Peripheral Vascular Disease WPCCS May2013 Mr Ian Williams Consultant Vascular Surgeon UHW Prof Julian Halcox Prof Julian Halcox Consultant Cardiologist UHW
Case 1? Ischaemic Legs
History 85 years lady?varicose veins bilaterally R > L Pain++ worse on walking, can t sleep Limited walking distance
Risk factors Hypertension Age?Raynauds many years
Varicosities Examination Ischaemic foot No pulse distal to femoral Venous guttering on elevation
Diagnosis Acute on chronic ischaemic leg Varicose veins Investigations duplex and angiogram
Medical Rx Continued Amlodipine i Bendroflumethiazide Started Simvastatin Aspirin
Real World 2 Prev Rx of Incident Vascular Dx PAD N=34,160 CAD N=154,183 Both N=9,570 Subherwal et al. Circulation 2012; 126: 1345
Aspirin in PAD Antithrombotic Trialists' Collaboration (ATC) 9214 patients with PAD in 42 trials 23% proportional reduction in MACE with antiplatelet therapy (primarily aspirin) i vs control (p=0.004). 004) similar between PAD patients with intermittent claudication, peripheral surgery and peripheral angioplasty
CAPRIE: Superior Efficacy of Clopidogrel versus ASA Patients with recent ischemic stroke, recent MI or symptomatic PAD t rate* (% %) Cumulat tive even 20 16 12 8 4 0 8.7% RRR ASA (p=0.043) Clopidogrel 0 3 6 9 12 15 18 21 24 27 30 33 36 Months of follow-up *MI, ischemic stroke or vascular death Intent-to-treat analysis (n=19,185) CAPRIE Steering Committee. Lancet 1996; 348: 1329 1339.
CHARISMA: 1 Endpoint (MI/Stroke/CV Dth) Pts c Previous MI, IS, or PAD* rimary Outcome Event Ra ate (%) P * Post hoc analysis. CAPRIE-like Cohort 10 N=9,478 8.8% Placebo + ASA 8 Clopidogrel + ASA 7.3% 6 4 2 0 RRR: 17.1 % (95% CI: 4.4%, 28.1%) P=0.01 0 6 12 18 24 30 Months Since Randomization Bhatt DL, Flather MD, Hacke W, et al. J Am Coll Cardiol. 2007;49:1982-1988.
Blood Pressure
Management of Hypertension NICE CG127
Treatment t options at step 4 after ACD Beta-BlockerBlocker Potassium sparing diuretic (Spironolactone Amiloride) Alpha Blockers (Doxazosin) Further treatment t t options after step 4 Moxonidine, Clonidine, MethylDOPA Hydralazine Minoxidil Aliskiren Renal Nerve Ablation
BP Targets: What s New in NICE Clinic BP <150/90 if over 80y <140/<90 if under 80y Daytime Average ABPM Home BPM <145/85 if over 80y <135/<85 if under 80y NICE CG127
Lipids
Secondary Prevention NICE CG67 May 08 CV Risk Assessment and Modification of Blood Lipids for Primary and Secondary Prevention of CVD General CVD Patients Offer Lipid Modification Rx ASAP Offer 40mg Simvastatin ti (or Rx with similar cost) To All CVD Patients TC<4 LDL<2 Atorvastatin Now Generic Consider Increase to 80mg Simvastatin (or Rx with similar cost) Audit level of TC 5mmol Recognise <50% will achieve TC<4, LDL<2 Always consider: Informed preference Comorbidity Other Rx Risks vs Benefits
Case 2
Acute Presentation: Lower limb ischaemia 4/12/9?ischaemic legs L > R Moving legs, no neurology Femoral pulses +ve, nil distal Transferred on Full anticoagulation Arrange CT scan
Duplex Duplex no aaa CFAs, prox and mid SFAs patent t Acute thrombus popliteals bilaterally 2 vessel run off calf bilaterally
Other Past History angina, hypertension MI 2009, DVT x2 2009 Other Investigations Echo: Severe Global LV Dysfunction, LVH Ejection Fraction 25%, No Thrombus Previous Coronary Angiogram: No Significant obstruction (Minor Atheroma) Class IV CKD, Euthyroid
Options for treatment Vascular Surgery Conservative (observe and Rx medically) Radiological (angiogram +/- plasty stent Other Ix/Rx Heart Failure, Hypertension, Lipids
4 years Viable legs Current situation Occasional aching (venous and arterial disease Venous duplex (11/2011) deep veins ok Left ssv + right perforator incomp
Management of (Hypertension in) Heart Failure ACEi/ARB + Beta Blocker + Diuretics (Aldosterone Antag +/- Loop) + C (DIHYDROPYRIDINES) + More D + Other
Why are OACs preferred to aspirin in AF? Warfarin better Placebo better AFASAK SPAF BAATAF CAFA SPINAF EAFT RRR 64% *, ARR 2.7% All trials (95% CI: 49 74%) 100 50 0 50 100 RRR (%) Random effects model; Error bars = 95% CI; * p>0.2 2 for homogeneity; Relative risk reduction (RRR) for all strokes (ischaemic and haemorrhagic) Compared to a 19% RRR, 0.7% ARR for aspirin Hart RG et al. Ann Intern Med 2007;146:857 67.
The BAFTA study: similar haemorrhagic risk with aspirin i and warfarin Aspirin Warfarin RR p Major extracranial 1.4% 1.6% 0.87 0.67 All major (intracranial & haemorrhagic stroke) 1.9% 2.0% 0.96 0.90 Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) Study compared the efficacy and safety of warfarin compared with aspirin in 973 patients, aged 75 years or more. Mant J et al. Lancet 2007;370:493-550.
SYMPLICITY HTN2 RCT 106 patients with resistant hypertension (>160mmHg on 3+ Rx) 52 Radiofrequency Ablation RSN vs 54C 6/12 BP Outcomes in Renal Denervation Pts Office BP -32/12 mmhg Home BP ABP No decrease in 10% SBP >10mmHg in 84% SBP <140mmHg in 39% -20/12 mmhg -11/7 mmhg
Selection for Renal Denervation Sustained Clinic BP >160 mm Hg ASBP >150mmHg g( (>140 mm Hg in T2DM) egfr >45ml/min/1.73m2 3 medications + proven use of step 4 Rx Exclusion of non-concordance Exclusion of white coat HTN Exclusion of causes of secondary HTN Suitable renal artery anatomy (Trained Operator, entry of data on UK Registry) Caulfield et al. Joint Societies Statement on Renal Denervation for Resistant Hypertension http://www.bhsoc.org
Key Issues in BP Management Treat BP comprehensively including isolated systolic hypertension and elderly Lifestyle modification is fundamental Polypharmacy usually required Compliance improved by Once Daily Drugs Combination Preparations Acceptable Side Effect Profiles Manage lipids and diabetes aggressively Patient OWNERSHIP of their condition
Practical Prescribing ACE + C + D If intolerant of ACE try ARB If BP not at target consider more potent ARB (At stage 2-3) Beta Blocker and/or Spironolactone and/or Other Diuretic and/or Doxazosin at step 4/5/6 Vasodiators and/or Centrally acting drug (NB Moxonidine often effective in Obesity/Sympathetically-driven HTN)