ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas
TRANSCRIPT
![Page 1: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/1.jpg)
Mamdouh El-Nahas
Professor of Internal Medicine Endocrinology and Diabetes Unit
Mansoura University
![Page 2: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/2.jpg)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
![Page 3: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/3.jpg)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
![Page 4: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/4.jpg)
One in three patients with diabetes mellitus have PAD (ADA 2006)
![Page 5: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/5.jpg)
20% of in people with diabetes >40 years of had PAD.
30% of patients with diabetes >50 years of age hadPAD.
Practical Diabetes Int 16:163–166, 1999
JAMA 286:1317–1324, 2001
![Page 6: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/6.jpg)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The impact of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
![Page 7: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/7.jpg)
1. Age
2. Sex – predominantly male
3. Genetic predisposition
4. Dyslipidaemia
5. Hypertension
6. Smoking
7. Obesity
8. Alcohol
9. Diet
10. Sedentary lifestyle
![Page 8: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/8.jpg)
Smoking
Tobacco use in any form is the single most importantmodifiable cause of PAD internationally.
The magnitude of the association is greater than thatreported for coronary heart disease.
Lu et al 2013: Meta-analysis of the association between cigarette smokingand peripheral arterial disease
![Page 9: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/9.jpg)
Smoking More than 80%-90% of patients with lower extremityperipheral arterial disease are current or formersmokers.
The most effective treatment for PAD is to stopsmoking. This single measure reduces the risk ofdisease progression amongst patients with peripheralarterial disease and dramatically reduces the need forlimb amputation and the risk of premature death
![Page 10: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/10.jpg)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
![Page 11: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/11.jpg)
1- Increased risk of foot ulceration and failure of theulcer to heal
![Page 12: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/12.jpg)
2- Patients with foot infections and PAD are atparticularly high risk for major limb amputation.
![Page 13: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/13.jpg)
3- A major risk factor for lower-extremity amputation.
![Page 14: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/14.jpg)
4- A marker for systemicvascular disease.
Coronary heart disease
PAD
Cereb VD
![Page 15: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/15.jpg)
Eur J Vasc Endovasc Surg 2007; 33: S14 4
![Page 16: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/16.jpg)
![Page 17: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/17.jpg)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The Danger of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
![Page 18: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/18.jpg)
![Page 19: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/19.jpg)
Intermittent Claudication
Cramping, oraching painrelated towalking andrelieved byrest.
![Page 20: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/20.jpg)
![Page 21: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/21.jpg)
Atypical presentation
![Page 22: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/22.jpg)
![Page 23: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/23.jpg)
Inspection of the foot
![Page 24: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/24.jpg)
Pedal pulses
![Page 25: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/25.jpg)
Other clinical signs of PAD
Temperature gradient
Color changes
Capillary refill time
![Page 26: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/26.jpg)
Simple bedside tests to diagnose PAD
![Page 27: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/27.jpg)
![Page 28: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/28.jpg)
A low ABI (<0.9)indicates PAD.
While ABI values (>0.9)may be unreliable inruling out of PAD.
![Page 29: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/29.jpg)
ADA recommendations for ABI (2016)
Diabetic patients 50 years of age and older
Patients under 50 years of age who have other PAD riskfactors (e.g., smoking, hypertension, dyslipidemia, orduration of diabetes >10 years)
Any patient with symptoms or signs of PAD.
![Page 30: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/30.jpg)
Handheld Doppler Ultrasound
![Page 31: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/31.jpg)
Toe pressure
![Page 32: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/32.jpg)
Imaging modalities
Duplex ultrasonography,
Magnetic resonance angiography,
Computed tomographic angiography,
Angiography
![Page 33: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/33.jpg)
![Page 34: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/34.jpg)
Biochemical Tests Screening for atherosclerotic risk factors e.g. lipid
abnormalities, proteinuria, renal insufficiency
For patients with early-age onset of disease, familyhistory of thrombotic events, or when there is a lackof common risk factors for atherosclerosis:
Hypercoagulability screening
Homocysteine levels (either fasting or aftermethionine loading)
![Page 35: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/35.jpg)
Peripheral Arterial Diseases(PAD)
1. Prevalence
2. Atherosclerosis and its risk factors
3. The impact of PAD
4. Diagnosis of PAD
5. Laboratory diagnosis
6. Management
![Page 36: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/36.jpg)
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 37: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/37.jpg)
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 38: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/38.jpg)
Tobacco smoking
Cigarette smoking is one of the most importantpreventable risk factor for PAD in both men andwomen
![Page 39: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/39.jpg)
Treatment of dyslipidemia Lifestyle modification should be recommended. A
Statin therapy should be added to lifestyle therapy,regardless of baseline lipid levels, for diabetic patients:
with overt CVD A
without CVD who are over the age of 40 years and haveone or more other CVD risk factors (family history ofCVD, hypertension, smoking, dyslipidemia, oralbuminuria). A
![Page 40: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/40.jpg)
For lower-risk patients than the above (e.g., withoutovert CVD and under the age of 40 years), statintherapy should be considered in addition to lifestyletherapy if LDL cholesterol remains above 100 mg/dL orin those with multiple CVD risk factors. C
![Page 41: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/41.jpg)
Hypertension
In an analysis of the UK Prospective Diabetes Study(UKPDS) data, a reduction of systolic BP by 10 mm Hgconferred a 16% decrease in rate of limb amputation ordeath from PAD ((UKPDS 36) BMJ 2000).
![Page 42: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/42.jpg)
All pharmacologic agents that lower BP reduce the riskof cardiovascular events.
ACE inhibitors have shown benefit, specifically inPAD, potentially beyond their blood pressure–lowering effect.
![Page 43: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/43.jpg)
Control of hyperglycemia
![Page 44: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/44.jpg)
Management of PAD
1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 45: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/45.jpg)
Aspirin has been shown to be effective in reducingcardiovascular morbidity and mortality in high-riskpatients with previous MI or stroke (secondaryprevention).
Its net benefit in primary prevention among patientswith no previous cardiovascular events is morecontroversial.
![Page 46: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/46.jpg)
Aspirin vs. Clopidogrel For patients with CVD and documented aspirinallergy, clopidogrel (75 mg/day) should be used. B
Dual antiplatelet therapy is reasonable for up to a yearafter an acute coronary syndrome. B
![Page 47: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/47.jpg)
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 48: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/48.jpg)
Supervised exercise programs are as effective asendovascular revascularization in their effectiveness toimprove functional capacity and do so at a much lowercost (J Vasc Surg 2008; 48:1472)
![Page 49: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/49.jpg)
The recommended exercise regimen is supervisedexercise for 30 minutes 3 times a week for at least 12weeks, with further increase of exercise time to an houreach session.
![Page 50: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/50.jpg)
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 51: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/51.jpg)
1. Cilostazol
2. Naftidrofuryl
![Page 52: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/52.jpg)
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 53: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/53.jpg)
Patient education
Appropriate footwear
Daily foot inspection
The use of topical moisturizing creams
Skin lesions should be addressed urgently
![Page 54: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/54.jpg)
Management of PAD1. Risk Factor Modification
2. Antiplatelet Therapy
3. Exercise
4. Pharmacotherapy for Intermittent Claudication
5. Preventative foot care.
6. Vascular Specialist Care
![Page 55: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/55.jpg)
For patient with critical limb ischemia
Revascularization either endovascular or bypasssurgery.
![Page 56: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/56.jpg)
![Page 57: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/57.jpg)
Peripheral arterial disease is a common problem indiabetes.
Clinicians should actively seek out patients for PADbecause they are at very high risk for futurecardiovascular events and mortality.
![Page 58: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/58.jpg)
Once the diagnosis of PAD is established, all patientsmust receive a comprehensive program to lower theirrisk for future cardiovascular events.
Patients with critical Limb ischemia should beimmediately refereed for vascular specialist.
![Page 59: Ueda2016 diabetes & peripheral arterial diseases -mamdouh el nahas](https://reader035.vdocuments.us/reader035/viewer/2022070308/5874689c1a28abab198b7523/html5/thumbnails/59.jpg)