Clinician-to-Clinician Update Clinician-to-Clinician Update

Vascular Medicine: Holistic Vascular Disease Diagnosis and Treatment

August 2016

Vascular diseases are diverse, include disorders of the arteries, veins and lymphatic vessels, and affect nearly every family. None of these diseases occur in isolation. Peripheral artery disease represents a manifestation of systemic atherosclerosis. Aneurysms in one location define aneurysmal risk at other arterial sites and among other family members. Traditionally, treatment and healthcare resources have primarily addressed only the acute life or limb-threatening events. While important, this approach alone is not sufficient. Contemporary care recognizes that a preventive long-term approach to vascular health creates more cost-effective, quality outcomes and better helps patients manage their risk of future ischemic or thromboembolic events.

Vascular medicine, a cardiovascular subspecialty, recognizes blood vessels as an organ system.1 First formally recognized by the American Medical Association in 1997 through the efforts of University of Minnesota faculty, vascular medicine is devoted to the prevention, detection, and comprehensive treatment of these diseases. Vascular medicine physicians work in collaboration with colleagues in vascular surgery and radiology. The care approach encompasses a range of lifestyle, pharmacological, end vascular, and surgical treatment strategies.

August-2016-Heart-Care-Main-Article-Image-Drs
— Vascular medicine specialists Heidi Ekman, APRN, CNP, and Drs. Alan Hirsch and Abdi Jama confer at the Clinics and Surgery Center. The specialty emphasizes noninvasive, multidisciplinary approaches to the treatment of vascular disease.

Vascular medicine’s holistic care model is exemplified by the specialty’s approach to treating peripheral artery disease (PAD).2 PAD is common, affecting 8% to 10% of people over the age of 65 and 20% of those 80 years of age or older.3 (See Case Study). Unrecognized PAD represents a very high risk of cardiovascular disease. Rates of preventable heart attack and stroke are higher among individuals with PAD, regardless of leg symptoms, than among most individuals who have already suffered a first heart attack (3–5% per year2). PAD is associated with potentially devastating impacts on functional capacity, mental health4 and quality of life5. PAD can also progress to critical limb ischemia (CLI), among the most dangerous of atherosclerotic diseases. All-cause mortality rates at 5 years from CLI diagnosis may reach 25-50%.

Vascular medicine specialists emphasize noninvasive, evidence-based, risk-reduction care strategies as a guideline-based first therapeutic approach. Two key treatments, PAD supervised exercise and the FDA-approved generic medication cilostazol, have been demonstrated to improve claudication symptoms. Currently, however, over 90% of Minnesotans and Americans with PAD and claudication are treated through invasive procedures, contrary to national evidence-based guidelines. Although invasive treatments can be effective, exercise therapies performed by patients in a supervised environment are as or more effective than endovascular therapies in improving functional capacity. As a prescribed therapy, exercise helps improve risk factors and is safe, as durable as any other therapy, and is well-accepted by patients.6

Vascular medicine specialists can help these patients halt disease progression and avoid CLI and the risk of amputation. For patients with PAD, it is critical that cardiovascular risk reduction interventions, including state-of-the-art antithrombotic interventions, be universally achieved.

References

  1. Creager MA, et al. Postgraduate training in vascular medicine: proposed requirements and standards. Vasc Med. 2003;8:47-52.
  2. Hirsch AT, et al. ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations 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)--summary of recommendations. Circulation 2006;113:1474-1547.
  3. Hirsch AT, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317-1324.
  4. McDermott MM, Greenland, P, Guralnik, JM et al. Depressive symptoms and lower extremity functioning in men and women with peripheral arterial disease. J Gen Intern Med. 2003;18:461-467.
  5. Regensteiner JG, et al. The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Program. Vasc Med. 2008;13:15-24.
  6. Murphy TP, Reynolds MR, Cohen DJ, et al. Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease. J Amer Coll Cardiol. 2015;65:999–1009.

When to refer

The M Health Vascular Medicine program provides a comprehensive, evidence-based approach to vascular disease detection and treatment. Our specialists offer patients the full range of lifestyle, pharmacologic, endovascular and open surgical therapeutic options that are proven to improve symptoms and quality of life, prevent progressive vascular disease, and lower cardiovascular risk. The Vascular Medicine team addresses all vascular diseases, including:

  • Aortic aneurysms and aortic dissection, integrating with the M Health Aortic Center;
  • Edema, including venous insufficiency;
  • Cardiovascular disease prevention;
  • Carotid artery disease;
  • Coronary artery disease;
  • Fibromuscular dysplasia;
  • Functional (vasoreactive) vascular disorders;
  • Hypertension;
  • Lymphedema;
  • Marfan’s syndrome and other aortopathies;
  • Peripheral artery disease, including claudication and critical limb ischemia;
  • Thromboangitis obliterans and arteritis;
  • Venous thromboembolic disease (DVT and PE)

Clinical Research

The M Health Vascular Medicine program is an international leader in the evaluation of novel pharmacotherapies and state of the art treatments, including exercise and smoking-cessation programs. We provide patients with vascular diseases the best proven strategies of care as well as access to the most promising clinical trials. Consultations are designed to inform patients of the totality of their care options.

Collaborative Care

Our goal is to foster patient autonomy and be an ally of primary care. Our program emphasizes the critical benefit that occurs when clinicians and fully informed patients work together to create effective, lifelong care plans. We collaborate with vascular and cardiothoracic surgeons, interventional radiologists, cardiac and peripheral artery disease rehabilitation specialists, lymphedema therapists, and wound specialists, among others. The Vascular Medicine program coordinates this multidisciplinary care, facilitating and streamlining the process for your patients.

Find current clinical trials available through M Health's Study Finder: visit studyfinder.umn.edu.

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