beth abramson, toronto sonia anand, hamilton tom forbes, london anil gupta ,brampton

Canadian Cardiovascular Society Consensus Conference 2005:

Peripheral Arterial Disease

B. L. Abramson V. Huckell Co-Chairs• Beth ABRAMSON, Toronto

• Sonia ANAND, Hamilton

• Tom FORBES, London

• Anil GUPTA ,Brampton

• Ken HARRIS, London

• Vic HUCKELL, Vancouver

• Asad JUNAID, Winnipeg

• Tom LINDSAY, Toronto

• Finlay McALISTER, Edmonton

• Andre ROUSSIN, Montreal

• Jacqueline SAW, Vancouver

• Koon TEO, Hamilton

• A. G TURPIE, Hamilton

• Subodh VERMA, Toronto

Goals of the CCS Consensus Process

• to put Peripheral Arterial Disease on the radar screen

• to ensure better treatment, to reduce both morbidity and mortality in the patient with vascular disease

• to foster discussion regarding newer models to deliver care across disciplines

• to serve as a guide to the busy clinician

CCS Consensus Conference 05

• Involved a broad range of specialists caring for the PAD patient

• In Collaboration with the Can. Society of Vascular Surgeons

• Executive Summary: C. J. Cardiol 05; 21(2)997-1006

• Complementary to larger AHA/ACC, TASC

• Practical focus for our membership - thoracic and abdominal

aortic disease, renal arterial disease discussed

• Current version will not discuss:

carotid disease, digital disease, pulmonary arterial disease,

erectile dysfunction, venous disease

QUALITY OF EVIDENCE AND CLASSIFICATION OF RECOMMENDATIONS

Quality of Evidence 1 Evidence obtained from at least one properly randomized

controlled trial or one large epidemiological study2 Evidence based on at least one non-randomized cohort

comparison or multi-centre study, chronological series or extra ordinary results from large non-randomized studies.

3 Opinions of respective authorities, based on clinical experience, descriptive studies or reports of expert committees.

Classification and RecommendationsA Evidence sufficient for universal use (usually based on RCTs)B Evidence acceptable for widespread use, evidence less robust, but

based on randomized clinical trials.C Evidence not based on randomized clinical trials.

A. Gupta

PAD - Epidemiology• PAD is often asymptomatic, under-diagnosed,

under-recognized, and under-treated

• 16% of North America and Europe has PAD, correlating to 27 million people

• Of these 16.5 million are asymptomatic

• Little contemporary epidemiological data for the prevalence of PAD in Canada but it likely represents 4% of the population over age 40

PAD - Epidemiology

A. Gupta

PATHOPHYSIOLOGY OF ATHEROSCLEROSIS

• a systemic and generalized disorder of the arterial tree

• involves a close interplay between endothelial dysfunction and inflammation, which in turn may modify the vascular responses to oxidative stress, and platelet-endothelial interaction

• when compensatory mechanisms fail, complications of atherosclerosis such as stenosis, plaque ulceration, embolization and thrombosis appear

S. Verma

PAD Risk Factors: Recommendations Grade1 All individuals with symptomatic or

asymptomatic PAD should be assessed for all modifiable risk factors.

1A

2 Identified risk factors should be managed appropriately in order to reduce the risk of (a) adverse cardiovascular events, and (b) progression of the PAD.

1A1B

3 Individuals should be advised to quit smoking and have regular walking programs to:(a) reducing overall cardiovascular risk, and (b) improving symptoms of the PAD.

1A1B

K. Teo

AORTIC ANEURYSMS• Aortic aneurysms are silent killers.

• They develop mostly in patients over the age 60

• 90% of all abdominal aortic aneurysms (AAA) occur below the renal arteries

• incidence of 4-5% in the general population

• Survival rates for aortic rupture depend upon the aneurysm location and the population examined

• Mortality rates can be as low as 40%

• Series that take into account pre hospital deaths show mortality rates up to 90%.

T. Lindsay

RecommendationsAneurysm Screening

Grade

1 Men age 65-74 1A

2 Women aged 65 who have cardiovascular disease and positive family history of AAA

3C

3 Men aged 50 and above with a positive family history

3C

T. Lindsay

Initial size Grade

<3.0 cm Repeat ultrasound follow-up in 3-5 years

1A

3.1-3.5cm Repeat ultrasound in 3 years 1A

3.6-3.9 cm Repeat ultrasound in 2 years 1A

4.0-4.5 cm Repeat ultrasound in 1 year 1A

4.6 cm or > Referral to Vascular Surgeon and repeat ultrasound every 3-6 months

1A

If > 1cm growth in 1 year

Referral to Vascular Surgeon 1A

RecommendationsAAA Follow-up Based on Initial Size

T. Lindsay

ATHEROSCLEROTIC RENAL ARTERY STENOSIS (RAS)

• The incidence of renal arterial disease is up to

45% in those with acute, severe or refractory HT

• PAD patients are at high risk of RAS

• Patients with moderate or severe hypertension and

otherwise unexplained pulmonary edema are

much more likely to have either bilateral renal

arterial disease or arterial stenosis of a solitary

functioning kidney

A. Junaid

Main Indications for Investigation

• Uncontrolled Hypertension despite maximum

dosing of 3 HT medications & Creatinine < 300

• Rapid (within weeks to months) otherwise

unexplained decline in renal function and

serum Cr. < 300 mol/l

• Otherwise unexplained recurrent flash

pulmonary edema

A. Junaid

Recommendations: Atherosclerotic RAS Management

Revascularization should be attempted with perc. balloon angioplasty & stenting

Grade

1 In patients with >70% luminal compromise of one or both renal arteries and uncontrolled hypertension (BP>140/90) despite the use of 3 medications at maximum dose.

I B

2 Patients with recurrent episodes of flash pulmonary edema and no other readily identifiable cause and greater than 70% stenosis of at least one renal artery.

II C

3 For preservation of renal function in patients with either bilateral renal artery stenosis/stenosis supplying a single functioning kidney who have a rapid decline in renal function and creatinine < 300 mol/l

II C

A. Junaid

Screening & Diagnosis

PAD DiagnosisRecommendation Grade

Taking a directed history for symptoms of PAD. A validated questionnaire, such as the Edinburgh Questionnaire, can help diagnose arterial claudication in patients suspected of suffering from PAD.

1A

Performing a directed examination focusing on physical findings that have been proven useful to detect PAD as defined as an ABI < 0.9

1A

Ordering an ABI to help diagnose arterial claudication in patients suspected of claudication. An ABI below 0.9 is diagnostic of PAD with values below 0.4 associated with severe disease.

1A

Ordering an ABI to diagnose PAD in asymptomatic patients with arterial bruits or diminished pulses

1A

A. Roussin

PAD Diagnosis continued

Recommendation Grade

Consider: an ABI to diagnose PAD in patients with a high CV risk, esp. patients over the age of 40 with smoking or diabetes. Femoral bruits are specific (95%) for PAD and reduced pulses are quite sensitive (±70%) for PAD but the ABI will still detect PAD in a fair number of patients with a normal physical exam

1B

A. Roussin

RecommendationsMedical Therapies to Reduce

Cardiovascular Events in PAD

RecommendationsMedical Therapies to Reduce

Cardiovascular Events in PAD

Class of Agents Grade

1 Statins 1A2 ACE Inhibitors 1A3 Oral Hypoglycemics or

Insulin2B

4 Antiplatelet 1A

S. Anand, A. Turpie

Choice of Anti-Platelet Agent Given Current Evidence

Agent Recommendation Grade

Aspirin Lifelong aspirin therapy, 75-325mg/d, in comparison to no antiplatelet therapy in patients with or without clinically manifest coronary or cerebrovascular disease

1A

Clopidogrel Clopidogrel in comparison to no antiplatelet therapy

1A

Ticlopidine Aspirin or Clopidogrel recommended over ticlopidine

1B

S. Anand, A. Turpie

NON-MEDICAL MANAGEMENT• The vast majority of patients with claudication, are

best treated conservatively• Surgical or interventional approaches should be

considered in patients whose claudication prevents them from meeting their work and everyday responsibilities and with very poor quality of life

• Those with limb threatening ischemia suffer from such symptoms as rest pain, gangrene, non-healing ulcers or sores, and diabetic foot infections

• These patients should be urgently referred for consideration of revascularization procedures

T. Forbes, K. Harris

Non-Medical Management of Chronic Limb Ischemia


1 The majority of claudicants should undergo risk factor modification, medical management and a walking program rather than revascularization

1B

2 Only those who suffer from severely limiting claudication should be considered for revascularization

1B

3 Patients with critical limb ischemia should be considered for revascularization

1A

4 An aortobifemoral bypass grafting offers superior long term patency compared to extraanatomic bypasses as an inflow procedure.

2B

T. Forbes, K. Harris

Percutaneous Interventions – Clinical Indications


(where technically feasible)

Severe intermittent claudication that interferes with work or lifestyle despite pharmacologic and exercise therapies

2 C

Chronic critical limb ischemia (rest pain, non-healing ulcer, gangrene)

2 C

J. Saw

PERIOPERATIVE RISK ASSESSMENT FOR VASCULAR SURGERY

• General internists and cardiologists are frequently asked to perform preoperative assessments on patients who are scheduled for vascular surgery.

• The purpose should not be to “clear” someone for surgery, but rather to evaluate the severity and stability of the medical conditions and optimize their management before surgery.

• The preoperative assessment should be seen as a venue for the provision of risk estimates to the surgeon, patient, and anaesthetist which can be used to inform decision making.

F. McAlister

PERIOPERATIVE RISK ASSESSMENT THREE PRINICPLES

1. the approach should be appropriate to the situation i.e. -tailored evaluation with a surgical emergency

2. preoperative coronary revascularization should not be done to try to reduce surgical risk, but rather should only be considered in patients who would warrant revascularization for medical reasons independent of the proposed operation

3. the preoperative approach should be tempered by the patient’s overall health status F. McAlister

Additional Highlights

• Screening and Diagnosis

• – A. Roussin, MD

• Medical Management

• – S. Anand, MD

• Perioperative Risk Assessment

• – B. Abramson, MD

• A National Call to Action• - V. Huckell MD

CCS PAD 2005 CONSENSUSScreening and Diagnosis

• Taking a directed history for symptoms of PAD.

• A validated questionnaire, such as the Edinburgh Questionnaire, can help diagnose arterial claudication in patients suspected of suffering from PAD

Grade 1A recommendation


• Performing a directed examination focusing on physical findings that have been proven useful to detect PAD as defined as an ABI < 0.9



• Ordering an ABI to help diagnose arterial claudication in patients suspected of claudication.

• An ABI below 0.9 is diagnostic of PAD with values below 0.4 associated with severe disease



• Ordering an ABI to diagnose PAD in asymptomatic patients with arterial bruits or diminished pulses



• Considering an ABI to diagnose PAD in patients with a high cardiovascular risk, particularly patients over the age of 40 with smoking or diabetes.

• Femoral bruits are specific (95%) for PAD and reduced pulses are quite sensitive (±70%) for PAD but the ABI will still detect PAD in a fair number of patients with a normal physical exam

Grade 1B recommendation


• Considering Segmental pressures, Duplex scanning and Treadmill testing in conjunction with a vascular specialist

Grade 3C recommendation

PAD Investigation and ImagingMost useful methods in 2005

• Ankle-Brachial Index (ABI) to confirm PAD

• Duplex for screening in view of further

investigation

• Claudication & normal creatinine• Consider CT-Angio

• Claudication & diabetes or renal failure• Consider MR-Angio

• Critical ischemia• Consider MR-Angio

#1: Smoking Cessation

• Top Priority reduces CV events and improves claudication

• Doctors make an impact***

• Single most powerful Single most powerful preventive intervention inpreventive intervention in clinical practiceclinical practice

# 2: Antiplatelet Tx Reduces CV Events in PAD Patients (Grade 1A)

184 RCT's 140,000vascular patients

MI 30% stroke 30% mortality 16%

39 RCT's 9000 patientswith PAD

21% RRR in CV death,MI, stroke

Lifelong Antiplatelet Therapy is Indicated in All PAD Patients

# 3: Statins (Grade 1A)

• Reduce CV death, MI, and stroke in PAD patients

• May improve walking distance in intermittent claudication

# 4: ACE Inhibitors (Grade 1A)

• Blood Pressure Lowering

• Reduction in clinical events over and above BP Lowering (HOPE)

The HOPE Study: PAD Subgroup Analysis

0.6 0.8 1.0 1.2

PAD 4046 22.0

No PAD 5251 14.3

No. of Patients

Incidence of Composite Outcome

in Placebo Group

The Heart Outcomes Prevention and Evaluation Study Investigators N. Engl. J. Med. 2000; 342: 145-153

Relative Risk in Ramipril Group

Supervised Exercise to improve Claudication (1A)

• Cochrane Meta-analysis (only RCT’s) • 10 trials, 250 Patients • Exercise increased maximum walking

time by 6.51 min (95% CI: 4.36-8.66]

• Prescription: 3 sessions x 30 minutes per week

Leng, Cochrane Database

PERIOPERATIVE RISK ASSESSMENT FOR

VASCULAR SURGERY

Proposed Algorithm:

Need for noncardiac vascular surgeryPROCEED TO OPERATION

1. Cancel/Delay surgery2. Treat modifiable conditions & re-

evaluate3. Consider cath if revasc. would be

appropriate for reasons independent of planned OR

PROCEED TO OPERATION

Noninvasive Testing

Not Low Risk

Emergent

Elective

Yes and asymptomatic since

Yes

No (or new symptoms)

No

No

Yes

Yes

No

Functional capacity < 1-2 blocks walkingPLUS ANY MINOR RISK PREDICTOR:

Age >70 yearsRhythm other than sinus

Abnormal ECG (LVH, LBBB, ST-T)BP > 180/110 mm Hg

ANY MAJOR RISK PREDICTOR:MI within 4 weeks

CCS Class III/IV or unstable anginaDecompensated CHF

Severe valvular diseaseHigh grade AV block

Symptomatic vent. arrhythmiasUncontrolled ventricular response

Low Risk

ANY INTERMEDIATE RISK PREDICTOR:MI > 4 weeks ago

CCS class I or II anginaCompensated heart failure

Diabetes Mellitus, Renal insufficiencyCerebrovascular disease

Revascularization or favourable result on coronary evaluation within 2 years?

Resting ECG normal?

History of ventricular arrhythmias, uncontrolled hypertension, or resting

hypotension?

History of bronchospasm, second degree AV block, theophylline

dependence, or valvular dysfunction?

Exercise ECG Stress Test

Exercise perfusion imaging

Dipyridamole myocardial perfusion

scintigraphy Other

Dobutamine Stress Echo

No

No

Yes Yes

No

Yes

No Yes

Patient scheduled for elective vascular surgery and non-invasive testing

indicated

Patient able to exercise?

Non-exercise Stress Test

An (inter) national(inter) organ

(inter) specialty disease

PAD

A national call to action

Critical issues

1. Increase awareness of PAD and its consequences

• Ischemic burden• Dissemination of clinical definition• Prediction of CVD and CAD• Vascular disease foundations and

networks• Vascular societies

Increase Awareness of PAD

and Its Consequences

Critical issues


2. Improve the identification of patients with symptomatic PAD

Improve the identification of patients with symptomatic PAD

• Public awareness campaigns• Patient and physician education

Critical issues


2. Improve the identification of patients with symptomatic PAD

3. Initiate a screening protocol for patients at high risk for PAD

Initiate a screening protocol for patients at high risk for PAD

• Review traditional risk factors• Examine peripheral pulses• Consider ABI

Critical issues

4. Improve treatment rates among patients diagnosed with symptomatic PAD

Improve treatment rates among patients diagnosed with symptomatic PAD

• Life style modification• Intensive risk reduction interventions• Antiplatelet therapy

Critical issues


5. Increase the rates of early detection among the asymptomatic population

Increase the rates of early detection among the asymptomatic population

• Review patients with multiple risk factors

• Clinical examination where indicated

Critical issues


5. Increase the rates of early detection among the asymptomatic population

6. Develop national implementation strategies for guidelines and consensus conferences

Develop national implementation strategies for guidelines and consensus conferences

• Prevention of atherothrombotic disease network

• ACC / AHA guidelines• Vascular societies

• Quebec Vascular Society• Atlantic Vascular Society• Western Vascular Society

• Vascular biology working groups

Develop national implementation strategies for guidelines and consensus conferences

• Publication of the consensus conference

• CCS visiting professor series• Dedicated website(s)• Enduring materials

• Physician handouts• Patient handouts

beth abramson, toronto sonia anand, hamilton tom forbes, london anil gupta ,brampton

Documents

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