Polyvascular atherosclerotic disease: recognizing the risks and managing the syndrome

BACKGROUND: Patients with an initial ischemic event secondary to atherosclerosis have an increased risk of suffering a recurrent event not only in the same vascular territory, but in other territories as well. Patients with polyvascular disease, or atherosclerotic disease in more than one vascular territory, have worse clinical outcomes than those with disease in a single vascular territory. This suggests that atherosclerosis should be treated as a systemic disease with appropriately aggressive secondary preventive measures in order to prevent recurrent events throughout the arterial tree. OBJECTIVE: To discuss relevant findings for the management of patients with polyvascular disease and provide guidance to clinicians who may not be aware of how best to manage these patients. METHODS: Relevant English-language articles published from 1950 through February 2009 were identified by searching the Cochrane, MEDLINE, and Ovid databases using the terms 'atherosclerosis,' 'atherothrombosis,' 'cerebrovascular disease,' 'coronary artery disease,' 'cross-risk,' 'management guidelines,' 'peripheral arterial disease,' 'polyvascular,' and 'secondary prevention' either singly or in combination. FINDINGS AND CONCLUSIONS: According to limited data from patient registries, anywhere from 15% to 30% of patients with atherosclerosis present with disease in multiple vascular territories and experience significantly greater rates of adverse cardiovascular events. Despite these findings, a search of the literature reveals a lack of studies comprised of patients with polyvascular disease only and very few reports on the results of patients with polyvascular disease enrolled in existing secondary prevention studies. Although any conclusions are limited by this small number of studies, clinicians typically treat only the initially affected territory without consideration of the other affected territories and may lack awareness of the overall atherothrombotic syndrome. In the future, clinical trials focused specifically on patients with polyvascular disease should be conducted in order to increase our knowledge on how to manage these patients. Evidence-based clinical practice guidelines are also necessary to improve the management of patients with polyvascular disease.