Since the practising of evidence-based medicine is deemed increasingly important, there is concern that current knowledge on the prevention of cardiovascular events may only benefit a minority of PAD patients. This notion is supported by the observed low level of CHD preventive measures adopted by physicians treating their PAD patients.
In a retrospective review of all patients operated on for critical lower extremity ischaemia in 1998, Bismuth et al. showed that only 5% of patients were treated with lipid-lowering therapy, and only 39% were using acetylsalicylic acid.
The mortality of these patients over 2 years was 35%, compared with only 10% in the sex- and age-matched control group. In a similar study, designed to assess the implementation of secondary prevention guidelines for CHD in patients undergoing peripheral re-vascularization surgery, Nass et al. demonstrated that patients with lower extremity disease were significantly less likely than patients with carotid disease to be on aspirin (45% versus 62%; ), a lipid-lowering agent (30% versus 45%; ), or a β-blocker (26% versus 39%; ).
In the primary care setting, the PAD Awareness, Risk, and Treatment: NEw Resources for Survival (PARTNERS) programme found that patients with PAD, compared with patients with CHD, were receiving significantly less lipid-lowering therapy (50% versus 73%; ), antihypertensive therapy (86% versus 95%; ), and antiplatelet agents (44% versus 71%; ).
It is therefore clear that patients with PAD are not being treated adequately. Since multiple studies have confirmed that PAD patients are at high risk of cardiovascular events, it is surprising that the level of implementation of CHD prevention strategies in this patient population remains low. Perhaps it is because, in most countries, symptoms of PAD are dealt with by vascular surgeons who are not educated in risk-factor modification; or because specialists within internal medicine are less interested in patients with PAD. Regardless of the reasons for undertreatment, responsibility for the management of PAD must be better defined.
Despite the problem of undertreatment, the ankle-brachial index (ABI) is a strong predictor of CHD morbidity and mortality in PAD patients, and should be included in general health examinations – at the very least to provide at-risk individuals with the impetus to adopt lifestyle changes (e.g. smoking cessation, initiation of an exercise regime and dietary modification).
The ‘one-stop clinic’
The patient with PAD has many requirements in order for their condition to be effectively managed: dietary advice; advice on smoking cessation; supervised exercise from a physiotherapist; treatment/monitoring by an endocrinologist; treatment/monitoring by a cardiologist; clinical physiological examination; radiological examination (X-ray, ultrasound, magnetic resonance). To overcome the logistical complexity of effective management, the concept of a `one-stop clinic’ was developed, firstly in the UK, and has now been taken up by other countries. The idea is that the activities listed above are centralized around the patient. The patient is seen by a consultant and a treatment plan is drawn up for them, based on the clinical investigations, laboratory tests and physiological measurements that are carried out the same day. The patient also sees a vascular nurse, who gives advice on exercise, diet and smoking cessation. Since most PAD patients should be managed medically (at least to begin with), the patient is prescribed platelet inhibitors and statins, according to guidelines. The patient returns to the clinic for follow-up after 1, 3, 6 and 12 months and, at each visit, is given a report to take home, outlining his/her medications and diet, which also includes a record of weight, blood pressure, lipid parameters, ABPI, walking ability, etc., so the patient can monitor how they are progressing. Interventional treatment should only be considered if medical treatment fails, or if the patient is at risk of losing a limb, and should always be carried out in conjunction with medical treatment.
It is likely that, in addition to reducing cardiovascular events and increasing survival rates in PAD patients, medical therapy for CHD prevention will be found to improve the results of peripheral arterial interventions such as PTA and surgery. New interventional technologies will become available, and it is likely that new drug therapies will also be developed. However, greater effort should be made to improve the reporting of treatment results and the quality assurance of treatment, in order that the overall service that is provided to the patient with PAD is as good and as comprehensive as possible. Of greatest importance is that effective treatment is provided for the PAD patient as a whole, and not just for their lower limb symptoms.
Department of Vascular Surgery, KAS Gentofte University of Copenhagen, N. Andersensuej, 2900 Hellerup, Denmark
Correspondence: Dr. H. Sillesen, Department of Vascular Surgery, KAS Gentofte University of Copenhagen, N. Andersensuej, 2900 Hellerup, Denmark. Tel. +45-39-77-3402; fax: +45-39-77-7614
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