Vascular Health: Tips for Better Circulation

Tips for Better CirculationVascular health

Brian R. Beeman, MD, FACSVascular Surgery

www.SpringfieldClinic.com/DoctorIsIn

What does a vascular surgeon do?

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

Relative Risk

SmokingDiabetesHypertensionHypercholesterolemiaHyperhomocysteinemiaC-Reactive Protein

Reduced Increased

Risk Factors for PAD

1 2 3 4 5 60

Risk Factors for Vascular Disease

1. Smoking

2. Diabetes 3. Cholesterol 4. Hypertension 5. Family history 6. Age7. Lack of physical activity

Cigarette Smoking

Smoking is the single most important Smoking is the single most important avoidable avoidable risk factor for the risk factor for the

development of PAD and intermittent development of PAD and intermittent claudicationclaudication

Cigarette Smoking• Two to fivefold increased risk of PAD

• ~ 90% of pts with claudication are current or ex-smokers

• Smoking increases the risk of PAD>>CAD

• Diagnosis of PAD is made 10 yrs earlier among smokers

• The amount and duration of tobacco use correlate directly with the development of PAD

• Patients that continue to smoke experience– More common progression to CLI and limb loss – Decreased surgical and endovascular patency rates

443,000 US deaths per year from Cigarette smoking

• Lung Cancer…128,000• Heart disease…126,000• COPD / emphysema…92,000• Other….44,000• Stroke….15,900• Other cancers…35,300

• What does smoking do to your arteries….– CO, propylene glycol, glycerol, urea, other known carcinogens – Nicotine…. HR, BP, vasoconstriction, – Hardens arteries (atherosclerosis) – Increases risks of blood clotting x4 in arteries and veins– Insulin resisistance– Vascular wall injury– Increased inflammation– Increase in LDL cholesterol and decrease in HDL chol.

Effects of Cigarette Smoking

• Direct injury to blood vessel endothelium• Promotes systemic atherogenesis• Oxidation of LDL cholesterol• Increases carboxyhemoglobin levels• Promotes vasoconstriction

Weitz Jl. Circulation. 1996;94:3026-49.

Cardiovascular morbidity/mortality

Population Aged >55 yIntermittent claudication

PAD outcomes

Worsening claudication

16%

Leg bypass surgery

7%

Major amputation

4%

Nonfatal events (MI/stroke)

20%

Mortality 30%

Stable claudication

73%

(5-year outcomes)

Limb related outcomes at 5 years

73

167 4

0

20

40

60

80

100

StableClaudication

WorseningClaudication

Leg BypassSurgery

MajorAmputation

PAD Patients(%)

Weitz Jl. Circulation. 1996;94:3026-49.

Most of these patients do NOT progress to surgical disease

Diabetes Mellitus• Three to fourfold increased risk of PAD

• Different anatomic characteristics:– Extensive disease– Greater propensity for vascular calcification– Infrapopliteal disease more common

• Among patients with PAD diabetics • more likely to have an amputation

• Optimize glucose control with goal hemoglobin A1c < 7%

• PAD in patients with diabetes is 30%

• Amputation rates in diabetic patients is 5-10 times higher than others

• Sensory neuropathy and increased infections contribute to high amp rate

Importance of Optimal Diabetes Control

• UK prospective diabetes study (UKPDS)

• Risk reduction per 1% reduction in HgA1c:– Risk for amputation 37%– Death from PAD 43%– Myocardial infarction 14%– Stroke 12%– Heart failure 16%– (P <0.0001)

Stratton IM. BMJ. 2000 Aug 12;321(7258):405-12

(TASC II). Eur J Vas Endovasc Surg 2007;33(Suppl 1):S1-75

Heart Protection Study:Vascular Event by Prior Disease

CBD=cerebrovascular disease; CHD=congestive heart disease. Reprinted with permission from Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22 from Elsevier.

Previous MI 23.5 29.4Other CHD 18.9 24.2No prior CHD or CBV disease 18.7 23.6

Diabetes 13.8 18.6All patients 19.8 25.2

1.0 1.2 1.40.80.60.4

24% Reduction (P<.0001)

Existing diseaseStatin Control

Incidence of events

(n=10,269) (n=10,267) Statin favored

Placebo

Risk vs Control

PAD 24.7 30.5

Nutrition • Obesity epidemic

• High fructose corn syrup is second greatest threat to your health

• HFCS is poison

• Robert Lustig, MD Endocrinologist UCSF – “The bitter truth”– Fat chance : Beating the odds against sugar, processed foods, obesity,

and disease

Exercise• Supervised exercise walking programs improve symptoms of

claudication– Sessions of 30-60 min in duration– At least 3 times a week– At least 3-6 months

• Results in ~ 100-150% ↑↑ in walking distance• Possible mechanisms:

– Formation of collateral vessels– Improvement of endothelium-depended vasodilators– Improvement of muscle metabolism– Improved walking efficiency

Stewart KJ. Exercise training for claudication. N Engl J Med 347:1941, 2002

Treatment• Smoking cessation• Lipid control

– LDL-C, LDL-C, 100 mg/dL 100 mg/dL (Ideally <70)(Ideally <70)

– Raise HDL-CRaise HDL-C– Lower triglyceridesLower triglycerides

• BP control– Use ACE inhibitorsUse ACE inhibitors– (? B-blockers)(? B-blockers)

• Diabetes controlDiabetes control– HbA1C 7.0%

• Antiplatelet therapy– ASA, clopidogrel

• Achieving ideal body weight

• ExerciseExercise

Indications for Revascularization for PAD• Lifestyle-limiting symptoms

– Continued disability despite appropriate non-surgical management

• Critical Limb ischemia– Tissue loss, Gangrene and resting symptoms

• Technically feasible revascularization options exist

• Expectation of a favorable risk/benefit ratio• Revascularization options:

– Percutaneous, Surgical, Combined “hybrid approach”