Optimizing Anticoagulation in Vascular Disease Patients: Reimagining the Standard of Care - Episode 1

Peripheral Artery Disease (PAD) Pathophysiology and Coronary Artery Disease

Drs Manesh Patel and Amr Abbas begin our discussion by laying out the defining characteristic of peripheral artery disease (PAD) and how it compares to coronary artery disease (CAD).

Manesh Patel, MD: Hello and welcome to this HCPLive® Peer Exchange titled, “Optimizing Anticoagulation in Our Vascular Patients: Reimagining the Standard of Care.” I’m Manesh Patel, chief of cardiology at Duke University, Durham, North Carolina, and I’m excited to be here with a panel of experts for a fun hour where we will discuss important data in how we care for our patients. Our goal is to make this interactive, important, and relevant to your practice. Joining me is Chris Granger, also from Duke University. Chris, thanks for joining us.

Christopher Granger, MD: Thanks, Manesh.

Manesh Patel, MD: Also joining us is Amr Abbas, from Oakland University William Beaumont School of Medicine, in Rochester, Michigan, and Larry Allen from the University of Colorado School of Medicine, in Aurora, Colorado. Thanks for joining us.

Larry Allen, MD: Yes, thanks for having me.

Manesh Patel, MD: Today, we will discuss diagnosis, management, and treatment of peripheral artery disease [PAD]. We’ll also discuss current and emerging treatment strategies for patients undergoing revascularization but other options also. We’re excited despite all the crazy things that have been going on in the world during the pandemic, and we appreciate all the health care professionals taking care of themselves and our patients. We’re in a studio with a separated live audience that will ask us questions at the end. Let’s begin with the first part, which is to discuss peripheral artery disease. I’ll do a 2-minute discussion of what peripheral artery disease is, and then get in depth about what we know about it.

Peripheral artery disease is atherosclerosis that is defined peripherally. It’s a cardiologist’s perspective, any artery that’s not the heart artery has somehow become the peripheral artery. Generally, people talk about peripheral artery disease in the lower extremities, sometimes in the carotids. Cerebrovascular disease is considered separately but could fit in, also abdominal vasculature. It’s estimated in the United States that somewhere around 8 million people have peripheral artery disease. Worldwide, there might be 200 million people with peripheral artery disease, and that’s just scratching the surface because we know we’re not very good at identifying patients with peripheral artery disease. It’s atherosclerosis that occurs in the lower extremities and eventually limits people’s livelihood, walking function, and sometimes cardiovascular events. It’s an important condition that we’ve learned has been affecting our patients for many years, but hopefully we have some treatment strategies. One fundamental question I think about when I talk to my fellows and colleagues is, is peripheral artery disease the same as coronary artery disease [CAD]? For many years I’ve thought that it was, but there are some things that are making me think that it’s part of a spectrum. Amr, can you tell us about how you think about your patients with PAD and CAD?

Amr Abbas, MD: To start, about 30% to 35% of your patients with CAD will also have PAD. It’s pretty significant when you think that about 1 in every 3 people will also have PAD. Unfortunately, if you ask patients, 75% will not tell you that they have PAD. You must instigate and ask for the symptoms because patients don’t tend to volunteer this information. Another important aspect is that we used to look at the atherosclerotic vascular bed as just 1 body, and think about risk factors for PAD as the same as those for CAD, which is true for the most part. There are some specific risk factors that play a larger role in PAD; for example, smoking has a higher hazard ratio for patients developing PAD as opposed to, for example, diabetes or high blood pressure with stroke in CAD. The majority of trials that looked at patients with PAD previously, looked at their cardiovascular outcomes. It is imperative that when you think of somebody who has PAD, that you realize that statin treatment will be beneficial when they have symptoms. Also, aspirin, and antiplatelet agents, as we’ll see, other novel therapies that we’re going to address, controlling blood pressure, tobacco cessation. So there’s a big common ground between those patients, and at the end, it’s to try to make patients live longer and also live better.

Manesh Patel, MD: You highlighted something interesting, which is that PAD is present in about a third of patients with coronary artery disease. It’s interesting, at least clinically relevant, that coronary artery disease is present in about a third of patients with PAD.

This transcript has been edited for clarity.