When to screen for PAD? Prof. Dr.Tine De Backer Prof. Dr. Jean-Claude Wautrecht

How do we define asymptomatic PAD? A. ABI < 1 B. ABI < 0.9 C. ABI < 0.8 D. ABI > 1

Which % of the common population has A. < 1% asymptomatic PAD? B. 10%-20% C. >20% D. 5-10%

Prevalence 3-10% total population has asymptomatic peripheral arterial disease (ABI<0.9) 1/4 tot 1/3 is symptomatic Increases with age Prognosis is independent of complaints (cardiovascular!)

The PARTNERS Registry (Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival) Hirsch AT et al, JAMA 2001;286: 1317-1324

Patients With PAD (%) Prevalence of PAD Increases With Age Rotterdam Study (ABI <0.9) 1 San Diego Study (PAD by noninvasive tests) 2 60 50 40 30 20 10 0 55-59 60-64 65-69 70-74 75-79 80-84 85-89 Age (years) ABI=ankle-brachial index 1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Criqui MH, et al. Circulation. 1985;71:510-515.

Prevalence (%) Gender Differences in the Prevalence of PAD 18 16 14 12 10 8 6 4 2 Women Men 6880 Consecutive Patients (61% Female) in 344 Primary Care Offices 0 <70 70 74 75 79 80 84 >85 Age (years) Adapted from Diehm C. Atherosclerosis. 2004;172:95-105 with permission from Elsevier.

Prognosis in PAD determined by A. cardiovascular events B. limb amputation C. cancer D. lung disease

Natural History of PAD Age > 50 years Limb Morbidity Cardiovascular Morbidity / Mortality Stable Claudication 70-80% Worsening Claudication 10-20% Critical Limb Ischemia Nonfatal CV Events 20% Mortality 15-30% 1-2% CV Causes 75% Non CV Causes 25%

Relative Risk (95% CI) Relative Risk of Death in Patients with PAD 10 8 6 5.9 (3.0 6.6) 6.6 (2.9 14.9) 4 3.1 (1.9 4.9) 2 0 All Causes CVD CHD Cause of Death CI=confidence interval; CHD=coronary heart disease; CVD=cardiovascular disease. Criqui MH, et al. N Engl J Med. 1992;326:381-386.

Patients (%) 10-Year Natural History in Patients with Intermittent Claudication 100 80 60 40 20 Survival MI Intervention Amputation 0 0 1 2 3 4 5 6 7 8 9 10 Time (years) Ouriel K. Lancet. 2001;358;1257-1264.

Defining a Population At Risk for Lower Extremity PAD Age less than 50 years with diabetes, and one additional risk factor (e.g., smoking, dyslipidemia, hypertension, or hyperhomocysteinemia) Age 50 to 69 years and history of smoking or diabetes Age 70 years and older Leg symptoms with exertion (claudication) or ischemic rest pain Abnormal lower extremity pulse examination Known atherosclerotic coronary, carotid, or renal artery disease Positive Edinburgh questionnaire

Most important risk factor for PAD A. Cholesterol B. Diabetes mellitus C. Smoking D. Hypertension

Risk factors >> Smoking Diabetes Arterial Hypertension Hypercholesterolemia Renal Insufficiency Hyperhomocysteinemia CRP

Fontaine Classification I : no complaints II: pain with exercise = claudicatio intermittens IIa: > 200 m/250 m IIb: < 200 m/250 m III: pain at rest IV: trophic lesions

Rutherford Classification Degree Category Clinical 0 0 Asymptomatic I 1 Mild claudication I 2 Moderate claudication I 3 Severe claudication II 4 Ischemic rest pain II 5 Minor tissue loss, non-healing ulcus III 6 Major tissue loss > metatarsal level, functional foot loss Rutherford RB, J Vasc Surg 1997; 26: 517-538

62 year old smoker, pain in legs for 5 months What will you ask?

History When pain?: after how many meters walking, when walking in a hurry or uphill? Rest pain? Left leg right leg - bilateral? Where?: buttocks, upper legs, calfs How does the pain disappear? DD: orthopedic, back pain, neurogenic

Buttock claudication Thigh claudication Leg claudication Sole claudication

Claudication pain improves with A. Elevation of the leg B. Bending forward C. Standing still D. Laying down

Edinburgh Vragenlijst voor opsporen Claudicatio Intermittens Courtesy of prof. d. G Fowkes

Vascular review of symptoms 1.Exertional impairment 2.Wound healing 3. Leg or feet pain 4. Abdominal pain 5. Family history 6. Coronary artery disease 7. Cerebrovascular disease

Clinical examination Palpation peripheral pulses( carotides/ femorales/popliteae/dorsales pedis/tibiales posteriores) Auscultation (carotides, AA, iliacae, femorales) Color Cold = aspecific Trophic anomalies Delayed capillary refill

Vascular examination : how? Inspection (Percussion) BP 2 arms HR Rhythm Palpation Auscultation

D G Temporales + + Carotides + + Sous-clavières + + Humérales + + Radiales + + Cubitales + + Aorte + Iliaques (+) (+) Fémorales + + Fémorales sup. (+) (+) Poplitées + + Pédieuses + + Tibiales post. + + Péronières (+) (+) TRV - - symétriques? souffles? souffles? symétriques? souffle? diam.? sensible? souffles? souffles? symétriques? souffles? souffles? calibre? pressions perfusion pressions perfusion

B C D A A Dorsalis pedis B Tibialis anterior C Tibialis posterior D Peronealis

0 absent 1 diminished 2 normal 3 bounding Pulse intensity

Technical investigations Doppler Ultrasonography Strandness test Stepladdertest MR angio CT angio IA DSA

Doppler Ankle Brachial Index Belgische Cardiologische Liga Prof. dr. D. Clement

Doppler ABI meting

ABI is A. SBP arms/sbp legs B. DBP arms/dbp legs C. SBP legs/sbp arms D. DBP legs/dbp arms

Ankle-Brachial Index (ABI) ABI = Ankle systolic pressure Brachial systolic pressure Measure ankle and brachial systolic pressures with Doppler Use highest arm and each ankle pressures 1. TASC Working Group. Int Angiol 2000; 19 (suppl): 5-34. 2. Vascular Disease Foundation, 2003. Available at:http://www.vdf.org/abi.htm.

Doppler Measurement of pressure and registration of curve Ankle-Brachial index (ABI) Normal: Pressure Legs > Pressure Arms: ABI > 1 > 0.9 : still normal 0.8-0.9: mildly diminished 0.5-0.8: moderately diminished <0.5: strongly diminished Sensitivity of the test after exercise (walking test or tiptoeing) = Exercise ABI Abnormal ABI is independent predictor of cardiovascular mortality (RR~4) and cerebrovascular diseases (RR~2)

Treadmill test J. Strapart, Q Devreese, J.C. Wautrecht CFPV Paris, 15-17 Mars 2017

Orthopedics 2008 - Volume 31 Issue 8

Cave: Doppler: ABI Resting value can be false negative Normal to increased ABI if calcified vessels Non compressible vessels in diabetes False normal ABI with iliac stenosis: repeat immediately after walking/ knee bending ABI >1,40 (calcifications) (>1.30) TBI: Toe Brachial Index (< 0.70: PAD)

ABI A high level of specificity (83.3-99.0%) and accuracy (72.1-89.2%) was reported for an ABI 0.90 in detecting 50% stenosis, but there were different levels of sensitivity. Sensitivity was low, especially in elderly individuals and patients with diabetes. The test of ABI 0.90 can be a simple and useful tool to identify PAD with serious stenosis, and may be substituted for other non-invasive tests in clinical practice Sensitivity ~79% Specificity ~96% Ultrasound Med Biol 1996; Vasc Med. 2010 Oct;15(5):361-9

Usefulness ABI Confirms clinical suspicion of PAD Diagnosis in asymptomatic patients DD other causes of leg pain Prognostic information: < 0.9: RR cardiovascular mortality ~3-6 The lower ABI, the worse prognosis Strong correlation with coronary and cerebrovascular disease Risk stratification when increased risk profile

Total Mortality (%) Association Between ABI and All-Cause Mortality* 80 70 60 Risk increases at ABI values below 1.0 and above 1.3 N=5748 50 40 30 20 10 0 <0.61 0.61-0.70 0.71-0.80 0.81-0.90 0.91-1.00 1.01-1.10 1.11-1.20 1.21-1.30 1.31-1.40 >1.40 (n=156) (n=141) (n=186) (n=310) (n=709) (n=1750) (n=1578) (n=696) (n=156) (n=66) Baseline ABI Age range=mid- to late-50s; ABI=ankle-brachial index; *Median duration of follow-up was 11.1 (0.1 12) years. Adapted from O Hare AM et al. Circulation. 2006;113:388-393.

Percent (%) There is a strong correlation between the decrease of ABI and the increased risk of cardiovascular death 70 60 50 40 30 20 10 0 All-cause mortality CVD mortality Baseline ABI* *Mean participant follow-up 8.3 years Resnick HE et al. Circulation 2004; 109: 733-739.

Ankle Brachial Index (ABI) is an independent predictor of all-cause and coronary mortality in healthy middle-aged working Belgian men after eighteen year follow-up Coronary mortality JC Wautrecht et al. Europrevent 2006

CHD Event Outcomes per Year (%) Cardiovascular Risk Increases With Decreases in Ankle-Brachial Index Framingham High Risk = 20% at 10 years Every patient with PAD is at very high risk 4 3 2 5-year risk: 10% 2% 5-year risk: 19% 3.8% 1 0 1.4% >1.1 1.1 1.01 1.0 0.91 0.9 0.71 <0.7 ABI PAD *Fatal or nonfatal MI. ABI=ankle-brachial index; CHD=chronic heart failure Leng GC, et al. Brit Med J. 1996;313:1440-44.

Who to screen with ABI? All patients with exercise bound complaints in the legs Patients > 50 j with several risk factors Each pt > 70j All pts with CV risk 10-20% (Framingham) If +: behandel als secundaire preventie

People to screen with ABI < 50 j with diabetes mellitus, and one additional risk factor 50-69 j and diabetes mellitus or smoking > 50 j and several risk factors Cardiovascular risk 10-20% (Framingham) > 70 j Complaints/Symptoms in the legs at exercise Abnormal pulsations at clinical exam of the legs Known atherosclerotic coronary, carotid or renal disease Positieve Edinburgh questionnaire TvG 2017 in press; De Backer T, Vermassen F.

Thank You for your attention