PADPADA Call to ActionA Call to Action

PAD: A Call to ActionPAD: A Call to Action

-- What is peripheral arterial disease What is peripheral arterial disease (PAD)? and why is it so dangerous? (PAD)? and why is it so dangerous?

-- Diagnosing PAD in the primary care Diagnosing PAD in the primary care settingsetting

-- The importance of aggressive riskThe importance of aggressive risk

management of PADmanagement of PAD

-- Evidence base for protecting Evidence base for protecting patients with PADpatients with PAD

Major manifestations of Major manifestations of atherothrombosis includeatherothrombosis include

Cerebrovascular diseaseCerebrovascular disease

Coronary artery diseaseCoronary artery disease

Renal artery stenosisRenal artery stenosis

Visceral arterial diseaseVisceral arterial disease

Peripheral arterial diseasePeripheral arterial disease– Intermittent claudicationIntermittent claudication– Critical limb ischemiaCritical limb ischemia

Prevalence of metabolic syndrome in each patient

group (%)

Prevalence of metabolic syndrome in each patient

group (%)

Cross-Sectional survey of 1,045 vascular disease patientsCross-Sectional survey of 1,045 vascular disease patients

40%40%

00

2020

4040

6060

CHDCHD

43%43% 45%45%

57%57%

StrokeStroke AAAAAA PADPAD

Olijhoek JK et al. Eur Heart J 2004; 25: 342-348.

Metabolic syndrome is more Metabolic syndrome is more common in PAD than in CHD or common in PAD than in CHD or

strokestroke

AAA = Abdominal Aortic Aneurysm

Prevalence of PAD increases Prevalence of PAD increases with agewith age

0

10

20

30

40

50

60

55-59 60-64 65-69 70-74 75-79 80-84 85-89

Age group (y)

Figure adapted from Creager M, ed. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000.

1 Meijer WT et al. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.

2.Criqui MH et al. Circulation 1985; 71: 510-515.

Pat

ien

ts w

ith

PA

D (

%)

Pat

ien

ts w

ith

PA

D (

%)

Rotterdam Study (ABI Test <0.9)1 San Diego Study (PAD by noninvasive tests)2

Mortality is very high in patients Mortality is very high in patients with severe PADwith severe PAD

Relative 5-year mortality

1. Criqui MH. 1. Criqui MH. Vasc MedVasc Med 2001; 2001; 66 (suppl 1): 3–7. (suppl 1): 3–7.

2. McKenna M 2. McKenna M et alet al. . AtherosclerosisAtherosclerosis 1991; 1991; 8787: 119–28. : 119–28.

3. Ries LAG 3. Ries LAG et alet al. (eds). . (eds). SEER Cancer Statistics ReviewSEER Cancer Statistics Review, 1973–1997. US: National Cancer Institute; 2000., 1973–1997. US: National Cancer Institute; 2000.

Pat

ien

ts (

%)

0

5

10

15

20

25

30

35

40

45

50

Colon/rectalcancer1

Breast cancer1

SeverePAD2

Non-Hodgkin’slymphoma3

15

38

44

48

Resnick HE et al. Circulation 2004; 109: 733-739.

There is a strong two-way There is a strong two-way association between decreased ABI association between decreased ABI

and increased risk for and increased risk for cardiovascular deathcardiovascular death11

Baseline ABI*

Per

cen

t

0

20

40

60

<0.60 (n=25)

70

50

30

10

0.60-<0.70 (n

=21)

0.70-<0.80 (n

=40)

0.80-<0.90 (n

=130)

0.90-<1.0 (n

=195)

1.0-<1.10 (n

=980)

All-cause mortality

CVD Mortality

*Mean participant follow-up 8.3 years

Guidance for PAD diagnosisGuidance for PAD diagnosisSTEP 1STEP 1 Assess patient for risk factorsAssess patient for risk factors

– smokingsmoking– diabetesdiabetes– hypertension hypertension – age: men >55 years and women >65 years age: men >55 years and women >65 years – hyperlipidaemiahyperlipidaemia– history of cardiovascular diseasehistory of cardiovascular disease

Assess patient for leg symptomsAssess patient for leg symptoms– intermittent claudicationintermittent claudication– critical limb ischaemiacritical limb ischaemia

Tools: PAD checklist, Rose questionnaire, Tools: PAD checklist, Rose questionnaire, Edinburgh questionnaireEdinburgh questionnaire

STEP 2STEP 2 If suspicion of PAD, perform an ABI to If suspicion of PAD, perform an ABI to

confirm diagnosis using a hand-held confirm diagnosis using a hand-held DopplerDoppler

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

A screening ABI should be performed in patients A screening ABI should be performed in patients with with diabetesdiabetes

The American Diabetes Association The American Diabetes Association recommends screening for PAD in recommends screening for PAD in

patients with diabetespatients with diabetes

1. American Diabetes Association. Diabetes Care 2003; 26: 3333-3341.

2. Estes JM, Pomposelli FB Jr. Diabet Med 1996: 13: S43- S57.

Those <50 years of age who Those <50 years of age who have other risk factors have other risk factors associated with PADassociated with PAD

• SmokingSmoking• HypertensionHypertension• HyperlipidaemiaHyperlipidaemia• Duration of diabetes Duration of diabetes >10 years>10 years

Those >50 years of ageThose >50 years of age

• If normal an exercise If normal an exercise test should be test should be carried out carried out

• The ABI test The ABI test should be repeated should be repeated every 5 yearsevery 5 years

• Foot care is also important in diabetic patients as PAD is a major contributor to diabetic foot problems2

Risk factor management Risk factor management approach approach

Smoking cessationSmoking cessation

Weight reductionWeight reduction

Total cholesterol <175 mg/dL / <4.5 mmol/LTotal cholesterol <175 mg/dL / <4.5 mmol/L

LDL cholesterol <100 mg/dL / <2.6 mmol/LLDL cholesterol <100 mg/dL / <2.6 mmol/L

Glycosylated haemoglobin <7.0% Glycosylated haemoglobin <7.0%

Blood pressure (BP) <140/90 mm HgBlood pressure (BP) <140/90 mm Hg

– For patients with diabetes BP < 130/80mm HgFor patients with diabetes BP < 130/80mm Hg

Platelet inhibitionPlatelet inhibition

Hiatt WR. N Engl J Med 2001; 344: 1608-1621.

Key learning pointsKey learning points

Ensure aggressive and early Ensure aggressive and early risk management of patients risk management of patients who are at high risk but may who are at high risk but may be asymptomaticbe asymptomatic

Screen patients with diabetes Screen patients with diabetes >50 years of age, and those >50 years of age, and those <50 years of age who have <50 years of age who have additional risk factors additional risk factors associated with PADassociated with PAD

Only 1 in 10 patients withOnly 1 in 10 patients withPAD have typical PAD have typical claudicationclaudication11

Patients with diabetes are Patients with diabetes are at high risk of PADat high risk of PAD

It is important to improve It is important to improve the management of PAD tothe management of PAD toprotect patients from an protect patients from an increased risk of ischaemic increased risk of ischaemic eventsevents

REMEMBER ACTION

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

Overall learning pointsOverall learning points PAD is a reliable warning sign that a patient is at high PAD is a reliable warning sign that a patient is at high risk for life threatening cardiovascular and risk for life threatening cardiovascular and cerebrovascular eventscerebrovascular events

PAD is easily overlooked by both patients and PAD is easily overlooked by both patients and physicians – assess whether patients presenting with physicians – assess whether patients presenting with symptoms or associated risk factors have PADsymptoms or associated risk factors have PAD

Treatments are available to protect the patients with Treatments are available to protect the patients with PAD from future MI or strokePAD from future MI or stroke

Help protect patients Help protect patients with PAD with PAD

from their increased from their increased risk of MI or strokerisk of MI or stroke