Chapter 12: Overlap of Atherosclerotic Disease

CORONARY ARTERY AND SYSTEMIC ARTERIAL DISEASE

According to the most recent data, currently there are approximately 71 million people in the United States with some form of cardiovascular disease (CVD).¹ The burden of CVD on the society is enormous. CVD has been the number one killer disease in the United States every year since 1900 except 1918.¹ It kills more Americans every year than the next four leading causes of death combined together (cancer, chronic lower respiratory tract disease, accidents, and diabetes).¹

The spectrum of CVD includes hypertension (HTN), angina, myocardial infarction (MI), heart failure, cerebrovascular accidents, etc. Of this, the prevalence of coronary artery disease (CAD), which includes angina and MI, is estimated to be approximately 13 million.¹ Considering the diffuse nature of atherosclerotic vascular disease, it would be reasonable to expect patients with CAD to have a systemic distribution of arterial disease. In fact, it has been recognized since the middle of the 20th century that patients with atherosclerotic vascular disease in one vascular bed are likely to develop disease in other arteries as well and clinically manifest symptoms of such disease.²

When studying incidence of CAD, data suggest that the incidence of single and multiple vessel CAD (defined as >50% angiographic stenosis) is as high as 21% to 41%, respectively, regardless of the principal vascular diagnosis (AAA, PAD, carotid artery disease).³ Manifestations of arterial disease frequently seen in patients with CAD include renal artery stenosis (RAS), peripheral arterial disease (PAD), carotid artery disease, and aneurysms of the aorta and its branches (subclavian artery, celiac trunk, superior mesenteric artery, and inferior mesenteric artery).

Recently, the REACH database, which included 67 888 patients from an international population, demonstrated that of patients with symptomatic atherothrombotic disease almost 16% had significant polyvascular disease.⁴ It should be noted that the prevalence of polyvascular arterial disease would have been much higher had these patients also been screened for asymptomatic vascular disease.⁴

With this in mind, it should not be surprising that the risk of angiographically significant RAS increases with multi-vessel CAD.⁵ Presence of significant CAD with more than two vessel involvement has been shown to be a predictor of RAS with a sensitivity of 0.84 and specificity of 0.77.⁶ It has been further demonstrated that the risk of significant RAS (defined as >50% stenosis of a renal artery) ranges from 22% to 89% in patients with CAD.^7,8 In patients with prior history of percutaneous coronary intervention, the prevalence of significant RAS is around 39%⁹ (Table 12-1).