The compelling arguments for the need of medical vascular physicians in Europe

<b></b> The burden of vascular diseases is growing worldwide, as the population ages, prompting a call to action not only in terms of awareness but also and most urgently in recognizing the need for vascular physicians, also called angiologists. Vascular medicine views the vascular system (arteries, veins, and lymphatics) as a whole, unique, and independent entity requiring specialized competencies. Vascular physicians offer a holistic and comprehensive approach to vascular patients including provision of interventional procedures, management of a heterogeneous group of multi-morbid and frail patients affected by multi-vessel diseases, and connecting different specialists in a multidisciplinary effort. Vascular medicine practise varies across European countries. While it is a firmly accepted medical speciality in many European countries it is not formally recognized by the European Union limiting adoption in the other countries. The lack of vascular physicians likely accounts for inequality of care of vascular patients as compared for example to patients with heart disease and might contribute to adverse outcomes and healthcare costs associated with vascular diseases. To move forward in the struggle to provide efficient care for multimorbid poly-vascular patients, it is essential to establish vascular medicine programs in Europe and worldwide. Important steps to achieve this goal include improving public awareness of vascular diseases, attain formal recognition by the EU of angiology/vascular medicine as a medical specialty, creating specialized treatment guidelines, and to harmonize vascular care in Europe

Supervised exercise training in patients with lower extremity peripheral artery disease

The optimal first line management of patients with symptomatic chronic lower extremity peripheral artery disease (PAD) includes secondary prevention of cardiovascular risk factors, pharmacological treatment, and supervised exercise therapy (SET). SET programs have shown to be effective in improving walking performance, functional performance, and quality of life. However, despite a large body of evidence, and despite national and international guidelines recommending SET as first line therapy, SET remains largely underused in patients with chronic PAD. This position paper aims to describe how SET is perceived, its accessibility and structure through Europe. An anonymous web-based survey was used. It comprised 21 questions developed in conjunction with an angiologist and a clinical exercise physiologist specialist in vascular rehabilitation. We had 131 responders from 17 countries. For patients with PAD, SET programs exist only in 59% of European countries. SET reimbursement is available in 41% of countries. SET programs showed to be heterogeneous across countries. Thirty-four percent of the SET programs are PAD-dedicated, while 23% are part of a cardiac rehabilitation program. In addition, among existing SET programs, 65% are dedicated to symptomatic patients with PAD only, 9% to both asymptomatic and symptomatic, 8% to post-revascularized patients only, and 1% to asymptomatic patients with PAD only. Finally, 17% reported not knowing which patients are eligible for enrolment in a SET program. Duration, frequency, and modality of SET also varied from country to country. Overall, these data indicate that a large variability of SET availability and characteristics exists across Europe. Therefore, there is an urgent need to provide detailed guidance to deliver optimal exercise therapeutic care in patients with PAD

Hyperdynamic Myocardial Response to Beta-Adrenergic Stimulation in Patients With Chest Pain and Normal Coronary Arteries

ObjectivesThe goal of this study was to test the hypothesis that an abnormal response to beta-adrenergic stimulation may play a role in the pathophysiology of chest pain in patients with normal coronary arteries.BackgroundThe mechanism of angina-like (AL) chest pain in patients with angiographically normal coronary arteries remains controversial.MethodsFifty-eight patients with AL pain and a normal coronary angiogram underwent dobutamine echocardiography (DE) to evaluate regional wall motion and intraventricular flow velocities (IFV). Control patients consisted of 22 matched patients free of angina and coronary artery disease. Abnormal IFV were defined as dagger-shaped Doppler spectrum ≥3 m/s.ResultsDobutamine-induced regional wall motion abnormalities did not develop in any of the patients. An IFV ≥ 3 m/s was found in 28 patients (48%) with AL pain but in only 4 (18%) control patients (p < 0.05). In the subgroup of patients with AL pain and IFV ≥3 m/s, plasma renin concentration (PRC) was higher as compared with those with IFV <3 m/s (18 ± 17 pg/ml vs. 9 ± 6 pg/ml, p < 0.05). There were no differences in plasma ADR, NADR, or angiotensin-converting enzyme levels. Fourteen patients with angina and IFV ≥3 underwent control DE and blood sampling after 6 weeks treatment with 10 mg of bisoprolol. In these patients, a decrease in IFV (from 3.4 ± 0.35 m/s to 2.46 ± 0.64 m/s, p < 0.001) and a decrease in angina score (from 5.4 ± 1.5 to 0.6 ± 1.4, p < 0.001) were observed at follow-up.ConclusionsThe present data suggest that an exaggerated myocardial response to beta-adrenergic stimulation plays a role in the mechanisms of chest pain in some patients with normal coronary arteries

ESVM Guideline on peripheral arterial disease

International audienc

Successful Treatment of an Iatrogenic Giant Femoral Artery Pseudoaneurysm With Percutaneous Thrombin Injection

A femoral artery pseudoaneurysm (FAP) is one of the most troublesome complications following invasive procedures related to the femoral arterial access. Post-procedure FAP rarely occurs; however, its occurrence tends to increase with the more frequently antiplatelet agents, anticoagulants, and larger-sized catheter used for interventional procedures. Traditionally, surgical repair has been considered as the standard treatment modality for FAP; however, less invasive methods currently exist such as blind manual or ultrasound-guided compression repair (UGCR) as well as percutaneous thrombin injection, both of which have replaced the need for surgery. We report a case of a giant pseudoaneurysm in a femoral artery, which had developed as a complication of stenting in a patient with carotid artery stenosis and ischemic heart disease, and was subsequently successfully treated using percutaneous thrombin injection

Urgent need to clarify the definition of chronic critical limb ischemia - a position paper from the European Society for Vascular Medicine

Chronic critical lower limb ischemia (CLI) has been defined as ischemia that endangers the leg. An attempt was made to give a precise definition of CLI, based on clinical and hemodynamic data (Second European Consensus). CLI may be easily defined from a clinical point of view as rest pain of the distal foot or gangrene or ulceration. It is probably useful to add leg ulcers of other origin which do not heal because of severe ischemia, and to consider the impact of frailty on adverse outcome. From a hemodynamic viewpoint there is no consensus and most of the existing classifications are not based upon evidence. We should thus propose a definition and then validate it in a prospective cohort in order to define the patients at major risk of amputation, and also to define the categories of patients whose prognosis is improved by revascularisation. From today\u27s available data, it seems clear that the patients with a systolic toe pressure (STP) below 30 mmHg must be revascularised whenever possible. However other patients with clinically suspected CLI and STP above 30 mmHg must be evaluated and treated in specialised vascular units and revascularisation has to be discussed on a case by case basis, taking into account other data such as the WiFi classification for ulcers.In conclusion, many useful but at times contradictory definitions of CLI have been suggested. Only a few have taken into account evidence, and none have been validated prospectively. This paper aims to address this and to give notice that a CLI registry within Europe will be set up to prospectively validate, or not, the previous and suggested definitions of CLI

International public awareness of peripheral artery disease

This is the author accepted manuscript. the final version is available from Hogrefe via the DOI in this recordBackground: Peripheral artery disease (PAD) of the lower limbs is a common condition with considerable global burden. Some country-specific studies suggest low levels of public awareness. To our knowledge public awareness of PAD has never been assessed simultaneously in several countries worldwide. Patients and methods: This was an international, general public, internet-based quantitative survey assessing vascular health and disease understanding. Questionnaires included 23 closed-ended multiple-choice, Likert scale and binary choice questions. Data were collected from 9,098 survey respondents from nine countries in Europe, North and Latin America during May-June 2018. Results: Overall, familiarity with PAD was low (57% of respondents were “not at all familiar”, and 9% were “moderately” or “very familiar”). Knowledge about PAD health consequences was limited, with 55% of all respondents not being aware of limb consequences of PAD. There were disparities in PAD familiarity levels between countries; highest levels of self-reported awareness were in Germany and Poland where 13% reported to be “very” or “moderately” familiar with PAD, and lowest in Scandinavian countries (5%, 3% and 2% of respondents in Norway, Sweden and Denmark, respectively). There were disparities in awareness according to age. Respondents aged 25–34 were most familiar with PAD, with 12% stating that they were “moderately” or “very” familiar with the condition, whereas those aged 18–24 were the least familiar with PAD (7% “moderately” or “very” familiar with PAD). In the 45–54, 55–64 and 65+ age groups, 9% said they were “moderately” or “very” familiar with the term. There was no important gender-based difference in PAD familiarity. Conclusions: On an international level, public self-reported PAD awareness is low, even though PAD is a common condition with considerable burden. Campaigns to increase PAD awareness are needed to reduce delays in diagnosis and to motivate people to control PAD risk factors.Bayer A

ESVM guidelines:the diagnosis and management of Raynaud's phenomenon

Regarding the clinical diagnosis of Raynaud's phenomenon and its associated conditions, investigations and treatment are substantial, and yet no international consensus has been published regarding the medical management of patients presenting with this condition. Most knowledge on this topic derives from epidemiological surveys and observational studies; few randomized studies are available, almost all relating to drug treatment, and thus these guidelines were developed as an expert consensus document to aid in the diagnosis and management of Raynaud's phenomenon. This consensus document starts with a clarification about the definition and terminology of Raynaud's phenomenon and covers the differential and aetiological diagnoses as well as the symptomatic treatment

Usefulness of NT-pro BNP monitoring to identify echocardiographic responders following cardiac resynchronization therapy

<p>Abstract</p> <p>Background</p> <p>Cardiac resynchronization therapy (CRT) improves left ventricular (LV) volumes, mitral regurgitation (MR) severity and symptoms of patients with heart failure (HF). However, ≥ 30% of patients have no significant clinical or echocardiographic improvement following CRT. Reverse remodeling after CRT correlates with improved clinical outcomes. We hypothesized that in NT-pro BNP monitoring is accurate to identify responders following CRT.</p> <p>Methods</p> <p>42 consecutive patients (mean age 66 ± 12 years, male 68%) with HF undergoing CRT were prospectively enrolled. Responders at follow-up were defined by echocardiography (decrease in LV end systolic volume ≥ 15%). Echocardiography and NT-pro BNP measurement were performed at baseline and repeated 3 to 6 month after CRT.</p> <p>Results</p> <p>There was no significant difference between responders (n = 29, 69%) and non-responders (n = 13, 31%) regarding baseline NT-pro BNP level. Responders had significantly higher decrease in NT-pro BNP levels during follow-up than non-responders (absolute: -1428 ± 1333 pg.ml^-1vs. -61 ± 959 pg.ml^-1, p = 0.002; relative: -45 ± 28% vs. 2 ± 28%, p < 0.0001). A decrease of ≥ 15% in NT-pro BNP 3–6 months after CRT identifies echocardiographic responders with a sensitivity of 90% and a specificity of 77%.</p> <p>Conclusion</p> <p>NT-pro BNP monitoring can accurately identify echocardiographic responders after CRT.</p

Therapeutic decision-making for patients with fluctuating mitral regurgitation

Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve)