Cardiovascular Disease in CLI Patients

Transcription

1 L E I P Z I G I N T E R V E N T I O N A L C O U R S E Nurse and Technician Forum - Part II Cardiovascular Disease in CLI Patients Corneliu Popescu Universitätsklinikum Leipzig

2 Disclosure Speaker name:... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) x I do not have any potential conflict of interest

3 Introduction: Case-Presentation 71 years old male patient Hospital admission : infected non-healing wounds on right foot, acute deterioration of symptoms Diabetes mellitus type 2 PAOD, Stenting left CIA, fem.-popl. Bypass left 2007 and Re-Bypass left 2011, Minor amputations left CAD (3 vessel-disease) DUS on admission: SFA-Occlusion right AB + Recanalization

4 Introduction: Angiography Long SFA- and BTK-Occlusions Failled primary recanalisation-attempt During intervention: neglect, aphasia, hemiplegia left CT-Scan

5 Introduction: CT-Scan Chronic Occlusion of right ICA but acute stroke (drop of bloodpressure) Stroke-Unit-Treatment

6 Introduction: Disease Process Neurologic disorders, dysphagia, aspiration, pneumonia, intubation, tracheostoma : NSTEMI Coronary angiography: LCA-main stem and RCX- stenosis, RCA-Occlusion During PTCA: CPR Further deterioration Death!!

7 Coprevalence of PAD and polyvascular Disease ~ 3/5 of the 8,273 patients with PAD also have atherothrombotic disease in other arterial territories RISK FACTORS ONLY Patients with PAD = 12.2% of the total REACH Registry population Coronary Artery Disease 1.6% Cerebrovascular 4.7% Periph Art Disease 4.7% 1.2% REACH Registry Investigators, JAMA 2006

8 Mortality Rates in PAD % GetABI-Study S3,German Guideline, PAD, 2015 Diehm C, European Heart Journal (2006) 27,

9 PAD 4-year Mortality Risks Lung Cancer, NIH National Cancer Institute % died within 12 months Kaplan-Meier Model Estimates Reinecke H, Eur Heart J, 2015

10 How to reduce these high mortality risks in PAD?

11 Smoking cessation ESC, 2017 Smoking is the most important risk factor The extent of smoking exposure correlates with PAD disease severity and mortality 1 ES VascSurg, 2011 Smoking cessation programme (22% cessation rate) vs. 5% in the group not undergoing this programm 1 1 Hirsch AT Vasc Med 1997;2(3):243 51

12 Antiplatelet therapy in PAD ESC, 2017 CV risk reduction 1 of 23% (no difference: Aspirin, Clopidogrel) EUCLID-Trial 2 : Ticagrelor not superior to Clopidogrel COMPASS-Trial 3 : Rivaroxaban (2.5 mg twice daily) + Aspirin better CVoutcomes, lower MALE but more major bleeding events 1 Clagett et al, Chest 2004;126(3):609S-626S 3 COMPASS Cardiovascular OutcoMes for People Using Anticoagulation Strategy 2 Hiatt WR et al., N Engl J Med. 2017; 376: 32-4

13 Statins in PAD ESC, 2017 Statins: reducing major vascular events by 22% 1 Statins may prevent plaque instability and thrombosis due to their pleiotropic effects 2 PCSK9-Inhibitors (Evolocumab) added to Statins better reduction of LDL-levels and major events (FOURIER-Trial 3) PAD-subgroup benefits more 1 Lancet 2002;360(9326):7 22, Heart Protection Study 3 2 Sadowitz et al, Vasc Endovascular Surg 2010;44(4):

14 Antihpertensive and diabetes therapy HOPE-Trial 1 : 22% CV risk reduction on in patients randomised to Ramipril Benefit of ACE independent of lowering BP ESC, 2017 Controversial data to CV-mortality Significant postive effects on microvascular complications 2 1 N Engl J Med 2000;342: Patel et al, N Engl J Med 2008;358(24):

15 Patients not receiving proven therapy (%) Undertreatment of risk factors 60 Antiplatelets Lipid-lowering Statin CAD (n=40,258) Cerebrovasc Dis (n=18,843) PAD (n=8,273) Multiple Risk Factors (n=12,389) REACH Registry Investigators, JAMA 2006

16 Adherence to Guidelines & Survival 56% CLI-patients Adherence to guideline-recommended therapies (smoking cessation, antiplatelet, antihypertensive (ACE) & statin therapy) improves survival in PAD patients Only 32% of the patients met all 4 guideline-recom. therapies Armstrong EJ et al. JAHA 2014

17 Summary Cardiovascular mortality in PAD patients is high Cardiovascular mortality in CLI patients is higher Still lacks in medical therapy in patients with PAD/CLI Treat PAD-patients accordingly to guidelines: Statins Platelet-Inhibitors ACE-Inhibitors Smoking cessation Promissing new data from NOACs and PSCK9-Inhibitors on further risk reduction