Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas
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Transcript of 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
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
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The impact of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
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
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
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
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
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)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The impact of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
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
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
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
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
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
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.
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
1. Cilostazol
2. Naftidrofuryl
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
Patient education
Appropriate footwear
Daily foot inspection
The use of topical moisturizing creams
Skin lesions should be addressed urgently
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
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.