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Dr. Patel:
Hello. My name is Manesh Patel, and I'm excited you're joining us for, I think, what's going to be a really exciting episode. We're talking about, what are the latest updates on clinical PAD. There have been guidelines, and we're sort of interested in understanding screening, diagnosis, and a little bit about the changing risk factors. I'm joined by a friend and a colleague who is really an expert in the field, Marc Bonaca. Marc, you want to introduce yourself? And thanks for joining. 

Dr. Bonaca:
Yeah, thanks, Manesh. Marc Bonaca here, a Vascular Medicine Physician at University of Colorado, and a great topic for us to talk about today.

Dr. Patel:
Yeah, Marc. And you know, we've been obviously caring a lot about these patients, the science, how do we take care of them? And maybe just a brief background on just the prevalence in the management of vascular disease, or peripheral vascular disease. Here we're talking about peripheral artery disease of the lower extremity, and I'm sure a lot of people know that there's vascular disease throughout the whole body. But you know, broadly, over the last several years, we've understood that vascular disease often starts, unfortunately, in the femoral arteries and maybe even in the carotids, before it's in the coronaries, people have different beds, but it's estimated over 200 million people worldwide, if not even more, and that's symptomatic PAD patients. Marc, do you have a number on the number of people that might not be unrecognized, or any sense on what the overall PAD burden is out of the several billion people on planet Earth?

Dr. Bonaca:
Yeah, it's a great question. You know, analyses have of sort of estimated maybe 230 million globally, somewhere between 12 and 20 million in the U.S. But we don't actually really know, because we don't have systematic screening of patients at risk, and that's been an area of hot debate. We know there are a lot of people at risk: obesity, diabetes, aging, those are some of the key risk factors. So it's highly prevalent and widely underdiagnosed.

Dr. Patel:
Yeah, and maybe we'll come back to the diagnosis part here in a second. But one of the key updates, I guess, from this, what were some of the key impactful updates from the guidelines that you'd say that are most new for thinking about these at least 230 million worldwide patients with PAD?

Dr. Bonaca:
Yeah, I think there are some really key findings in the new guidelines that should really hallmark a transition in how we think about peripheral artery disease. The first and really key is about health equity and the recognition that there are populations like African Americans in the U.S. that have more than twofold the risk of amputation versus others, and why that is. And we can get into diagnosis, screening, and treatment, but ultimately we have to recognize PAD as a health equity emergency.

I think the second thing is the recognition that there's heterogeneity. When we say PAD, there are differences in terms of the limb manifestations, there's also differences in comorbidity, and you know, who has chronic kidney disease, what their age is, frailty, other things that really should inform how we think holistically about treating patients.

Dr. Patel:
Yeah, I think those are maybe the two important impactful updates and things that, unfortunately, if you've been in the field, you know, is quite so true, right? That PAD is almost an identifier of people that unfortunately have poor social determinants of health, maybe poor access to care, often rural, certainly a higher proportion of underrepresented patients that have adverse outcomes more than others. So I think that's a real important feature.

The second might be the comorbidities, sort of the complexity of our PAD patients. You know, when I was earlier in my career, thinking about it, would always see fellows and say, if I don't see them as having tobacco or diabetes, it's rare that they may have PAD. But actually, the comorbidities have really expanded beyond that time when we used to think of just the traditional risk factors. Are there ways that you think about the comorbidity burden of these patients now?

Dr. Bonaca:
Yeah, well, you know, you find in almost every data set that, if you're looking for who's at highest risk of adverse outcomes associated with peripheral artery disease, it's really interesting. Even when you look at heart failure, having peripheral artery disease is an independent predictor of heart failure. Having peripheral artery disease is associated with chronic kidney disease, with age, with frailty. You know, it is a real common denominator for complex comorbidities, and actually it makes treatment much more challenging as we think about competing therapies, for example, anticoagulation, multiple doses, you know, in a patient with PAD and AFib who has advanced age and chronic kidney disease. And how do you think about that? And so, these are not only the highest risk patients that many of us see, but they're also the most complex from a comorbidity perspective.

Dr. Patel:
Yeah, I think, you know, PAD is a marker for overall vascular risk and burden. And as you think about it as a broad burden risk factor, these patients unfortunately have really poor adverse outcomes. And maybe one of the big impacts, I'd say, from my side, from the guidelines, is recognizing, just like a lot of our other care, we need a vascular team that's expert in multiple areas to take care of these patients. We certainly saw it in revascularization trials like BEST-CLI where you need a team of people to think about it. We're still working through how we revascularize patients, but maybe more importantly than revascularizing patients is making sure they get access to proven therapies, and we have more of those now that we're going to talk about in some treatment areas. But I would say, you know, often these teams have pharmacists that help us make sure patients are getting access to care. Often, they have vascular medicine clinicians like yourself or others, sometimes revascularization doctors, diabetologists. Certainly, a group of people that are helping them. Often, nephrology is involved.

So this has been a really great episode, as we've talked about sort of the broad ways we can think about it. As of today, it's a growing problem with a large burden and comorbidities, and we really encourage those of you listening to make sure you're looking out and caring for your patients with PAD.

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