Work Up Atherosclerosis

Question 1

What are the percentage of PAD Patients who have CAD ?

What are the percentage of PAD Patients who have Carotid Stenosis ?

Answer 1

60-90 % of Patients with PAD have Coronary artery Disease (CAD)

25% have significant carotid artery stenosis.

Question 2

How is the overall mortality rate in patients with PAD ?

Answer 2

The overall mortality rate among patients all with PAD is 15-30% (75% cardiovascular) and risk of non-fatal myocardial infarction (MI) or stroke is 20% at 5 years.

Question 3

How does the cardiovascular outcome look in patients with CLI ?

Answer 3

Patients with CLI have much worse cardiovascular outcomes with an annual CV mortality of 25% and annual amputation rate of 25 %.

Question 4

How do we reduce this high cardiovascular morbidity and mortality in PAD patients ?

Answer 4

1. Antiplatelet Therapie
2. Statin Therapie
3. Antihypertensive Therapie
4. Smoking Cessation
5. Treatment of Diabetes Mellitus
6. Other Risk Factors

Question 5

Antiplatelet Therapie

Whats the benefit ? Where is the evidence ?

Answer 5

20-30% risk reduction of nonfatal MI, nonfatal stroke or vascular death.
Meta-Analysis of the Antithrombotic Trialists Collaboration

Question 6

Statin Therapie

Whats the benefit ? Where is the evidence ?

Answer 6

Heart Protection Study : 22% relative risk reduction in the rate of first major vascular event.
Recent studies : reduction in amputations rates in patients with CLI and improvement in walking distance in patients with claudication.

Question 7

Statin Therapie

Guidelines Recommendations

Answer 7

All patients younger than 75 years with PAD should be on high intensity statin (LDL under 50) Atorvastatin 40-80mg, Rosuvastatin 20-40mg

All patients older than 75 years with PAD should be on at least moderate intensity statin

Question 8

Antihypertensive Therapie

Whats the benefit ? Where is the evidence ?

Answer 8

HOPE study: ramipril reduced the risk of stroke, MI and vascular death

RCTs: ramipril improve claudication symptoms

Question 9

Antihypertensive Therapie

Guidelines Recommendations

Answer 9

First line therapy in PAD patients is ACE-Inhibitors

B-Blockers can be safely used in PAD patients.

Question 10

Smoking Cessation
What if patients do not stop smoking ?

Guidelines Recommendations

Answer 10

Smokers have 2-6 fold increased risk of developing PAD.

Smokers with PAD have worse outcomes, with high incidences of critical limb schema, amputation rates, and higher procedural complications, including increased bypass graft failure, compared to non smokers.

Guidelines Recommendations
At every visit, physicians should ask patients about their current smoking status.