Slide 1 - Tulane University Heart and Vascular Institute

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					Peripheral Vascular Disease in Cardiac Patients
Jason Finkelstein, M.D. Cardiology Fellow Tulane University HSC 9/23/03

Characterized by arterial stenosis and occlusions in the peripheral arterial bed

• Can be symptomatic or asymptomatic • Under diagnosed and under treated disease

• Patient and physician awareness is low

• Ranges in severity from intermittent
claudication to limb ischemia

• Patients have a decreased quality of life

due to a reduction in walking distance and speed leading to immobility

• Most cases of PAD are asymptomatic

• 27 million people in Europe and North America
have PAD (16% of the population 55 yrs or older)
– 10.5 million are symptomatic – 16.5 million are asymptomatic

• Three recent programs have demonstrated high
PAD detection rates when specific populations were at risk for PAD were screened

POPADAD study
• 8000 patients • 40 yrs or older with DM Type I or II • Had no clinical symptoms of arterial

• Results:
– 20.1% of patients had ABI < 0.9

PAD Awareness & Detection
• Total of 6979 patients • Ages 70 yrs or older or 50-69 with diabetes or
smoking history

• PAD was considered present if ABI< 0.9 or a h/x
of limb revascularization CVD was defined as coronary, cerebral, or aortic aneurysmal disease

• Criqui, et al, JAMA 2001: 286; 1317-1324

• • • •
PAD was detected in 1865 pts ( 30%) 44% of these pts had newly diagnosed PAD only 366 pts had newly diagnosed PAD and CVD (35%) Among pts with PVD, classic claudication was distinctly uncommon PAD is relatively underdiagnosed by physicians PAD patients were less intensely treated than patients with CVD

• •

• Criqui et al, JAMA 2001 286. 1317-1324

Natural History of PAD
• Associated with significant mortality because of
association with coronary and cerebrovascular events including death, MI, and stroke PAD

• 6x more likely to die within 10 yrs than patients without • 5 yr mortality rate in pts with claudication is about 30% • Continued use of smoking results in a two fold risk of

• Severity of symptoms has been found to
correlate with survival
– San Diego Artery study • Survival rates decreased with increasing severity

• Another study showed that patients with

symptoms had a 22% survival rate over a 15 yr period compared to a 78% survival rate of pts w/o symptoms

• Belch et al, Arch Intern Med; April 2003; 884-892

Predictors of Mortality in PAD
• 297 patients
– 213 had intermittent claudication – 84 had CLI defined by gangrene, ulcerations or persistent rest pain > 2 weeks – All subjects had ABI < 0.9

• Results

– Patients with CLI had a 1 yr death rate of 22% – 3 yr survival was 52% compared to 86% in pts with intermittent claudication – Data suggests that pts with advance PAD have widespread arteriosclerotic disease – CLI was a stronger predictor of death than a low ABI

Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60

• Patients suffer from peripheral
atherosclerosis • Symptomatic deficiency in blood supply to exercising muscle which is relieved by rest

• Largely a disorder of the elderly • Only 1-2% of those ages 37-69 • Clinical history extremely important

Risk Factors
• Diabetes mellitus
– have worse arterial disease and poorer outcomes than non-diabetics

• Advanced age

• Hyperlipidemia
• Cigarette smoking • Hypertension

Cardiac Risk
• Pts with PVD have a 60% risk of CAD
• Up to 30 % of pts have correctable 3
vessel disease with reduced LVEF

• Patients with an ABI < 0.9 are twice as
likely to have CAD

Clinical Presentation
• Can vary from severe disabling discomfort at rest to a
bothersome pain of seemingly little consequence

• Can present with buttock, thigh, calf or foot claudication
singly or in combination

• Diminished pulses with occasional bruits over stenotic

• Poor wound healing, unilateral cool extremity, shiny skin,
hair loss, and nail changes

• Calf
– Cramping in upper 2/3 usually due to SFA stenosis

• Thigh • Foot

– Usually occlusion of the common femoral artery

– Occlusive disease of the tibial and peroneal vessels

• Buttock and Hip

– Aortoiliac occlusive disease (Lariche’s syndrome)

Diagnostic tests
• Ankle-brachial index
– Measures the resting and post exercise systolic BP in both the ankle and arms – Normal > 1.0 – Below 0.9 has a 95 % sensitivity for detecting angiogram positive PVD
– 0.4 to 0.9 suggests arterial obstruction • Highly predictive of morbidity and mortality of CV events
linked to PAD

– Below 0.4 represents advanced ischemia

Diagnostic Tests
• Segemental limb pressures
– > 20 mmHg reduction significant

• Duplex U/S
• MRA • Conventional angiography

• Indicated for:
– Defining vessel anatomy – Evaluating therapy – Documenting disease

Long term survival
• 2, 296 patients reviewed from CASS found to have PAD • Mean follow up period was 10.4 yrs • Pts with PAD had a higher frequency of CV risk factors
– HTN, DM, CHF, previous CABG, or smoked

• Controlled for all independent risk factors • Vascular disease retained a highly significant correlation with
– Pts had a 25% increased risk of dying at any time during followup ( p< 0.001)

Eagle et al, JACC 1994;23:1091-5

Premature PAD
• 59 male patients with premature PAD • Age of onset < 45 yrs of age • PAD assessed by ABI and CAD assessed by

• •

exercise treadmill testing or coronary angiogram Mean ABI was 0.65 Arteriography performed in 56/59 pts

• Valentine et al, J of Vasc Surg (1994; 19; 668-674)

Premature PAD
• 30 month period of the study • 43 patients had significant CAD (73%)
– 17 pts had single vessel disease – 4 pts had 2 vessel disease – 22 pts had 3 vessel disease

• 32 pts experienced an MI and 23 pts requires an
intervention to help control angina

• 8% mortality rate in the study
• Valentine et al, J Vasc Surg (1994; 19:668-674)

Management of PAD & CAD
• Close association of PAD and CAD • Pts with CAD undergoing PV surgery are at increased risk of early
and late CV events

• Coronary revasc. is likely to improve outcome but mortality rate
after CABG is not as good as in pts w/o PVD • Recommends hemodynamic monitoring • Definitive guidelines are not available

• Gersch et al, J am Coll Card; 1991;18:203-214

PVD and Role of CRP
• 51 pts with PVD who underwent lower limb • • •
revasc. (screened 170 pts) 24 month f/u period 39 pts had PTA and 12 pts had bypass surgery CRP levels were measured pre-op All mortality, cardiac mortality and MI were considered major events

• Rossi et al, Circulation 2002; 105:800-803

PVD and Role of CRP
• 34% incidence of fatal and nonfatal MI over 2 yrs

• CRP > 9 predicted 60 % o f MI’s in pts undergoing lower limb revasc. ( p

• Conclusion
– CRP level in pts with PVD severe enough for revasc. may give incremental information about CV events and had a high predictive value – Pts may benefit from therapy modulating the immune response – More studies needed


Rossi et al, Circulation; 2002; 105: 800-803

PAD Management
• Anti-platelet agents • Diabetic control • Smoking cessation • Anti-hypertensives

• Statin therapy
• Exercise rehabilitation • Revascularization/PTCA/stenting

• Indications for intervention (PTA)
– Persistent limiting claudication that prevents patient from performing daily activities – Rest pain – Tissue loss – Patients who are poor surgical candidates

• Long term success of PTA depends on site and length of
the lesion
– Limited to focal, short segment occlusions – No significant difference in outcome between PTA or surgery

• Lesions might be better treated surgically
– Long segments – Multi focal stenoses – Long segment occlusions – Eccentric, calcified lesions

• Need to increase awareness of PAD and its
consequences Improve the identification of patients with symptomatic PAD Initiate a screening protocol at high risk for PAD Improve treatment rates for those who have been diagnosed Increase the rates of early detection in asymptomatic patients

• •

• PAD is a powerful indicator of systemic artherosclerosis • Mandates aggressive risk factor modification and
pharmacologic therapy

• Goal is to improve the functional capacity of our patients
and decrease morbidity and mortality

• Cardiologists need to take a more active role in treating
PAD along with co-existing CAD

Case #1
• Mr. EG is a 52 yr old male with PMHx of
HTN, tobacco abuse and CAD with a 5 vessel CABG in June 2000
– LIMA – LAD – SVG to D1 – SVG to OM1 & OM2 – SVG to RCA

Case #1
• Last cath was in April of 2001 which showed
patent grafts and medical management was recommended

• Now pt has recurrent chest pain on exertion < 1

• Cardiolyte stress test revealed 1 mm ST

depression and anterior ischemia. LVEF is 44%

Case # 2
• Mr. JG is a 60 yr old male with PMHx of
severe tobacco abuse, AAA, PVD with ischemic rest pain, Right CEA, HTN, who presents with occasional atypical angina

• Persantine Cardiolyte stress test showed
reversible anterior and septal ischemia

Case # 2
• TEE revealed normal LVEF with mild
inferobasal HK

• Moderate to severe eccentric MR
• Physical exam revealed b/l carotid bruits
and 2/6 SEM

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