Joshua A. Beckman, MD. Brigham and Women s Hospital

Transcription

1 Peripheral Vascular Disease: Overview, Peripheral Arterial Obstructive Disease, Carotid Artery Disease, and Renovascular Disease as a Surrogate for Coronary Artery Disease Joshua A. Beckman, MD Brigham and Women s Hospital

2 Agenda Discuss the concept that atherosclerosis is a systemic disease PAD Carotid disease Renal artery stenosis

3 Atherosclerosis A Progressive Disease Atherosclerosis Thrombosis Stable angina/intermittent claudication Unstable angina MI Ischemic stroke/tia Critical leg ischemia Intermittent claudication CV death ACS Adapted from Libby P. Circulation. 2001;104:

4 Definition of Peripheral Artery Disease (PAD) The presence of a stenosis or occlusion in the aorta or arteries of the limbs One of the three cardinal manifestations of atherosclerosis in addition to CAD & CVD. Associated with an increased risk of cardiovascular and cerebrovascular events, including death, MI, and stroke

5 Prevalence of PAD NHANES 1 Aged >40 years San Diego 2 Mean age 66 years NHANES 1 Aged 70 years Rotterdam 3 Aged >55 years Diehm 4 Aged 65 years 4.3% 11.7% 14.5% PARTNERS 5 Aged >70 years, or years with a history diabetes or smoking 19.1% 19.8% In a primary care population defined by age and common risk factors, the prevalence of PAD was approximately one in three patients 29% 0% 5% 10% 15% 20% 25% 30% 35% NHANES=National Health and Nutrition Examination Study; PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program]. 1. Selvin E, Erlinger TP. Circulation. 2004;110: Criqui MH et al. Circulation. 1985;71: Diehm C et al. Atherosclerosis. 2004;172: Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18: Hirsch AT et al. JAMA. 2001;286:

6 Risk Factors for PAD Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia C-Reactive Protein Relative Risk Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

7 PARTNERS: Prevalence of PAD and CVD in Primary Care Practices 29% of Patients Were Diagnosed With PAD Using ABI 29% 44% 56% Patients diagnosed with PAD PAD only PAD and CVD ABI=ankle-brachial index; CAD=coronary artery disease; CVD=cardiovascular disease. Hirsch AT et al. JAMA. 2001;286:

8 Long-term Survival in Patients With PAD 100 Survival (%) Normal subjects Asymptomatic PAD Symptomatic PAD Severe symptomatic PAD Year Criqui MH et al. N Engl J Med. 1992;326:

9 Contemporary PAD Rates of Myocardial Infarction and Death 3649 subjects (average age 64 yrs) followed up for 7.2 years % Hooi JD, et al. J Clin Epid. 2004;57:

10 Diehm, C. et al. Circulation 2009;120: Event-Free Survival by PAD Status at 5 Years in 2009 Prospective cohort of 6880 unselected patients >65 years of age with follow-up for 5 years pts had no PAD, 836 had asx PAD and 593 had symptomatic PAD

11 Diabetes Increases Risk of Adverse Outcome Among PAD Patients N=136 Patients with PAD undergoing LE Angio Follow-up 4.5 Years OR=5.4 OR=3.1 Jude EB, et al., Diabetes Care. 2001;24:1433.

12 Atherothrombosis & Life Expectancy: Framingham Heart Study In the FHS, healthy individuals aged 60 years who did not have atherothrombosis were expected to live a further 20 years to the age of 80 Comparatively, patients with a history of MI lived 9.2 fewer years Those with a history of CVA lived 12 fewer years Life Expectancy (Years) Fewer years 12 Fewer years 0 Healthy History of MI History of CVA Bakhai A. Pharmacoeconomics 2004; 22(suppl 4): 11-18

13 Proportion of ischemic stroke subtypes: NOMASS White, H. Circ 2005;111:1327

14 Current Event Rates In Patients with Asymptomatic Carotid Stenosis 2684 consecutive patients with arterial disease or type 2 DM, but without a history of cerebral ischemia, with a mean follow up of 3.6 years Goessens, BMB. Stroke. 2007;38:

15 Mayo Clinic Asymptomatic Carotid Endarterectomy (MACE) Study % Mayo Asymptomatic Carotid Endarterectomy Study Group. Mayo Clin Proc. 1992;67:

16 Carotid Bruits Predict Cardiovascular Death Better Than Stroke Pickett, CA. Lancet 2008; 371: 1587

17 Causes of Death in ACAS at 5 Years ACST-Outcome Related Mortality Both Groups Immediate CEA Deferral Perioperative Non-perioperative stroke Other mortality MI or Cardiac Respiratory Neoplastic ACAS Executive Committee JAMA 1995; 273(18):

18 Causes of Death in ACST at 10 Years ACST-Outcome Related Mortality Both Groups Immediate CEA Deferral Logrank p- value Perioperative Non-perioperative stroke Other mortality Vascular Neoplastic Other Halliday, A Lancet 2010; 376:

19 Even Medical Therapy for Carotid Disease Works Better for CAD Heart Protection Study Results Vascular Simvastatin Placebo Net difference Coronary 587 (5.7%) 707 (6.9) 120 Other Vascular 194 (1.9%) 230 (2.2%) 36 Non-Vascular Neoplastic 359 (3.5%) 345 (3.4%) 14 Respiratory 90 (0.9%) 114 (1.1) 8 HPS Study Group. Lancet 2002;360:7-22

20 Blood Pressure Lowering Agents Improve CHD Outcomes More Than Stroke Outcomes HOPE Study Results Vascular Rampril Placebo Net difference CV Death 282 (6.1%) 377 (8.1%) 95 MI 459 (9.9%) 570 (12.3%) 111 Stroke 156 (3.4%) 226 (4.9%) 70 Death 482 (10.4%) 569 (12.2%) 87 HPS Study Group. Lancet 2002;360:7-22

21 Renal and Cardiovascular Events in ASTRAL N. Engl.J.Med: 361: , 2009

22 Mortality in Patients With ARVD Retrospective analysis of records from patients who underwent renal arterial interventions, endovascular or open bypass, between January 1984 and January Ann Vasc Surg 2005; 19:

23 Aboyans, V. JACC 2007; 49(14): By The Way, It s Every Vascular Bed! Baseline and follow-up data (mean 9.8 years) were complete in 1,778 participants. Subclavian stenosis was found in 157 (8.8%) subjects.

24 Summary Atherosclerosis is a systemic disease The rates of cardiovascular morbidity and mortality are always higher than the specific arterial bed involved If you discover atherosclerosis anywhere, know it is everywhere, and needs aggressive medical treatment.