Be active for 30 minutes a day.

To Learn More about P.A.D. Visit:

P.A.D. Coalitionwww.PADCoalition.org

Vascular Disease Foundation www.vdf.org

Stay in Circulationwww.aboutpad.org

http://www.padcoalition.org/�http://www.vdf.org/�

Long-Term Survival in Patients With PAD

Criqui MH et al. N Engl J Med. 1992;326:381-386. Copyright © 1992 Massachusetts Medical Society. All rights reserved.

Normal subjects

Asymptomatic PAD

Symptomatic PAD

Severe symptomatic PAD

100

75

50

25

0 2 4 6 8 10 12

Surv

ival

(%)

Year

PAD is often underestimated, under-evaluated, and requires proper diagnosis:

ABI is a non-invasive, easily performed measurement that reliably predicts ischemic risk in PAD patients

Symptoms of intermittent claudication (PAD) serves as an important marker for systemic atherosclerotic complications

Key Points

Key Points

Aggressive management of modifiable risk factors is paramount in decreasing risk for atherothromboembolic complications

Proactive and vigilant management of patients identified with PAD will significantly decrease premature mortality & morbidity increase the quality of life

Atherosclerosis: Systemic Problem

Peripheral Artery Disease (PAD): Diagnosis and ManagementAcknowledgmentsWhat is P.A.D.?Why should you learn about P.A.D.?Peripheral Arterial DiseaseOverlap of �Atherosclerotic DiseaseHow do you know if you have P.A.D.?What are the signs and symptoms of P.A.D.?What causes P.A.D.?Are you at risk for P.A.D.?Prevalence of PAD�PARTNERS: Prevalence of PAD �and Other CVD in Primary Care PracticesSlide Number 14Gender Differences in the �Prevalence of PADEthnicity and PAD:�The San Diego Population StudyMore signs and symptoms of P.A.D.Slide Number 18Cardiologists and PAD�RationaleAt risk for P.A.D.? Then…Think you may be at risk? Ask your health care provider…Physical Exam Findings of PADSlide Number 25More questions for your health care provider…The First Tool to Establish the PAD Diagnosis:�A Standardized Physical ExaminationABI Procedure = Ankle/Brachial IndexExercise ABI TestingMagnetic Resonance Angiography (MRA)Computed Tomographic Angiography (CTA)Slide Number 32The overall goals for treating P.A.D. Two main treatment approachesTwo main treatment approachesPAD: Prevention is KeyRisk Factors for PADEffect of Smoking Cessation on SurvivalIntensive Antihypertensive Therapy in PAD: The ABCD TrialEffects of Exercise Training �on ClaudicationHow can I reduce my risk for P.A.D.?To Learn More about P.A.D. Visit:Long-Term Survival in Patients With PADSlide Number 44Key Points