PAD Guidelines Changes2005 >>> 2011Slides by Omron Healthcare

Published online September 29, 2011http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.023

Updated summary

Category 2005 Guidelines 2011 Guidelines

1 ABI test - targets

-Symptoms

- 70 years and older

- 50 yrs & older (smoking, DM)

-Symptoms

-65 years and older

- 50 yrs & older (smoking, DM)

2Cut-off　 - ABI borderline

Not definedBorderline defined as

0.91-0.99

Cut-off - ABI normal

0.91-1.30 1.00-1.40

3 Treatment - Drug

PAD patientsABI below 0.9 asymptomatic PAD patients

4 Treatment - Smoking

Stop smokingStop smoking

(smoking cessation proguram, drug treatment)

2005 2011

* What is level of evidence? See reference page

I IIa IIb III

MustDo

Reasonale

Consider

NoNeed

Change 1 Enlarged Target for Screening

PAD screening targetLeg symptoms from exertionNonhealing wounds70 years and older50 years and older with a history ofsmoking or diabetes.

(Level of Evidence: C)

PAD screening targetLeg symptoms from exertionNonhealing wounds65 years and older50 years and older with a history of smoking or diabetes

(Level of Evidence: B)

Background of the above changeOn the basis of a large epidemiologic study*, 21% had either asymptomatic or symptomatic PAD. (*The German Epidemiologic Trial on ABI Study Group)

Increased value of “Pulsewave” function of VP1000+ for better diagnosis of borderline PAD!

The 2005 guidelines are not clearly defined.

Borderline is clearly defined !

More patients will be diagnosed as PADChange 2

>1.401.00-1.400.91-0.99

<0.90

2005　 2011

>1.301.00-1.290.91-0.990.41-0.90

0.00-0.40

Noncompressible NormalBorderline???PAD (mild-moderate)

PAD (Severe)

I IIa IIb III

MustDo

Reasonale

Consider

NoNeed

* What is “B”? See reference page

Noncompressible NormalBorderline

(No change below 0.9)

-The upper cut-off has been increased to 1.4, as in TASCII.-ABI borderline is clearly defined as 0.91-0.9

Increased importance of Antiplatelet Therapy(esp: Asymptomatic with ABI below 0.9)

Change 3

　

Antiplatelet therapy is indicated to reduce the risk of MI, stroke, or vascular death in PAD patients

Antiplatelet therapy is useful to reduc

e the risk of MI, stroke, and vascular death in asymptomatic patients with an ABI 0.9 or less.

Antiplatelet therapy is indicated to reduce the risk of MI, stroke, or vascular death in following patients.

-Symptomatic PAD patients with intermittent claudication, ischemia, revascularization, or amputation.

The usefulness of antiplatelet therapy in asymptomatic patients with borderline ABI, is not well established. (should be established)

More specific

2005　 2011

NEW

Wider chance for collaboration with antiplatelet pharma companies! Even without symptoms, drug can be prescribed for patients with ABI below 0.9.(See reference page for the pharma list.)

NEW

Firmer insistence to Stop Smoking(Smoking cessation program, pharmacological treatment)

Chance for Omron to collaborate with anti-smoking drug companies!

2005 2011

Current or former smokers should be advised by clinicians to stop it. And should be offered smoking cessation interventions, including behavior modification therapy, nicotine replacement therapy, or bupropion.

2. Patients should be assisted with counselling & in developing a plan for quitting that includes pharmacotherapy and/or smoking cessation program.

3. Current or former smokers should be advised by clinicians to stop smoking and offered behavioral and pharmacotherapy.

4. (If patients can take drugs), one or more of the following should be offered.

New

MoreSpecific

New

New

-Bupropion (GSK:Zyban)-Varenicline (Pfizer: CHANTIX)-Nicotine replacement therapy (Nicotine patch)

*Pharma names and products names are not mentioned in the guidelines but for reference.

Change 4

1. Current or former smokers should be asked at every visit about their smoking.

Unchanged but important points

For all new patients, ABI should be measured in both legs to confirm the diagnosis of lower extremity PAD and establish a baseline.

The toe-brachial index should be used to establish PAD diagnosis. Targeted patients are those who are clinically suspected as PAD with “noncompressible” ABI value. (usually long-standing DM or advanced age)

ABI should be performed on every PAD suspected patient.

Not only specialists, but all clinicians should do ABI!

2-cuff ABI device is not sufficient. ABI should be measured in both legs at the same time!

We can actively target the DM market with: “Better PAD diagnosis by adding TBI”

2005 2011

Unchanged

Omron promotion

Unchanged

Dr Alan Hirsch (University of Minnesota, Minneapolis)vice chair of the writing committee chair of the 2005 guidelines

• He continues to be concerned that cardiovascular practitioners and primary-care physicians —less than full-time PAD-focused vascular surgeons or interventional radiologists— might not recognize critical limb ischemia as a key cardiovascular syndrome that represents a "slow-burning vascular emergency."

• "For this reason, in every community we lose legs, quality of life, and lives," said Hirsch.

Voice from Dr. Hirsch

Source: heartwire

Standard agreed to only experts

[Reference] What is the level of the evidence?

Level A

Level B

Level C

Limited population but single study

Multiple study

[Reference] Antiplatelet pharma

Drug Product Company

Acetylsalicylic acid Aspirine Bayer

Cilostazol Pletaal Otsuka

Clopidogrel Pravix Sanofi Aventis

Beraprost Na Dorner Astellas

Typical/ most prescribed Antiplatelet