The year 2017 in cardiology: aorta and peripheral circulation
█ Current opinion
Victor Aboyans1,2*, Sigrid Braekkan3, Lucia Mazzolai4, Henrik Sillesen5, Maarit Venermo6 and Marco De Carlo7; on behalf of the ESC Working Group on Aorta and Peripheral Vascular Diseases
1Department of Cardiology, Dupuytren University Hospital
2Martin Luther King Ave., Limoges, France; Inserm 1094, Limoges School of Medicine, Ave Dr. Marcland, 87025 Limoges, France;
3K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT – The Arctic University of Norway, Hansine Hansens veg 18, 9037, Tromsø, Norway;
4Division of Angiology, Department of Heart and Vessel, Lausanne University Hospital, Ch du Mont-Paisible 18, Lausanne, 1011, Switzerland;
5Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen, 2100, Denmark;
6Department of Vascular Surgery, Helsinki University Hospital, Haartmaninkatu 4, FI-00290 Helsinki, Finland;
7Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospealiero-Universitaria Pisana, via Paradisa, Pisa, Italy
More than 83 million people live with cardiovascular (CV) disease in the ESC member countries, with peripheral vascular diseases as the most predominant condition (more than 35 million) followed by ischaemic heart disease (>29 million), underlining the public health burden of the former in our continent (1).
The ESC collaborated with European Society of Vascular Surgery (ESVS) to publish the most comprehensive guidelines document on the management of peripheral arterial diseases (PADs), encompassing all the peripheral territories (2). Compared to the 2011 version, major changes regard risk stratification for patients with asymptomatic carotid disease, and those with critical limb-threatening ischaemia (CLTI), and a new specific chapter on cardiac diseases in patients with PADs. Any presentation of PADs is associated with a very high risk for CV events, and all patients require best medical therapy for secondary prevention. In this respect, the VIVA (3) and COMPASS (4) trials are definitely the two seminal randomized controlled trials (RCTs) of the year.
The VIVA trial demonstrated the interest of multiple vascular screening to improve population longevity (Table 1) (3). Over 50,000 Danish men were randomized to receive an invitation for vascular screening or not. Vascular screening consisted of arm blood pressure and ankle-brachial index (ABI) measurement, and abdominal aorta ultrasound. Positive cases were invited to consult their general practitioners, while large abdominal aorta aneurysm (AAA) were referred to vascular surgeons. After 4.4 years, the mortality was significantly lower in the screening group (Table 1). The number needed to screen to prevent one death was 169, far below the one necessary for any cancer screening.
The COMPASS trial randomized 27,395 patients either with coronary artery disease (CAD) or PADs [lower-extremity artery disease (LEAD) or carotid stenosis or prior carotid revascularization] to three different antithrombotic strategies. In the pre-defined sub-analysis of patients with PADs, the results were consistent with those obtained in the entire population (Table 1): the combination of rivaroxaban 2.5 mg b.i.d. + aspirin 100 mg was associated with a significant 28% reduction of a combination of CV death, myocardial infarction, or stroke and a 46% reduction of major adverse limb events (MALE), including amputation, as compared to aspirin 100 mg (4). Bleeding events were higher under the combination therapy, except for fatal bleeding. The net benefit including ischaemic and major bleeding events remained in favour of the combination strategy. The clinical implication for the management of these patients needs further analyses to select specific subgroups with an optimal benefit/risk ratio (RR). Also, the external applicability of these results is important; among REACH participants with LEAD, 68% were COMPASS-compatible, fulfilling inclusion, and exclusion criteria (15). The main reason for not being COMPASS-compatible was a high-bleeding risk. Hence, the bleeding risk stratification is of paramount importance.