Peripheral Vascular Disease in Primary Care Setting

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1 Disclosures Peripheral Vascular Disease in Primary Care Setting Soundos Moualla MD FACC FSCAI Mayo Clinic Florida Department of Cardiovascular Medicine Interventional Cardiologist Medical Director of the Vascular Laboratory 01/26/2015 No commercial support No conflict of interest No relevant financial disclosures SOWEGA-AHEC CURE Activity Overview Vascular diseases of the upper extremities Peripheral arterial disease (PAD) of the lower extremities Aneurysmal Disease of the Aorta Arterial disease of the visceral vessels Carotid disease Vasculitis and connection tissue disease Venous disease Overview Epidemiology and Prognosis Patient evaluation Treatment options 2011 MFMER Overview Epidemiology and Prognosis Patient evaluation Treatment options Peripheral Artery Disease PAD affects 10-15% in community dwelling older men and women PAD affects 25-30% of patients > 50 years in primary care practice Only 10-30% of these patients have the classic symptoms of intermittent claudication 1

2 Peripheral Artery Disease Patients with PAD are at 2-4 X fold increased risk of mortality compared to no PAD Most Deaths (75%) are secondary to cardiovascular causes Association of PAD and CV mortality is independent of DM, smoking, HTN, older age Etiology of PAD Atherosclerotic vascular disease (stenotic and embolic) Fibro-muscular dysplasia (FMD) Vasculitis Thromboangiitis Obilterans (Buerger s disease) Miscellaneous: Cystic adventitial disease Popliteal entrapment Endofibrosis Differential Diagnosis of PAD Neurogenic causes Spinal stenosis Peripheral Neuropathy Venous claudication Musculoskeletal causes Risk Factors for Atherosclerotic PAD Smoking: PAD is 4X as common in smokers vs non-smokers Diabetes Mellitus: PAD is 2X as common in DM vs non-dm Hyperlipidemia: stronger risk factor for CAD Hypertension Age: 12% (65-75), 20% (75-79), 25% (80-84) 30% (>85 YO) Risk Factors for Atherosclerotic PAD Gender is NOT a risk factor, prevalence of PAD is similar between men and women prevalence in African- Americans prevalence in patients with CKD Inflammation (hscrp) level of homocysteine is associated with prevalence of PAD Symptoms Intermittent Claudication Calf pain caused with exertion Does not occur at rest Does not resolve during walking Stops the patient from continued activity Resolves within 10 minutes of rest pain, ache, tiredness, tightness, weakness, numbness) 1% of patients with IC develop CLI 2

3 Symptoms Intermittent Claudication (IC) is the most classic symptom Symptoms Asymptomatic 50% Typical IC 15% Atypical 30% Critical limb ischemia 1-2% 1% Many patients with PAD are asymptomatic or have atypical symptoms (25-60%) 33% Asymptomatic Diagnosing PAD requires screening with noninvasive testing (clinical examination and ABI) Intermittent claudication 15% 51% High risk patients should be screened McDermott, et al. JAMA 2001;286: Intermittent Claudication (IC) In Framingham Study: incidence of IC 5.4/1000 patients (65-75 YO) IC is the Tip of the Iceberg Patients > 55 YO Intermittent Claudication 5-15% Other studies: prevalence of IC 5-13% among patients > 50 YO PAD outcomes/limb specific outcomes Cardiovascular Morbidity and mortality Sensitivity is low: 10-30% of patients with PAD have classic IC, 25-60% asymptomatic, but IC is more common in patient with severe PAD Stable claudication 73% Progressive claudication 16% Surgical revascularization 7% Amputation 4% 5 Year mortality 30% CV death 75% Non-fatal CV events 20% Adapted from Weitz. Et al. Circulation 1996;94: ) Overview Epidemiology and Prognosis Patient Evaluation History (risk factors +/- symptoms) Physical Examination Patient evaluation Treatment options Non-invasive evaluation Ankle brachial index (ABI) w/wo exercise Segmental pressures and PVR Duplex ultrasound CTA/MRA Invasive evaluation/angiography 3

4 Physical Examination Pulse Examination New recommendation ACC/AHA =absent pulse 1= Diminished pulse 2= Normal pulse 3= Bounding /aneurysmal Other findings: ulceration, nail changes, soft tissue changes, capillary refill, elevation induced pallor, dependency induced rubor Physical Examination Abnormal pedal pulses Prolonged venous refill time, Cold extremity (unilateral) Femoral bruit, Other: popliteal artery pulse, AAA, Allen Test Carotid bruit JACC 2006;47: Patient Evaluation History (risk factors +/- symptoms) Physical Examination Non-invasive evaluation Ankle brachial index (ABI) w/wo exercise Segmental pressures and PVR Duplex ultrasound CTA/MRA Invasive evaluation/angiography Ankle Brachial index (ABI) Calculated as highest Doppler-recorded SBP in the ankle/highest Doppler-recorded SBP in the brachial artery 5-10 MHz Doppler, Ankle Brachial Index (ABI) Ankle Brachial Index It is simple, non-invasive, inexpensive ABI for PAD = ECG for CAD Goal = is there PAD? Adapted from Hiatt WR. Medical treatment of peripheral vascular disease and claudication. NEJM 2001;344:

5 Diagnostic tool Ankle Brachial Index Prognostic tool Patients with ABI <0.9 and >1.4 have increased mortality compared to those with ABI Patients with PAD, ABI is predictive of mortality Ankle Brachial Index > 1.3 = non-compressible vessels > = Normal > = Borderline > = Mild PAD > = Moderate PAD = Severe PAD JAMA 2008;300: Ankle Brachial Index Limitation of the ABI Calcified vessels can give normal ABI CKD DM Older patients Long term steroid Aortoiliac disease can have normal ABI which will become abnormal with exercise JAMA 2008;300(2): Segmental Pressure and PVR (pulse volume recording) Segmental Pressure and PVR 2011 MFMER

6 Segmental Pressure and PVR Thigh SBP should be mmhg > brachial There should be no more than 20 mmhg change from segment to segment There is should be no more than 20 mmhg difference from limb to limb at the same anatomical level Pulse Volume Recording PVR Plethysmography based Inflate the cuff to 65 mmhg, as the blood passes through the artery, it causes volume change in the artery which causes changes in the air within the cuff which translate to a waveform Limitations: calcified arteries, stenosis vs occlusion, segmental lesions, inflow disease Exercise Testing 2 MPH, 12% incline Maximum 5 minutes Abnormal: >20 mmhg Drop in ABI/segmental with exercise Or > 0.2 drop in ABI in ABI following exercise Duplex U/S Non-invasive and reproducible How long the lesion is, stenosis vs occlusion, sequential lesions Useful for pre-intervention Useful post intervention Duplex U/S Duplex U/S 2011 MFMER

7 Duplex Ultrasound in LE PAD Weitz. et al. Circulation 1996;94: ACC/AHA Guidelines for Patient Evaluation Clinical History Tests recommended Level of recommendation Asymptomatic patients ABI I (level of evidence C) Exercise ABI or PVR IIa (level of evidence C) Intermittent Claudication ABI, segmental pressure/pvr, exercise ABI I (level of evidence B) Possible claudication Exercise with ABI Vein graft bypass Duplex U/S I (level of evidence B) AAA Duplex U/S, CTA or MRA Candidates for revascularization Duplex U/S, CTA or MRA JACC 2013;61(14): CTA/MRA Diagnosis, confirm DX, Severity of disease (treat or Not) Baseline to compare for F/U after therapy Anatomical level of disease (where and how) CTA: faster, less $, high spatial resolution, radiation, contrast, stent MRA: longer, more $, metal artifact, lumen evaluation, Treatment of PAD Focused on prevention Prevent skin breakdown and infection Supervised exercise programs to improve conditioning Pharmacotherapy for claudication Revascularization Risk factors modification Indication for Revascularization Critical limb ischemia (CLI) Rest pain Ulcers Gangrene Debilitating claudication Question 1 What is considered normal for ABI based on the new criteria of ACC/AHA A B C D. >0.9 Change in quality of life 7

8 Question 2 What is the relative risk of cardiovascular mortality in patients with PAD X fold X fold X fold C fold Question 3 What is the first line therapy for patients with LE intermittent claudication 1. anticoagulation more than aspirin 2. Phosphodiesterase inhibitors 3. Supervised exercise program 4. Endovascular therapy 5. LE bypass Question 4 In which population should Cilostazol be avoided for the treatment of intermittent claudication 1. Diabetic patients 2. Patients with CAD 3. Patients with clinical evidence of CHF 4. Patients with arrhythmia Question 5 Which of the cardinal signs of acute limb ischemia predict poor prognosis 1. Pain 2. Pallor 3. Pulselessness 4. Poikiolothermia 5. Paresthesia 6. Weakness and paralysis Evaluation Questions? Attended Live Activity on Attended On-Demand Activity or later 8