Cardiology 2015: Peripheral Circulation

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    DOI

    https://doi.org/10.15836/ccar2016.314

    Full Text

    ## Introduction At the initiative of the Croatian Cardiac Society (CCS), the Working Group on Angiology and Peripheral Vascular Diseases decided to address the state of Croatian angiology during 2015, based on the example of the Working Group on Peripheral Circulation of the European Society of Cardiology that was published in the European Heart Journal. The goal was to provide an overview of the positions and goals that CCS holds, based on the current knowledge and events in the European cardiologic community that marked the year 2015. ( 1 ) This editorial will briefly address the prevention of cardiovascular diseases and the importance of new markers in cardiovascular identification, diagnosis and treatment of peripheral artery disease, and finally the current issues related to venous thromboembolism treatment. ## Prevention of cardiovascular diseases Prevention of cardiovascular diseases is still very topical, and has in recent years increasingly included the expanded “vascular territories”, primarily carotid and peripheral circulation, in the assessment of cardiovascular risk. Table 1 includes some of the recommendations published in current guidelines for the prevention of cardiovascular diseases ( 2 ) by the European Society of Cardiology (ESC) in May 2016. Carotid intima-media thickness (CIMT) has become interesting clinical evidence and a marker in the focus of cardiovascular research as a potential challenge in the reclassification of cardiovascular risk, although current guidelines do not recommend it for routine application. A prospective multi-center study found that CIMT measurement was associated with cardiovascular events in participants under 45 years of age. ( 3 ) CIMT increase did not provide further information beyond that from the standard risk factors, but the study supported its use as a biomarker for persons that are still not qualified for screening for standard cardiovascular risk factors, given that these are usually used in persons above 40 years of age. ( 1 ) The position of CCS on this issue is fully in line with the ESC guidelines published in 2012 and 2016 ( 2 , 4 ) ( Table 2 ), although CIMT is still in the category of professional and scientific interest regarding cardiovascular risk assessment in our relatively small cardiovascular community and has no wider clinical application in routine risk assessment. CCS shares the positions and adheres to the rules of ESC, which states that CIMT measurement could cause inadequate concern and treatment in cases of false-positive results, but even a negative result could lead to unnecessary laxity and a false sense of safety regarding the proper relationship to a healthy lifestyle. Thus, the systematic assessment of cardiovascular risk in men younger than 40 years of age and women younger than 50 remains advocated by the newest guidelines on cardiovascular prevention published in 2016. A scientific conference was held on the topic of cardiovascular prevention at the Croatian Academy of Sciences and Arts in Zagreb on April 9, 2015, where the significance of biomarkers in atherosclerosis prevention was discussed. The topic of the conference was “Asymptomatic Atherosclerosis”, and the professional lectures were summarized and published in the Conference Proceedings. The conclusion of these discussions was that there was a need to position CIMT as a new method in clinical practice that still requires clinical and economic studies but has potential for cardiovascular risk reclassification in the population under intermediate risk. ( 5 ) The need for personalized prevention of asymptomatic atherosclerosis also became apparent over the course of this conference, stressing the potential value of new methods that have not yet been applied to routine clinical practice and vascular status assessment in healthy individuals. An association was demonstrated between cardiovascular vulnerability and hemodynamic indicators associated with cardiovascular diseases that thus represent disease markers, which are: pulse wave velocity (PWV), flow mediated dilatation (FMD), and ankle brachial index (ABI). Routine clinical application in the Republic of Croatia is still the subject of scientific studies on risk assessment in healthy asymptomatic individuals. ( 6 ) Our own studies ( Table 3 ) are proof in our scientific interest for endothelial function in the assessment and the importance of vascular markers for cardiovascular diseases. ( 7 ) ABI measurement was confirmed to be a vascular indicator, a biomarker whose values reclassified risk assessed using the Framingham Risk Score in patients with intermediate risk in a wide age-range (35 to 74 years of age) in a special cohort study in a Spanish population. ( 8 ) In Croatia, ABI measurement is, though long-established as an accepted and indispensable method, still underused in the assessment of cardiovascular risk and unfortunately also in functional assessment of the state of the peripheral arteries of the lower extremities. This fact has been confirmed by a poll conducted in Croatia during the 10 th CCS congress in October 2014. The results of the poll, in which 88 physicians took part (62 cardiologists, 14 internists, and 12 other physicians with other specialties) bear witness to the neglect for this method in the overall cardiologic practice. Approximately 20% of the participants responded to the poll. Active participation in the diagnostic process and assessment of peripheral artery disease did not include any method in the diagnosis of peripheral arterial disease for 56% of those polled, and only 7% used ABI as a screening method and as the initial, key method in the severity assessment in peripheral artery disease. A total of 55% respondents believed that ABI measurement would contribute to total cardiovascular status assessment in patients during routine assessment of arterial disease. All this indicates the need to once again ensure adherence to recommendations in the ESC guidelines for the diagnosis and treatment of peripheral artery disease that were presented as early as 2011 and were translated as summarized guidelines in the Republic of Croatia in 2013. ( 9 , 10 ) We believe it would be worthwhile to alert the cardiologic public to the importance of the application of vascular biomarkers in primary and secondary cardiovascular prevention, so in Table 4 we showed only the most important biomarkers with A-level evidence that have been accepted so far. ## Peripheral artery disease The diagnostic process and disease assessment for peripheral artery diseases, despite the published guidelines, still relies only on clinical signs, arterial circulation duplex ultrasound, and angiography. Only a negligible number of centers use plethysmography, segmental blood pressure, and ABI in the diagnostic process, despite the fact that this method is an indispensable part of peripheral artery disease assessment. Based on data from the Information Health System of the Republic of Croatia (CEZIH) of the Croatian Health Insurance Fund (HZZO), a total of 644 angiointerventions on peripheral arteries were performed in 2015 in the Republic of Croatia (527 with the implantation of 1 stent and 117 with the implantation of 2 or more stents). This number also includes carotid artery interventions. Carotid endarterectomy, based on the same data, was performed in 1213 carotid arteries, which is in line with the recommendations and evidence from the publication we are referring to, suggesting that endarterectomy is a method that is still preferred over endovascular treatment for carotid stenosis. ## Vein thrombosis Public awareness is low regarding venous thromboembolism (VTE) and deep vein thrombosis (DVT) as well as pulmonary embolism (PE) and is estimated at 44% to 59%, which is lower than awareness of myocardial infarction (88%) and stroke (90%) as well as arterial hypertension (90%). ( 11 ) Additional public or media engagement is necessary in order to increase public awareness of the significance of VTE and thus reduce the disease burden of this widespread but preventable disease. We do not have clear objective data on the prevalence of venous thrombosis for the Republic of Croatia, since a registry for venous thrombosis does not exist. Knowing the true prevalence of the disease is only partially possible, since data only applies to the hospitalized part of the population. According to data from the CEZIH/HZZO database for 2015, it is estimated that approximately 1925 patients were treated for venous thrombosis in hospital conditions. It is not possible to determine the data on the true incidence of the disease based on this number of patients that had venous thrombosis as their initial diagnosis. If we accept that the incidence of venous thrombosis in Croatia is similar to the incidence reported in European and US publications, we can expect that the annual incidence in the general population is between 6000 and 7000 cases. It is important to once again point out the abovementioned results of the poll on the way VTE is being treated. The data show that 68% of physicians believe that the application of vitamin K antagonists (VKA) in the treatment of DVT and thromboembolism prophylaxis is a cause for concern, since only 30% that patients treated with VKA achieve target international normalized ratios (INR). Approximately 88% hold that the application of new oral anticoagulants would contribute to better compliance, comfort, and safety for venous thrombosis treatment. Approximately 70% of the respondents believed this would also reduce treatment costs for patients with DVT due to the increase in effectiveness, especially due to lower incidence of side effects. The initiative of the Working Group on Angiology and Peripheral Vascular Diseases of the CCS to improve interest and awareness of venous thrombosis is related to the preparation of the National Guidelines for the Diagnosis and Treatment of Venous Thrombosis and Venous Thromboembolism, which will soon be presented to the public and which, given the lack of ESC guidelines on the diagnosis and treatment of venous thrombosis, mostly rely on the recommendations published in the Chest Journal during 2016 and treatment guidelines for acute pulmonary embolism. ( 12 , 13 ) ## Conclusion We believe it is not irrelevant that as many as 78% of cardiologists thought that further education in angiology should be ensured for the treatment and diagnostics of venous diseases and peripheral artery diseases. To satisfy these needs, which would lead to better clinical practice and compliance with current guidelines, it is necessary to achieve synergy between the possibilities determined by the Croatian Health Insurance Fund, but also strengthen the initiative of the CCS, encourage and develop registries in the field of angiology, and encourage professionals to be sensitive to the issues related to angiology in the Republic of Croatia. We also believe it is important to emphasize that in addition to the CCS, the scientific and professional activities of the Croatian Academy of Sciences and Arts in 2015 also contributed to public and professional awareness of the academic community regarding the current topics in peripheral artery diseases and biomarkers in cardiovascular risk assessment.

    Cardiologia Croatica
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    Cardiology 2015: Peripheral Circulation

    Editorial
    Issue8
    Published
    Pages314-318
    PDF via DOIhttps://doi.org/10.15836/ccar2016.314

    Authors

    Ljiljana Banfić*ORCIDCroatia

    Full Text

    ## Introduction At the initiative of the Croatian Cardiac Society (CCS), the Working Group on Angiology and Peripheral Vascular Diseases decided to address the state of Croatian angiology during 2015, based on the example of the Working Group on Peripheral Circulation of the European Society of Cardiology that was published in the European Heart Journal. The goal was to provide an overview of the positions and goals that CCS holds, based on the current knowledge and events in the European cardiologic community that marked the year 2015. ( 1 ) This editorial will briefly address the prevention of cardiovascular diseases and the importance of new markers in cardiovascular identification, diagnosis and treatment of peripheral artery disease, and finally the current issues related to venous thromboembolism treatment. ## Prevention of cardiovascular diseases Prevention of cardiovascular diseases is still very topical, and has in recent years increasingly included the expanded “vascular territories”, primarily carotid and peripheral circulation, in the assessment of cardiovascular risk. Table 1 includes some of the recommendations published in current guidelines for the prevention of cardiovascular diseases ( 2 ) by the European Society of Cardiology (ESC) in May 2016. Carotid intima-media thickness (CIMT) has become interesting clinical evidence and a marker in the focus of cardiovascular research as a potential challenge in the reclassification of cardiovascular risk, although current guidelines do not recommend it for routine application. A prospective multi-center study found that CIMT measurement was associated with cardiovascular events in participants under 45 years of age. ( 3 ) CIMT increase did not provide further information beyond that from the standard risk factors, but the study supported its use as a biomarker for persons that are still not qualified for screening for standard cardiovascular risk factors, given that these are usually used in persons above 40 years of age. ( 1 ) The position of CCS on this issue is fully in line with the ESC guidelines published in 2012 and 2016 ( 2 , 4 ) ( Table 2 ), although CIMT is still in the category of professional and scientific interest regarding cardiovascular risk assessment in our relatively small cardiovascular community and has no wider clinical application in routine risk assessment. CCS shares the positions and adheres to the rules of ESC, which states that CIMT measurement could cause inadequate concern and treatment in cases of false-positive results, but even a negative result could lead to unnecessary laxity and a false sense of safety regarding the proper relationship to a healthy lifestyle. Thus, the systematic assessment of cardiovascular risk in men younger than 40 years of age and women younger than 50 remains advocated by the newest guidelines on cardiovascular prevention published in 2016. A scientific conference was held on the topic of cardiovascular prevention at the Croatian Academy of Sciences and Arts in Zagreb on April 9, 2015, where the significance of biomarkers in atherosclerosis prevention was discussed. The topic of the conference was “Asymptomatic Atherosclerosis”, and the professional lectures were summarized and published in the Conference Proceedings. The conclusion of these discussions was that there was a need to position CIMT as a new method in clinical practice that still requires clinical and economic studies but has potential for cardiovascular risk reclassification in the population under intermediate risk. ( 5 ) The need for personalized prevention of asymptomatic atherosclerosis also became apparent over the course of this conference, stressing the potential value of new methods that have not yet been applied to routine clinical practice and vascular status assessment in healthy individuals. An association was demonstrated between cardiovascular vulnerability and hemodynamic indicators associated with cardiovascular diseases that thus represent disease markers, which are: pulse wave velocity (PWV), flow mediated dilatation (FMD), and ankle brachial index (ABI). Routine clinical application in the Republic of Croatia is still the subject of scientific studies on risk assessment in healthy asymptomatic individuals. ( 6 ) Our own studies ( Table 3 ) are proof in our scientific interest for endothelial function in the assessment and the importance of vascular markers for cardiovascular diseases. ( 7 ) ABI measurement was confirmed to be a vascular indicator, a biomarker whose values reclassified risk assessed using the Framingham Risk Score in patients with intermediate risk in a wide age-range (35 to 74 years of age) in a special cohort study in a Spanish population. ( 8 ) In Croatia, ABI measurement is, though long-established as an accepted and indispensable method, still underused in the assessment of cardiovascular risk and unfortunately also in functional assessment of the state of the peripheral arteries of the lower extremities. This fact has been confirmed by a poll conducted in Croatia during the 10 th CCS congress in October 2014. The results of the poll, in which 88 physicians took part (62 cardiologists, 14 internists, and 12 other physicians with other specialties) bear witness to the neglect for this method in the overall cardiologic practice. Approximately 20% of the participants responded to the poll. Active participation in the diagnostic process and assessment of peripheral artery disease did not include any method in the diagnosis of peripheral arterial disease for 56% of those polled, and only 7% used ABI as a screening method and as the initial, key method in the severity assessment in peripheral artery disease. A total of 55% respondents believed that ABI measurement would contribute to total cardiovascular status assessment in patients during routine assessment of arterial disease. All this indicates the need to once again ensure adherence to recommendations in the ESC guidelines for the diagnosis and treatment of peripheral artery disease that were presented as early as 2011 and were translated as summarized guidelines in the Republic of Croatia in 2013. ( 9 , 10 ) We believe it would be worthwhile to alert the cardiologic public to the importance of the application of vascular biomarkers in primary and secondary cardiovascular prevention, so in Table 4 we showed only the most important biomarkers with A-level evidence that have been accepted so far. ## Peripheral artery disease The diagnostic process and disease assessment for peripheral artery diseases, despite the published guidelines, still relies only on clinical signs, arterial circulation duplex ultrasound, and angiography. Only a negligible number of centers use plethysmography, segmental blood pressure, and ABI in the diagnostic process, despite the fact that this method is an indispensable part of peripheral artery disease assessment. Based on data from the Information Health System of the Republic of Croatia (CEZIH) of the Croatian Health Insurance Fund (HZZO), a total of 644 angiointerventions on peripheral arteries were performed in 2015 in the Republic of Croatia (527 with the implantation of 1 stent and 117 with the implantation of 2 or more stents). This number also includes carotid artery interventions. Carotid endarterectomy, based on the same data, was performed in 1213 carotid arteries, which is in line with the recommendations and evidence from the publication we are referring to, suggesting that endarterectomy is a method that is still preferred over endovascular treatment for carotid stenosis. ## Vein thrombosis Public awareness is low regarding venous thromboembolism (VTE) and deep vein thrombosis (DVT) as well as pulmonary embolism (PE) and is estimated at 44% to 59%, which is lower than awareness of myocardial infarction (88%) and stroke (90%) as well as arterial hypertension (90%). ( 11 ) Additional public or media engagement is necessary in order to increase public awareness of the significance of VTE and thus reduce the disease burden of this widespread but preventable disease. We do not have clear objective data on the prevalence of venous thrombosis for the Republic of Croatia, since a registry for venous thrombosis does not exist. Knowing the true prevalence of the disease is only partially possible, since data only applies to the hospitalized part of the population. According to data from the CEZIH/HZZO database for 2015, it is estimated that approximately 1925 patients were treated for venous thrombosis in hospital conditions. It is not possible to determine the data on the true incidence of the disease based on this number of patients that had venous thrombosis as their initial diagnosis. If we accept that the incidence of venous thrombosis in Croatia is similar to the incidence reported in European and US publications, we can expect that the annual incidence in the general population is between 6000 and 7000 cases. It is important to once again point out the abovementioned results of the poll on the way VTE is being treated. The data show that 68% of physicians believe that the application of vitamin K antagonists (VKA) in the treatment of DVT and thromboembolism prophylaxis is a cause for concern, since only 30% that patients treated with VKA achieve target international normalized ratios (INR). Approximately 88% hold that the application of new oral anticoagulants would contribute to better compliance, comfort, and safety for venous thrombosis treatment. Approximately 70% of the respondents believed this would also reduce treatment costs for patients with DVT due to the increase in effectiveness, especially due to lower incidence of side effects. The initiative of the Working Group on Angiology and Peripheral Vascular Diseases of the CCS to improve interest and awareness of venous thrombosis is related to the preparation of the National Guidelines for the Diagnosis and Treatment of Venous Thrombosis and Venous Thromboembolism, which will soon be presented to the public and which, given the lack of ESC guidelines on the diagnosis and treatment of venous thrombosis, mostly rely on the recommendations published in the Chest Journal during 2016 and treatment guidelines for acute pulmonary embolism. ( 12 , 13 ) ## Conclusion We believe it is not irrelevant that as many as 78% of cardiologists thought that further education in angiology should be ensured for the treatment and diagnostics of venous diseases and peripheral artery diseases. To satisfy these needs, which would lead to better clinical practice and compliance with current guidelines, it is necessary to achieve synergy between the possibilities determined by the Croatian Health Insurance Fund, but also strengthen the initiative of the CCS, encourage and develop registries in the field of angiology, and encourage professionals to be sensitive to the issues related to angiology in the Republic of Croatia. We also believe it is important to emphasize that in addition to the CCS, the scientific and professional activities of the Croatian Academy of Sciences and Arts in 2015 also contributed to public and professional awareness of the academic community regarding the current topics in peripheral artery diseases and biomarkers in cardiovascular risk assessment.