European Journal of Vascular & Endovascular Surgery
Volume 33, Issue 2 , Pages 190-191, February 2007

Secondary Prevention in Patients with Peripheral Arterial Disease: Are We Letting Our Patients Down?

  • R.S. Vohra

      Affiliations

    • Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
    • Corresponding Author InformationCorresponding author.
    • ,
  • M.J. Gough

      Affiliations

    • Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
    • ,
  • S. Homer-Vanniasinkam

      Affiliations

    • Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
    • ,
  • A.I.D. Mavor

      Affiliations

    • Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
    • ,
  • S. Howell

      Affiliations

    • Academic Unit of Anaesthetics, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK

Accepted 12 November 2006. published online 12 December 2006.

Article Outline

 

Patients with symptomatic peripheral arterial disease (PAD) are at increased risk of cardiovascular morbidity and mortality.1 The Reduction of Atherothrombosis for Continued Health (REACH) registry is an international database of 70 000 outpatients with established cardiovascular diseases, of which 8 000 have PAD.2 Nearly 16% of patients in the database had symptomatic disease involving >1 vascular bed.2 The incidence of asymptomatic coronary artery disease is likely to be even higher,3 thus atherosclerosis should be regarded and managed as a systemic disease. Recent guidelines recommend aggressive risk factor modification and cardioprotective therapy (antiplatelet agents, statins, angiotensin-converting enzyme inhibitors (ACEi) and β-blockers) in patients with PAD.4 However, we are not fully utilising opportunities to optimise risk factor management in these patients.

In the REACH registry risk factor profile was consistent across all diseased vascular beds and geographic regions studied, as was the underutilisation of established lifestyle changes and therapies regardless of medical speciality. When medication use was split by speciality, antiplatelets agents were used in 86.4% of patients recruited by vascular surgeons, statins in 62.3%, β-blockers in 34.2% and ACEi in 36.1%. Except the use of antiplatelet agents, the prescription of cardioprotective medication was low when compared to other specialties.

An audit performed in our unit of 99 patients who underwent major non-cardiac vascular surgery (peripheral bypass, carotid endarterectomy and abdominal aortic aneurysm repair) suggests that opportunities for secondary prevention at discharge are also missed. In our cohort prescription rates for antiplatelet agents (87.9%), statins (85.9%), β-blockers (29.3%) and ACEi (42.4%) were similar to those in the REACH registry. Screening for diabetes mellitus and hypercholesterolemia occurred in 78.8% and 61.8% of patients respectively. Non-fasting glucose was elevated in 42.5% of non-diabetic patients and despite treatment 31% had a random total cholesterol >5.0mmol/L (>200mg/dL). These trends are again similar to those found in the REACH registry.

This data indicates that there is a substantial gap between established recommendations and actual practice and opportunities for implementing secondary prevention for PAD patients are missed. In particular there is a reluctance of vascular surgeons to prescribe cardioprotective drugs. This may be due to inexperience with certain classes of drugs, especially ACEi, and historical reasons. One such fallacy is the use of β-blockers in PAD: evidence suggests they do not cause a deterioration in claudication symptoms.5 While the value of perioperative β-blockade in improving outcomes following non-cardiac vascular surgery remains uncertain,6 many patients undergoing vascular surgery will have a primary indication for β-blockade, e.g. previous myocardial infarction.

Another concern is the incidence of renovascular disease in PAD patients. The ‘Heart Outcomes Prevention Evaluation’ (HOPE) investigators found that ramipril significantly reduced the number of cardiovascular events in both symptomatic and asymptomatic PAD patients.7 Once these classes of drugs are prescribed careful monitoring of blood pressure and renal function are required over the following six weeks.8 However the balance of risk and benefit supports the use of these inhibitors in most patients.

These issues highlight the question as to whether vascular surgeons are best placed to instigate such measures for secondary prevention. The role of antiplatelet drugs and statins in secondary prevention is unequivocal and should be started in either the in- or out-patient setting. Further reluctance to institute therapy with certain classes of cardioprotective drugs may reflect concerns in blood pressure that may occur in the perioperative period.

Many of these difficulties would be addressed by establishing multidisciplinary risk factor clinics that could provide aggressive secondary prevention for patients with PAD. They provide lifestyle advice and pharmacological agents to treat the core set of risk factors for cardiovascular disease.9 It is attractive to suggest that these clinics could be run by a nurse specialist who has easy access to vascular disease specialists (cardiologists, neurologists and diabetologists). Further advice, including prescription of β-blockers, might also be available from anaesthetists in pre-admission clinics.

Secondary prevention can be implemented by the family-care physician. In the UK recent national guidelines issued by the Joint British Societies propose definitive care pathways for patients with cardiovascular disease.4 In addition the General Medical Services Contract for family doctors in the UK is in part linked to cardiovascular prevention quality indicators.

In summary, secondary risk factor prevention for patients with PAD is suboptimal at the present time. Clear responsibility for this with an emphasis on a systematic approach encompassing all risk factors is required. Vascular surgeons have numerous opportunities to implement this either themselves, or in a properly organised risk factor clinic. A holistic approach to the management of vascular disease is crucial for patient care.

Back to Article Outline

References 

  1. Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, McCann TJ, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326(6):381–386
  2. Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295(2):180–189
  3. Hertzer NR, Beven EG, Young JR, O'Hara PJ, Ruschhaupt WF, Graor RA, et al. Coronary artery disease in peripheral vascular patients. Ann Surg. 1984;199(2):223–233
  4. Joint British recommendations on prevention of coronary heart disease in clinical practice: summary. BMJ. 2000;320(7236):705–708
  5. Radack K, Deck C. Beta-adrenergic blocker therapy does not worsen intermittent claudication in subjects with peripheral arterial disease. Arch Intern Med. 1991;151(9):1769–1776
  6. Devereaux PJ, Yusuf S, Yang H, Choi PT, Guyatt GH. Are the recommendations to use perioperative beta-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence?. Can Med Assoc J. 2004;171(3):245–247
  7. Ostergren J, Sleight P, Dagenais G, Danisa K, Bosch J, Qilong Y, et al. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J. 2004;25(1):17–24
  8. Hobbs SD, Thomas ME, Bradbury AW. Manipulation of the renin angiotensin system in peripheral arterial disease. Eur J Vasc Endovasc Surg. 2004;28(6):573–582
  9. Youssef F, Gupta P, Mikhailidis DP, Hamilton G. Risk modification in patients with peripheral arterial disease: a retrospective survey. Angiology. 2005;56(3):279–287

PII: S1078-5884(06)00648-4

doi:10.1016/j.ejvs.2006.11.007

European Journal of Vascular & Endovascular Surgery
Volume 33, Issue 2 , Pages 190-191, February 2007

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