Canadian Cardiovascular Society
Consensus Conference 2005:
Peripheral Arterial Disease
B. L. Abramson V. Huckell Co-Chairs
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Beth ABRAMSON, Toronto
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Tom LINDSAY, Toronto
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Sonia ANAND, Hamilton
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Finlay McALISTER, Edmonton
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Tom FORBES, London
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Andre ROUSSIN, Montreal
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Anil GUPTA ,Brampton
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Jacqueline SAW, Vancouver
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Ken HARRIS, London
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Koon TEO, Hamilton
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Vic HUCKELL, Vancouver
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A. G TURPIE, Hamilton
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Asad JUNAID, Winnipeg
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Subodh VERMA, Toronto
Goals of the CCS
Consensus Process
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•
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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
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Involved a broad range of specialists caring for the PAD patient
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In Collaboration with the Can. Society of Vascular Surgeons
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Executive Summary: C. J. Cardiol 05; 21(2)997-1006
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Complementary to larger AHA/ACC, TASC
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Practical focus for our membership - thoracic and abdominal
aortic disease, renal arterial disease discussed
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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 study
2
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 Recommendations
A 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.
PAD - Epidemiology
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PAD is often asymptomatic, under-diagnosed,
under-recognized, and under-treated
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16% of North America and Europe has PAD,
correlating to 27 million people
•
Of these 16.5 million are asymptomatic
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Little contemporary epidemiological data for
the prevalence of PAD in Canada but it likely
represents 4% of the population over age 40
A. Gupta
PAD - Epidemiology
A. Gupta
PATHOPHYSIOLOGY OF
ATHEROSCLEROSIS
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•
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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:
Grade
Recommendations
1
2
3
1A
All individuals with symptomatic or
asymptomatic PAD should be assessed for
all modifiable risk factors.
Identified risk factors should be managed
appropriately in order to reduce the risk of
(a) adverse cardiovascular events, and
(b) progression of the PAD.
1A
1B
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.
1A
1B
K. Teo
AORTIC ANEURYSMS
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Aortic aneurysms are silent killers.
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They develop mostly in patients over the age 60
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90% of all abdominal aortic aneurysms (AAA) occur
below the renal arteries
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incidence of 4-5% in the general population
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Survival rates for aortic rupture depend upon the
aneurysm location and the population examined
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Mortality rates can be as low as 40%
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Series that take into account pre hospital deaths
show mortality rates up to 90%.
T. Lindsay
Recommendations
Aneurysm Screening
Grade
1 Men age 65-74
1A
2 Women aged 65 who have cardiovascular
disease and positive family history of AAA
3 Men aged 50 and above with a positive family
history
3C
3C
T. Lindsay
Recommendations
AAA Follow-up Based on Initial Size
Initial size
<3.0 cm
Grade
1A
3.1-3.5cm
Repeat ultrasound follow-up in 3-5
years
Repeat ultrasound in 3 years
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 >
1A
1A
Referral to Vascular Surgeon and
repeat ultrasound every 3-6
months
1A
If > 1cm growth Referral to Vascular Surgeon
in 1 year
T. Lindsay
ATHEROSCLEROTIC
RENAL ARTERY STENOSIS (RAS)
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The incidence of renal arterial disease is up to 45%
in those with acute, severe or refractory HT
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PAD patients are at high risk of RAS
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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
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Uncontrolled Hypertension despite maximum
dosing of 3 HT medications & Creatinine < 300
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Rapid (within weeks to months) otherwise
unexplained decline in renal function and
serum Cr. < 300 mol/l
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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.
IB
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 Diagnosis
Recommendation
Grade
Taking a directed history for symptoms of PAD. A validated
1A
questionnaire, such as the Edinburgh Questionnaire, can
help diagnose arterial claudication in patients suspected of
suffering from PAD.
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 1B
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
A. Roussin
Recommendations
Medical Therapies to Reduce
Cardiovascular Events in PAD
Recommendations
Medical Therapies to Reduce
Cardiovascular Events in PAD
Class of Agents
Grade
1 Statins
2 ACE Inhibitors
3 Oral Hypoglycemics or
Insulin
4 Antiplatelet
1A
1A
2B
1A
S. Anand, A. Turpie
Choice of Anti-Platelet Agent
Given Current Evidence
Agent
Aspirin
Recommendation
Grade
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
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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, nonhealing 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
Grade
Recommendation
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
Recommendation
Grade
(where technically feasible)
Severe intermittent claudication that
2C
interferes with work or lifestyle despite
pharmacologic and exercise therapies
Chronic critical limb ischemia (rest pain, non- 2 C
healing ulcer, gangrene)
J. Saw
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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.
2.
3.
the approach should be appropriate to the
situation i.e. -tailored evaluation with a
surgical emergency
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
the preoperative approach should be
tempered by the patient’s overall health
status
F. McAlister
Additional Highlights
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Screening and Diagnosis
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Medical Management
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– S. Anand, MD
Perioperative Risk Assessment
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– A. Roussin, MD
– B. Abramson, MD
A National Call to Action
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- V. Huckell MD
CCS PAD 2005 CONSENSUS
Screening 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
CCS PAD 2005 CONSENSUS
Screening and Diagnosis
•
Performing a directed examination
focusing on physical findings that
have been proven useful to detect
PAD as defined as an ABI < 0.9
 Grade
1A recommendation
CCS PAD 2005 CONSENSUS
Screening and Diagnosis
•
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
 Grade
1A recommendation
CCS PAD 2005 CONSENSUS
Screening and Diagnosis
•
Ordering an ABI to diagnose PAD in
asymptomatic patients with arterial
bruits or diminished pulses
 Grade
1A recommendation
CCS PAD 2005 CONSENSUS
Screening and Diagnosis
•
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
CCS PAD 2005 CONSENSUS
Screening and Diagnosis
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Considering Segmental pressures,
Duplex scanning and Treadmill
testing in conjunction with a vascular
specialist
 Grade
3C recommendation
PAD Investigation and Imaging
Most useful methods in 2005
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Ankle-Brachial Index (ABI) to confirm PAD
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Duplex for screening in view of further
investigation
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Claudication & normal creatinine
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Claudication & diabetes or renal failure
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Consider CT-Angio
Consider MR-Angio
Critical ischemia
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Consider MR-Angio
#1: Smoking Cessation
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Top Priority reduces CV
events and improves
claudication
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Doctors make an impact***
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Single most powerful
preventive intervention in
clinical practice
# 2: Antiplatelet Tx Reduces CV Events
in PAD Patients (Grade 1A)
184 RCT's
140,000
vascular patients
 MI 30%
 stroke 30%
 mortality 16%
39 RCT's
9000 patients
with PAD
21% RRR in CV death,
MI, stroke
Lifelong Antiplatelet Therapy is Indicated
in All PAD Patients
# 3: Statins (Grade 1A)
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Reduce CV death, MI, and stroke in
PAD patients
May improve walking distance in
intermittent claudication
# 4: ACE Inhibitors (Grade 1A)
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Blood Pressure Lowering
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Reduction in clinical events over and
above BP Lowering (HOPE)
The HOPE Study: PAD Subgroup Analysis
Incidence of
No. of
Patients Composite Outcome
in Placebo Group
PAD
4046
22.0
No PAD
5251
14.3
0.6
0.8
1.0
1.2
Relative Risk in Ramipril Group
The Heart Outcomes Prevention and Evaluation Study Investigators
N. Engl. J. Med. 2000; 342: 145-153
Supervised Exercise to improve
Claudication (1A)
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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 surgery
Emergent
PROCEED TO
OPERATION
Elective
Revascularization or favourable result
on coronary evaluation within 2 years?
Yes and asymptomatic since
No (or new symptoms)
ANY MAJOR RISK PREDICTOR:
MI within 4 weeks
CCS Class III/IV or unstable angina
Decompensated CHF
Severe valvular disease
Yes
High grade AV block
Symptomatic vent. arrhythmias
Uncontrolled ventricular response
1. Cancel/Delay surgery
2. Treat modifiable conditions & re-evaluate
3. Consider cath if revasc. would be
appropriate for reasons independent of
planned OR
Not Low Risk
No
ANY INTERMEDIATE RISK PREDICTOR:
MI > 4 weeks ago
CCS class I or II angina
Compensated heart failure
Diabetes Mellitus, Renal insufficiency
Cerebrovascular disease
Yes
Noninvasive Testing
Low Risk
No
Functional capacity < 1-2 blocks walking
PLUS ANY MINOR RISK PREDICTOR:
Age >70 years
Rhythm other than sinus
Abnormal ECG (LVH, LBBB, ST-T)
BP > 180/110 mm Hg
Yes
No
PROCEED TO
OPERATION
Patient scheduled for elective vascular
surgery and non-invasive testing
indicated
Patient able to exercise?
Yes
Resting ECG
normal?
Yes
Exercise ECG
Stress Test
No
No
Non-exercise Stress Test
Exercise perfusion
imaging
History of bronchospasm, second
degree AV block, theophylline
dependence, or valvular dysfunction?
No
Yes
History of ventricular arrhythmias,
uncontrolled hypertension, or resting
hypotension?
No
Dipyridamole
myocardial perfusion
scintigraphy
Yes
Dobutamine Stress Echo
Other
PAD
An
(inter) national
(inter) organ
(inter) specialty disease
A national call to action
Critical issues
1.
Increase awareness of PAD and its
consequences
Increase Awareness of PAD
and Its Consequences
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Ischemic burden
Dissemination of clinical definition
Prediction of CVD and CAD
Vascular disease foundations and
networks
Vascular societies
Critical issues
1.
2.
Increase awareness of PAD and its
consequences
Improve the identification of
patients with symptomatic PAD
Improve the identification of patients
with symptomatic PAD
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•
Public awareness campaigns
Patient and physician education
Critical issues
1.
2.
3.
Increase awareness of PAD and its
consequences
Improve the identification of
patients with symptomatic PAD
Initiate a screening protocol for
patients at high risk for PAD
Initiate a screening protocol for
patients at high risk for PAD
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•
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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
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•
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Life style modification
Intensive risk reduction interventions
Antiplatelet therapy
Critical issues
4.
5.
Improve treatment rates among
patients diagnosed with
symptomatic PAD
Increase the rates of early
detection among the asymptomatic
population
Increase the rates of early detection among
the asymptomatic population
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•
Review patients with multiple
risk factors
Clinical examination where
indicated
Critical issues
4.
5.
6.
Improve treatment rates among
patients diagnosed with
symptomatic PAD
Increase the rates of early
detection among the asymptomatic
population
Develop national implementation
strategies for guidelines and
consensus conferences
Develop national implementation strategies for
guidelines and consensus conferences
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Prevention of atherothrombotic
disease network
ACC / AHA guidelines
Vascular societies
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Quebec Vascular Society
Atlantic Vascular Society
Western Vascular Society
Vascular biology working groups
Develop national implementation strategies for
guidelines and consensus conferences
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Publication of the consensus
conference
CCS visiting professor series
Dedicated website(s)
Enduring materials
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Physician handouts
Patient handouts