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1 DECLARATION OF CONFLICT OF No conflict INTEREST
2 Mangement of Polyvascular Disease Diagnostic work-up Augusto Gallino, Bellinzona Switzerland ESC, Paris, august 29 th 2011
3 Polyvascular Disease In the last years the scientific and medical communities have recognized the important increasing role of peripheral and polyvascular disease TASC I Vasc Surg 2000;31:S1-S296 TASC II. J Vasc Surg 2007;45 Suppl S:S5-67 Eur Heart J 2006;27: JAMA 2007;297: Circulation 2006;113:e
4 Prevalence of peripheral arterial disease 1 in 5 elderly people (aged 65 years) visiting the GP has PAD Diehm C et al. Atherosclerosis 2004; 172(1):
5 Prevalence of peripheral arterial disease 1 in 5 elderly people (aged 65 years) visiting the GP has PAD Only 1 in 10 of these PAD patients will have classical symptoms of intermittent claudication Diehm C et al. Atherosclerosis 2004; 172(1):
6 Prevalence of peripheral arterial disease 1 in 5 elderly people (aged 65 years) visiting the GP has PAD Only 1 in 10 of these PAD patients will have classical symptoms of intermittent claudication If one relies solely on classical symptoms of intermittent claudication you will not see much PAD Diehm C et al. Atherosclerosis 2004; 172(1):
7 *Eurostat, **getabi Estimated prevalence of peripheral arterial disease in the European Union 500,000,000 inhabitants* 17.1% aged > 65 years* 20% of patients aged > 65 years have PAD**
8 *Eurostat, **getabi Estimated prevalence of peripheral arterial disease in the European Union 500,000,000 inhabitants* 17.1% aged > 65 years* 20% of patients aged > 65 years have PAD** 17,000,000 patients with PAD in EU
9 Cumulative survival (%) Prognosis of polyvascular patients CAD=CORONARY ARTERY DISEASE CVD=CEREBROVASULAR DISEASE PAD=LOWER LIMB ARTERY DISEASE AAA=AORTIC ANEURYSM CAD CVD PAD AAA Follow-up (years) Patients with noncoronary atherosclerosis have a poorer prognosis than patients with isolated CAD Welten et al. JACC 2008;51:
10 Co-prevalence of disease Circulation. 2006;113:e46
11 Co-prevalence of disease Circulation. 2006;113:e46
12 Co-prevalence of disease Circulation. 2006;113:e46
13 Co-prevalence of disease Circulation 2006;113:e Gallino A, Lekakis J,Baumgartner, Vlachopoulos B,Cosentin F EHJ (submission)
14 Co-prevalence of disease Circulation 2006;113:e
15 Co-prevalence of atherosclerosis The distribution, Predominance, and Co-prevalence of atherosclerosis remain frequently elusive Circulation. 2006;113:e46 Gallino A, Lekakis J,Baumgartner, Vlachopoulos B,Cosentino F et al EHJ (submission) Am J Epidemiol. 2006;164: Lekakis, Vlachopoulos B, Gallino A,Cosentino F et al JEur J Cardiovasc Prev Rehabil. 2011
16 Co-prevalence of atherosclerosis Loco regional hemodynamic, Rheological factors - turbulent flow at bifurcations or - side branches Bianda,Wyttenbach,Gallino et al EHJ in press 2011
17 Chronic positive remodeling of Carotid Atherosclerosis in vivo non invasive demonstration by plaque MRI femoral carotid Bianda,N Wyttenbach R, Segatto JM,Gallino A et al EHJ in press 2011 baseline 2 year follow-up
18 Bianda,N Wyttenbach R,Segatto JM Gallino A et al EHJ in press 2011
19 Co-prevalence of disease depends on the diagnostic tools PAD patient : prevalence of CAD history : 1/3 stress test: 2/3 Coronary angiography:>70% Circulation. 2006;113:e46 J Vasc Surg. 2007;45:S5 S67
20 Co-prevalence of disease in CVD 60% 50% 51% 40% 30% 20% 10% 0% Courtesy Prof Schouten 37% 25% 17% 12% 4% AAA CAD PAD Known Total
21 DIAGNOSTIC WORK-UP IN POLYVASCULAR DISEASE
22 DIAGNOSTIC WORK-UP IN POLYVASCULAR DISEASE Typical claudication Clinical examination ABI
23 DIAGNOSTIC WORK-UP IN POLYVASCULAR DISEASE CAD PAD AAA CVD
24 DIAGNOSTIC WORK-UP IN POLYVASCULAR DISEASE ABI The ability - through simple diagnostic tools, such as the measurement of the ankle pressure brachial index (ABI) has increased the attention for this field. 7 JAMA 2001;286:
25 ABI Diehm C. et al. Circulation 2009;120:
26 Duplex carotid screening is justified in a selected population 1,2 1)J Vasc Surg. 2003; 37: )J Vasc Surg. 2003; 38:
27 TEE R. Corti, A. Gallino. Circulation 1999;100:
28 US for AAA U.S. Preventive Services Task Force: 1-time screening with abdominal for all men age 65 to 74 years who have ever smoked 1 AHA guidlines: screening men > 60 years with family history MASS (UK):sustained benefit in men >65 < 75 2 Screening in Polyvascular disease?! 1)Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. 2005;142: ) Ann Intern Med. 2007;146:
29 CT Corti R, Gallino A Circulation 1998; 98 :
30 Dewey, M. et al. Circulation 2009;120: J Nucl Cardiol 2005;12: CT CT-scanning: <1mSv Few minutes Automated Reproducable ~200 $
31 Periphere arterielle Krankheit :Aorta Massive atheroslcerose MRI Vergleichender Befund in Magnet Resonanz vor der OP Vor OPS Massive atherosclerose der Aorta Chirurgischer Befund R.Corti and A.Gallino, Circulation,1999;100:
32 Won Yong Kim, Anne Sofie Astrup, Matthias Stuber Circulation 2007;115; Wyttenbach R, Gallino A., Fuster V. et al Circulation. 2004;110:
33 Diagnostic work-up in Polyvascular disease
34 Polyvascular disease Diagnostic work-up in case of PAD CAD? : ask for symptoms test for detection of ischemia if consider coronary angiography in case of no CAD symptoms: consider seriously test for detection of ischemia CVD? : ask for symptoms,clinical examination, consider Duplex US extracranial cerebral arteries AAA? :consider abdominal US when >55, tobacco use arterial hypertension Circulation 2006;113:e Gallino A, Lekakis J,Baumgartner, Vlachopoulos B, Cosentino F et al EHJ (submission)
35 Polyvascular disease Diagnostic work-up in case of CVD PAD? : ask for symptoms:when + determine ABI CAD? : ask for symptoms:only when / or necessity of CVD revascularisation consider test for detection of ischemia and when needed- revascularisation AAA? :consider abdominal US when >55, tobacco use arterial hypertension Circulation 2006;113:e Gallino A, Lekakis J,Baumgartner, Vlachopoulos B, Cosentino F et al EHJ (submission)
36 Polyvascular disease Diagnostic work-up in case of CAD PAD? : look for symptoms or clinical finding, measure ABI : when consider further tests and TX CVD? : look for symptoms or clinical findings: when consider Duplex US AAA? : consider abdominal US when >55, tobacco use arterial hypertension Circulation 2006;113:e Gallino A, Lekakis J,Baumgartner, Vlachopoulos B, Cosentino F et al EHJ (submission)
37 TAKE HOME MESSAGE 1 Awareness of, and active search of polyvascular disease with the help of simple diagnostic tools are essentials for the detection of disease Once diagnosed efforts should be made for a holistic management aiming at treating and preventing the whole spectrum of the disease
38 TAKE HOME MESSAGE 2 Ideally an interdisciplinary including: dedicated cardiologist, specialist in vascular medicine, vascular surgeon, radiologist and an endovascular specialist,
39 TAKE HOME MESSAGE 3 The greater the number of sites affected, the greater the risk of major cardiac event. Take steps to lower your odds Duke Med Health News Jul;14(7):4-5
40 THANK YOU
Joshua A. Beckman, MD. Brigham and Women s Hospital
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