hi there and thanks for listening to this presentation on Lorex Germany arterial disease diagnosis by non-invasive techniques and the role of the podiatrists this is part one out of two parts in this lecture presentation the natural history for people with pad Peripheral arterial disease or PID is one of the manifestations of generalized atherosclerotic disease affecting the circulation of the legs estimated to be present in up to 20 of patients older than 60 years old pad presents as a spectrum ranging from asymptomatic reduction in ankle pressures to limb and life-threatening disease the link between pad and cardiovascular disease is often missed with only one to two percent of clothings will ever progress to limb loss but some 25 percent will die from a cardiovascular cause initially presented in 2007 Armstrong and colleagues compared diabetic foot ulcer complications and peripheral vascular complications to cancer they recently updated the best available data in 2020 and refreshed this with current pool data to reveal these new results which are alarming they identified that patients with neuropathic foot ulcers had a higher five-year mortality than patients with breasts prostate and colon cancers and those who were diagnosed with critical limb threatening ischemia or had experienced a major amputation we're considered to be two of the worst conditions with the highest five-year mortality risk beaten only by those with lung and pancreatic cancers so to place this into context all of your patients who experience a major limb amputation over half of them will have died within five years the natural history for people with PID ER from the Framingham heart study have shown that hypertension and hyperlipidemia are independent risk factors for the development of Peripheral arterial disease they've been able to show this by demonstrating that a blood pressure of greater than 160 over 95 milligrams of mercury increased the risk of developing intermittent claudication two and a half folding men and four-fold in women they were also able to demonstrate a fasting cholesterol concentration greater than 7 millimoles per liter was associated with a two-fold increase in the risk of claudication PD and cardiovascular disease PD is an independent risk factor for cardiovascular disease I've reduced ankle brachial pressure index or abpi less than 0.9 is associated with twice the risk of cardiovascular mortality critical limb ischemia which represents much more severe disease of Peripheral arterial disease with an even worse cardiovascular risk for patients with critical limb ischemia within one year of diagnosis 30 of patients with critical limb ischemia will require amputation and 50 are thought to die mostly from these cardiovascular disease complications such as heart attack or stroke it is therefore vital to keep the high risk of cardiovascular disease risks or for these patients clearly in mind and whilst morbidity and mortality from coronary artery disease overall continues to fall with mortality at 13 at six years cardiovascular events in pad have remained the same with the mortality rate persisting at 25 at five years type 2 diabetes and cardiovascular disease type 2 diabetes typically occurs in the setting of The metabolic syndrome which includes abdominal obesity hypertension hyperlipidemia and increased coagulability these other factors can also act to promote cardiovascular disease even in the setting of multiple risk factors type 2 diabetes acts as an independent risk factor for the development of ischemic disease stroke and death and patients with type 2 diabetes will have a much higher risk of stroke with an increased risk of between 150 to 400 percent and among people with type 2 diabetes women may be at higher risk of coronary artery disease than men diabetes is a major risk factor for PID where patients are twice as likely as those without diabetes to develop the condition pet mainly affects the infropopylate arteries in these patients and glycemic control is Paramount importance it is shown in the evidence that one percent increase in glycated hemoglobin that is hba1c is associated with a 26 increase in the risk of developing PUD for these patients but we mustn't forget that other conditions are also linked with increased risk to the development of ped and one of these are of course those of the rheumatological conditions rheumatoid arthritis patients or rheumatological condition patients have an increased risk of subclinical vascular disease shown by either a higher prevalence of carotid disease or that of Peripheral arterial disease and among traditional risk factors steroid usage highlighted to be one of the potential risk factors so what is the scope of this problem the scope of the problem is that PID is under diagnosed and ultimately undertreated evidence suggests about half of patients with pad will have atypical pain resulting in patients not presenting with early symptomology or being referred to msk specialisms in Podiatry and physiotherapy for example elderly populations who themselves put pain in the legs down to arthritis or back troubles or even GPS can do the same and understandably are reluctant to palpate peripheral pulses within a 10-minute appointment slot with the knowledge that about a third of palpations are wrong in an inexperienced hands other causes for delays in patient-reported symptomology can be that of celebrity endorsed non-evidence-based symptom relief product advertising for here we have a an example of a circulation booster endorsed by a well-known daytime television couple um who really are promoting a product that will relieve the symptoms of lower leg pain namely that of intermittent claudication this particular piece which I've taken from the Internet is also as you can see in the bottom right hand corner endorsed by a vascular surgeon so to those of you who don't know if it's endorsed by a vascular surgeon then this product must be good and will cure all your ailments the unfortunate thing is that this may trigger an individual to rather than report to health care professional for a thorough assessment and potentially um diagnose somebody who is in a critical limb status and have our overall health check which may even help them in terms of the cardiovascular risk will delay them presenting to a healthcare professional and actually encourage them to spend three or four hundred pounds on a product that will in actual fact and provide them with no health benefits in terms of the current evidence available today the reach registry and other recent papers clearly link cardiovascular endpoints in pad to poor risk management of these patients and show improved outcome with positive management even within the last couple of years publication showed disproportionate levels of fatal and non-fatal cardiovascular events with those with PID and reasons for this include failure of the quality outcomes framework or the quaff to include ped and its outcome measures currently only involving stroke and cardiac disease and further to that secondary care for patients with ped is delivered by vascular surgeons whose training is predominantly Surgical and it's only very recently that Statin therapy and anti-platelet agents were introduced by vascular surgeons and a few surgeons to treat to Target that is 40 decrease in an individual's high-density lipoprotein as recommended by sine 149 in our Scottish national guidance Studies have shown that patients on a Statin had less likelihoods of developing intermittent claudication a few but small interesting studies required in critical evaluation show increased walking distance with statins better than the vascular outcomes and importantly fewer amputations in a number of large population-based studies of intensive therapy if you look at the table on the right hand side you would also see that an increased intensity in Statin dose also had a greater impact in the five-year mortality of these patient groups compared to those with no Statin M dose other recent Studies have shown medical treatment to not only decrease cardiovascular events but also amputation and this includes the Fourier study with a p a ck9 inhibitor which is a type of cholesterol lowering drug and the compass study with vascular dose of vivaroxaban which is an anticoagulant and aspirin the first line treatment for the management of ped should therefore include optimization of these modifiable cardio risk factors to minimize And Delay avoidable cardiovascular events so what can we do in the management of ped risk factors and of course the presence of intermittent claudication well these include smoking cessation best cardiovascular medicine therapy as discussed in the slide previously supervised exercise programs an example of which in the image on the right hand side where you are considered providing a supervised exercise program for people with intermittent claudication and involves a two-hour of supervised exercise a week for a three-month period or encouraging people to exercise to the point of maximal pain or even self-exercise programs out with a supervised program for people with PID to encourage the increase in cardiovascular and leg exercise by walking to stimulate the development of collateral stimulation is a circulation and of course for cardiovascular disease of the heart here's examples of national vascular guidelines for Scotland and England um they are for the treatment and management of Peripheral arterial disease saying 89 and for the nice guideline in England cg147 for resistimation and the prevention of cardiovascular disease we have for Scotland the same guidelines sign 149 and in NHS England the nice guidelines which is cg181 sign is recommended for guidance and care for Scotland NHS Scotland and of course nice for guidance from recommendation of care in England these um documents can also be used to influence integrated care Pathways out with their countries of origin so of course we regard nice as a very high quality um a piece of work which is evidence-based and peer-reviewed in terms of how this can influence our um creation of local care Pathways for our patients so obey that we have seen in Scotland you know it is possible if you are designing an integrated care pathway locally that of course you can use nice in addition to sign in terms of how to um evidence recommendations of care for your local population type so here is a couple of examples of integrated care Pathways one of them is a pain in acute hospitals trust where they have used a reference from nine nice and sign and task and to create this local care pathway for the identification of patients with Peripheral arterial disease in order to um recommend them in categories of risk and get the best targeted and Speedy care pathway for those patients and on the right hand side you can see here's another example of it this one produced by foot and diabetes UK for the lower limb amputation and prevention guidance specifically during the covid-19 situation where Services were cut and they were wanting to make sure that they were influencing patients who needed urgent care to be able to get that in a speedy and methodical way in 2018 a cross-sectional observational online survey of registered podiatrists in the UK was conducted to assess lower limb vascular assessment techniques of podiatrists within the United Kingdom 307 participants were included in the analysis and that related to practitioner characteristics vascular testing methods barriers to completing vascular assessments interpretation of vascular assessment techniques education provision ongoing management and referral pathways in their findings they included that the majority of vascular assessments currently performed by podiatrists in the UK were inconsistent with UK and international vascular guidelines and recommendations as mentioned previously they found that most podiatrists felt confident in diagnosing referring and managing patients with pad however many felt that they needed more education to feel confident to assist patients with pad to manage their cardiovascular risk management so have a think and consider what are your learning needs currently are you confident with your post-pulpation your Doppler skills and interpretation of um physics sounds do you know your abpi from your TP do you know ped and cardiovascular risk management strategies and are you confident to make recommendations of care thank you for listening to this lecture presentation and I look forward to seeing you for part two