ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas

Mamdouh El-Nahas

Professor of Internal Medicine Endocrinology and Diabetes Unit

Mansoura University

Peripheral Arterial Diseases(PAD)

1. Prevalence

2. Atherosclerosis and its risk factors

3. The Danger of PAD

4. Diagnosis of PAD

5. Laboratory diagnosis

6. Management

One in three patients with diabetes mellitus have PAD (ADA 2006)

20% of in people with diabetes >40 years of had PAD.

30% of patients with diabetes >50 years of age hadPAD.

Practical Diabetes Int 16:163–166, 1999

JAMA 286:1317–1324, 2001


1. Prevalence


3. The impact of PAD

4. Diagnosis of PAD


6. Management

1. Age

2. Sex – predominantly male

3. Genetic predisposition

4. Dyslipidaemia

5. Hypertension

6. Smoking

7. Obesity

8. Alcohol

9. Diet

10. Sedentary lifestyle

Smoking

Tobacco use in any form is the single most importantmodifiable cause of PAD internationally.

The magnitude of the association is greater than thatreported for coronary heart disease.

Lu et al 2013: Meta-analysis of the association between cigarette smokingand peripheral arterial disease

Smoking More than 80%-90% of patients with lower extremityperipheral arterial disease are current or formersmokers.

The most effective treatment for PAD is to stopsmoking. This single measure reduces the risk ofdisease progression amongst patients with peripheralarterial disease and dramatically reduces the need forlimb amputation and the risk of premature death


1. Prevalence



4. Diagnosis of PAD


6. Management

1- Increased risk of foot ulceration and failure of theulcer to heal

2- Patients with foot infections and PAD are atparticularly high risk for major limb amputation.

3- A major risk factor for lower-extremity amputation.

4- A marker for systemicvascular disease.

Coronary heart disease

PAD

Cereb VD

Eur J Vasc Endovasc Surg 2007; 33: S14 4


1. Prevalence



4. Diagnosis of PAD


6. Management

Intermittent Claudication

Cramping, oraching painrelated towalking andrelieved byrest.

Atypical presentation

Inspection of the foot

Pedal pulses

Other clinical signs of PAD

Temperature gradient

Color changes

Capillary refill time

Simple bedside tests to diagnose PAD

A low ABI (<0.9)indicates PAD.

While ABI values (>0.9)may be unreliable inruling out of PAD.

ADA recommendations for ABI (2016)

Diabetic patients 50 years of age and older

Patients under 50 years of age who have other PAD riskfactors (e.g., smoking, hypertension, dyslipidemia, orduration of diabetes >10 years)

Any patient with symptoms or signs of PAD.

Handheld Doppler Ultrasound

Toe pressure

Imaging modalities

Duplex ultrasonography,

Magnetic resonance angiography,

Computed tomographic angiography,

Angiography

Biochemical Tests Screening for atherosclerotic risk factors e.g. lipid

abnormalities, proteinuria, renal insufficiency

For patients with early-age onset of disease, familyhistory of thrombotic events, or when there is a lackof common risk factors for atherosclerosis:

Hypercoagulability screening

Homocysteine levels (either fasting or aftermethionine loading)


1. Prevalence


3. The impact of PAD

4. Diagnosis of PAD


6. Management

Management of PAD

1. Risk Factor Modification

2. Antiplatelet Therapy

3. Exercise

4. Pharmacotherapy for Intermittent Claudication

5. Preventative foot care.

6. Vascular Specialist Care

Tobacco smoking

Cigarette smoking is one of the most importantpreventable risk factor for PAD in both men andwomen

Treatment of dyslipidemia Lifestyle modification should be recommended. A

Statin therapy should be added to lifestyle therapy,regardless of baseline lipid levels, for diabetic patients:

with overt CVD A

without CVD who are over the age of 40 years and haveone or more other CVD risk factors (family history ofCVD, hypertension, smoking, dyslipidemia, oralbuminuria). A

For lower-risk patients than the above (e.g., withoutovert CVD and under the age of 40 years), statintherapy should be considered in addition to lifestyletherapy if LDL cholesterol remains above 100 mg/dL orin those with multiple CVD risk factors. C

Hypertension

In an analysis of the UK Prospective Diabetes Study(UKPDS) data, a reduction of systolic BP by 10 mm Hgconferred a 16% decrease in rate of limb amputation ordeath from PAD ((UKPDS 36) BMJ 2000).

All pharmacologic agents that lower BP reduce the riskof cardiovascular events.

ACE inhibitors have shown benefit, specifically inPAD, potentially beyond their blood pressure–lowering effect.

Control of hyperglycemia

Management of PAD

1. Risk Factor Modification


3. Exercise




Aspirin has been shown to be effective in reducingcardiovascular morbidity and mortality in high-riskpatients with previous MI or stroke (secondaryprevention).

Its net benefit in primary prevention among patientswith no previous cardiovascular events is morecontroversial.

Aspirin vs. Clopidogrel For patients with CVD and documented aspirinallergy, clopidogrel (75 mg/day) should be used. B

Dual antiplatelet therapy is reasonable for up to a yearafter an acute coronary syndrome. B

Management of PAD1. Risk Factor Modification


3. Exercise




Supervised exercise programs are as effective asendovascular revascularization in their effectiveness toimprove functional capacity and do so at a much lowercost (J Vasc Surg 2008; 48:1472)

The recommended exercise regimen is supervisedexercise for 30 minutes 3 times a week for at least 12weeks, with further increase of exercise time to an houreach session.



3. Exercise




1. Cilostazol

2. Naftidrofuryl



3. Exercise




Patient education

Appropriate footwear

Daily foot inspection

The use of topical moisturizing creams

Skin lesions should be addressed urgently



3. Exercise




For patient with critical limb ischemia

Revascularization either endovascular or bypasssurgery.

Peripheral arterial disease is a common problem indiabetes.

Clinicians should actively seek out patients for PADbecause they are at very high risk for futurecardiovascular events and mortality.

Once the diagnosis of PAD is established, all patientsmust receive a comprehensive program to lower theirrisk for future cardiovascular events.

Patients with critical Limb ischemia should beimmediately refereed for vascular specialist.

ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas

Health & Medicine