Peripheral Arterial Disease Medical Approach and Management

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1 Peripheral Arterial Disease Medical Approach and Management April 2, 2016 Michael F. Hagerty, MD FACC

2 PAD: Classic and New Concepts Let s take a look at what s new and what s old or classic in 2016.

3 PAD: What s Old PAD can kill and disable, but nothing like the numbers of CAD and stroke. Pre-op evaluation, the good and bad. Why does it occur in some locations more than others?

4 PAD: What s New Concept of Aortopathy New Screening for AAA around the corner BRIDGE Trial SPRINT Trial

5 Important Concept: PAD rarely kills compared to CAD and stroke. Atherosclerosis of the heart and brain kills and disables. The overall disease burden is related to mortality. The lower the ankle:brachial index, the higher the risk of AMI, stroke, death

6 Medical Approach PAD Surrogate for CAD Rx every patient with PAD as if they have had an MI, stent, CAD

7 Definition of PAD Presence of a stenosis in the aorta or some other expression of aortopathy (aneurysm). Stenosis of extremities in the limbs.

8 PAD Etiology Same etiology and risk factors as coronary atherosclerosis. Often stenosis occurs at bifurcations and kinking due to the rheology of flow. Laminar (internal mammary, brachial, radial) flow vessels have little or no stenosis Origin often just distal to branch vessels non laminar flow perpendicular to these surfaces just distal to bifurcation.

9 Bifurcations and kinks have the added load of rheology and turbulent flow when combined with the underlying basic risk factors in an individual with atherosclerosis Smoking, HTN, cholesterol, FH, etc.

10 10

11 CAD Lesions Common Just distal to bifurcations: Proximal CAD Proximal Circumflex Proximal Diagonal

12 PAD Patients Pre-op By definition, a high risk group. Surrogate for CAD Older Functional class generally <4 METS. DM, HTN, etc.

13 Pre-op Stress Testing Simply increases the predictive probability compared with clinical risk indexes alone RCRI (Recessed Cardiac Risk Index) NSQ18 MICA (National Surgical Quality Improvement Program for Myocardial Infraction and Cardiac Arrest) Still MI in 30% of patients with normal stress tests* *Beattie etal, Met Analysis of Preop Nuclear Testing and Stress Echo Imaging, Anes Analog 2006; 102:8-16.

14 Pre-Op Medications to Reduce Cardiac Risk Perioperationly Aspirin B-Blocker Statins Though commonly used, data is mixed.* *Devereaux, etal. Cardiac Complications in Non Cardiac Surgery. NEJM 372:23; 2015, pp

15 Medical Management of Claudication Smoking cessation Smoking cessation Smoking cessation Exercise program, cardiac rehab Pharmacologic agents

16 PAD: What s New Concept of Aortopathy New Screening for AAA around the corner BRIDGE Trial SPRINT Trial

17 Medical Approach PAD Aortopathy Weakness and/or dilation of a major artery due to congenital (marfan, bicuspid aortic valve) or acquired (smoking, vasculitis, hypertension).

18 Screening for abdominal aortic aneurysm Changes in standard screening Males Age >65, present or former smoker All men >75 would pick up 20-25% of all AAA deaths 300 Scans to save one life 34 Scans to save one year of life

19 By 2030: 91% >65 years of age 62% >75 years of age 29% Female (As people live longer and smoking decreases) Very unusual today to see a AAA in someone who has never smoked, but with aging, that will change.

20 Bridging Patients with Afib BRIDGE Trial non-inferiority Bridge with Lovenox vs NO Bridging

21 BRIDGE Trial Douketis etal, Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. NEJM, 2015, 373:

22 BRIDGE Trial Randomized, double blind, placebo controlled Afib patient s on anticoagulation pre-op Half bridged, Lovenox 1 mg / kg, BID for 3 days preprocedure, D/C 24 before operation. *NEJM 373, 2015; pp

23 BRIDGE Trial Restart Lovenox post-op, D/C when INR >2 versus no BRIDGE Stop Warfarin 5 days pre-op and resume 24 hours post-op

24 BRIDGE Trial Results: No inferiority for thromboembolism (0.4% no BRIDGE, 0.3 % BRIDGE) Major bleeds No BRIDGE 1.3% BRIDGE 3.2% P valve 0.005

25 SPRINT Trial Systolic Blood PRessure InterveNtion Trial *NEJM, Nov : ; The SPRINT Research Group sponsored by NHLBI, NIH Grant.

26 Randomized patients <75, No diabetes with BP >130 systolic on treatment: ½ observe, usual care, leave BP systolic ½ get to 120 systolic

27 Most Remarkable Observation Trial stopped due to profound end point changes after only 3 ¼ years Stroke, MI, CHF, death all reduced P < to 0.003

28 Expected Side Effects More pre-syncope, syncope Electrolyte problems Acute renal injury All higher in intensive Rx group

29 What Did SPRINT Teach Us The lower the BP, the better in nondiabetic < age 75 Hard end point reduction highly conclusive Get ready for the side effects This will change management in only the highly motivated patient

30 Medical Approach to PAD Always ask myself two questions when across from a patient: How can I help you feel better? How can I help you live longer?

31 Physician Use of Secondary Prevention Therapies in PAD Statin Use 18.7% 57.5% ACE/ARD Use 20.8% 34.3% AntiPlatelet Use 27.4% 65.8% 0.0% 17.5% 35.0% 52.5% 70.0% PAD With CUD PUD Without CAD

32 Medical Approach HTN, 120 systolic (SPRINT Trial) LDL no floor, lower is better Cigarette cessation (is the e-cig an alternative?) DM control Aspirin, Plavix Oral anticoagulation as indicated

33 Conclusions When you see a patient with a bad irreversible stroke, amputation, a ruptured aneurysm you get the picture The game has often been played and we ve lost.

34 Conclusions con t. Best to aggressively identify and treat these people earlier, when we have a real shot at lowering morbidity and mortality.

35 Conclusions con t. No cigs, nicotine probably okay. Drop LDL to the floor Drop BP as low as patient allows Thin the blood

36 Thank you for your time! Any Questions?

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Medical Apps for Cardiology Uses There s an App for That! Audience Participation Question #1 1. ASCVD Risk App What is the predicted 10 year CV event rate for a 57 y/o black male patient with treated