diffuse vascular disease (focus on peripheral arterial disease [pad])
DESCRIPTION
Case Study: Diane Leary. Diffuse Vascular Disease (Focus on Peripheral Arterial Disease [PAD]). Learning Objectives. At the end of this session, participants should be able to: Identify patients with peripheral arterial disease (PAD) - PowerPoint PPT PresentationTRANSCRIPT
Diffuse Vascular DiseaseDiffuse Vascular Disease (Focus on Peripheral Arterial Disease [PAD])(Focus on Peripheral Arterial Disease [PAD])
Case Study: Diane LearyCase Study: Diane Leary
Learning ObjectivesLearning Objectives
At the end of this session, participants should be able to:
Identify patients with peripheral arterial disease (PAD)
Apply Canadian guidelines for the screening and management of PAD
Identify patients with diffuse vascular disease and implement strategies for the prevention of atherothrombotic events in these patients
Patient PresentationPatient Presentation
▪ Diane is a 65-year-old retired school teacher
▪ She complains of left calf pain when walking a couple of blocks; the pain goes away after she rests for 5 minutes
▪ No other complaints
HistoryHistory
▪ NSTEMI 20 months ago
▪ Carotid bruit
▪ Hypertension
▪ Type 2 diabetes (diagnosed 5 years prior)
▪ Hyperlipidemia
▪ No family history of diabetes or cardiovascular disease
▪ Former smoker
NSTEMI: non-ST-elevation myocardial infarction
MedicationsMedications
▪ ASA 81 mg/day
▪ Ramipril 10 mg/day
▪ Metformin 500 mg tid
▪ Atorvastatin 20 mg/day
▪ Metoprolol 25 mg bid
ASA: acetylsalicylic acid
Physical ExaminationPhysical Examination
▪ Height: 1.65 m
▪ Weight: 81.6 kg
▪ BMI: 29 kg/m2
▪ Waist circumference: 104 cm
▪ BP in-office: 128/72 mmHg
▪ Heart rate: 80 bpm
▪ Left femoral bruit
▪ Carotid bruit
▪ Bilateral reduced pedal pulsesBMI: body mass index; BP: blood pressure
Laboratory InvestigationsLaboratory Investigations
▪ FPG: 6.2 mmol/L
▪ A1C: 7.5%
▪ Lipids at desired values– TC < 5.2 mmol/L
– TG < 2.3 mmol/L
– HDL-C > 1.20 mmol/L (female)
– LDL-C < 2.0 mmol/L
– TC/HDL-C < 4.0
▪ Urine ACR: 1.9 mg/mmol
▪ Complete blood count within normal limits
▪ ECG normal
FPG: fasting plasma glucose; A1C: hemoglobin A1C; TC: total cholesterol; LDL-C: low-density lipoprotein cholesterol; HDL-C: high-density lipoprotein cholesterol; TG: triglycerides; ACR: albumin-to-creatinine ratio; ECG: electrocardiogram
Question 1Question 1
What is your initial diagnosis?
Key PointsKey Points
▪ Patient presents with typical symptom of PAD (intermittent claudication) and has a number of risk factors for the disease
▪ Basic screening should include directed history and physical exam focusing on femoral bruits and pedal pulses
▪ Non-invasive evaluation should include an ABI
ABI: ankle-brachial index
Risk Factors for PADRisk Factors for PAD
Teo KK. Can J Cardiol. 2005;21(12):997–1006.
• Risk factors for PAD are similar to those for atherosclerosis in other beds and include:
• Smoking and diabetes are the most predictive for development of symptomatic claudication
Non-Modifiable Modifiable
▪ Age▪ Male sex▪ Family history
▪ Elevated lipid levels▪ Cigarette smoking▪ Hypertension▪ Sedentary lifestyle▪ Obesity▪ Diabetes
Varied Presentation of PADVaried Presentation of PAD
PAD can be silent or cause symptoms ranging PAD can be silent or cause symptoms ranging from pain to critical limb ischemiafrom pain to critical limb ischemia
Typical AtypicalIntermittent claudication: pain, ache, cramp, numbness, muscle fatigue in calves, thighs or buttocks; exacerbated by exercise and relieved by rest
Decreased walking ability: (speed or distance) for reasons other than classical symptoms of intermittent claudication
Critical limb ischemia: rest pain, ulcers, gangrene
Pain in other areas: e.g., general aching
McDermott MM et al. JAMA 2001;286:1599-1606.
CVD
16.6%CAD
44.6%8.4%
1.2%4.7%
1.6%
PAD
4.7%
REACH RegistryREACH RegistryAtherothrombosis: Overlapping Manifestations of DiseaseAtherothrombosis: Overlapping Manifestations of Disease
The REACH Registry found overlapping manifestations of disease in patients with CAD, CVD, and PAD
The REACH Registry found overlapping manifestations of disease in patients with CAD, CVD, and PAD
18.3% of patients in the REACH Registry did not have manifestations of atherothrombosis, but were included based on risk factors
18.3% of patients in the REACH Registry did not have manifestations of atherothrombosis, but were included based on risk factors
▪ 61% of PAD patients also had symptomatic disease in the coronary or cerebral circulation
▪ 40% of CVD patients also had symptomatic disease in the coronary or peripheral circulation
▪ 25% of CAD patients also had symptomatic disease in the cerebral or peripheral circulation
Bhatt DL, et al; for the REACH Registry Investigators. JAMA. 2006;295:180-189.
CAD: coronary artery disease; CVD: cerebrovascular disease; PAD: peripheral arterial disease
Increased Risk of PAD with DiabetesIncreased Risk of PAD with Diabetes
12.5
19.922.4
0
5
10
15
20
25
**
*
Normal glucosetolerance
Impaired glucosetolerance
Diabetes
Pre
vale
nce
of
PA
D (
%)
Impaired glucose tolerance was defined as oral glucose tolerance test value ≥140 mg/dL <200 mg/dL.* P≤0.05 vs. normal glucose tolerance.
Lee AJ, et al. Br J Haematol. 1999;105:648–654.
Question 2Question 2
What additional investigations would you perform?
Key Points: Diagnosis of PADKey Points: Diagnosis of PAD
History Edinburgh Questionnaire
Physical examination Bruit Peripheral pulses
Non-invasive tests ABI Arterial Duplex
Adapted from Roussin A, et al. Can J Cardiol. 2005;21(12):997–1006.
CCS Guidelines: Diagnosis of PADCCS Guidelines: Diagnosis of PAD
Roussin A, et al. Can J Cardiol. 2005;21(12):997–1006.
Recommendation 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 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 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
Edinburgh Questionnaire
Do you get a pain or discomfort in your leg(s) when you walk?• YES (If patient answers no, then stop here)
Does this pain ever begin when you are standing still or sitting?• NO
Do you get it when you walk uphill or hurry?• YES
Do you get it when you walk at an ordinary pace on level ground?• YES (Answer may also be ‘no’ depending on severity of claudication)
What happens to it if you stand still?• Pain usually disappears in 10 minutes or less (pain continuing for more than 10 minutes is not consistent with PAD)
Where do you get this pain or discomfort?• Patient marks calf and/or thigh and/or buttock
(A positive diagnosis of PAD requires the responses indicated in yellow for all questions)
Leng GC, et al. J Clin Epidemiol. 1992;45:1101–1109.
Measuring ABI
Adapted from Roussin A, et al. Can J Cardiol 2005;21(12):997-1006.
RIGHT ABI
LEFT ABI
INTERPRETATION OF ABI
Right-armsystolicpressure
Left-armsystolicpressure
Right-anklesystolic pressure
Left-anklesystolic pressure
DP
PT
DP
PT
>1.30
0.91-1.30
0.41-0.90
0.00-0.40
Noncompressible
Normal
Mild-to-moderate peripheral arterial disease
Severe peripheral arterial disease
Higher right-ankle pressure
Higher arm pressure
Higher left-ankle pressure
Higher arm pressure
Question 3Question 3
What if the patient’s pedal pulses were palpable and there were no bruits? Would this change your diagnosis?
Key PointKey Point
▪ Palpable pedal pulses and an absence of femoral bruits do not preclude PAD
PAD Regardless of ClaudicationPAD Regardless of Claudication
• Value of physical examination relative to presence of PAD
McGee SR, et al. Arch Intern Med. 1998;158:1357–1364.
ITEM Sensitivity Specificity RR if present
Reduced pedal pulses 68% 95% 27
Femoral bruit 29% 95% 5.7
Slow venous filling 23% 95% 4.1
Cold skin 10% 98% 5.8
Abnormal colour 35% 87% 2.8
Trophic changes 46% 46% 1.5
Case EvolutionCase Evolution
▪ Based on your clinical examination, you diagnose Diane with PAD. You perform further investigations and find that she has an ABI of 0.65, which confirms your diagnosis.
Significance of ABI values ►
Question 4Question 4
How would you manage this patient’s:a) claudication?b) overall vascular risk?
Key Points: Key Points: Objectives of PAD TherapyObjectives of PAD Therapy
Prevent death and disability
Reduce risk of MI (PAD quadruples MI risk)
Reduce risk of stroke (PAD triples stroke risk)
Relieve symptoms
Improve QOL
Improve walking ability
Save limbs
Prevent major amputations
Avoid tissue loss QOL: quality of life
Survival Following Diagnosis of PAD Survival Following Diagnosis of PAD by Diabetes Statusby Diabetes Status
Migliaccio-Walle K, et al. Can J Diabetes. 2007;31(2):140-147.
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
10
20
30
40
50
60
70
80
90
100
Pro
po
rtio
n a
live
(%
)
Time (years)
Diabetes
No diabetes
CCS Guidelines for PAD: CCS Guidelines for PAD: Risk Reduction StrategiesRisk Reduction Strategies
Anand SS, et al. Can J Cardiol. 2005;21(12):997–1006.
Non-pharmacologic Pharmacologic
• Exercise• Blood pressure control• Lipid control• Habits
- Smoking
• Antiplatelet therapy• Angiotensin converting enzyme
inhibitors (ACE-I)• Diabetes control• Hypertension control• Statin use
Risk Factor ManagementRisk Factor Management
Smoking cessation
Weight reduction
Regular physical activity
LDL-C < 2.0 mmol/L
Glycosylated hemoglobin < 6.0%
BP < 140/90 mmHg; < 130/80 mmHg in patients with diabetes
Platelet inhibition
Hiatt WR. N Engl J Med. 2001;344:1608-1621.
McPherson R, et al. Can J Cardiol. 2006;22:913-927.
CDA 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Available at http://www.diabetes.ca/cpg2003
2007 CHEP Recommendations. Available at www.hypertensions.ca
Medical therapies to reduce cardiovascular events in PAD
CCS Guidelines for PAD: CCS Guidelines for PAD: Pharmacologic ApproachPharmacologic Approach
Anand SS, et al. Can J Cardiol. 2005;21(12):997–1006.
CLASS OF AGENTS GRADE
Statins 1A
ACE inhibitors 1A
Oral hypoglycemics or insulin 2B
Antiplatelet 1A
CCS Guidelines:CCS Guidelines:Antithrombotic TherapiesAntithrombotic Therapies
Anand SS, et al. Can J Cardiol. 2005;21(12):997–1006.
AGENTS RECOMMENDATION GRADE
ASA or Clopidogrel
Lifelong antiplatelet therapy with ASA (75 to 325 mg/day) or clopidogrel (75 mg/day) in patient with or without clinically manifest coronary or cerebrovascular disease.
1A
Ticlopidine ASA or clopidogrel recommended over ticlopidine. 1B
Cilostazol* Recommendation for patients with disabling intermittent claudication who do not respond to conservative measure (risk factor modification and exercise therapy) and who are not candidates for surgical or catheter-based intervention
1B
Pentoxifylline Pentoxifylline is not recommended 2B
Vitamin K Antagonists
Anticoagulant therapy is not recommended 2B
*Not available in Canada
Supervised Exercise in the Supervised Exercise in the Management of Symptomatic PADManagement of Symptomatic PAD
Exercise prescription is fundamental for all patients with claudication
Supervised programs have patients walk to the point of moderate pain, followed by rest and repeat exercise
Benefit is observed as early as 4 weeks and continues to improve for at least 1 year
Anand SS, Turpie AGG, et al. Can J Cardiol. 2005;21(12):997–1006.
Question 5Question 5
Could warfarin be added to antiplatelet therapy in patients with PAD?
WAVE: WAVE: Warfarin Antiplatelet Vascular EvaluationWarfarin Antiplatelet Vascular Evaluation
COMBINATIONn=1080 (%)
ANTIPLATELETONLY
n=1081 (%)
RELATIVE RISK
(95% CI) P
MI, stroke, or CV death 12.2 13.3 0.92 (0.73 - 1.16)
0.48
MI, stroke, CV death, or severe CAD– or PAD-related ischemia
15.9 17.4 0.91 (0.74 - 1.12)
0.37
Ischemic stroke 2.2 3.5 0.64 (0.38 - 1.06)
0.09
Hemorrhagic stroke 1.3 0 15.2 (2.0 - 115.6)
0.001
Life-threatening bleeding 4.0 1.2 3.41 (1.84 - 6.35)
<0.001
Moderate bleeding 2.9 1.0 2.82 (1.43 - 5.58)
0.002
Minor bleeding 38.6 10.6 3.63 (3.01 - 4.38)
<0.001
WAVE Trial Investigators. N Engl J Med. 2007;357(3):217-27.
Question 6Question 6
Given this patient’s history of ACS and current diagnosis of PAD (ie, diffuse vascular disease), how long should she remain on the prescribed antiplatelet regimen?
Review pathophysiology & epidemiology of polyvascular disease and atherothrombosis ►
Key PointsKey Points
▪ High risk of CV death, MI, stroke or hospitalization in patients with diffuse vascular disease1
▪ Aggressive risk reduction strategies and dual antiplatelet therapy should be considered for these patients
▪ Currently no guideline recommendations on the optimal duration of antiplatelet therapy in patients with diffuse vascular disease; however, many experts would agree that this patient requires lifelong antiplatelet therapy
– CCS recommends lifelong antiplatelet therapy in PAD2
– CHARISMA showed that patients with a prior atherothrombotic event (MI, stroke or PAD) benefit from long-term dual antiplatelet therapy (median follow-up 27 months), but at the cost of an increased rate of bleeding3
1. Steg PG, et al.; for the REACH Registry Investigators. JAMA. 2007;297:1197-206. 2. Abramson BL, et al. Can J Cardiol. 2005;21(12):997–1006. 3. Bhatt DL, et al.; CHARISMA Investigators. J Am Coll Cardiol. 2007;49(19):1982-8.
CHARISMA: Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance
REACHREACHMajor endpoints as a Function of Single vs Major endpoints as a Function of Single vs Multiple and Overlapping LocationsMultiple and Overlapping Locations
Single Arterial Bed Polyvascular Disease
Overall CAD alone
CVD alone
PAD alone Overall CAD + CVD +
PAD
CV Death 1.5 1.5 1.4 1.2 2.4 3.6
Non-fatal MI 1.2 1.4 0.5† 1.0 1.5 1.8
Non-fatal stroke 1.5 0.9 3.5† 0.6 3.1 4.0
CV death/MI/stroke 3.4 3.1 4.5† 2.3 6.0 7.4
CV death/MI/stroke/ hospitalization*
12.8 13.3 10.0† 18.2§ 22.0 26.9‡
Risk doubles with diffuse vascular disease
† P<0.001 (ref class: CAD alone)§ P<0.001 (ref class: PAD alone)‡ P<0.001 (ref class: CAD + CVD)
Steg PG, et al.; for the REACH Registry Investigators. JAMA. 2007;297:1197-206.
CCS Guidelines:CCS Guidelines:Antithrombotic TherapiesAntithrombotic Therapies
Anand SS, et al. Can J Cardiol. 2005;21(12):997–1006.
Agents Recommendation Grade
ASA or Clopidogrel
Lifelong antiplatelet therapy with ASA (75 to 325 mg/day) or clopidogrel (75 mg/day) in patient with or without clinically manifest coronary or cerebrovascular disease.
1A
Ticlopidine ASA or clopidogrel recommended over ticlopidine. 1B
Cilostazol Recommendation for patients with disabling intermittent claudication who do not respond to conservative measure (risk factor modification and exercise therapy) and who are not candidates for surgical or catheter-based intervention
1B
Pentoxifylline Pentoxifylline is not recommended 2B
Vitamin K Antagonists
Anticoagulant therapy is not recommended 2B
CAPRIE:CAPRIE:Clopidogrel vs. ASA in Multi-bed DiseaseClopidogrel vs. ASA in Multi-bed Disease
15
5
0
An
nua
l eve
nt r
ate
(%
)
Clopidogrel ASA
Events = ischemic stroke, MI or vascular death
CAPRIE Steering Committee. Lancet. 1996;348(9038):1329-39.
108.35%
10.74%
164 events 196 events
22.7%
Relative RiskReduction
CHARISMA:CHARISMA:Primary Endpoint (MI/Stroke/CV Death) in Patients with Primary Endpoint (MI/Stroke/CV Death) in Patients with Previous MI, IS, or PADPrevious MI, IS, or PAD
RRR: 17.1 % [95% CI: 4.4%, 28.1%]P=0.01
Pri
mar
y o
utc
om
e ev
ent
rate
(%
)
0
2
4
6
8
10
Months since randomization
0 6 12 18 24 30
Clopidogrel + ASA7.3 %
Placebo + ASA8.8 %
N=9,478
““CAPRIE-like Cohort”CAPRIE-like Cohort”
Bhatt DL, et al.; CHARISMA Investigators. J Am Coll Cardiol. 2007;49(19):1982-1988.
CHARISMA:CHARISMA:Primary and Secondary Safety EndpointsPrimary and Secondary Safety Endpoints
Endpoint, n (%)Clopidogrel +
ASA
(n=4735)
Placebo + ASA
(n=4743)
HR (95% CI)
P Value
Severe bleeding 79 (1.7) 71 (1.5) 1.114 (0.808–1.535) 0.509
Fatal bleeding 15 (0.3) 11 (0.2) 1.362 (0.626–2.966) 0.434
Primary intracranial hemorrhage 17 (0.4) 20 (0.4) 0.849 (0.445–1.621) 0.619
Moderate bleeding 97 (2.0) 61 (1.3) 1.597 (1.159–2.200) 0.004
Bhatt DL, et al.; CHARISMA Investigators. J Am Coll Cardiol. 2007;49(19):1982-1988.
CHARISMA:CHARISMA:Timing of Severe or Moderate BleedingTiming of Severe or Moderate Bleeding
Placebo + ASA
Clopidogrel + ASA
Days Since Randomization
15 60 135 270 450 630 810
0.00008
0.00007
0.00006
0.00005
0.00004
0.00003
0.00002
0.00001
0
Haz
ard
Fu
nct
ion
/d
Bhatt DL, et al.; CHARISMA Investigators. J Am Coll Cardiol. 2007;49(19):1982-1988.
Take-Home MessagesTake-Home Messages
▪ Patients with PAD are at increased risk of diffuse vascular disease (ie, CAD and CVD)
▪ Screen for PAD through history (Edinburgh Questionnaire) and physical examination (femoral bruits and pedal pulses)
▪ Definitive diagnosis of PAD requires an ABI < 0.9
▪ Aggressive risk factor management should be considered for patients with diffuse vascular disease
▪ Long-term dual antiplatelet therapy can also be considered in selected cases but it is important to weigh the benefits against the higher risk of bleeding
HYPERLINKSHYPERLINKS
Significance of ABI ValuesSignificance of ABI Values
GetABI: GetABI: Mortality (All-cause) by ABI CategoryMortality (All-cause) by ABI Category
Diehm C. Presented at ESC Congress. Vienna, Austria. September 4, 2007.
> 1.1
0.9 – 1.1
0.7 – 0.9
0.5 – 0.7
< 0.5
*Mean participant follow-up 8.3 years
Strong Association Between Decreased Strong Association Between Decreased ABI & Increased Risk for Vascular DeathABI & Increased Risk for Vascular Death
Baseline ABI*
Per
cen
t (%
)
0
20
40
60
<0.60 (n=25)
50
30
10
0.60-<0.70 (n
=21)
0.70-<0.80 (n
=40)
0.80-<0.90 (n
=130)
0.90-<1.0 (n
=195)
1.0-<1.10 (n
=980)
All-cause mortality
Vascular disease mortality
Resnick HE, et al. Circulation. 2004;109:733-739.RETURN
Pathophysiology, Epidemiology & BurdenPathophysiology, Epidemiology & Burdenof Atherothrombosisof Atherothrombosis
Pathophysiology of AtherothrombosisPathophysiology of Atherothrombosis
1. Munger MA et al. J Am Pharm Assoc. 2004;44(suppl 1):s5-s13.2. Libby P et al. Circulation. 2005;111:3481-3488.
AtherosclerosisAtherosclerosis +
Atherosclerosis leads to any number of four possible types of thrombus formation
InflammationAccumulationof lipids
Normalartery
Smooth muscle cell progression,
plaque progression
Thrombus FormationThrombus Formation
Rupture of Fibrous Cap
Erosion of Endothelium
Erosion of Calcium Nodule
Intraplaque Hemorrhage
▪ Patients with atherothrombosis have thrombus formations that can manifest in multiple vascular beds throughout the body
Atherothrombosis Can Manifest in Atherothrombosis Can Manifest in Multiple Vascular BedsMultiple Vascular Beds
▪ Atherothrombosis is a process that includes the following clinical consequences:– Ischemic stroke, MI, and PAD
Munger MA et al. J Am Pharm Assoc. 2004;44(suppl 1):s5-s13.
Cerebrovascular disease (CVD)
Peripheral Arterial Disease (PAD)
Coronary artery disease (CAD)
9%14%
13%
5%
Atherothrombosis: Disease Overlap
Patients with > 1 manifestation = 41%
Aronow WS, Ahn C. Am J Cardiol. 1994;74:64-65.
Epidemiology of Atherothrombotic Epidemiology of Atherothrombotic Manifestations in CanadaManifestations in Canada
Stroke1.0%1
Stroke1.0%1
MI2.7% (men)2
1.5% (women)2
MI2.7% (men)2
1.5% (women)2
PAD3.0%
(10.5 million†4
in North America)
PAD3.0%
(10.5 million†4
in North America)
Patients with a Patients with a history of history of
atherothrombosis atherothrombosis are most likely to are most likely to die of a recurrent die of a recurrent atherothrombotic atherothrombotic
eventevent5,6,75,6,7
Patients with a Patients with a history of history of
atherothrombosis atherothrombosis are most likely to are most likely to die of a recurrent die of a recurrent atherothrombotic atherothrombotic
eventevent5,6,75,6,7
Prevalence(Patients with
disease history)
Prevalence(Patients with
disease history)MortalityMortality
MI=myocardial infarction; PAD=peripheral arterial disease.†PAD patients in North America (USA and Canada): symptomatic (37.5%) and asymptomatic (62.5%).
1. Heart and Stroke Foundation of Canada. 5. Hardie K, et al. Stroke. 2003;34:1842-1846.2. Manuel DG, et al. Can J Cardiol. 2003;19:997-1004. 6. Taneja AK, et al. Eur Heart J. 2004;25:2013-2018.3. Ouriel K. Lancet. 2001;358:1257-1264. 7. Hirsch AT, et al. J Am Coll Cardiol. 2006;47:1239-1312.4. Weitz JI, et al. Circulation. 1996;94:3026-3049.
Stroke 40,000 – 50,0001
Stroke 40,000 – 50,0001
MI75,0001
MI75,0001
PADVariable depending
on population3
PADVariable depending
on population3
Incidences per yearIncidences per year
Patients with Previous Atherothrombotic Patients with Previous Atherothrombotic Events are at Increased Risk of Further EventsEvents are at Increased Risk of Further Events
Increased risk versus general population
MI Stroke
Ischemic stroke 2-3x(includes angina and sudden death*)1
9x2
MI 5-7x(includes death)3
3-4x(includes TIA)1
PAD 4x(includes only fatal MIand other CHD death†)4
2-3x(includes TIA)2
* Sudden death defined as death documented within one hour and attributed to coronary heart disease (CHD).† Includes only fatal MI and other CHD death; does not include non-fatal MI.
1. Kannel WB. J Cardiovasc Risk.1994;1:333–339.; 2. Wilterdink JL, et al. Arch Neurol. 1992;49:857–863. 3. Adult Treatment Panel II. Circulation. 1994;89:1333–1363. 4. Criqui MH, et al. N Engl J Med. 1992;326:381–386.
Framingham Heart Study:Framingham Heart Study:Atherothrombosis Reduces Life ExpectancyAtherothrombosis Reduces Life Expectancy
0
5
10
15
20
Healthy History of MI History of CVA
In the FHS, healthy individuals aged 60 years who did not have atherothrombosis were expected to live a further 20 years to the age of 80 Comparatively, patients with a history of MI lived 9.2 fewer years Those with a history of CVA lived 12 fewer years
In the FHS, healthy individuals aged 60 years who did not have atherothrombosis were expected to live a further 20 years to the age of 80 Comparatively, patients with a history of MI lived 9.2 fewer years Those with a history of CVA lived 12 fewer years
9.2Feweryears
12Feweryears
Lif
e E
xpec
tan
cy (
Yea
rs) 2020
MI=myocardial infarction; CVA=cerebrovascular accident.Adapted from Bakhai A. Pharmacoeconomics. 2004;22(suppl 4):11-18.
Atherothrombosis as a Cause of DeathAtherothrombosis as a Cause of Death
4.9%6.5%
9.1%
12.5%
19.1%
22.3%
0
5
10
15
20
25
Mo
rta
lity
(%
)
Athero-thrombosis
InfectiousDisease
Cancer Injuries PulmonaryDisease
AIDS
According to the World Health Organization in 2004 atherothrombosis was the leading cause of death worldwide—more than AIDS and cancer
According to the World Health Organization in 2004 atherothrombosis was the leading cause of death worldwide—more than AIDS and cancer
Bakhai A. Pharmacoeconomics. 2004;22(suppl 4):11-18.
Economic Burden of AtherothrombosisEconomic Burden of Atherothrombosis
0
100
200
300
400
500
Cardiovascular Disease Cancer HIV
Indirect Costs
Direct Costs
The annual cost of CVD in 2006 was estimated to be higher than HIV and cancer in 2004
The annual cost of CVD in 2006 was estimated to be higher than HIV and cancer in 2004
$403.1 billion
Es
tim
ate
d C
os
t (i
n b
illi
on
s)
American Heart Association. Heart Disease and Stroke Statistics—2006 Update. 2006.
$190 billion
$28.9 billion
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