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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EPeripheral arterial disease (PAD) affects more than 8 million adults in the United States, many of whom have one or more coinciding cardiovascular disease risk factors [D Lloyd-Jones. \u003Cem\u003ECirculation\u003C\/em\u003E 2010]. It is associated with high mortality rates, poor outcomes, and is often undetected due to a lack of symptoms [Mukherjee D et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2007; Saw J et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2006; Aboyans V et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2005]. This article discusses prognostic and management strategies for this prevalent disease, as well as recent data concerning thoracic aortic aneurysm and various treatment approaches.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EPeripheral arterial disease (PAD) affects more than 8 million adults in the United States, many of whom have one or more coinciding cardiovascular disease risk factors [D Lloyd-Jones. \u003Cem\u003ECirculation\u003C\/em\u003E 2010]. It is associated with high mortality rates, poor outcomes, and is often undetected due to a lack of symptoms [Mukherjee D et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2007; Saw J et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2006; Aboyans V et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2005]. Jonathan L. Halperin, MD, Mt. Sinai Medical Center, New York, NY, discussed prognostic and management strategies for this prevalent disease.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EAnkle brachial index (ABI), which evaluates the presence of lower extremity PAD in patients with symptoms of intermittent claudication or rest ischemia, may provide information that is needed for early detection in asymptomatic patients. In a meta-analysis that included 480,325 patient-years of follow-up, subjects (24,955 men and 23,339 women) with no previous history of coronary heart disease, a low ABI (\u22640.90) was associated with approximately twice the rate of 10-year all-cause mortality, cardiovascular mortality, and major coronary events compared with the overall rate in each Framingham Risk Score (FRS) category. Authors found that addition of ABI to the FRS would result in reclassification and modification of treatment recommendations in 19% of men and 36% of women [ABI Collaboration. \u003Cem\u003EJAMA\u003C\/em\u003E 2008]. Studies that focused on PAD detection in the primary care setting revealed similar findings that suggested that ABI may be a valuable diagnostic tool prior to PAD symptom manifestation [Diehm C et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009; Hirsch AT et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2001]. ABI measurement is simple, inexpensive, and accurate, and it is a powerful biomarker that merits further consideration, concluded Dr. Halperin.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThoracic aortic aneurysm (TAA), which is often found in heritable diseases, such as Marfan Syndrome (MFS), is also associated with high rates of morbidity and mortality, due in major part to increased risk of thoracic aortic dissection (TAD). Valentin Fuster, MD, PhD, FACC, Mt. Sinai Medical Center, New York, NY, discussed recent data concerning TAA and various treatment approaches.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EGenetic mutations and aortic wall abnormalities have been shown to contribute to TAA and TAD [Tadros TM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009; Fedak PW et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2002; El-Hamamsy et al. \u003Cem\u003ENat Rev Cardiol\u003C\/em\u003E 2009]. Fibrillin-1 and transforming growth factor-\u03b2 (TGF-\u03b2) play key roles in the development of TAA, TAD, and MFS. Fibrillin-1 mutations have been found to lead to aortic wall stiffening, increased TGF-\u03b2 activity, inflammation, matrix metalloproteinase (MMP) upregulation, elastolysis, cell disarray, and loss of structural integrity of the matrix [Tadros TM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009; Fedak PW et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2002; El-Hamamsy et al. \u003Cem\u003ENat Rev Cardiol\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ERecent studies have investigated the use of angiotensin II receptor blocker (ARB) therapy for the treatment of MFS. In a study by Dietz and colleagues, aortic aneurysm in a mouse model of MFS was associated with increased TGF-\u03b2. When treated with the ARB losartan, noncardiovascular manifestations of MFS were partially reversed [Dietz HC et al. \u003Cem\u003EScience\u003C\/em\u003E 2006]. Additionally, a correlation was observed between circulating TGF-\u03b21 and aortic root diameters in mice (p\u0026lt;0.002). In humans, circulating total TGF-\u03b21 concentrations were elevated in MFS patients compared with control (p\u0026lt;0.0001). MFS patients who were treated with losartan or \u03b2-blockers showed significantly lower total TGF-\u03b21 concentrations compared with untreated MFS patients (p\u0026lt;0.05) [Matt P et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009]. In a study by Ahimastos and colleagues, MFS patients who were treated with perindopril, an angiotensin-converting enzyme inhibitor (ACEi), had reduced aortic stiffness and aortic root diameter compared with placebo, possibly through attenuation of TGF-\u03b2 signaling [Ahimastos AA et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2007]. Larger studies are needed to evaluate the efficacy of these therapies for the treatment of MFS.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003ESurgery may be indicated, depending on the size of the aneurysm, rate of expansion, and the presence of symptoms and comorbidities (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). However, in the case of type A intramural hematoma (IMH), a variant form of TAD, timely surgery is suggested to avoid progression to typical dissection and is associated with favorable outcomes compared with medication alone [Kitai T et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009; Estrera A et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009; Song JK et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009]. The predictive role of aortic diameter and hematoma thickness in IMH remains controversial and requires further investigation. Though there are many potential treatment approaches for TAA, additional studies are needed before definitive strategies can be established.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11525\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11525\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11525\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003ESurgery is Indicated for TAA Under the Following Conditions:\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/9\/6\/16.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmv41\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmv41\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}