CVS

د. حسين محمد جمعه

اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2012



Diagnosis and management of lower limb peripheralarterial disease: summary of NICE guidance
BMJ 8August 2012

Lower limb peripheral arterial disease (referred to as peripheral arterial disease in this summary) is common, affecting 3% to 7% of people in the general population and 20% of people over
the age of 75.
It is associated with an increased risk of
cardiovascular morbidity and mortality and severely limits people’s functional capacity and quality of life.

Peripheral arterial disease is often asymptomatic, but when it is symptomatic the most common presentation is intermittent claudication (pain in the legs, buttocks, or thighs brought on by walking and relieved by rest). Critical limb ischaemia is characterised by severely diminished circulation, ischaemic pain, ulceration, tissue loss, and/or gangrene. Owing to rapid changes in diagnostic methods, endovascular treatments, and vascular services, there is considerable uncertainty about the management of people with peripheral arterial disease, with management varying greatly across England and Wales.
This article summarises some of the most recent recommendations from (NICE) on the management of peripheral arterial disease.


Recommendations
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Secondary prevention of cardiovascular disease in people with peripheral arterial disease

• Offer all people with peripheral arterial disease information, advice,support, and treatment with respect to the secondary prevention of cardiovascular disease, in line with published NICE guidance on smoking cessation
; diet, weight nmanagement, and exercise
; lipid modification and statin therapy
; the prevention, diagnosis, and management of
Diabetes.
; the prevention, diagnosis, and management
of high blood pressure
; and antiplatelet therapy.
[Based on the experience and opinion of the Guideline Development Group (GDG)

Diagnosis

• Assess people for the presence of peripheral arterial disease
if they:
-Have symptomssuggesting peripheral arterial disease (for example, leg pain brought on by exertion, rest pain, tissueloss, and/or foot ulcers)
-Have diabetes, non-healing wounds, or unexplained leg pain
-Are being considered for interventions to the leg or foot -Need compression hosiery.
[Based on the experience and opinion of the GDG]


• Assess people with suspected peripheral arterial disease
by:
-Asking about the presence and severity of possible
symptoms of intermittent claudication and critical limb
ischaemia (for example, about the nature and location of leg pain, how far the patient can walk, and the presence of nocturnal rest pain).

-Examining the legs and feet for evidence of critical limb ischaemia (for example, ulceration)
-Examining the femoral, popliteal, and foot pulses
-Measuring the ankle brachial pressure index (see
recommendation below).
[Based on the experience and opinion of the GDG]

• Measure the ankle brachial pressure index in the following way:

-The person should be resting and supine if possible.
-Record systolic blood pressure with an appropriately sized cuff in both arms and in the posterior tibial, dorsalis pedis, and, where possible, peroneal arteries.
-Take measurements manually using a Doppler probe of suitable frequency in preference to an automated system.
-Document the nature of the Doppler ultrasound signals in the foot arteries.
-Calculate the index in each leg by dividing the highest
ankle pressure by the highest arm pressure.
[Based on experience and opinion of the GDG]


Imaging
• Offer duplex ultrasonography as first line imaging to all people for whom revascularisation is being considered.
• Offer contrast enhanced magnetic resonance angiography to people who need further imaging (after duplex ultrasonography) before considering revascularisation. If contrast enhanced magnetic resonance angiography is contraindicated or not tolerated, offer computed tomography angiography instead.
[Both points are based on low to moderate quality evidence from diagnostic studies]

Management of intermittent claudication

• Offer a supervised exercise programme to all people with intermittent claudication.
[Based on very low to moderate quality evidence from randomised controlled trials and on an original health economic model with minor limitations and direct applicability]
• Consider providing a supervised exercise programme that involves two hours of supervised exercise a week for athree month period and encourages exercise to the point of maximal pain. [Based on experience and opinion of the GDG]

• Offer angioplasty to treat intermittent claudication only when:

-Advice on the benefits of modifying risk factors has been reinforced and
-A supervised exercise programme has not led to a
satisfactory improvement in symptoms and
-Imaging has confirmed that angioplasty is suitable for the person.
[Based on very low to moderate quality evidence from randomised controlled trials and on an original health economic model with minor limitations and direct applicability]

• Offer bypass surgery to treat severe, lifestyle limiting

intermittent claudication only when angioplasty has been
unsuccessful or is unsuitable, and when imaging has
confirmed that bypasssurgery is appropriate for the person.
[Based on very low to moderate quality evidence from randomised controlled trials and on an original health economic model with minor limitations and direct
applicability]


• Consider naftidrofuryl oxalate for treating people with intermittent claudication, starting on the least costly
preparation, only when supervised exercise has not led to a satisfactory improvement and the person prefers not to be referred for angioplasty or bypass surgery. Review progress after three to six months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit.
[Based on experience and opinion of GDG]

Management of critical limb ischaemia

• Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.
[Based on the experience and opinion of the GDG]
• Offer angioplasty or bypass surgery to people with critical limb ischaemia who require revascularisation, taking into account factors such as comorbidities, pattern of disease, availability of a vein, and patient preference.
[Based on very low to moderate quality evidence from randomised
controlled trials and published cost effectiveness evidence with potentially seriouslimitations and direct applicability]

• Do not offer major amputation to people with critical limb ischaemia unless all optionsfor revascularisation have been considered by a vascular multidisciplinary team.
[Based on the experience and opinion of the GDG and on published cost effectiveness evidence with potentially serious limitations and direct applicability]

Overcoming barriers

A major problem in current practice is the failure to recognise the cardiovascular risk associated with a diagnosis of peripheral arterial disease and the importance of managing thisrisk through
exercise, a healthy diet, smoking cessation, and management of diabetes, hypertension, and other related cardiovascular disease.

The Guideline Development Group considered that the

modification of risk factors for cardiovascular disease was akey priority for implementation as it was concerned that, although peripheral arterial disease is known to be a significant risk factor for cardiovascular morbidity and mortality, it may not be as widely recognised or as actively managed as other
known risk factors.


The guideline recommendation to offer
supervised exercise programmes to all people with intermittent claudication is likely to lead to a major change to practice, but the availability and use of such programmes is variable and largely occurs within a secondary care setting.
Ideally, such programmes should be community based and easily accessible to patients.

The set-up costs of new exercise programmes may

be a barrier to implementation, but providers should note that the guideline recommendation of supervised exercise is backed by a detailed analysis showing this to be cost effective. Services
could make use of or modify existing exercise programmes for cardiac or respiratory rehabilitation.