Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease ？

Why Are We Invloved in the Detection and Treatment of Peripheral Artery

Disease？

HU Dayi

Major Clinical Manifestations of Atherothrombosis

Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.

Transient ischemic attack

Angina

Ischemicstroke

Myocardial infarction

Peripheral arterialdisease:• Intermittent claudication• Rest Pain• Gangrene• Necrosis

Renal artery stenosis

Atherosclerotic nephrology

NCEP ATP III: Evaluation—CAD Risk Equivalents

• Diabetes

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.

• Atherosclerotic disease– Peripheral artery disease

– Abdominal aortic aneurysm

– Symptomatic carotid artery disease

• CAD 10-year risk >20%

1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9. 3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63. 4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.

*Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD)†Includes only fatal MI and other CHD death; does not include non-fatal MI

Increased risk vs general population (%)

Original event Myocardial infarction Stroke

Myocardial infarction

Stroke

Peripheral arterial disease

5–7 x greater risk1

(includes death)3–4 x greater risk2

(includes TIA)


(includes angina and sudden death*)

9 x greater risk3

4 x greater risk4

(includes only fatal MI and other CHD death†)


(includes TIA)

Risk of a Second Vascular Event

Why A PAD Guideline?

• To enhance the quality of patient care• Increasing recognition of the importance of

atherosclerotic lower extremity PAD:– High prevalence– High cardiovascular risk– Poor quality of life

• Improved ability to detect and treat renal artery disease

• Improved ability to detect and treat AAA• The evidence base has become increasingly robust,

so that a data-driven care guideline is now possible

Natural History of PADAge > 50 years

Limb

Morbidity

Cardiovascular Morbidity / Mortality

Worsening Claudication

10-20%

Critical Limb

Ischemia

1-2%

Nonfatal CV Events

20%

Mortality 15-30%

Stable Claudication

70-80%

CV Causes75%

Non CV Causes25%

Quality of Life in Patients with PAD

• Individuals with asymptomatic lower extremity PAD have a worse quality of life and limb function than an age-matched cohort

• The quality of life for patients with severe CLI can be worse than that of patients with terminal cancer

McDermott MM, J Am Geriatr Soc 2002;50:238-46.

Dormandy JA, J Vasc Surg 2000;31(1 pt 2):S1-S296.

Defining a Population “At Risk” for Lower Extremity PAD

• Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia)

• Age 50 to 69 years and history of smoking or diabetes

• Age 70 years and older

• Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain

• Abnormal lower extremity pulse examination

• Known atherosclerotic coronary, carotid, or renal artery disease

Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication

Only 1 in 10 of these patients has classical symptoms of

intermittent claudication (IC)

1 in 5 people over 65

has PAD†

† ABI<0.9

Diehm C et al. Atherosclerosis 2004; 172; 95-105.

Lower extremity systolic pressureBrachial artery systolic pressure ABI =

• The ankle-brachial index is 95% sensitive and 99% specific for PAD

• Establishes the PAD diagnosis

• Identifies a population at high risk of CV ischemic events

• “Population at risk” can be clinically & epidemiologically defined:

The Ankle-Brachial Index

Exertional leg symptoms, non-healing wounds, age > 70, age > 50 years with a history of smoking or diabetes.

• Toe-brachial index (TBI) useful in individuals with non-compressible pedal pulses

Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34; Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14

Lipid Lowering and Antihypertensive Therapy

Treatment with an HMG coenzyme-A reductase inhibitor

(statin) medication is indicated for all patients with

peripheral arterial disease to achieve a target LDL

cholesterol of less than 100 mg/dl.

Antihypertensive therapy should be administered to

hypertensive patients with lower extremity PAD to a goal of

less than 140/90 mmHg (non-diabetics) or less than 130/80

mm/Hg (diabetics and individuals with chronic renal

disease) to reduce the risk of myocardial infarction, stroke,

congestive heart failure, and cardiovascular death.

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Antihypertensive Drug

Beta-adrenergic blocking drugs are effective antihypertensive agents and are not contraindicated in patients with PAD.

The use of angiotensin-converting enzyme inhibitors is reasonable for symptomatic patients with lower extremity PAD to reduce the risk of adverse cardiovascular events



Antiplatelet Therapy

Antiplatelet therapy is indicated to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.

Aspirin, in daily doses of 75 to 325 mg, is recommended as safe and effective antiplatelet therapy to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.



Clopidogrel (75 mg per day) is recommended as an effective alternative antiplatelet therapy to aspirin to reduce the risk of myocardial infarction, stroke, or vascular death in individuals with atherosclerotic lower extremity PAD.


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Why Are We Invloved in the Detection and Treatment of Peripheral Artery Disease ？