Treatment Approach to Patients with Combined Peripheral and Coronary Artery Disease
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Abstract
Atherothrombotic disease is one of the leading causes of mortality across the globe. A significant percentage of patients have a combined involvement of more than one vascular bed at the same time, which has a substantial effect on cardiovascular outcomes. Peripheral arterial disease is often underdiagnosed, especially in patients with coronary artery disease. This article reviews the approach to patients with combined peripheral and coronary artery disease and highlights the importance of identifying the presence of combined disease, their risk factors, diagnosis and management.
VASCULAR DISEASE MANAGEMENT 2010;7:E135–E141
Key words: atherothrombotic disease, coronary artery disease, peripheral artery disease, cardiovascular risk factors
Introduction
Coronary artery disease (CAD) and peripheral arterial disease (PAD) are important manifestations of atherothrombotic disease. A large proportion of patients with atherothrombotic disease have polyvascular disease.1–7 The presence of these two concurrently has a huge negative impact on cardiovascular morbidity and mortality.1,3,5,6,8,9 PAD is often overlooked during the diagnosis and management of CAD, even among a specialist’s care.10–12 With cardiovascular disease being one of the leading causes of mortality in the United States and across the globe, strategies targeting patients with both CAD and PAD need to be reevaluated.13,14
Prevalence and Risk of Combined PAD and CAD
The prevalence of CAD and PAD. Both CAD and PAD are manifestations of atherothrombotic disease. Recent data suggest that more than 13 million suffer from CAD, while more than 8 million adults have PAD in the United States.13,14 Many patients are found to have involvement of both these vascular beds, with the prevalence of both conditions increasing with age.1,2,4,7,12,15–17 In the Reduction of Atherothrombosis for Continued Health (REACH) Registry, an international observational registry of 67,888 patients aged > 45 years with an established history of CAD, PAD, cerebrovascular disease (CVD)or ≥ 3 atherosclerotic risk factors who were followed prospectively for 24 months, 4.7% had both CAD and PAD1 (Figure 1). Several studies have also noted a higher prevalence of PAD in patients with CAD, especially in patients with acute coronary syndromes or those undergoing coronary artery revascularization.2,4,7,12,15–17 Yet, PAD is still an underdiagnosed and undertreated condition both under primary and specialty care.10–12,18 Results from The PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program showed that in primary-care practice, physician awareness of PAD is relatively low.10 This study was conducted at 27 sites (350 primary-care practices) in United States recruiting 6,979 patients aged > 70 years or 50–69 years of age with a history of smoking or diabetes mellitus who were evaluated by history and ankle brachial index (ABI) measurements. This study was conducted to assess the ability of PAD diagnosis in the primary-care setting and also assess the awareness of both patients and physicians.10 Intermittent claudication, the classic manifestation of PAD, is infrequently seen in patients, especially those with CAD.10,19 A large percentage of high-risk patients with coexistent disease may not be diagnosed with underlying PAD, as they may be largely asymptomatic. Thus, standard screening questionnaires have poor sensitivity.19 With the use of the ABI, studies have shown that there is a significant increase in diagnosis of patients with PAD who have coexistent CAD.10,20–22 This suggests an important role for ABI in screening of high-risk individuals, especially those with a coexistent diagnosis of CAD.
CAD in patients with PAD.
PAD is considered a strong marker for systemic atherosclerotic disease, and a large number of patients have coexistent CAD. A systematic review with nearly 45,000 patients from 11 different studies conducted in 6 different countries showed that a low ABI (< 0.9) was associated with an increased presence of clinical cardiovascular disease.23 A high percentage of patients with PAD have underlying CAD, especially in the elderly population. In a study done involving geriatric patients, CAD was present in more than two-thirds of the patients who had a diagnosis of PAD.2 Also, it has been demonstrated that patients with PAD have a higher incidence of asymptomatic CAD.4,17,24
Studies have consistently shown that patients with PAD have more severe CAD, often with severe and multivessel involvement, than CAD patients without PAD.12,15,25,26 Sukhija et al showed that patients with PAD had a higher incidence of left main and triple-vessel disease compared to the cohort without PAD.25 Similar results of a higher prevalence of multivessel disease and left main disease were seen in the Peripheral Arterial Disease in Interventional Patients Study (PIPS), a prospective study assessing PAD by history, medical questionnaires and ABI measurements in 800 patients aged > 70 years or 50–69 years with a history of smoking and/or diabetes referred for coronary angiography without a prior diagnosis of PAD.12
1. Bhatt DL, Ohman EM, Hirsch AT, et al; REACH Registry Investigators: International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA 2006;295:180–189.
2. Ness J, Aronow WS. Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice. J Am Geriatr Soc 1999;47:1255–1256.
3. Saw J, Bhatt DL, Moliterno DJ, et al. The influence of peripheral arterial disease on outcomes: A pooled analysis of mortality in eight large randomized percutaneous coronary intervention trials. J Am Coll Cardiol 2006;48:1567–1572.
4. Poredos P, Jug B. The prevalence of peripheral arterial disease in high risk subjects and coronary or cerebrovascular patients. Angiology 2007;58:309–315.
5. Makowsky MJ, McAlister FA, Galbraith PD, et al. Alberta Provincial Program for Outcome Assessment in Coronary Heart Disease I: Lower extremity peripheral arterial disease in individuals with coronary artery disease: Prognostic importance, care gaps, and impact of therapy. Am Heart J 2008;155:348–355.
6. Bhatt DL, Harrington RA, Ou FS, et al; CRUSADE Investigators. Prior polyvascular disease: Risk factor for adverse ischaemic outcomes in acute coronary syndromes. Eur Heart J 2009;30:1195–1202.
7. Welten GM, Schoutern O, Chonchol M, et al. Prognosis of patients with peripheral arterial disease. J Cardiovasc Surg (Torino) 2009;50:109–121.
8. Eagle KA HA, Califf RM, Alberts MJ, et al; REACH Registry Investigators. Cardiovascular ischemic event rates in outpatients with symptomatic atherothrombosis or risk factors in the United States: Insights from the reach registry. Crit Pathw Cardiol 2009;8:91–97.
9. Cotter G, Cannon CP, McCabe CH, et al. Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes: Are we doing enough? Results from the orbofiban in patients with unstable coronary syndromes-thrombolysis in myocardial infarction (opus-timi) 16 study. Am Heart J 2003;145:622–627.
10. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001;286:1317–1324.
11. Chan AW. Expanding roles of the cardiovascular specialists in panvascular disease prevention and treatment. Can J Cardiol 2004;20:535–544.
12. Moussa ID JM, Mehran R, Gray W, et al. Prevalence and prediction of previously unrecognized peripheral arterial disease in patients with coronary artery disease: The peripheral arterial disease in interventional patients study. Catheter Cardiovasc Interv 2009;73:719–724.
13. Lloyd-Jones D, Adams R, Carnethon M, et al. American Heart Association Statistics C, Stroke Statistics S: Heart disease and stroke statistics — 2009 Update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:e21–e181.
14. Pleis J, Lucas J. Summary health statistics for u.S. Adults: National health interview survey, 2007. Vital Health Stat 2009;10:240.
15. Papanas N, Tziakas D, Hatzinikolaou E, et al. Revisiting the frequency of peripheral arterial disease in patients with coronary artery disease: Is there a difference between diabetic and non-diabetic patients? Vasa 2006;35:227–231.
16. Froehlich JB, Mukherjee D, Avezum A, et al; GRACE Investigators. Association of peripheral artery disease with treatment and outcomes in acute coronary syndromes. The global registry of acute coronary events (GRACE). Am Heart J 2006;151:1123–1128.
17. Hirose K, Chikamori T, Hida S, et al. Prevalence of coronary heart disease in patients with aortic aneurysm and/or peripheral artery disease. Am J Cardiol 2009;103:1215–1220.
18. D’Souza J, Patel NN, Rocker M, et al. Management of cardiovascular risk factors by primary care physicians in patients with peripheral arterial disease. Surgeon 2008;6:144–147.
19. Dieter RS, Biring T, Tomasson J, et al. Classic intermittent claudication is an uncommon manifestation of lower extremity peripheral arterial disease in hospitalized patients with coronary artery disease. Angiology 2004;55:625–628.
20. Dieter RS, Tomasson J, Gudjonsson T, et al. Lower extremity peripheral arterial disease in hospitalized patients with coronary artery disease. Vasc Med 2003;8:233–236.
21. Mourad JJ, Cacoub P, Collet JP, et al; on behalf of the ESC, Study I. Screening of unrecognized peripheral arterial disease (PAD) using ankle-brachial index in high cardiovascular risk patients free from symptomatic PAD. J Vasc Surg 2009;50:572–580. Epub 2009 Jun 27.
22. Cacoub P, Cambou JP, Kownator S, et al. Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: A cross-sectional study. Int J Clin Pract 2009;63:63–70.
23. Heald CL, Fowkes FG, Murray GD, et al. Risk of mortality and cardiovascular disease associated with the ankle-brachial index: Systematic review. Atherosclerosis 2006;189:61–69.
24. Her K, Choi C, Park Y, et al. Concomitant peripheral artery disease and asymptomatic coronary artery disease: A management strategy. Ann Vasc Surg 2008;22:649–656.
25. Sukhija R, Yalamanchili K, Aronow WS. Prevalence of left main coronary artery disease, of three- or four-vessel coronary artery disease, and of obstructive coronary artery disease in patients with and without peripheral arterial disease undergoing coronary angiography for suspected coronary artery disease. Am J Cardiol 2003;92:304–305.
26. Fiandra U, Bo M, Poli L, et al. Correlation between ankle-arm blood pressure index (aai) and atherosclerotic vascular involvement in coronary arteries. Arch Gerontol Geriatr 1996;22(Suppl 1):85–94.
27. Lane JS, Vittinghoff E, Lane KT, et al. Risk factors for premature peripheral vascular disease: Results for the national health and nutritional survey, 1999–2002. J Vasc Surg 2006;44:319-324; discussion 324–315.
28. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992;326:381–386.
29. Suarez C, Castillo J, Esmatjes E, et al; en representacion de los investigadores del registro REACH. [Cardiovascular complications at 1-year of follow-up in patients with atherothrombosis. On behalf of Spain’s REACH registry.]. Med Clin (Barc) 2009;132:537–544.
30. Steg PG BD, Wilson PW, D’Agostino R Sr, et al; REACH Registry Investigators. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 2007;297:1197–1206.
31. Monreal M, Alvarez L, Vilaseca B, et al. Investigators FRENA. Clinical outcome in patients with peripheral artery disease. Results from a prospective registry (FRENA). Eur J Intern Med 2008;19:192–197.
32. Mukherjee D, Eagle KA, Smith DE, et al; Blue Shield of Michigan Cardiovascular Consortium. Impact of extracardiac vascular disease on acute prognosis in patients who undergo percutaneous coronary interventions (data from the Blue Cross & Blue Shield of Michigan Cardiovascular Consortium [BMC2]). Am J Cardiol 2003;92:972–974.
33. Chiu JH, Topol EJ, Whitlow PL, et al. Peripheral vascular disease and one-year mortality following percutaneous coronary revascularization. Am J Cardiol 2003;92:582–583.
34. Rihal CS, Sutton-Tyrrell K, Guo P, et al. Increased incidence of periprocedural complications among patients with peripheral vascular disease undergoing myocardial revascularization in the bypass angioplasty revascularization investigation. Circulation 1999;100:171–177.
35. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 2007;33(Suppl 1):S1–S75.
36. Faglia E, Clerici G, Clerissi J, et al. Long-term prognosis of diabetic patients with critical limb ischemia: A population-based cohort study. Diabetes Care 2009;32:822–827.
37. Pencina MJ, D’Agostino RB Sr, Larson MG, et al. Predicting the 30-year risk of cardiovascular disease. The Framingham heart study. Circulation 2009;119:3078–3084. Epub 2009 Jun 8.
38. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: Results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation 2004;110:738–743.
39. Brevetti G, Piscione F, Silvestro A, et al. Increased inflammatory status and higher prevalence of three-vessel coronary artery disease in patients with concomitant coronary and peripheral atherosclerosis. Thromb Haemost 2003;89:1058–1063.
40. O’Hare AM, Glidden DV, Fox CS, Hsu CY. High prevalence of peripheral arterial disease in persons with renal insufficiency: Results from the National Health and Nutrition Examination Survey 1999–2000. Circulation 2004;109:320–323.
41. Leskinen Y, Salenius JP, Lehtimaki T, et al. The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: Requirements for diagnostics. Am J Kidney Dis 2002;40:472–479.
42. Chonchol M, Whittle J, Desbien A, et al. Chronic kidney disease is associated with angiographic coronary artery disease. Am J Nephrol 2008;28:354–360.
43. Astor BC, Hallan SI, Miller ER 3rd, et al. Glomerular filtration rate, albuminuria, and risk of cardiovascular and all-cause mortality in the U.S. population. Am J Epidemiol 2008;167:1226–1234.
44. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296–1305.
45. Ostchega Y, Paulose-Ram R, Dillon CF, et al. Prevalence of peripheral arterial disease and risk factors in persons aged 60 and older: Data from the national health and nutrition examination survey 1999-2004. J Am Geriatr Soc 2007;55:583–589.
46. Criqui MH, Vargas V, Denenberg JO, et al. Ethnicity and peripheral arterial disease: The San Diego population study. Circulation 2005;112:2703–2707.
47. Erren M, Reinecke H, Junker R, et al. Systemic inflammatory parameters in patients with atherosclerosis of the coronary and peripheral arteries. Arterioscler Thromb Vasc Biol 1999;19:2355–2363.
48. Wildman RP, Muntner P, Chen J, et al. Relation of inflammation to peripheral arterial disease in the national health and nutrition examination survey, 1999–2002. Am J Cardiol 2005;96:1579–1583.
49. Brevetti G, Piscione F, Schiano V, et al. Concomitant coronary and peripheral arterial disease: Relationship between the inflammatory status of the affected limb and the severity of coronary artery disease. J Vasc Surg 2009;49:1465–1471.
50. Bosevski M, Kostoska S, Tosev S, Borozanov V. Prognostic importance of haemostatic parameters in polyarterial disease. Prilozi 2005;26:81–92.
51. Khandanpour N, Loke YK, Meyer FJ, et al. Homocysteine and peripheral arterial disease: Systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2009; 38:316–322. Epub 2009 Jun 27.
52. Hirsch AT, Hertzer NR, Bakal CW, et al; American Association for Vascular Surgery/Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society of Interventional Radiology; ACC/AHA Task Force on Practice Guidelines. ACC/HA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease) — Summary of recommendations. J Vasc Interv Radiol 2006;17:1383–1397.
53. Bazzano LA, Reynolds K, Holder KN, He J. Effect of folic acid supplementation on risk of cardiovascular diseases: A meta-analysis of randomized controlled trials. JAMA 2006;296:2720–2726.
54. Poussa H, Strandberg TE, Tikkanen I, et al. Diagnosis and treatment of dyslipidemia are neglected in patients with peripheral artery disease. Scand Cardiovasc J 2007;41:138–141.
55. Rice TW, Lumsden AB. Optimal medical management of peripheral arterial disease. Vasc Endovascular Surg 2006;40:312–327.
56. Bush RL, Kallen MA, Liles DR, et al. Knowledge and awareness of peripheral vascular disease are poor among women at risk for cardiovascular disease. J Surg Res 2008;145:313–319.
57. Aronow WS. Drug treatment of peripheral arterial disease in the elderly. Drugs Aging 2006;23:1–12.
58. Hirsch AT, Gotto AM Jr. Undertreatment of dyslipidemia in peripheral arterial disease and other high-risk populations: An opportunity for cardiovascular disease reduction. Vasc Med 2002;7:323–331.
59. Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001;344:1608–1621.
60. Cacoub PP, Abola MT, Baumgartner I, et al; REACH Investigators. Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the reduction of atherothrombosis for continued health (REACH) registry. Atherosclerosis 2009;204:e86–e92.
61. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC, National Heart L, Blood I: AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113:2363–2372.
62. Chi YW, Jaff MR. Optimal risk factor modification and medical management of the patient with peripheral arterial disease. Catheter Cardiovasc Interv 2008;71:475–489.
63. Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service Report. Am J Prev Med 2008;35:158–176.
64. Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood Institute, American College of Cardiology, American Heart Association. Implications of recent clinical trials for the national cholesterol education program adult treatment Panel III Guidelines. Circulation 2004;110:227–239.
65. Raichlen JS, Healy B, Achuff SC, Pearson TA. Importance of risk factors in the angiographic progression of coronary artery disease. Am J Cardiol 1986;57:66–70.
66. Alderman EL, Corley SD, Fisher LD, et al. Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the coronary artery surgery study (CASS). CASS participating investigators and staff. J Am Coll Cardiol 1993;22:1141–1154.
67. American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care 2003;26:3333–3341.
68. Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. Br Med J 1994;308:81–106.
69. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE steering committee. Lancet 1996;348:1329–1339.
70. Cassar K, Bachoo P, Ford I, et al. Platelet activation is increased in peripheral arterial disease. J Vasc Surg 2003;38:99–103.
71. Izquierdo-Porrera AM, Gardner AW, Powell CC, Katzel LI. Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease. J Vasc Surg 2000;31:670–677.
72. Bendermacher BL, Willigendael EM, Teijink JA, Prins MH. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database Syst Rev 2006:CD005263.
73. Raghunathan A, Rapp JH, Littooy F, et al. Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: A subanalysis of the coronary artery revascularization prophylaxis (CARP) trial. J Vasc Surg 2006;43:1175–1182.
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