Coronary artery disease and peripheral vascular disease: Unraveling the links

Links between coronary and peripheral arterial atherosclerosis involve pathogenesis and risk. Risk factors overlap, except that hypertriglyceridemia is more frequent in patients with intermittent claudication than in those with angina pectoris. Diabetes mellitus increases the incidence of peripheral arterial disease five-fold and carries a greater risk of complications such as amputation. In terms of segmental involvement, femoropopliteal disease is the most prevalent form in patients more than 40 years old. Patients with symptomatic peripheral arterial disease have an annual mortality rate of more than 5%, mainly caused by coronary disease (CAD) 2-3 times greater than age-matched controls. The annual amputation rate is approximately 1.4% in unoperated cases. CAD can be overlooked, however, when intermittent claudication limits ambulation, and this contributes to the risk of myocardial ischemic events during surgery for peripheral arterial disease. Nearly 40% of patients referred for peripheral arterial disease surgery have angiographically significant CAD, accounting for most postoperative cardiac events. Noninvasive diagnostic methods for identification of patients at risk of ischemic cardiac events include exercise testing, ambulatory electrocardiography, pharmacologic myocardial perfusion imaging and stress-echocardiography, each of which carries specific advantages and disadvantages that must govern their selection for individual patients. Judicious perioperative management can improve the success of peripheral arterial disease surgery, but CAD risk is persistent and must be addressed to favorably influence long-term prognosis.