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Screen for PAD and Treat as CAD

Screening for peripheral arterial disease (PAD) should be performed routinely in all elderly patients and younger ones with cardiovascular risk factors, and should be aggressively treated just as coronary artery disease (CAD).

The time has come to stop treating patients with peripheral arterial disease as second-class citizens, say the authors of a new study. In getABI, they showed that simple screening of the ankle/brachial index by primary-care doctors can help identify patients with PAD, who have a significantly increased risk of death regardless of whether or not they have symptoms. These patients are also terribly undertreated

Dr Curt Diehm (Affiliated Teaching Hospital, Karlsbad-Langensteinbach, Germany), who reported the results of the German epidemiological study on ankle brachial index (getABI) also found that, those to have PAD should be treated in the same way as patients with coronary artery disease (CAD), he said, stressing that PAD patients are currently undertreated.

GetABI shows that PAD patients have a substantially increased risk of death — dying, on average, 10 years earlier than their peers — and that asymptomatic PAD patients are as much at risk as symptomatic ones, a vital fact that was not previously appreciated, he said. This latter point is very important; "This is the first time, in such a big study, that we have found no difference in mortality between asymptomatic and symptomatic PAD patients. We learned that PAD patients are usually asymptomatic, and we say in the guidelines that symptomatic patients have to be treated in a different way, but now we need to change the guidelines."

It is also imperative that the traditional view of PAD is changed, he said. "It used to be considered a disease of impaired walking distance, quality of life, or of amputation, or just a smoker’s disease — so-called smokers leg," Diehm said. But they found that half of the patients who had PAD had never smoked: "Today we see this disease in a new light."

Mortality Almost Twice as High in PAD Patients: GetABI began in 2001 and included a total of 6,880 unselected patients who underwent ankle brachial index (ABI) testing by their primary care physician in 344 offices. The mean age of the patients was 72.5 years, 46% were past or current smokers, 74% had hypertension, 24% diabetes mellitus and 52% lipid disorders.

Diehm explained that in healthy individuals, the systolic blood pressure at the ankle should be at least as high as the pressure in the arm — ie, ABI should be 1 or greater. An ABI of < 0.9 indicates PAD, and an ABI of < 0.5 indicates severe PAD. In the study, asymptomatic PAD was defined as an ABI of < 0.9 and symptomatic PAD as ABI < 0.9 with intermittent claudication or PAD-related amputation or revascularization.

At the end of the five-year observation period, all-cause mortality was 23.9% in the 596 patients with symptomatic PAD (hazard ratio 1.8; p < 0.001), 19.1% in the 835 patients with asymptomatic PAD (HR 1.6; p < 0.001) and 9.4% in the 5390 patients without PAD. Even after adjusting for all other known cardiovascular risk factors, PAD has the best ability to predict future death, stroke or MI, Diehm said.

ABI: An Important Prognostic Factor — Simple, Quick, and Cost-Effective: Screening for PAD using ABI is very simple, he explained — measurement is quick, taking just eight minutes, the equipment costs only a few hundred dollars and nurses can be trained in its use "within 15 minutes." It is also highly specific for leg artery stenosis (> 50%) and highly sensitive (> 95%), he noted.

Diehm added that in this trial, they used the higher of the two values for blood pressure in the leg, as per the American Heart Association recommendations, "but in our opinion, this is absolutely wrong because you miss distal occlusions." He said if the lower of the two leg values is used, the prevalence of PAD comes out as much higher.

The new results illustrate the feasibility of using ABI in primary care, he says. "The good news is that the ABI test is not limited to expert use but can be performed in general practice. We need to implement ABI as a screening tool in GPs [general practitioners’] offices to identify high-risk patients, and we have to change this very quickly now."

Treat PAD Patients as You Would CAD Patients: Diehm explained that PAD patients are severely undertreated compared with CAD patients. Most PAD patients should be on aspirin or clopidogrel, he said, plus a statin, beta-blocker and angiotensin-converting enzyme inhibitor. Sub-group analyses of large trials such as 4S with a statin, or HOPE-2 with an angiotensin-converting enzyme inhibitor, have shown the benefit of these agents in patients with intermittent claudication, he noted.

Despite this data, "many doctors are still afraid that beta-blockers are contra-indicated in this disease, which is absolute nonsense," Diehm said. Poldermans agreed wholeheartedly. "We have known since 1990 that beta-blockers are not contra-indicated in PAD. We all know that these patients will benefit from medical therapy, but we just don’t do it. We need to keep medical therapy optimized."

Diehm concluded: "Family physicians can identify high-risk patients and initiate and maintain effective treatment in this large group. PAD patients should no longer be treated as second-class atherothrombotic patients — whether you are asymptomatic or symptomatic, you die 10 years early. A huge number of lives could be saved if patients with atherosclerosis would be identified with ABI and treated timely."

Practice Pearls

  • GetABI, a study in which 6880 unselected patients were screened with ABI, showed that 5-year all-cause mortality was 23.9% in the 596 patients with symptomatic PAD (ABI < 0.9 with intermittent claudication or PAD-related amputation or revascularization), 19.1% in the 835 patients with asymptomatic PAD (ABI < 0.9 without symptoms), and 9.4% in the 5390 patients without PAD. After adjustment for all other known cardiovascular risk factors, PAD was the best predictor of future death, stroke, or MI.
  • Screening for PAD with ABI is very simple, quick, inexpensive, and highly specific and sensitive for leg artery stenosis, making it feasible to use in primary care. Patients in whom PAD is detected should be further screened for aortic aneurysms, carotid disease, and CAD and treated aggressively with aspirin or clopidogrel plus a statin, beta-blocker, and angiotensin-converting enzyme inhibitor.

European Society of Cardiology (ESC) World Congress 2007. Presented September 4, 2007.
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