Advances in the Medical Management of Peripheral Arterial Disease

1
Advances in theMedical Management of Peripheral
Arterial Disease

• Warner P. Bundens, MD, MS
• Associate Clinical Professor of Surgery
• Associate Clinical Professor of Family and
  Preventive Medicine
• School of Medicine
• University of California, San Diego
• La Jolla, California

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Key Question

• How many of your patients with CV risk do
• you test for peripheral arterial disease?
• 0-24
• 25-50
• 51-75
• 76-100
• Use your keypad to vote now!

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Faculty Disclosure

• Dr Bundens grants/research support
  sanofi-aventis Group.

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Learning Objectives

• Describe the prevalence and disease burden of PAD
• State medical treatments for improving leg
  symptoms of the patient with PAD
• Discuss interventions used to prevent systemic
  complications in the patient with PAD

PAD peripheral arterial disease.
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Peripheral Arterial Disease What Is It?

• PAD
• PAOD

PAOD peripheral arterial obstructive disease.
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Lesions
What Is It?
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Who Gets It?

• PAD Risk Factors
• Age
• Uncommon lt50 years old
• 50-70 years old
• 10 overall
• 20 with history of smoking or diabetes
• gt70 years old
• 20

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Who Gets It?

• PAD Risk Factors
• Age
• Diabetes 4
• Smoking 3.5
• Past or present
• Hypertension 2
• Hyperlipidemia 0.1

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How Do You Diagnose It?

• PAD Symptoms
• May be asymptomatic
• Claudication

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Claudication

• A Reproducible and
• Consistent Symptom

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Claudication

• Muscular pain brought on by activity (walking)
  that is relieved by stopping that activity

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Claudication
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Claudication

• Muscular pain brought on by activity (walking)
  that is relieved by stopping that activity
• Does not occur at rest
• Is not brought on by standing

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Other Causes of Leg Pain Pseudoclaudication

• Spinal stenosis
• Nerve root compression
• Arthritis/joint disease, especially the hip
• Compartment syndrome
• Venous claudication
• Symptomatic Bakers cyst

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How Do You Diagnose It?

• PAD Symptoms
• May be asymptomatic
• Claudication
• Ischemic rest pain

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Ischemic Rest Pain

• Distal foot
• Worse at night
• Decreased by lowering foot

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How Do You Diagnose It?

• PAD Symptoms
• May be asymptomatic
• Claudication
• Ischemic rest pain
• Tissue loss, nonhealing lesions, gangrene

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Arterial Ulcer/Gangrene
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Not Arterial

• Nocturnal Leg/Foot Cramps

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PAD Physical Findings

• Pulses
• Pallor
• Dependent rubor
• Thick nails
• Hairlessness
• Tissue loss/ulcer/gangrene

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PAD Physical Findings

• Poor Sensitivity and Specificity
• for Mild-to-Moderate PAD

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PAD An Objective Test

• Flow vs Pressure

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Ohms Law
Electrical E IR Voltage Drop Current
Resistance Fluids P FR Pressure Drop Flow
Resistance
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Ohms Law
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Office Measurement ofthe Ankle-Brachial Index
(ABI)
Supine Patient
Right arm pressure
Left arm pressure
Pressure Posterior tibial Anterior tibial
Pressure Posterior tibial Anterior tibial
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Ankle Pressure
Patient Must Be Supine
Posterior Tibial
Anterior Tibial
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The ABI

• Both ankle and brachial systolic pressures should
  be taken using a hand-held Doppler instrument
• For arm and leg, use higher of 2 pressures

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The ABI
Right Arm 150 mm Hg Right AT 68 Right
PT 75
Left Arm 143 Left AT 120 Left
PT 100
Right ABI 75/150 0.50
Left ABI 120/150 0.80
AT anterior tibial PT posterior tibial.
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What Do the Numbers Mean?

• ABI
• Typical values
• Normal 1.25-0.9
• Claudication 1.0-0.3
• Rest pain lt0.4
• Tissue loss lt0.3

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ABI lt0.90
95 Sensitive and 99 Specific for PAD
?
TASC Working Group. J Vasc Surg. 200031(1
suppl)S1-S296.
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ABI Occasional Gray Areas

• ABI gt1.0
• Most of these people do not have PAD

• ABI 1.0-0.9
• Most of these people have PAD

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ABI Workshops

• Demonstrations available throughout the day

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Further Noninvasive Testing

• Segmental pressures
• Doppler waveforms
• Exercise test

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Lower Extremity Arterial Exam
Further Testing
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Relative 5-Year Mortality Rates
PAD Is a Bad Disease
American Cancer Society. Cancer Facts and
Figures, 2000. Criqui MH et al. N Engl J Med.
1992326381-386.
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WHY ?
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Key Question

• Without intervention, what percentage of
• PAD patients will have an MI or stroke in
• the next 5 years?
• 10
• 25
• 50
• 75
• Use your keypad to vote now!

MI myocardial infarction.
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Clinical Outcomes in Patients With PAD
PAD Patient
Intermittent claudication 40
Critical leg ischemia 10
Asymptomatic 50
Cardiovascular morbidity/mortality
PAD outcomes
(5-year outcomes)
Worsening claudication 16
Leg bypass surgery 7
Major amputation 4
Stable claudication 73
Nonfatal events (MI/stroke) 20
Mortality 30
Adapted from Weitz Jl. Circulation.
1996943026-3049.
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PAD and All-Cause Mortality
1.00
Normal subjectsAsymptomatic LV-PADSymptomatic
LV-PADSevere symptomatic LV-PAD
0.75
0.50
Survival
0.25
0.00
0
2
4
6
8
10
12
Year
Kaplan-Meier survival curves based on mortality
from all causes. Large-vessel PAD Adapted from
Criqui MH et al. N Engl J Med. 1992326381-386.
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Diagnosis
2 Problems
Cardiovascular Risk
Leg Symptoms Claudication Rest
Pain Tissue Loss
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Cardiovascular Risk
Treatment

• Stop smoking
• Program
• Toes vs cigarettes
• Blood pressure control
• 140/90 mm Hg
• 130/80 mm Hg if patient has diabetes or renal
  disease
• Lipid control
• LDL lt100 mg/dL
• Diabetes control
• HbA1C lt7
• Antiplatelet medication

Hirsch A et al. J Am Coll Cardiol, 2006471239-13
12.
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Antiplatelet Medications

• Aspirin

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Key Question

• What is the proper daily dose of aspirin
• for cardiovascular risk reduction?
• 75 mg
• 81 mg
• 300 mg
• 325 mg
• Use your keypad to vote now!

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Antiplatelet Medications

• Aspirin 81 mg/d

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Aspirin Dosage
Antiplatelet Medications
Aspirin Dose No. Trials OR ()
OR
500-1500 mg 34 19
160-325 mg 19 26
75-150 mg 12 32
lt75 mg 3 13
Any aspirin 65 23
0
0.5
1.5
1.0
2.0
Antiplatelet Better
Antiplatelet Worse
OR odds ratio. Antithrombotic Trialists
Collaboration. BMJ. 200232471-86.
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Aspirin Dosage Risk of Major Bleeding
Antiplatelet Medications
Clopidogrel Aspirin
Placebo Aspirin
Aspirin Dose
lt100 mg 3.0 1.9 100-200 mg
3.4 2.8 gt200 mg
4.9 3.7
CURE Trial. Circulation. 20031081682-1687.
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Antiplatelet Medications

• Aspirin
• 81 mg
• Clopidogrel
• 75 mg

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CAPRIEClopidogrel vs ASA MI, Ischemic Stroke,
or Vascular Death
16
8.7 Overall RRR (P .045)
Clopidogrel ASA
5.83
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5.32
(N 19,185)
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Cumulative Event Rate ()
Subjects had a recent MI, recent ischemic stroke,
or symptomatic PAD
4
0
0
3
6
9
12
15
18
21
24
27
30
33
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Months of Follow-up
Median follow-up 1.91 years
ITT analysis ASA aspirin CAPRIE Clopidogrel
vs Aspirin in Patients at Risk of Ischemic
Events RRR relative risk reduction. CAPRIE
Steering Committee. Lancet. 19963481329-1339.
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Subgroup Analysis
CAPRIE
No. Patients
Patient with stroke 6431
Patient with MI 6302
Patient with PAD 6452
All patients 19,185
-40
-30
-20
-10
0
10
20
30
40
ASA Better
Clopidogrel Better
Risk Reduction ()
CAPRIE Steering Committee. Lancet.
19963481329-1339.
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Leg Problems
PAD Treatment

• Asymptomatic
• No specific treatment
• Claudication
• Do nothing

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Clinical Outcomes in Patients With PAD
PAD Patient
Critical leg ischemia 10
Asymptomatic 50
Intermittent claudication 40
PAD outcomes
Cardiovascular morbidity/mortality
(5-year outcomes)
Nonfatal events (MI/stroke) 20
Mortality 30
Worsening claudication 16
Leg bypass surgery 7
Major amputation 4
Stable claudication 73
Adapted from Weitz Jl. Circulation.
1996943026-3049.
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Leg Problems
PAD Treatment

• Asymptomatic
• Claudication
• Do nothing
• Walking program
• Best are supervised
• Few programs available
• Rarely reimbursable by insurance
• Most patients must do their own

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Walking Program
Claudication Treatment

• Regular
• At least 5/week
• Length
• 40-60 min/d
• Typical results
• Doubling of walking distance each year
• Excuses
• Pain, hills, cold, heat, rain, etc.

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Walking Program
Claudication Treatment

• Additional benefits
• Good for
• Heart
• Lungs
• Weight loss
• Muscles
• See your neighborhood
• See new areas
• Their dog will love it (if they have one)

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Walking Program
Claudication Treatment

• Avoid negative walking programs
• Disability parking
• Wheelchairs
• Motorized carts

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Walking Program
Claudication Treatment
The Best Treatment, But Requires the Patients
Commitment
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Leg Problems
PAD Treatment

• Asymptomatic
• Claudication
• Walking program
• Drugs pentoxifylline cilostazol

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Cilostazol
PAD Treatment

• Not a cure
• Average benefit
• 65 increase in maximum walking distance at 6
  months
• Results not immediate
• Exact mechanism unknown
• Common side effects
• Headache, diarrhea, ankle swelling, palpitations
• Contraindicated in patients with a history of
  congestive heart failure
• Reduce dosage indicated with some concomitant
  medications, eg, omeprazole, diltiazem

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Leg Problems
PAD Treatment

• Asymptomatic
• Claudication
• Walking program
• Drugs pentoxifylline cilostazol
• Invasive angioplasty/stenting surgery

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My Approach/Recommendations

• Claudication
• Walking program
• Drug(s) cilostazol
• Invasive angioplasty/stenting surgery

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Leg Problems
PAD Treatment

• Asymptomatic
• Claudication
• Ischemic rest pain
• Refer
• Nonhealing wounds/ulcers/tissue loss
• Refer

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Critical Limb Ischemia
PAD Treatment

• These patients need revascularization
• Angioplasty/stenting
• Surgery
• If revascularization is not possible
• May need amputation

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Case Study
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Patient Case Study

• Patients first visit to your practice because he
  is new to your area
• 58-year-old, male
• Occupation In sales
• Complaint My leg hurts.
• History of present illness
• 6-month history of right calf pain with walking
• Pain begins at 60 yards patient has to stop at
  100 yards
• Pain goes away within 1 minute of stopping and
  standing
• No pain at rest

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Patient Case Study

• Medical history
• Not on any medications
• Once told his blood pressure was a little high
• Doesnt know his cholesterol or diabetes status
• Has only sought medical care for acute problems
  in the past
• Smoking history
• Smokes 1-2 packs/d 35 years

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Patient Case Study

• Positive physical findings
• Right arm systolic blood pressure 160 mm Hg
• Left arm systolic blood pressure 152 mm Hg
• Left carotid bruit
• Absent right popliteal, PT, dorsalis pedis pulses
• Right PT pressure 80 mm Hg
• Right AT pressure 66 mm Hg
• Left PT pressure 135 mm Hg
• Left AT pressure140 mm Hg

AT anterior tibial PT posterior tibial.
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Patient Case Study

• Right ABI 80/160 0.50
• Left ABI 140/160 0.88
• Has abnormal ABIs both legs
• Only has symptoms in his right leg

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Decision Point

• What etiology might account for unilateral
• claudication?
• Vascular disease limited to one leg
• Bilateral vascular disease worse in one leg
  causing symptoms to appear earlier in one leg
  than another
• Peripheral neuropathy due to diabetes
• Use your keypad to vote now!

69
Patient Case Study

• You tell the patient he has
• PAD
• A serious disease
• It is the cause of his walking problem
• It is also a marker for the systemic disease
  atherosclerosis and he is at risk for heart
  attack or stroke
• Probable hypertension

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Decision Point

• What test(s) would you consider now?
• Lipid, glucose, repeat ABI
• Lipid, glucose, segmental pressures
• Lipid, glucose, carotid duplex, and repeat blood
  pressure
• Segmental pressures
• Use your keypad to vote now!

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Patient Case Study

• He needs further evaluation
• Repeat blood pressure checks
• Blood tests lipid panel, glucose
• Carotid duplex
• He needs treatment for his cardiovascular risks

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Patient Case Study

• Treatment for his cardiovascular risks
• Stop smoking teach him how or refer
• Probable blood pressure control
• Lipids?
• Diabetes?
• Antiplatelet therapy

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Patient Case Study

• He says
• I hear you. I know those things are important,
  but I came in here for this right calf pain I get
  with walking. What can we do about that? I had a
  neighbor who had the balloon treatment and he
  was cured.
• You may be thinking
• Im trying to save his life.
• But unless you address his claudication, he may
  not come back and give you the chance
• You may need to address the claudication first

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Patient Case Study

• You describe the treatment options
• Walking program
• Drug(s) cilostazol
• Invasive angioplasty/stenting surgery

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Q A
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PCE Takeaways
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PCE Takeaways

• PAD is a common disease
• PAD is a serious disease
• A marker for the systemic disease atherosclerosis
• Diagnosis usually is not difficult
• Management usually is straightforward

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Key Question

• Will you use ABI testing to diagnose patients
• at risk for PAD?
• Not likely
• Somewhat likely
• Very likely
• Extremely likely
• Use your keypad to vote now!