Not Just Clogged Coronaries: Recognizing Atherosclerosis as a Head-to-Toe Problem
Disclosure: Dr. Gornik has modest research grant relationships with Summit Doppler Systems and Sanofi Aventis.
Pub Date: Tuesday, Dec. 23, 2008
Author: Heather L. Gornik, MD, MHS
If a practicing cardiologist was asked to perform free association on the term atherosclerosis, the likely responses would include plaque, myocardial infarction, coronary artery disease (CAD), and coronary stent. Up until most recent times, it would be unlikely for terms such as claudication, peripheral artery disease (PAD), and carotid endarterectomy to come to mind. Ask the vascular surgeon to perform the same task, however, and the results would likely be quite the opposite.
Traditionally, the management of patients with atherosclerosis has been compartmentalized. While cardiologists take care of angina, CAD, lipids, and hypertension, the vascular surgeon addresses claudication, carotid stenosis, and abdominal aortic aneurysm (AAA). This division of care conflicts with the recognition of atherosclerosis as a truly head-to-toe disease process, with the heart being but one of many arterial beds affected.
Atherosclerosis is a systemic vascular disorder that mandates coordinated cardiovascular care and meticulous attention to the modification of its risk factors. The coexistence of coronary and noncoronary atherosclerosis in the same patient is the rule, rather than the exception. In published studies, up to 60%-80% of patients with PAD have significant CAD, with up to 25% of patients having severe disease.[1-3] Up to one-quarter of patients with PAD have significant carotid artery stenosis.[4,5] Conversely, the presence of CAD increases the likelihood of PAD, and an abnormal ankle-brachial index (ABI) is a risk factor for poor outcome across the spectrum of CAD, including prior myocardial infarction and surgical and percutaneous coronary revascularization.[6-8] Even erectile dysfunction, which previously belonged to the exclusive domain of the urologist, is now well established as a marker of increased CV risk. Thus, to manage a patient's CAD while ignoring the blood vessels outside of the heart, and visa versa, represents incomplete patient care.
In recognition of the systemic nature of atherosclerosis and the need for comprehensive care of patients with atherosclerotic vascular disease, there is a growing movement to promote noncoronary atherosclerotic vascular disease to the uppermost tier of cardiovascular disorders, sharing well-deserved equal footing with CAD. In order to achieve this goal, synergy among all cardiovascular specialists in the recognition of the public health threat posed by noncoronary atherosclerosis is crucial. Multiple health care providers have a stake in the management of patients with atherosclerosis, not just cardiologists and vascular surgeons, but also internist, nurses, vascular medicine physicians, endocrinologists, radiologists, neurologists, nephrologists, and even urologists.
During the past decade, a series of successful interdisciplinary collaborations have increased professional and public awareness of the panvascular nature of atherosclerosis and have placed the spotlight on the peripheral arterial tree. Evidence of such collaboration includes the Trans-Atlantic Inter-Society Consensus on the Management of Peripheral Arterial Disease (TASC), the American College of Cardiology/American Heart Association Peripheral Arterial Disease (ACC/AHA) PAD guidelines, and the American Heart Association/American Stroke Association guidelines for the prevention and management of ischemic stroke.[10-13]
The proceedings of the second Atherosclerotic Peripheral Vascular Disease Symposium is another important interdisciplinary effort to advance the care of patients with coronary and noncoronary atherosclerosis. The conference, which occurred in the summer of 2006, included diverse representation of surgery, medicine, radiology, neurology, cardiovascular epidemiology, and cardiovascular nursing, with participants drawn from among the preeminent leaders in each discipline.
The proceedings of the conference are presented in eight sections, six of which offer evidence-based reviews of the state-of-the art with regard to noninvasive vascular imaging (section III); therapy for acute stroke (section IV); endarterectomy versus stenting for revascularization for carotid artery stenosis (section V); endovascular versus open repair of AAA (section VI); endovascular lower extremity revascularization (section VII); and endovascular therapy for renal artery stenosis (section VIII). Two additional sections take on standardization of nomenclature for noncoronary vascular disorders (section I) and discussion of whether widespread screening programs for select atherosclerotic vascular diseases should be undertaken (section II).
The state-of-the art reviews are comprehensive and include detailed summaries of the most recent scientific literature, including studies published well beyond the date of the 2006 meeting. While most of the sections complement and extend the recommendations of the 2005 ACC/AHA PAD guidelines, there is much original material here, including a detailed discussion of technological advances in endovascular treatment of lower extremity PAD and a lively discussion of endarterectomy versus stenting of carotid artery stenosis that may preview the tone of forthcoming consensus guidelines in this area. The section on renal artery stenosis is outstanding, not only providing a comprehensive discussion of technique and procedural complications but offering a new conceptual framework for the management of this disorder. The section on screening for vascular disease not only affirms the benefit of AAA screening for at-risk patients, consistent with the 2005 ACC/AHA PAD guidelines, but calls for clinical outcome trials and cost effectiveness studies before weighing in on the appropriateness of screening programs for PAD (with the ABI) and carotid atherosclerosis (with duplex ultrasound). While the call for outcome data before implementation of a large-scale ABI screening program makes sense on a scientific level, it does represent a divergence from the 2005 ACC/AHA PAD guidelines, which already give a class I recommendation to such a program. This was a bit of a surprise to this reader.
The most important section of the document is also the most basic, a glossary that provides standardized terminology for vascular disorders (section I). This document is much needed, given the crowded alphabet soup that is the vascular vernacular (e.g., ASO, PVD, PAD, CVD, ABI, TBI, AAI, etc.) and will undoubtedly be of value to clinicians, health educators, medical journalists, and researchers for years to come. I have already made use of this document in my own practice and writings, and I encourage readers of the Symposium Proceedings to adopt the standardized nomenclature in their own practice to avoid confusion and ambiguity in how we communicate to patients and colleagues about vascular disease.
The participants of the second Atherosclerotic Peripheral Vascular Disease Symposium are to be congratulated on a dynamic document that not only reflects the interdisciplinary nature of medical care for the patient with atherosclerosis but further advances noncoronary atherosclerosis into the cardiovascular spotlight
- McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351(27):2795-2804.
- Valentine RJ, Grayburn PA, Eichhorn EJ, et al. Coronary artery disease is highly prevalent among patients with premature peripheral vascular disease. J Vasc Surg 1994;19(4):668-674.
- Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984;199(2):223-233.
- Cheng SW, Wu LL, Lau H, et al. Prevalence of significant carotid stenosis in Chinese patients with peripheral and coronary artery disease. Aust N Z J Surg 1999;69(1):44-47.
- Cheng SW, Wu LL, Ting AC, et al. Screening for asymptomatic carotid stenosis in patients with peripheral vascular disease: a prospective study and risk factor analysis. Cardiovasc Surg 1999;7(3):303-309.
- Rihal CS, Sutton-Tyrrell K, Guo P, et al. Increased incidence of periprocedural complications among patients with peripheral vascular disease undergoing myocardial revascularization in the bypass angioplasty revascularization investigation. Circulation 1999;100(2):171-177.
- Steg PG, Bhatt DL, Wilson PW, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 2007;297(11):1197-1206.
- Lee AJ, Price JF, Russell MJ, et al. Improved prediction of fatal myocardial infarction using the ankle brachial index in addition to conventional risk factors: the Edinburgh Artery Study. Circulation 2004;110(19):3075-3080.
- Thompson IM, Tangen CM, Goodman PJ, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA 2005;294(23):2996-3002.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006;113(11):e463-654.
- Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007;45:S5-67.
- Adams HP, Jr., del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation 2007;115(20):e478-534.
- Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke 2008;39(5):1647-1652.
- Creager MA, White CJ, Hiatt WR, et al. Proceedings of the Atherosclerotic Peripheral Vascular Disease Symposium II. Paper presented at: Atherosclerotic Peripheral Vascular Disease Symposium II, 2006. Boston, Massachusetts.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association