Jeffrey W. Olin, D.O., F.A.C.C., F.A.H.A. Professor of Medicine (Cardiology) Director of Vascular Medicine & the Vascular Diagnostic Laboratory Icahn School of Medicine at Mount Sinai Peripheral Artery Disease Role of Exercise, Endovascular and Surgical Options
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Jeffrey W. Olin, D.O., F.A.C.C., F.A.H.A.
Professor of Medicine (Cardiology)
Director of Vascular Medicine &
the Vascular Diagnostic Laboratory
Icahn School of Medicine at Mount Sinai
Peripheral Artery Disease Role of Exercise, Endovascular and Surgical Options
Peripheral Artery Disease (PAD)
• The presence of a stenosis or occlusion in the aorta or arteries of the limbs
• Usually caused by atherosclerosis
• Associated with an increased risk of death, myocardial infarction, and stroke
• May impair walking or cause critical limb ischemia
• The global burden of PAD is estimated to be 202 million persons
10%
40%50%
Classic Claudication Atypical Leg Pain Asymptomatic
Some Not So Well Known Facts
• Only 8%–10% of patients with
peripheral arterial disease (PAD)
have “classic” claudication
• ~40% of patients with PAD have
“atypical” leg symptoms
• ~50% of patients with PAD are
asymptomatic with regard to the
leg
ABI and Mortality
Ankle Brachial Index Collaboration. JAMA 2008.
Association of ABI with all-cause mortality in a meta-analysis of 16 cohort studies including 48,294 subjects and 480,325 person-years of follow-up.
Diehm, C. et al. Circulation 2009;120:2053-2061
The German Epidemiological Trial on ABI Study: Event-free Survival by PAD status
Reinecke et al. Eur Heart J 2015;36:932-938
Death (n= 10,880) Amputation (n= 7,825)
Contemporary PAD Outcomes in Germany
n = 41,882 PAD patients hospitalized during 2009 – 2011
Followed until 2013, (mean 1144 days)
Cardiovascular Risk Increases
With Decreases in ABI
>1.1 1.1–1.01 1.0–0.91 0.9–0.71 <0.7
ABI
CH
D E
ven
t O
utc
om
es*
per Y
ear (
%)
0
1
2
3
4
5-year risk:
10%
5-year risk:
19%
Framingham “High Risk” = 20% at 10 years Every patient with PAD is at “very high risk”
PAD *Fatal or nonfatal MI
2%
3.8%
1.4%
Leng GC et al. Brit Med J. 1996;313:1440-1444.
0
1
2
0
1
3
0
1
0
2
1
0
3
2
1
0
4
3
2
1
0
3.8%
2%
3.8%
The Peripheral Artery Disease Prescription
Olin JW et al. J Am Coll Cardiol 2016, In Press.
• 7458 eligible participants aged >40 years
• Prevalence of PAD is 5.9%, or 7.1 million US adults
with PAD – Statin use 30.5%
– ACE/ARB use 24.9%
– Aspirin use 35.8%
• Among patients with PAD (and no other clinical
cardiovascular disease), use of multiple preventive
therapy was associated with a 65% lower all-cause
mortality (HR 0.35, P=0.02)
Pande RL et al. Circulation. 2011;124:17-23.
National Health and Nutrition Examination
Study, 1999–2004
Armstrong E et al. J Am Heart Assoc 2014;3:e000697.
Adherence to Guideline-Recommended Medical Therapies
and Outcomes in Peripheral Artery Disease.
Major Adverse CV Events Major Adverse Limb Events
A total of 237 (32%) patients met all four guideline-recommended therapies
(antiplatelet, statin, ACE, smoking cessation)
The Efficacy of Statin Therapy The Heart Protection Study
Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22.
Previous MI 23.5 29.4
Other CHD 18.9 24.2
No prior CHD or CBV disease 18.7 23.6
Diabetes 13.8 18.6
All patients 19.8 25.2
1.2 1.4 0.6 0.4
24% Reduction
(P<.0001)
Existing disease
Statin Control
Incidence of events
(n=10,269) (n=10,267) Statin favored Placebo
Risk vs Control
PAD 24.7 30.5
0.8 1.0
ACE Inhibitors in PAD
The HOPE Trial
HOPE Study Investigators. N Engl J Med. 2000;342:145-153.
History of CAD 7477
No history of CAD 1820
Prior MI 4892
No prior MI 4405
CBV disease 1013
No CBV disease 8284
Peripheral vascular disease 4051
No peripheral vascular disease 5246
Microalbuminuria 1956
No microalbuminuria 7341
No. of Patients
Reduced Increased
Relative risk in ramipril group
0.6 0.8 1.0 1.2
Collagen
Thrombin
TXA2
ADP
TXA2
ADP Phosphodiesterase
ADP
(fibrinogen
receptor)
GP IIb/IIIa Activation
COX
Clopidogrel bisulfate
Ticlopidine HCl
ASA
Dipyridamole
cAMP
Mechanisms of Action of Oral Antiplatelet Therapies