Expert Perspectives on Managing Polyvascular Disease and Coronary Artery Disease - Episode 2
Dr Amy Pollak and other experts discuss their recommendations for screening for CAD and PAD in asymptomatic patients.
Deepak Bhatt, MD, MPH: Amy, now that we’re talking about polyvascular disease, certainly when it is identified in the clinic through history and physical, no one is going to argue—well, hopefully no one is going to argue—the value of that. Maybe we still have to convince the audience that there’s value in that. But a question that sometimes follows is, should we be screening for that? There are a lot of CT machines out there. Should we be doing random CT angiography from head to toe on everybody or on select people? What about things like ankle-brachial index? Should everybody get 1 of those? What about screening for carotid disease? The question of screening comes up, and the potential benefits of identifying disease early, but the potential risks of breaking the health care system bank by ordering a bunch of tests on people who are asymptomatic. Potentially we’re identifying disease, but should you do a procedure if you find some mere blockage? Going down that cascade. What’s your recommendation with respect to polyvascular disease, PAD [peripheral artery disease], cerebrovascular disease, and any screening absent symptoms? Obviously if someone is complaining of bad pain in the leg, or chest pain, that would appropriately prompt testing in the asymptomatic but high-risk individual.
Amy Pollak, MD: This is an outstanding question. I’m sure everyone agrees that this is something we face day in and day out in our clinical practice. It’s an important area to focus on nationally as we try to care for our patients with vascular disease. But if we take a step back, your point is a good one. If someone is symptomatic, then our path is pretty clear. But as we know, only about 10% of our patients with PAD are going to have this classic intermittent claudication. Often, we don’t ask patients about leg symptoms and whether they’re having more change in their exercise capacity and leg fatigue, some of these other atypical symptoms, or not having any symptoms because they’ve curtailed their exercise ability. Having that expanded discussion with patients to get a sense for how active they are and if they’re having any limitation in their ability to walk is part of it. Because then it’s a diagnostic test as opposed to a screening test in terms of doing an ABI [ankle brachial index test] to diagnose PAD.
The other part is the physical exam. We all have this kind of common refrain of making sure we take the socks off and check people’s pulses. Josh Beckman loves to remind folks to take the socks off in physical exam, and that’s critical. It’s easier in Florida where I live because people wear flip-flops. It’s harder in Minnesota, where you have to take off boots and socks. Nonetheless, it’s important to do that physical exam, not only doing the distal pulses but a thorough vascular exam. Because that’s no cost other than our time, and it can provide a lot of information. That would be a diagnostic test as opposed to a screening test for ABI.
We’re doing a history and physical, expanding that for a focus on vascular disease and the REACH [Reduction of Atherothrombosis for Continued Health] Registry with the work you’ve done. You know these data well. But it was striking that in patients who had symptomatic or clinical coronary artery disease, 30% had polyvascular disease. That’s a huge percentage and probably just the tip of the iceberg. They might have undiagnosed triple vessel disease or undiagnosed PAD. But of the patients with PAD in the REACH Registry, 60% had polyvascular disease. Thus, there’s a lot of disease if we’re looking for it.
There needs to be a change in how we approach screening. Identifying these highest-risk patients, the ACC [American College of Cardiology] and AHA [American Heart Association] have advocated in guidelines for years to screen patients who have diabetes, tobacco use, using different age criteria, patients who had known cardiovascular disease. Unfortunately, there’s this gap between the US Preventive Services Task Force and having adequate data to support screening. There’s a path forward where there’s a change in the screening guidelines, and hopefully we can see that in the near future.
Deepak Bhatt, MD, MPH: Those are terrific points. Maybe it’s because you’re from Mayo Clinic. It made me think of an article from many years ago in Mayo Clinic proceedings, in the catheterization lab, where they identified some strategies to screen patients for PAD. I wrote the accompanying editorial. At the time, it was really insightful that they were thinking about these things. Eric, what do you do when you’re in the cath lab for a patient with coronary disease? Is there anything you do to see if they have disease elsewhere?
Eric Secemsky, MD: The modern-day cath lab has changed a lot. We use a lot more vascular ultrasounds. That’s always your first clue. If it’s going into a frontal artery to get access, you’d see plaque in the frontal artery. Even for a coronary case, you’d know that this patient is a polyvascular patient. Turning on your fluoroscopy machine, you can already see that the vessel wall is calcified. We talk a lot about aortic pathology, which is related to this atherosclerotic process. Same thing with the mesenteric arteries, the renal arteries. You already get a lot of glimpses of this when you go in and do a procedure for a patient without even thinking about working that patient up for this information to have it in front of you at the table.
But the most important thing—the conversation we have before the patient comes on the table—is what are this patient’s risk factors? The conversation we have is always: do they have diabetes? What’s the renal function? What’s the strength of their heart or their ejection fraction? All of that gives you some insight. It’s not only what you’re predicting to see with the coronary disease, but the overall global risk and how you want to treat that patient. We take home that information, we do the procedure, we treat the patient for their coronary disease, but we use that to plan how to move forward. What are our next steps? We’ve already had 1 problem if they’re in the cath lab. How do we prevent the next problem? We put all these pieces of information together to make the right plan for that patient.
Deepak Bhatt, MD, MPH: You made a lot of valuable points. You mentioned heart failure. That’s something else to consider. Oftentimes, patients with heart failure—especially in the cath lab, where there’s an ischemic basis—have severe coronary disease but also severe cerebrovascular and peripheral artery disease. Those issues may factor into whether they are or aren’t good surgical candidates, so it brings up a lot of things.
The other thing I’ll bring up is my own pet peeves in the cath lab. Every patient should have their blood pressure checked in both arms. I’m surprised how many times there’s a patient with angina, but no one has checked the blood pressure in both arms. That bothers me when that doesn’t happen routinely, and it still doesn’t happen. It happens less with automated blood pressure cuffs than it used to. It’s a basic thing but often overlooked.
You mentioned taking off the socks. That’s important. In the cath lab, the socks are usually off, but then they’ve got bootees to keep their feet warm. It’s important to feel the pulses. You know, the PT [posterior tibial] and DP [dorsalis pedis] pulses should be tested but documented as well. That used to be something that was always the cardiology fellow’s job or intervention fellow’s job to do. You always check the groin, listen for bruits, that sort of thing. But those things fall a little by the wayside. As we’re doing more radio, sometimes the patients are wearing pants, so no one has taken off the socks or the pants or anything, listened to femorals, or felt the feet. It would be nice to bring back those skills.
Transcript Edited for Clarity