1. ACC/AHA 2006 guidelines on the management of PAD

2. 2 ▪First national guidelines on PAD ▪Written in collaboration with: –American College of Cardiology –American Heart Association –American Association for Vascular Surgery/Society for Vascular Surgery* –Society for Cardiovascular/Angiography and Interventions –Society of Interventional Radiology –Society for Vascular Medicine and Biology ▪Endorsed by: –American Association of Cardiovascular and Pulmonary Rehabilitation –National Heart, Lung, and Blood Institute –Society for Vascular Nursing –TransAtlantic Inter-Society Consensus –Vascular Disease Foundation *AAVS/SVS when guidelines were initiated, now merged into SVS. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

3. 3 ACC/AHA definition: Classification of recommendations IIIIIbIIaI ▪Class I: Conditions for which there is evidence for and/or general agreement that a given procedure or treatment is beneficial, useful, and effective ▪Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment –Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy –Class IIb: Usefulness/efficacy is less well established by evidence/opinion ▪Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful Class: Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

4. 4 ACC/AHA definition: Level of evidence ▪Level of evidence A: Data derived from multiple randomized clinical trials or meta-analyses ▪Level of evidence B: Data derived from a single randomized trial or nonrandomized studies ▪Level of evidence C: Only consensus opinion of experts, case studies, or standard of care A B C Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

5. 5 Patients at risk for PAD Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf Accessed March 22, 2006. By specific age  <50 years old diabetes and one other atherosclerotic risk factor  50–69 years old history of smoking or diabetes  ≥70 years old with or without risk factors At any age  Exertional leg symptoms or ischemic rest pain  Abnormal pulse in lower extremity  Atherosclerotic disease coronary, carotid, or renal artery 2006 ACC/AHA PAD guidelines

6. 6 Varying presentations of patients with PAD PAD patients ≥50 years Initial presentation*Claudication 10%–35% of patients Atypical leg pain 40%–50% of patients Asymptomatic 20%–50% of patients *Excluding patients with an initial presentation of critical limb ischemia. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006. The majority of PAD patients do not have the classical symptoms of claudication

7. 7 PAD patients are at increased risk for CV ischemic events PAD* (≥ 50 years old ) 5-year outcomes Limb morbidity 70%–80% Stable claudication 10%–20% Worsening claudication 1%–2% Critical limb ischemia CV morbidity 20% Nonfatal CV event (MI or stroke) Mortality 15% to 30% ▪75% from CV causes *Patients with an initial clinical presentation of asymptomatic PAD, atypical leg pain, or claudication. Adapted from Hirsch AT et al. Available at: www.acc.org. Accessed March 22, 2006. Up to 1/3 of PAD patients will die in 5 years, 75% from CV causes

8. 8 Class I recommendation: Use of the ankle-brachial index (ABI) 1.Asymptomatic patients Individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ABI (Class I; Level B) 2.Symptomatic patients Patients with symptoms of intermittent claudication should undergo a vascular physical examination, including measurement of the ABI (Class I; Level B) 3.The most cost-effective tool for lower extremity PAD detection is the ABI Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

9. 9 Pharmacologic treatment for claudication symptoms Cardiovascular risk reduction Cardiovascular risk reduction vs treatment for claudication symptoms Separate management strategies Clopidogrel prescribing information. Cilostazol: Indicated to reduce symptoms of intermittent claudication, as indicated by an increased walking distance Clopidogrel: Indicated to reduce the risk of atherothrombotic events (recent MI, recent ischemic stroke, or vascular death) in individuals with established PAD

10. 10 2006 ACC/AHA guidelines for the management of patients with lower extremity atherosclerotic PAD: Antiplatelet therapy* ACC=American College of Cardiology; AHA=American Heart Association. *Clopidogrel was not the only agent recommended. This represents an adaptation from the 2006 ACC/AHA guidelines for the management of patients with PAD. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006. Patient typeRecommended therapyClass/level of evidence Peripheral arterial disease Antiplatelet therapy Aspirin (75–325 mg/day) Clopidogrel (75 mg/day) Class I level A Class I level B

11. 11 ACC/AHA PAD guidelines recommend CV risk reduction and symptom relief Evidence basis for selected treatment recommendations CV risk reduction Treatment for claudication* RecommendationsClass EvidenceRecommendationsClass Evidence Antiplatelet therapyI ASupervised exercise trainingI A Antihypertensive therapy I ACilostazolI A Smoking cessationI BSurgical intervention in appropriate patients I B Statin therapyI B Glucose control therapy IIa CEndovascular procedures in appropriate patients I A *To improve symptoms and increase walking distance. Adapted from the 2006 ACC/AHA PAD guidelines. Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.