Peripheral Vascular DiseasePeripheral Vascular DiseaseWPCCS May2013y

Mr Ian WilliamsConsultant Vascular Surgeon UHWg

Prof Julian HalcoxProf Julian HalcoxConsultant Cardiologist UHW

Case 1Case 1

? Ischaemic Legs

Hi tHistory

• 85 years lady • ?varicose veins bilaterally R > L• Pain++• Pain++

worse on walking, gcan’t sleep

• Limited walking distance

Risk factors

• HypertensionHypertension • Age g• ?Raynauds many years

Examination • Varicosities• Ischaemic foot

N l di t l t f l• No pulse distal to femoral • Venous guttering on elevationVenous guttering on elevation

Diagnosis

• Acute on chronic ischaemic leg• Varicose veins

I ti ti• Investigations – duplex and angiogram– duplex and angiogram

M di l RMedical Rx

ContinuedA l di i• Amlodipine

• BendroflumethiazideBendroflumethiazide

Started• Simvastatin• Aspirin• Aspirin

“Real World” 2° Prev Rx of Incident Vascular Dx

PAD N=34,160CAD N=154,183Both N=9,570

Subherwal et al. Circulation2012; 126: 1345

Aspirin in PADp• Antithrombotic Trialists'

Collaboration (ATC)

9214 ti t ith PAD i 42 t i l• 9214 patients with PAD in 42 trials

• 23% proportional reduction in MACE• 23% proportional reduction in MACE with antiplatelet therapy (primarily

i i ) t l ( 0 004)aspirin) vs control (p=0.004).

• similar between PAD patients withsimilar between PAD patients with intermittent claudication, peripheral

d i h l i l tsurgery and peripheral angioplasty

CAPRIE: Superior Efficacy of Clopidogrel versus ASAPatients with recent ischemic stroke, recent MI or symptomatic PAD

%) 8.7%† RRR

20

16

t rat

e* (% ASA

Clopidogrel

(p=0.043)

8

12

tive

even

Clopidogrel

4

Cum

ulat

00 3 6 9 12 15 18 21 24 27 30 33 36

Months of follow-up

*MI, ischemic stroke or vascular death†Intent-to-treat analysis (n=19,185)

CAPRIE Steering Committee. Lancet 1996; 348: 1329–1339.

CHARISMA: 1° Endpoint (MI/Stroke/CV Dth) Pts c Previous MI IS or PAD*Pts c Previous MI, IS, or PAD*

“CAPRIE-like Cohort”

10 N=9 478at

e (%

)

8

10

Clopidogrel + ASAPlacebo + ASA

N=9,4788.8%8.8%

7.3%7.3%

Eve

nt R

a

6

8 Clopidogrel + ASA 7.3%7.3%

RRR: 17.1 % (95% CI: 4.4%, 28.1%)

Out

com

e E

4RRR: 17.1 % (95% CI: 4.4%, 28.1%)P=0.01

rimar

y O

2

P

0

Months Since Randomization0 6 12 18 24 30

Months Since Randomization* Post hoc analysis.

Bhatt DL, Flather MD, Hacke W, et al. J Am Coll Cardiol. 2007;49:1982-1988.

Blood Pressure

Management of HypertensionManagement of Hypertension

NICE CG127

T t t ti t t 4 ft ACDTreatment options at step 4 after ACD• Beta Blocker• Beta-Blocker• Potassium sparing diuretic (Spironolactone Amiloride)• Alpha Blockers (Doxazosin)• Alpha Blockers (Doxazosin)

F th t t t ti ft t 4Further treatment options after step 4• Moxonidine, Clonidine, MethylDOPA• Hydralazine Minoxidil• Aliskiren• Renal Nerve Ablation

BP Targets:Wh t’ N i NICEWhat’s New in NICE

Clinic BP• <150/90 if over 80y• <140/<90 if under 80yy

Daytime Average ABPM Home BPMDaytime Average ABPM Home BPM• <145/85 if over 80y• <135/<85 if under 80y

NICE CG127

Lipids

Secondary PreventionNICE CG67 May 08NICE CG67 May 08

CV Risk Assessment and Modification of Blood Lipids for Primary and Secondary Prevention of CVD

Offer Lipid Modification Rx ASAP

General CVD Patients

Offer Lipid Modification Rx ASAP

Off 40 Si t tiOffer 40mg Simvastatin (or Rx with similar cost)

To All CVD Patients

Consider Increase to

TC<4 LDL<2

Consider Increase to 80mg Simvastatin

(or Rx with similar cost)Always consider:

•Informed preference

AtorvastatinNow Generic

•Informed preference•Comorbidity•Other Rx•Risks vs Benefits

Audit level of TC≤5mmolRecognise <50% will achieveTC<4, LDL<2

Case 2

Acute Presentation:Acute Presentation:Lower limb ischaemia

• 4/12/9 ?ischaemic legs L > R• Moving legs, no neurology

F l l il di t l• Femoral pulses +ve, nil distal• Transferred on FullTransferred on Full

anticoagulation• Arrange CT scan

Duplex• Duplex – no aaa• CFAs, prox and mid SFAs

t tpatent• Acute thrombus poplitealsAcute thrombus popliteals bilaterally

• 2 vessel run off calf bilaterally

Other Past History• angina hypertension

Other Past History • angina, hypertension • “MI” 2009, DVT x2 2009,

Other InvestigationsOther Investigations• Echo: Severe Global LV Dysfunction LVHEcho: Severe Global LV Dysfunction, LVH

Ejection Fraction 25%, No Thrombus• Previous Coronary Angiogram: No Significant• Previous Coronary Angiogram: No Significant

obstruction (Minor Atheroma)Cl IV CKD E th id• Class IV CKD, Euthyroid

Options for treatment

Vascular• Surgery • Conservative (observe and Rx medically)( y)• Radiological (angiogram +/- plasty stent

Other• Ix/Rx Heart Failure, Hypertension, Lipids

Current situation• 4 years • Viable legs • Occasional aching (venous and• Occasional aching (venous and

arterial diseaseV d l (11/2011) d• Venous duplex (11/2011) – deep veins ok

• Left ssv + right perforator incomp

Management of Management of gg(Hypertension in) Heart Failure(Hypertension in) Heart Failure

ACEi/ARB + Beta Blocker

+

Diuretics (Aldosterone Antag +/- Loop)Diuretics (Aldosterone Antag +/- Loop)

+

C (DIHYDROPYRIDINES) + More D + Other

Why are OACs preferred to aspirin in AF?to aspirin in AF?

Warfarin better Placebo better

AFASAK

SPAF

BAATAFBAATAF

CAFA

SPINAFSPINAF

EAFT

All t i lRRR 64%*, ARR 2.7%

100 –10050 0 –50

All trials (95% CI: 49–74%)

Random effects model;Error bars = 95% CI;

* >0 2 f h it

RRR (%)† Compared to a 19% RRR, 0.7% ARR for aspirin

* p>0.2 for homogeneity;† Relative risk reduction (RRR) for all strokes (ischaemic and haemorrhagic)

Hart RG et al. Ann Intern Med 2007;146:857–67.

The BAFTA study: similar haemorrhagic i k ith i i d f irisk with aspirin and warfarin

Aspirin Warfarin RR p

Major extracranial 1.4% 1.6% 0.87 0.67

All major (intracranial &haemorrhagic stroke) 1.9% 2.0% 0.96 0.90

Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) Study comparedBirmingham Atrial Fibrillation Treatment of the Aged (BAFTA) Study compared the efficacy and safety of warfarin compared with aspirin in 973 patients, aged 75 years or more.

Mant J et al. Lancet 2007;370:493-550.

SYMPLICITY HTN2 RCTSYMPLICITY HTN2 RCT

• 106 patients with resistant hypertension106 patients with resistant hypertension (>160mmHg on 3+ Rx)

• 52 Radiofrequency Ablation RSN vs 54C• 52 Radiofrequency Ablation RSN vs 54C• 6/12 BP Outcomes in Renal Denervation Pts

• Office BP -32/12 mmHgNo decrease in 10%SBP >10mmHg in 84%SBP <140mmHg in 39%

• Home BP -20/12 mmHg• ABP -11/7 mmHg

Selection for Renal DenervationSelection for Renal Denervation

• Sustained Clinic BP >160 mm Hg • ASBP >150mmHg (>140 mm Hg in T2DM) g ( g )• eGFR >45ml/min/1.73m2• ≥3 medications + proven use of step 4 Rx • Exclusion of non-concordance• Exclusion of white coat HTN • Exclusion of causes of secondary HTN• Suitable renal artery anatomy • (Trained Operator, entry of data on UK Registry)

Caulfield et al. Joint Societies Statement on Renal Denervation for Resistant Hypertensionhttp://www.bhsoc.org

Key Issues in BP Management

• Treat BP comprehensively including y gisolated systolic hypertension and elderly

• Lifestyle modification is fundamentalLifestyle modification is fundamental• Polypharmacy usually required

C li i d b• Compliance improved by • Once Daily Drugs• Combination Preparations• Acceptable Side Effect ProfilesAcceptable Side Effect Profiles

• Manage lipids and diabetes aggressively• Patient “OWNERSHIP” of their condition

Practical Prescribingg• ACE + C + D• If intolerant of ACE try ARB• If intolerant of ACE try ARB• If BP not at target consider more potent

ARB (At stage 2-3)

• Beta Blocker and/or Spironolactone and/or Other Diuretic and/or Doxazosin at stepOther Diuretic and/or Doxazosin at step 4/5/6

• Vasodiators and/or Centrally acting drug (NB Moxonidine often effective in(NB Moxonidine often effective in Obesity/Sympathetically-driven HTN)