Peripheral Arterial Disease: Recognition and Screening

Transcription

1 Peripheral Arterial Disease: Recognition and Screening Pete Fong, M.D., F.S.C.A.I., F.A.C.C. December 8, 2012 Kingston, Jamaica

2 Disclosures Site primary investigator for the EUCLID trial (AstraZeneca) Site sub-investigator for the SYMPLICITY HTN-3 trial (Medtronic) No financial conflicts

3 The lower extremities: A pathway to the heart and brain in more ways than one...

4 The lower extremities: A pathway to the heart and brain in more ways than one...

5 PVD Non-coronary arterial Venous Circulation Lymphatic Circulation PAOD (PAD) Valvular incompetence Lymphedema Functional (vasoreactive) Venous htn acquired Aneurysmal DVT congenital PTE Postthrombotic syndrome Varicose veins

6 New patient visit CC: Establish care HPI: 65 yo woman with 50 pk yr tob use history, DM II, htn, hyperlipidemia. + nausea and fatigue without inciting event over the past 3 weeks. Denies cp or sob. C/o bilateral hip pain attributed to OA with walking to mailbox and with prolonged standing.

7 New patient visit Meds: Metformin 500 mg bid, effexor 100 mg qday, lotrel 5/20, nexium 40 qday, glucotrol 10 mg bid, vicodin prn ALL: Asa itching PE: P80, BP178/90, wt 130. CTA. RRR 2/6 sys murmur. No carotid bruits. Nl abd. DP and PT pulses 1+. Fem pulses 2+, bilateral bruit. Trophic pre-tibial skin changes. ECG: SR, NSST inf.

8 PAD recognition and screening Should she be screened for PAD? How should she be screened? What is her likelihood of having PAD and CVD? How should she be managed?

9 Pathophysiology Atherosclerosis: most common Collagen disorders (Marfan and Ehlers-Danlos syndrome; Cystic medial necrosis, arteriomegaly, neurofibromatosis, atherosclerotic aneurysms) Fibromuscular dysplasia Vasculitis Thromboembolic Vasospastic

10 Prevalence of PAD by Age Hirsch. ACC/AHA Practice Guidelines

11 PAD Prevalence is 12%. Typical claudication only in 1/3 of PAD patients. 50% have CV disease. Hiatt. NEJM. 344; 21. P 1609

12 Why screen for PAD?

13 Peripheral Disease Detection, Awareness, and Treatment in Primary Care. PARTNERS. Hirsch. JAMA. Sept 19, 2001; 286: 11. P pts >70 or with DM or smokers 350 primary care practices Evaluation History ABI PAD confirmed < 0.9 History of PAD (29%)

14 Within the PAD Subset of PARTNERS, over 50% also had CVD 1040 (56%)

15 Under usage of anti-platelet therapy

16 Increased Mortality, MI, and CVA risk with PAD 50% of pts with PAD have CAD. REACH Survey 10-20% of pts with CAD have PAD % increase in MI CVA risk increased 40% TASC II. Eur J Vasc Endovasc Surg 33, S1-70.

17 PAD: recognition In PARTNERS, physicians would have missed 85% of pts with PAD if they depended only on a history of classic intermittent claudication. Identifying patients with PAD is an opportunity to impact morbidity and mortality.

18 PAD: Natural history Adapted from Hirsch. ACC/AHA Practice Guidelines P5.

19 PAD patients have a 2-5 fold increased risk of CV death per year Hiatt. NEJM. 344; 21. P 1609

20 Annual mortality and morbidity of PAD patients Mortality= 2% per year Non-fatal MI, stroke and vascular death = 5%-7% per year TASC II. Eur J Vasc Endovasc Surg 33, S1-70

21 PAD Evaluation and Screening

22 Screening > 50 yo with h/o smoking or dm > 65 yo claudication or ischemic rest pain Abnormal le pulse exam Known atherosclerotic coronary, carotid, or renal arterial disease. Hirsch. ACC/AHA Practice Guidelines P3

23 Vascular History Location of symptoms Description of discomfort Ameliorating/exacerbating factors Reproducible characteristics? Non-healing ulcers? Atypical claudication

24 Vascular Physical bilateral arm bp s carotid palpation and auscultation abdomen and flank auscultation for bruits abdominal aortic pulsation and diameter brachial, radial, ulnar, femoral, popliteal, dp, pt pulse palpation. auscultation of bil fem arteries Pulse intensity: 0, absent; 1, diminished; 2, normal; 3, bounding Inspect feet for ulcers, skin integrity, color, temp, etc.? distal hair loss, trophic skin changes, hypertrophic nails

25 Screening Class I Screening recommendation Hiatt. NEJM. 344; 21. P 1609

26 Ankle Brachial Index ABI Interpretation > 1.4 Incompressible Normal Borderline NL Mild PAD Moderate PAD < 0.4 Severe PAD Hiatt. NEJM. 344; 21. P 1610

27 ABI: inverse relationship with mortality and cardiovascular event rate Each decrease in ABI of 0.1 is associated with a 10% increase in relative risk for a major vascular event. TASC II. Eur J Vasc Endovasc Surg 33, S1-70.

28 PAD Management PAD Tob cessation, LDL < 100 A1c < 7, BP < 130/85, (ACE-I) Asa or plavix Claudication? Severity? Location, walk distance Vocational or exercise limiting Critical leg ischemia Medical therapy (Cilostazol) Exercise program Symptoms improve. CPT Worsening symptoms: Localize lesion duplex, PVR segmental pressures, CTA, MRA, Angio Revascularization: Endovascular Surgery Hiatt. NEJM. 344; 21. P 1612

29 Management Risk factor Goals Therapy Efficacy Lipoproteins LDL < 100 mg/dl Statin (first line) ++ Anti-platelet Rx Mandatory ASA/clopidogrel ++ Blood pressure < 140/90 mm Hg ACEI (first line) B-BL with CAD DM HbAIC < 7.0% Orals/insulin Actos,avandia + + Tobacco smoking Complete cessation Counseling/drugs +++

30 Tobacco cessation Counseling and combination therapies are Key.

31 Smoking cessation: beneficial effects Decreases: Amputation Need for revascularization Failure of bypass grafts Improves walking times Improves survival

32 1 HOPE trial. NEJM. 2000; 342: Hope: Altace reduced mi, cva, vascular death 25% in PAD pts 1 Ahimastos: Ramipril associated with increased walking distance 2 2 Ahimastos. Ann Intern Med. 2006;144:

33 Statins: multiple benefits in PAD Prevent MI, Stroke, Death In heart protection study, simvastatin reduced risk of non-coronary revascularization by 20% Improves claudication May slow rate of functional decline Heart protection study. Lancet. 2002;360:7-22 Mohler. Circulation. 2003; 108:1481 Aronow. Am J Cardio 2003;92: Mondillo. Am J Med. 2003;114: Girgi. J Am Coll Cardiol. 2006;47:998

34 CAPRIE trial. Lancet. 348; P In the subset of 6300 pts with PAD; clopidogrel reduced MI, stroke, vascular death 23.8% compared with asa

35 EUCLID Hypothesis: Examining Use of ticagrelor In pad ticagrelor monotherapy when compared with clopidogrel monotherapy will reduce mace (CV death, MI, CVA) in patients with established PAD. Study Design: randomized, double blind 900 sites (350 us), 25 countries, 11,500 patients Pts followed for months

36 ACC / AHA Class I recommendations for asymptomatic PAD management Smoking cessation HTN management Lipid management DM management Anti-plt therapy

37 Case Summary Should she be screened for PAD? > 50 yo with h/o smoking or dm > 65 yo claudication (leg symptoms with exertion) or ischemic rest pain Abnormal pulse exam Known atherosclerotic coronary, carotid, or renal arterial disease. How should she be screened? History, physical exam and abi s. What is her likelihood of having PAD and / or CVD? 20-30%, 50% likelihood of having overlap pad and cvd if pad present. How should she be managed? Smoking cessation, asa, ace-i, dm management, statin

38 Symptomatic PAD HPI: 67 yo gentleman with CAD, hyperlipidemia, 40 pk yr tob use, and 1/2 block right lower extremity claudication relieved with rest. He would like to improve his exercise tolerance and walk with less pain. Meds: lisinopril 20 mg qday, metoprolol 100 mg qday, atorvastatin 40 mg qhs, asa 81 mg qday PE: BP 118/70, hr 65, Pulses bilateral fem 2+, lt pt 1+, lt dp 1+, rt pt 2+, rt dp 2+, no fem bruits.

39 Symtomatic PAD Evaluation and Management PAD Tob cessation, LDL < 100 A1c < 7, BP < 130/85, (ACE-I) Asa or plavix Claudication? Severity? Location, walk distance Vocational or exercise limiting Critical leg ischemia Medical therapy (Cilostazol) Exercise program Symptoms improve. CPT Worse: Localize lesion duplex, PVR segmental pressures, CTA, MRA, Angio Revascularization: Endovascular Surgery

40 Evaluation ABI. Rest and exercise TBI (Toe Brachial Index) Segmental pressures Pulse volume recordings Doppler Ultrasound Duplex Ultrasound Angiography: MRA, CTA, Peripheral Angiography

41 ABI Quick screening technique TBI Useful with noncompressible TP and PT (ABI > 1.3) Segmental Pressures - Anatomic localization, monitor perfusion post revascularization Doppler Anatomic localization, monitor perfusion post revascularization

42 CT angiogram Ionizing radiation Iodinated contrast Metal artifact Quick Readily available Doughnut CTA v. MRA MRA Magnetic field Paramagnetic agent Metal artifact Slow Moderate availability Tunnel

43 PERIPHERAL ANGIOGRAPHY

44 Options?

45 Medication Mechanism/effect Efficacy Cilostazol Pentoxifylline FDA approved for relief of claudication Type III PE inhibitor contraindicated if chf Vasodilator, anti-platelet, improves lipoprotein FDA approved for relief of claudication Methylxanthine derivative Improves RBC deformability, anti-platelet, reduce fibrinogen ++ +

46 Cilostazol (Pletal) Improves walking distance by 40 to 60% after weeks. Increases cyclic amp. Inhibits platelet aggregation, formation of arterial thrombi, and vascular smooth muscle proliferation, causes vasodilation. Blackbox warning for chf patients Hiatt. NEJM. 344; 21. P 1618

47 Exercise 20 randomized trials have demonstrated its benefits. Better than drugs (for walking distance) Class I: Supervised training x min minimum at least 3 x per week x 12 weeks. Key is walking to near maximal pain. Limitations: Needs a motivated patient in a supervised setting. Not covered by insurance. Must be maintained or benefits will be lost.

48 Surgery? Recommended for type D lesions: CTO of the Femoral > 20 cm, involving the popliteal artery CTO of the popliteal and proximal trifurcation vessels

49 Type A lesion: Single stenosis < 10 cm Endovascular therapies

50 Endovascular therapies Balloon angioplasty Stent Balloon Expandable (bare metal and covered) Self Expanding (nitinol and covered) Medicated Stents Atherectomy Medicated balloons (Paclitaxol)

51 Balloon Angioplasty Most long term data Least expensive Patency rates: 1 yr = 50-75% 3 yrs = 60% 5 yrs = 55% But, only 35% patency at 1 yr in long lesions (4-13 cm) Lesion length, run-off, and primary endpoint matter (revascularization v. duplex defined restenosis) Schillinger. Nejm.2000;354(18):

52 Stents Balloon expandable Self expanding Metal alloy, nitinol, or covered Drug eluting v. bare 1 yr patency: 60-80%

53 Zilver PTX Trial DES: 90% patency BMS: 73% patency Dake. Circ Cardiovas Interv. 2011; 4:

54 Atherectomy 1 yr patency = 80% Zeller. JACC. 2006; 48(8):1573-8

55 Many options... Depends on the location and length of the lesion. Depends on whether a stenosis or chronic total occlusion. Depends on run-off.

56 Atherectomy

57 Conclusions PAD is prevalent in the elderly, diabetics and tobacco users. PAD is associated with cardiovascular risk factors, coronary and carotid disease, and predicts cardiovascular and overall mortality. PAD screening, evaluation and management includes a combination of non-invasive, medical, endovascular and surgical options.

58 Thank You!