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Poi ci sono gli anziani che non camminano

PAD e MALATTIA CARDIOVASCOLARE Incontri Pitagorici di Cardiologia 2010 1-2 Ottobre - Crotone Agostino Talerico Unità Operativa Semplice di Angiologia Ospedale San Giovanni di Dio - Crotone. World ‘s top 10 causes of death 2004. Poi ci sono gli anziani che non camminano.

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Poi ci sono gli anziani che non camminano

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  1. PADeMALATTIA CARDIOVASCOLAREIncontri Pitagorici di Cardiologia 20101-2 Ottobre - CrotoneAgostino TalericoUnità Operativa Semplice di Angiologia Ospedale San Giovanni di Dio - Crotone

  2. World ‘s top 10 causes of death 2004 Poi ci sono gli anziani che non camminano

  3. Improvvisa e imprevedibile erosione o rottura di placca aterosclerotica con attivazione piastrinica e formazione di trombo erosione di placca rottura di placca Aterotrombosi Evento comune che provoca infarto miocardico, ictus ischemico, e morte vascolare

  4. Malattia Cerebrovascolare MalattiaCoronarica 8.4% 1.6% 1.2% PAD N=11770 Arteriopatia Periferica Aterotrombosi : concomitanza Elevata prevalenza di malattia polidistrettualeIl Registro di REACH Tra i pazienti sintomatici: • 8,4% CVD e CAD • 4,7% CAD e PAD • 1,2% CVD e PAD • 1,6% CVD,CAD e PAD PREVALENZA GLOBALE: 15,9% N=16901 N=38006 4,7% 11.8% Bhatt DL et al JAMA 2006:295:180-189

  5. Evento iniziale Infarto miocardico Ictus Infarto miocardico 5–7 volte1 (inclusa la morte) 3–4 volte2 (incluso TIA) Ictus 2–3 volte2 (inclusa angina e morte improvvisa*) 9 volte3 2–3 volte3 (incluso TIA) Arteriopatia obliterante periferica 4 volte4 (inclusi solo IM fatale e altre morti CV†) Rischio di un secondo evento vascolare Aumento del rischio vs. popolazione generale * morte documentata entro 1 ora e attribuita a cardiopatia ischemica † inclusi solo IM fatali e altre morti cardiache; non sono inclusi gli IM non fatali 1. Adult Treatment Panel II. Circulation 1994; 89: 1333–1363.2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–339.3. Wilterdink JI, Easton JD. Arch Neurol 1992; 49: 857–863.4. Criqui MH et al. N Engl J Med 1992; 326: 381–386.

  6. ATS and Life Expectancy Analysis of data from the Framingham Heart Study Peeters A et al: Eur Heart J 2002 23:458-466

  7. World ‘s top 10 causes of death 2004 PREVENZIONE Poi ci sono gli anziani che non camminano

  8. Risk Factors of ATS

  9. Prevalence of Peripheral Arterial Disease PAD affects 12 % of the adult population 1,2 - 20% of population aged > 70 PAD is associated with 6-fold increase in CV mortality 3 - underrecognised and untreated 4 PAD requires simple, inexpensive, non invasive measurement for appropriate diagnosis, risk assessment and screening PAD Patients need aggressive risk-factor modification and pharmacological treatment 1 Nicolaides AN Symposium Nov 1997 2 Hiatt WR Circulation 1995 91:1472-1479 3 Criqui MH NEJM 1992 326:381-386 4 Hirsch AT JAMA 2001 286:1317-1324

  10. PAD CLASSIFICATIONS FONTAINE Helv Chir Acta 1954; 21: 499-533J Vasc Surg 1997;26 (Suppl. 3):517-38 RUTHERFORD STAGE CLINICAL SIGNS & SYMPTOMS PATHOPHYSIOLOGY CLINICAL GRADE CATEGORY FORTUITOUS DISCOVERY OF AORTIC & ILIAC CALCIFICATIONS ASYMPTOMATIC 1ST ATS PLAQUE RISK PLAQUE INFLAMMATION ASYMPTOMATIC 0 / 0 MILD CLAUDICATION ABSOLUTE CLAUDICATION DISTANCE > 200 MT RECOVERY T. < 2 MIN DISCREPANCY OXYGEN REQUEST ARTERIAL SUPPLY MILD CLAUDICATION 2ND A I / 1 ACD < 100 M RECOVERY TIME > 2 MIN HIGHEST DISCREPANCY AND ACIDOSIS SEVERE CLAUDICATION I / 3 ACD < 200 M RECOVERY TIME > 2 MIN HIGHER DISCREPANCY OXYGEN REQUEST ARTERIAL SUPPLY MODERATE CLAUDICATION I / 2 MODERATE OR SEVERE CLAUDICATION 2ND B REST PAIN 3RD ISCHAEMIC REST PAIN SKIN HYPOXIA ACIDOSIS ISCHAEMIC REST PAIN II / 4 ULCERATION OR GANGRENE NECROSIS GANGRENE MINOR TISSUE LOSS SEVERE SKIN HYPOXIA ACIDOSIS INFECTIONS III / 5 4TH MAJOR TISSUE LOSS III / 6

  11. – Presentazione clinica della PAD • Asintomatica ( aterosclerosi occulta ) • Sintomatica ( claudicatio intermittens ) • CLI ( Ischemia critica cronica )

  12. Ischemia Cronica Critica (CLI) - Dolori a riposo (notturni) da più di 15 giorni - Necessità di analgesici - Lesioni trofiche cutanee European Working Group CLI Circulation 1991 OUTCOME (1 anno) % NON RIVASCOL. RIVASCOL. 40 60 MORTE 20 10 AMPUT.MAGGIORE 20 15 SALVATAGGIO D’ARTO 0 35 Dormandy J, Murray GD: Eur J Vasc Surg 1991 5 131-3

  13. The Diagnosis of CLI matches many different clinical pictures, each Patient need for an own pathophysiological assessment

  14. Definitions of Intermittent Claudication Mild Claudication leg’s pain that occurs during walking > 200 m. and goes away after resting leg’s pain after climbing more than two flights of stairs Moderate Claudication leg’s pain that occurs during walking < 200 m. and goes away after resting, with recovery time > 2 min. leg’s pain after climbing less than two flights of stairs Severe Claudication leg’s pain that occurs during walking < 100 m. and goes away after resting, with recovery time > 2 min. leg’s pain after climbing less than one flight of stairs

  15. Prevalenza di PAD Asintomatica(ABI patologico)e di Claudicatio Intermittens nella popolazione generale 12 % 2 %

  16. – Raccomandazioni TASC 2 per lo sreening dei pazienti con PAD asintomatica • Soggetti con una storia, o visita medica , suggestiva di PAD( B ) • Pazienti a rischio PAD ( tra 50 e 69 anni con storia di diabete o fumo, o chiunque abbia più di 70 anni ) ( A ) • Pazienti con un Framinghamrisk score di 10% -20% in 10 anni ( B ) • Concomitanza di malattia carotidea cardiaca o renale

  17. Sig.ra Maria • Donna • 60 anni • Madre deceduta per ictus • Padre vivente; cardiopatia ischemica • Impiegata • Sposta; due figli • Palestra 2 volte a settimana • Fuma 15 sigtte/die dall’età di 17 anni • Non diabetica • Colesterolo 230 mg/dl • LDL 110 mg/dl • Trigliceridi 201 mg/dl • BMI 28 • ECG negativo • PAO 140/80 mmHg

  18. Carta italiana del rischio Cardiovascolare Istituto Superiore di Sanità

  19. The new European Risk Chart based on SCORE data. Adapted from Conroy et al, Eur Heart J. 2003;24:987-1003. European Society of Cardiology.

  20. ATP III Risk categories • Established CHD and CHD risk equivalents • Multiple risk factors(2+) • Zero to one risk factor NCEP Report Adult Treatment Panel Scott M. Grundy Circulation. 2004;110:227-239.

  21. ATP III Risk categories E’ sufficiente ??

  22. Sottoporre la paziente ad indagini per Aterosclerosi occulta, sarebbe una buona idea ????

  23. Subclinical atherosclerosis tests

  24. ABI - Definition Ankle systolic pressure Brachial systolic pressure RATIO

  25. EquipmentformeasurementofAnkle/BrachialIndex (ABI) Doppler CW Probe 8 mHz Sphygmomanometer

  26. The measurementof ABI

  27. The measurementof ABI

  28. The measurementof ABI

  29. Calculation of Ankle/Brachial Index Right ABI Higher of the rigth ankle systolic pressure (dorsalis pedis or posterior tibial) Higher of the left ankle systolic pressure (dorsalis pedis or posterior tibial ) Higher brachial systolic pressure (Left or right arm) Left ABI Higher brachial systolic pressure (Left or right arm)

  30. Sig. ra Maria ABI =0.83 ABI =0.90-1.30 NORMAL VALUE

  31. ABI < 0.90 = Haemodynamicallysignificantarterialstenosis = PeripheralArterialDisease

  32. As the 85% of PAD is determined by ATHEROSCLEROSIS ABI < 0.90 = ATHEROSCLEROSIS

  33. Sig. ra Maria Rischio Cuore ISS <10% + ABI = 0.83 = Asymptomatic PAD = Subclinical ATHEROSCLEROSIS

  34. ATP III Risk categories • Established CHD and CHD risk equivalents • Multiple risk factors(2+) • Zero to one risk factor NCEP Report Adult Treatment Panel Scott M. Grundy Circulation. 2004;110:227-239.

  35. ATP III Risk categories • Established CHD and CHD risk equivalents • Multiple risk factors(2+) • Zero to one risk factor NCEP Report Adult Treatment Panel Scott M. Grundy Circulation. 2004;110:227-239.

  36. ATP III Risk categories • CHD risk equivalents include • Non coronary formsof clinical atherosclerotic disease • Diabetes • Multiple(2+) risk factors with 10-year risk for CHD >20% • Allpersons with CHD or CHD risk equivalents can be called highrisk NCEP Report Adult Treatment Panel Scott M. Grundy Circulation. 2004;110:227-239.

  37. ATP III Risk categories

  38. ATP III Risk categories

  39. Ankle Brachial Index Combined With Framingham Risk Score to Predict Cardiovascular Events and Mortality A Meta-analysis JAMA, 2008

  40. Algorithm for use of the ABI in the assessment of systemic risk in the population Primary prevention: No antiplatelet therapy LDL <3.37 mmol/L (<130 mg/dL) except in diabetes where the LDL goal is <2.59 mmol/L (<100 mg/dL) even in the absence of CVD (cardiovascular disease); appropriate blood pressure (<140/90 mmHg and <130/80 mmHg in diabetes/renal insufficiency) Secondary prevention: Antiplatelet therapy LDL <2.59 mmol/L (<100 mg/dL) (<1.81 mmol/L [<70 mg/dL] in high risk); blood pressure <140/90 mmHg and <130/80 mmHg in diabetes/renal insufficiency. In diabetes, HbA1c <7.0%. L. Norgren et al TASC 2007

  41. is The ABI a BIOmarker of Cardiovascular Risk ? SENSIBILITA’ 95% SPECIFICITA’ 100% Nel rivelare una malattia angiograficamente significativa Fowkes: Int J Epidemiol 1988

  42. is The ABI a BIOmarker of Cardiovascular Risk ? All-CauseMortalityby ABI Category Anand V. Arterioscler Thromb Vasc Biol 2005

  43. is The ABI a BIOmarker of Cardiovascular Risk ? All-CauseMortalityby ABI Category 0 Anand V. Arterioscler Thromb Vasc Biol 2005

  44. is The ABI a BIOmarker of Cardiovascular Risk ? Marzolo M, Verlato F, et al: Int Angiol. 2008 27(5):426-32

  45. is The ABI a BIOmarker of Cardiovascular Risk ? Inadherence to Diagnostic Guidelines 62% 45% 35% Marzolo M, Verlato F, et al: Int Angiol. 2008 27(5):426-32

  46. is The ABI a BIOmarker of Cardiovascular Risk ? 55% 45,7% 16,6% 13,9% 10,6% 5,4% Marzolo M, Verlato F, et al: Int Angiol. 2008 27(5):426-32 Patients not Adequately Treated

  47. is The ABI a BIOmarker of Cardiovascular Risk ? Mortality and Vascular Morbidity in Older Adults With Asymptomatic Versus Symptomatic Peripheral Artery Disease Diehm Circulation 2009

  48. is The ABI a BIOmarker of Cardiovascular Risk ? Resnick HE et al. Circulation 2004

  49. Fate of the Claudicant Patient(5 years) 100 pts Int. Cl. presenting to doctor 300 people with asymptomatic PAD 100 pts Int. Cl. do not present to doctor 75 stabilise or improve mild-moderate claudication Local Outcome Systemic Outcome 25 deteriorate 5-10 non-fatal CV events in 5 years 55-60 alive without new CV event 30 will die within 5 years 7 C.L.I. 18 severe claudication 16 cardiac 4 cerebral 3 other vascular 7 non-vascular 3 amputation 12 stabilise severe claudic 6 require intervention 4 limb salvage

  50. Quanto è frequente il riscontro di aterosclerosi asintomatica inteso come ABI patologico ( <=0.9 )nella popolazione ritenuta a rischio medio – basso ? • Studio GET ABI( Germania ): 6.880 soggetti consecutivi non selezionati che si riferivano all’ambulatorio del medico di famiglia età ≥65 anni . 12.2 % • Studio YPSILON( Francia ): 2077 soggetti di età media 67 anni con 2 o più fattori di rischio ma senza malattia aterosclerotica conclamata 10.4 % • StudioPANDORA(Italia,Grecia,Francia,Svizzera,Belgio,Olanda)10500 soggetti ( donne età ≥55, uomini ≥45 ed almeno 1 fattore di rischio aggiuntivo ( escluso diabete ) 17.8 %

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