The document discusses peripheral vascular disease (PVD) and venous thromboembolism (VTE). PVD is underdiagnosed and involves atherosclerosis in arteries outside the heart and brain. Common symptoms include leg pain with walking. VTE has a high prevalence in hospitalized patients, especially those with reduced mobility, and often goes undiagnosed. Ultrasound is useful for diagnosing PVD and Doppler criteria can estimate stenosis. Low molecular weight heparin reduces the risk of VTE compared to unfractionated heparin in heart failure patients.

1. 24 Januari 2009 Peripheral Vascular Disease A non-invasive perspective AZHARI GANI

3. Peripheral artery disease and cerebrovascular disease are artherosclerotic disease involving the the vascular tree of the particular organs Majority are asymptomatic Prevalence are increasing: Ageing population Co morbidities – cigarette, DM, HPT, Hyperlipidemia Better screening

4. Claudication intermittent is a sensation of aching, burning, heaviness, or tightness in the muscles of the legs that usually begins after walking a certain distance, walking up a hill, or climbing stairs, and goes away after resting for a few minutes. ● Buttock, thigh, or calf pain with exertion (claudication) ● No symptoms–diagnosed by abnormal ABI test ● Erectile dysfunction Uncommon ● Pain in legs and feet at rest ● Sore (ulcer) on leg that does not heal ● Arm pain with exertion (PAD of arms) ● Different blood pressures in the right and left arms of more than 15 points (PAD of arms)

5. painful joints (arthritis), tingling or a “pinsand- needles” sensation (neuropathy), pain running down the back of the thighs due to arthritis of the spine (sciatica or spinal stenosis).

6. PVD – prevalence 16% in men > 60 years 20% in men > 80 years 13% in women > 60 years Incidence of 3 vessel higher in patients with PVD (63%) than those without PVD (11%) Schroll M, J Chr Dis 1981 Sukhija R, Am J Cardiol 2003

7. Persons with PVD at increased risk for all cause mortality (RR 3.1), cardiovascular mortality (RR 5.9) and cardiovascular events. Marked reduction in QOL, similar to CCF and other chronic diseases Criqui MH, NEJM 1992 Jaff M, PCR 2003

8. “ PVD is a notably underdiagnosed and undertreated health condition. Offering a screening program is an excellent approach for providing services. PVD screening programs can tap new patient markets, increase referrals and ultimately boost direct and indirect revenue” “ Medicare contribution margin is 30% for PVD, comparable to cardiac services” Vesey J, Health Care Strategic Mx 2003

9. Supraaortic arteries – carotids, vertebral, subclavian Renal arteries Aorta – abdominal and thoracic Lower limbs – iliacs, femoral, infrageniculate Others areas Intracranial Penile Coeliac, mesenteric

10. Duplex USG is one of the most important techniques in evaluating PVD Combination of B mode, colour and pulsed Doppler is the way- accurate and simple Sensitivity and specificity of close to > 95% Newer tissue Doppler, harmonic imaging, contrast enhancement and 3D imaging yet to play role in daily practice CT and MRI has a role but impractical for screening

11. More than 80% of ischaemic events are due to arteriosclerosis affecting the extracranial arteries, mostly at the bifurcation/prox ICA Duplex examination most important Most vascular surgeons rely on USG alone prior to CEA Carotid artery stenting still limited to symptomatic patients with >50% stenosis and asymptomatic with >80% stenosis with high risk

13. Diagnosis of arterial occlusion usually made on basis of history and physical examination ABI plays a major role in screening Duplex scanning of arteries can identify specific segment for study with high accuracy Image however less accessible in the deeper vessels, pelvic area, adductor canal and infrageniculate arteries. Lower sensitivity for detecting second order stenosis, or stenosis distal to severe occlusions

14. Meluzin et al Eur J Echo 2003

15. Simple test to screen for arterial occlusion ABI : ratio of the leg pressure to the arm pressure (ankle blood pressure divided by arm blood pressure) ABI > 0.9 normal 0.7-0.89 mild disease 0.41-0.69 moderate < 0.4 severe Unreliable in calcified vessels, diabetics. Segmental blood pressure recordings might be measured to further pinpoint area of occlusion Plethysmography and exercise component may be added

21. USG proves to be useful in terms of safety, low cost and high sensitivity Several Doppler criteria from few groups: e.g. Renal aorta ratio > 3.5 signifies 60-99% stenosis, velocity >180cm/s Neumeyer M, Hershey Med Dept

22. Colour and CW Doppler from inflow, graft and outflow artery Doppler signals are triphasic and changes to biphasic can be significant Graft velocity of < 45 cm/s signifies a potential graft failure Peak stenotic and prestenotic systolic velocities will estimate narrowing : 2:1 ratio : >50% 4:1 ratio : >75% > 400cm/s : > 75%

23. Venous Thrombo-embolisms (VTE) is serious medical problem Prevalence of VTE is high VTE usually undiagnosed Many physicians still unrecognized VTE Heart failure is one of the high risk for VTE The best treatment VTE is prophylaxis

24. 1 Cohen AT. Presented at the 5th Annual Congress of the European Federation of Internal Medicine; 2005. 2 Eurostat statistics on health and safety 2001. Available from: http://epp.eurostat.cec.eu.int. Deaths caused of VTE: 543,454 1 Exceed combined deaths due to: AIDS 5,860 2 breast cancer 86,831 2 prostate cancer 63,636 2 transport accidents 53,599 2

25. Within 5 years of DVT, 80% of patients develop ed become P ost P hleb o tic S yndrome (varicose veins, ulceration veins) 30 -70% of patients with DVT (VTE) have A symptomatic P ulmonal Embolisms

26. GRIP- VTE SURVEY

27. 1 Geerts WH, et al. Chest. 2004;126:338S-400S. 2 Leizorovicz A, et al. Circulation. 2004;110(24 Suppl 1):IV13-9. (%) 17 20 50 50 0 10 20 30 40 50 60 Internal medicine General surgery Acute ischemic stroke Orthopedic surgery Prevalence of VTE is High DVT prevalence in stroke patients is one of the highest in hospitalized patients (no prophylaxis)

28. 70% of deaths due to PE occur in medical patients In 5,000 autopsies, VTE was discovered in 43% of patients PE causes 10% of hospital deaths 70% Medical 30% Surgical Inpatient VTE, % Adapted from: Diebold J, Lohrs U. Pathol Res Pract . 1991;187:260-266. 5,039 Hospitalized Patients

29. VTE mostly Undiagnosed Less than half of all cases of fatal PE are detected prior to death 1 Approximately 80% of DVT are clinically silent 2,3 1. Goldhaber SZ, et al. American Journal of Medicine 1982;73:822-826. 2. Lethen H, et al. American Journal of Cardiology 1997;80:1066-1069. 3. Sandler DA, et al. J. Royal Soc. Med. 1989; 82:203-205. 20 % 80 %

30. General medical patients 10-26% [Cade 1982, Belch et al., 1981] Stroke 11- 75% [Nicolaides et al.,1997] Myocardial infarction (MI) 17-34% [Nicolaides et al., 1997] Spinal cord injury 6 -100% [Nicolaides et al. , 1997] Congestive heart failure 20- 40% ( Anderson et al., 1950] Medical intensive care 25- 42% [Cade, 1982, Dekker et al., 1991, Hirsh et al., 1995] The Acute i ll ness Hospitalized medical Patients frequency of VTE “ in the absence of prophylaxis “

31. MECHANISME VTE IN HEART FAILURE

32. Venous stasis (I mmobilization) Vascular lesion (surgical, trauma, inflammation) Hypercoagulability. (Deficiency of Protein C, Protein S, AT III) Rudolf Ludwig Karl Virchow (1821-1902) &quot;Father of Pathology” Thrombogenesis

33. Chest 2002;122;1440-1456

34. Lopez, J. A. et al. Hematology 2004;2004:439-456 Model for venous thrombosis Endothelial activation Stasis (eg., RVF) -infection (TNF- ά ) (Vessel injury) Monocytes stimulation to produce TF -Cancer -IBD -infection (TNF- ά )

35. Venous thrombosis: Stasis leads to the development of a thrombus composed of red cells and fibrin Slow, turbulent blood flow in valve cusps result in areas of local stasis Prandoni P, et al. Haematologica 1997; 82 :423–428.

36. Venous thrombosis: Deep vein thrombosis Thrombus growth results in proximal progression along the vein Pulmonary embolism Damage to veins (PTS) Prandoni P, et al. Haematologica 1997; 82 :423–428.

38. Adapted from Sevitt S. The structure and growth of valve-pocket thrombi in femoral veins. J Clin Pathol. 1974;27:517-28

39. Symptoms : pain, redness and swelling of the leg , usually unilateral Within 5 years of DVT, 80% of patients develop post phlebitic syndrome, which manifest in chronic leg discomfort and swelling, varicose veins, skin discoloration and ulceration in severe cases. DOPPLER USG, VENOGRAPHY REMEMBER : 80-90% DVT ARE ASYMPTOMATIC (CLINACALLY SILENT) MANY PHYSICIANS UNREGCONIZED VTE

40. P U L M O N A R Y E M B O L I S M S A S Y M P T O M A T I C 80-90% 10-20% V T E C H F V T E S Y M P T O M A T I C

41. Practice guidelines ACCP 2008 - LDU H * or LMWH recommended in general medical patients with clinical risk factors for VTE (including cancer, bed rest, CHF, severe lung disease) (Grade 1A) International Consensus Statement 2001 - LMWH OD recommended for hospitalized patients with chronic respiratory disease or CHF (Grade A) *LDUH: UFH 5,000 U SC BID or TID 1. Albers GW, et al. Chest. 2008;133:71-109 2. Nicolaides AN. Int Angiol, 2001; 20: 1-37

42. PRIME 1 86% UFH 5000 IU tid Enoxaparin 40 mg od THE-PRINCE 2 19% UFH 5000 IU tid Enoxaparin 40 mg od Hillbom, et al 3 43% UFH 5000 IU tid Enoxaparin 40 mg od 1.4 0.2 Trial RRR Thromboprophylaxis Patients with VTE (%) 10.4 8.4 34.7 19.7 1 Lechler E, et al. Haemostasis. 1996;26 Suppl 2:49-56. 2 Kleber FX, et al. Am Heart J. 2003;145:614-21. 3 Hillbom M, et al. Acta Neurol Scand. 2002;106:84-92. P < 0.001 for equivalence P = 0.015 for equivalence P = 0.044 LMWH vs UFH tid = three times daily.

43. Safety end point Aes = adverse event; ALAT=Alanine aminotransferase; ASAT= aspartate aminotransferase *>5 cm diameter at injection site

44. CONSENSUS RECOMMENDATIONS IN ACUTE HEART FAILURE Consensus body Subcutaneous UFH LMWH + Recommendation grade** ACCP Consensus Statement 5 Recommendation 1 A International Union of Angiology* Subcutaneous UFH High dose LMWH + A * Recommendations are for medical patients with disease-related and/or additional patient-related risk factors + Enoxaparin (40 mg once-daily) is the only low molecular weight heparin licensed for the prevention of venous thromboembolism in hospitalised, acutely ill patients with heart failure NYHA Class III/IV **Grade of recommendation based on scientifically sound clinical trials in which the results are clear cut

45. VTE risk and ACCP prophylaxis use in medical patients with 6 key diagnoses Medical patients (%) Bergmann J-F, et al. XXIII World Congress of the I UA. June 2008;Athens, Greece.

46. Non invasive service in PVD is essential in screening and ensuring the livelihood of the peripheral intervention team Adequate training of personnel is available and accredited Good relationship with the vascular surgeons, interventional radiologists, cardiologist to ensure a healthy practice which benefits the patient Patients immobilized with critically ill condition including congestive heart failure (30%) are at risk of venous thrombo - embolism.