PVD: A systemic disease

One topic discussed at the 2005 American College of Cardiology meetings in New Orleans was the systemic manifestations of atherosclerotic disease. The generalized nature of atherosclerotic disease and its implications is a frequently underappreciated problem. Attention to risk factor modification in non-coronary patients is often less intensive than for coronary patients. Because the risk factors for coronary and peripheral vascular disease are the same, aggressive modification of those risk factors in all such patients is expected to improve overall survival.

Peripheral vascular disease is a well recognized marker of systemic atherosclerosis. Claudicants are almost three times more likely than the general population to die from concomitant heart disease and stroke. Patients with asymptomatic peripheral arterial disease have the same increased risk of cardiovascular events and death as found in claudicants. In women the risk of coronary heart disease, stroke, and cardiac failure was increased 3-4 times when diabetes and intermittent claudication occurred together compared to those in which either condition existed alone. In diabetic men, the presence of intermittent claudication doubled the risk of stroke. Cardiac failure was approximately three times more likely in patients with both conditions compared with either alone.  Despite these data, statins, anti-platelet therapy, and blood pressure therapies are frequently under-prescribed in this patient population when compared to cardiac patients. Often the reason for under-treatment is a lack of recognition of the disease process in other vascular beds.  Because screening for peripheral vascular disease is fairly straightforward, it is imperative that we aggressively look for it and treat it so the overall morbidity and mortality of cardiovascular disease can be reduced.

The American College of Cardiology has emphasized the need for screening all patients at risk for peripheral vascular disease. Such screening may lead to the identification of disease in other organ systems. Routine screening is most easily performed through a combination of directed questions (e.g. the Rose Questionnaire), routine palpation of peripheral pulses, and the measurement of ankle-brachial indices (ABI) in all at risk patients.

Obviously, a focused patient interview provides much valuable information. During our initial patient encounter, we use a screening questionnaire (Rose) to direct our further evaluation.
 
Palpation of peripheral pulses is a very valuable diagnostic tool. The absence of a palpable posterior tibial pulse correlates very strongly with the presence of significant coronary artery disease.

The ABI is an easily performed screening test with broad prognostic and therapeutic implications. It correlates well to the extent of atherosclerosis in both the peripheral and coronary arterial beds. Additionally, it is a useful tool for predicting survival in patients with peripheral vascular disease. (An ABI <0.90 was shown to be associated with a twofold increase in the risk of significant coronary artery disease). Additionally, the ABI is consistently associated with all major manifestations of clinical cardiovascular disease. It is a very useful marker of systemic atherosclerosis.

Recognition and long-term treatment of patient with multisystem CVD is clearly important to minimize their risk of future fatal events. Risk factor modification is a major component of the treatment program. Specifically targeting diabetics, smokers, hypertensives, and hyperlipidemics should be of primary importance.

We strongly encourage the regular use of these inexpensive and easily available office screening procedures to identify patients at risk for multisystem vascular disease. Clearly, recognition and modification of the systemic disease can have very significant implications for long term morbidity and mortality.