Suboptimal use of risk reduction therapy in peripheral arterial disease patients at a major teaching hospital
2011; King Faisal Specialist Hospital and Research Centre; Volume: 31; Issue: 4 Linguagem: Inglês
10.4103/0256-4947.83219
ISSN0975-4466
AutoresMohammed Al‐Omran, Subodh Verma, Thomas F. Lindsay,
Tópico(s)Health Systems, Economic Evaluations, Quality of Life
Resumooriginal articleSuboptimal use of risk reduction therapy in peripheral arterial disease patients at a major teaching hospital Mohammed Al-Omran, Subodh Verma, and Thomas F. Lindsay Mohammed Al-Omran the Li Ka Shing Knowledge Institute-King Saud University Colloborative Program, St. Michael's Hospital, University of Toronto , Subodh Verma Department of Surgery, Peripheral Vascular Disease Research Chair, King Saud University, Riyadh, Saudi Arabia , and Thomas F. Lindsay From the Division of Vascular Surgery, Toronto General Hospital, University of Toronto Published Online:4 Aug 2011https://doi.org/10.4103/0256-4947.83219SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractBACKGROUND AND OBJECTIVES: Current evidence suggests that modification of atherosclerosis risk factors plays an important role in reducing adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD). This study was undertaken to determine whether patients in this high-risk group were adequately using risk factor modification therapy.DESIGN AND SETTING: Prospective study of consecutive patients with PAD from a teaching hospital.PATIENTS AND METHODS: The collected data included information about atherosclerotic risk factors and utilization of risk factor modification therapyRESULTS: The 391 patients had a mean (standard deviation of 3 (1) atherosclerotic risk factors. Hypertension was identified in 56.8% of patients (222/391), of whom only 37.4% (83/222) had adequate blood pressure control (BP <140/90 mm Hg). The prevalence of diabetes mellitus (DM) was 35 % (137/391). Among patients with DM, only 49% (67/137) had adequate blood glucose control (glycosylated hemoglobin, HbA1c 2.5 mmol/L, compared to a rate of 76.5% (117/153) among non-statin users (P<.001). The majority of patients of patients ( 72.4%; 283/391) were overweight/obese. Many patients (67.3%; 263/391) were nonsmokers; however, most (73.4%; 193/263) had a history of smoking. Antiplatelets were prescribed for 78.3% of patients (306/391), of whom 70.6% (216/306) were taking aspirin. Angiotensin converting enzyme (ACE) inhibitors were prescribed for 44.8% of patients (175/391). Among rampril users, only 36.8% of patients (53/144) were on an optimal dose.CONCLUSION: Although atherosclerotic risk factors were prevalent in patients with PAD, we found that patients received sub-optimal use of risk reduction treatments. Effective strategies to encourage health professionals to use these adjunctive therapies need to be developed.IntroductionPeripheral arterial disease (PAD) is a marker for severe systemic atherosclerosis. Patients with PAD have widespread arterial disease and, therefore, are at a significantly increased risk of stroke, myocardial infarction (MI), and cardiovascular death.1 The prevalence of coronary artery disease (CAD) and cerebrovascular disease (CVD) in these patients can reach 92% and 50%, respectively.2,3 CAD is the most common cause of death in PAD patients, accounting for 40% to 60% of deaths, while stroke accounts for 10% to 20% of deaths.1 Furthermore, patients with PAD have a sixfold-increased risk of cardiovascular disease mortality compared to patients without PAD.4The risk factors for PAD are the same as those for atherosclerosis in general and include gender predilection (males at greater risk), advanced age, cigarette smoking, hypertension, diabetes mellitus, and hyperlipidemia.5 Atherosclerotic risk factor identification and modification plays an important role in reducing the number of adverse outcomes among patients with atherosclerosis. Risk reduction therapy decreases the risk of cardiovascular mortality and morbidity in patients with PAD,6–11 and is comprised of methods such as smoking cessation, blood sugar control, blood pressure control, and medical intervention by antiplatelets, statins, and angiotensin-converting enzyme (ACE) inhibitors. Because of the efficacy of these techniques, several expert committees have recommended their use in patients with PAD.12–14 Despite this, several studies have documented the underuse of risk reduction therapies in patients with PAD.15–23The aim of this study was to explore the extent to which risk factors were managed, in accordance with the current recommendations of the American Heart Association and American College of Cardiology (AHA/ACC) for patients with PAD, which are highlighted in Table 1.12,14Table 1 Current recommendations of the American Heart Association and American College of Cardiology (AHA/ACC) for risk reduction in patients with peripheral arterial disease12,14Table 1 Current recommendations of the American Heart Association and American College of Cardiology (AHA/ACC) for risk reduction in patients with peripheral arterial disease12,14PATIENTS AND METHODSWe prospectively collected data on the atherosclerotic risk factors and risk reduction therapies on consecutive PAD patients who were referred to the vascular surgery outpatient clinic at Toronto General Hospital, Toronto, Canada, between July 2004 and July 2006. This study was approved by the University Health Network Ethics Review Board in Toronto. Patients were defined as having PAD if they had previously undergone lower limb revascularization (bypass surgery and/or percutaneous transluminal angioplasty [PTA]) or a lower limb amputation for lower limb ischemia, or had received a clinical diagnosis of intermittent claudication, ischemic rest pain, or tissue loss in conjunction with ankle brachial index (ABI) 7 mmol/L when measured on two separate occasions), hypertension (defined as systolic blood pressure [BP] >140 mm Hg and/or diastolic BP >90 mm Hg), hyperlipidemia (defined as a low-density lipoprotein cholesterol level (LDL-C) >2.5 mmol/L and/or triglyceride levels (TG) >1.7 mmol/L), and being overweight (defined as having a body mass index [BMI] >25 kg/m2) or obese (BMI >30 kg/m2). In addition, HbA1c was measured in diabetic patients to assess whether they had achieved optimal control for diabetes. We also investigated the use of the following risk reduction pharmacotherapies: antiplatelet medications (e.g., aspirin and clopidegrol), statins, ACE inhibitors, oral hypoglycemic medications, insulin, and antihypertensive medications. Finally, we noted whether patients had any co-morbidities, such as a history of coronary artery disease (CAD), cerebrovascular disease (CVD), and any other major diseases.Values were expressed as frequencies and percentages, for categorical variables, and as means and standard deviations (SD), for continuous variables. Chi-square tests t tests were used, where appropriate, to make comparisons between groups. All reported P values are two tailed. Significance was defined as P<.05.RESULTSData was collected on 391 PAD patients. Baseline characteristics are shown in Table 2. The mean (SD) number of atherosclerotic risk factors was 3 (1). Hypercholesterolemia was diagnosed in 29.7% (116/391) patients, and hypertriglyceridemia in 40% (157/391) patients. Overall, patients did not adequately control their atherosclerotic risk factors (Table 3). Of the 56.8% (222/391) of patients with hypertension, only 37.4% (83/222) had adequate blood pressure control (e.g., had BP 140/90 mm Hg, as measured on two separate occasions at the clinic. Therefore, 64.7% of patients (253/391) either had inadequately-controlled (35.5%) or undiagnosed (29.2%) hypertension.Table 2 Baseline characteristics of peripheral arterial disease patients (n=391).Table 2 Baseline characteristics of peripheral arterial disease patients (n=391).Table 3 Achievement of the current recommendations of the American Heart Association and American College of Cardiology (AHA/ACC) for control of atherosclerotic factors in patients with peripheral arterial disease in the study.Table 3 Achievement of the current recommendations of the American Heart Association and American College of Cardiology (AHA/ACC) for control of atherosclerotic factors in patients with peripheral arterial disease in the study.The prevalence of DM was 35% (137/391). Of the affected patients, only 49% (67/137) had properly controlled blood sugar (HbA1c 6 mmol/L). Statins were currently prescribed in 61% (238/391) of patients. Despite this, 38.7% of statin-users continued to have LDL >2.5 mmol/L. Among non-statin users, this rate was even higher (76.5%; P<.001). Mean LDL level was significantly lower in statin users (2.31 [0.90] mmol/L) than in non-statin users (2.92 [0.96] mmol) (P<.01). The majority of patients (72.4%; 283/391) were either overweight (64.3%, 182/283; BMI 25-29.9 kg/m2) or obese (35.7%, 101/283; BMI >29.9 kg/m2). Although many patients (67.3%; 263/391) were nonsmokers, 73.4% (193/263) of these individuals were former smokers.Antiplatelets were prescribed for 78.3% (306/391) of patients, of whom 70.6% (216/306) were taking aspirin, 15.3% (47/306) were taking clopidogrel, 8.8% (27/306) were taking a combination of aspirin and clopidegrol, and 5.2% (16/306) were taking other agents. ACE inhibitors were prescribed for 44.8% (175/391) of patients, of whom 82.3% (144/175) were on ramipril. However, only 36.8% (53/144) of ramipril users were taking the optimal dose of 10 mg/day.9DISCUSSIONData was collected prospectively on 391 patients who were referred to a vascular surgery outpatient clinic at a tertiary care hospital. Based on the results of our analyses, we have suggested strategies to further increase the use of risk factor managing strategies.Atherosclerosis is the leading cause of death worldwide.24 PAD is a marker of advanced atherosclerosis and indicates an elevated risk of cardiovascular mortality and morbidity comparable to patients with coronary artery disease (CAD).25 Thus, intensive risk reduction therapy is critical in PAD patients. Therapeutic methods include blood pressure control and risk reduction pharmacotherapy (antiplatelets, statins, and ACE inhibitors), which have been proven to reduce the risk of cardiovascular mortality and morbidity of PAD patients in large-scale randomized clinical trials.9,11,26 Large observational studies have also shown that smoking cessation and blood sugar control help reduce adverse cardiovascular outcomes in patients with atherosclerosis.6–8 Based on this evidence, several expert cardiovascular panels, including the AHA/ACC and the Canadian Cardiovascular Society, have recommended the use of intensive risk factor control in PAD patients (Table 1).12–14 We found that many patients were not treated with optimal risk reduction therapy methods, and that, as a result, risk factors were inadequately controlled and risk factor goals were not achieved. For instance, we noted a deficiency in prescription of risk reduction pharmacotherapies.Our study is not the first to provide data that support a care gap in managing patients with PAD (Table 4). The inequities in the use of risk reduction therapies between patients with PAD and those with CAD in which the risk reduction should be similar have been well documented in the literature.27 We hope that these data will be useful in supporting a call-to-action for PAD management and public awareness.27 There are several possible explanations for our findings. First, the association of PAD and CAD is usually unrecognized by both patients and primary care physicians,28 and a significant number of patients with PAD may not have symptoms related to their CAD.15 Second, there may be gaps between what physicians know they should do, and what they actually do, to manage risk factors in patients with PAD.29–31 Third, there may be a reluctance to apply CAD guidelines to the PAD patient population even though the risks are similar, if not higher.Table 4 Comparison of compliance with risk factor control recommendations among patients in the current study and previously-published studies.Table 4 Comparison of compliance with risk factor control recommendations among patients in the current study and previously-published studies.We admit that this study had some limitations. First, a relatively small number of participants were included in this study. Second, this study reflects the techniques of physicians in one geographic area and therefore may not be generalizable to other locations. However, the validity of these results is strengthened by the prospective nature of our data collection methods.In conclusion, there is a high prevalence of atherosclerotic risk factors in patients with PAD. However, these individuals are receiving inadequate risk factor management therapies, and/or are not meeting risk factor control goals even when they are receiving treatment. In order to address this care gap, it is vital to develop effective strategies to encourage health professionals to comply with the current guidelines for cardiovascular risk reduction in PAD patients. These may include methods such as self-audit of practice, focused continuing medical education programs, and educational outreach programs.ARTICLE REFERENCES:1. "The TASC Working Group. Management of Peripheral Arterial Disease (PAD); Trans Atlantic Inter-Society Consensus (TASC)" . J Vasc Surg. 2001; 31:S1-288. Google Scholar2. Hertzer NR. "Clinical experience with preoperative coronary angiography" . J Vasc Surg. 1985; 2:510-4. Google Scholar3. In: Alexandrova NA, Gibson WC, Norris JW, Maggisano R. "Carotid artery stenosis in peripheral vascular disease" . J Vasc Surg. 1996; 23:645-9. Google Scholar4. In: 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; 326:381-6. Google Scholar5. In: Fowkes FG, Housley E, Riemersma RA, Macintyre CC, Cawood EH, Prescott RJ , et al.. "Smoking, lipids, glucose intolerance, and blood pressure as risk factors for peripheral atherosclerosis compared with ischemic heart disease in the Edinburgh Artery Study" . Am J Epidemiol. 1992; 135:331-40. Google Scholar6. In: Lu JT, Creager MA. "The relationship of cigarette smoking to peripheral arterial disease" . Rev Cardiovasc Med. 2004; 5:189-93. Google Scholar7. In: Willigendael EM, Teijink JA, Bartelink ML, Kuiken BW, Boiten J, Moll FL , et al.. "Influence of smoking on incidence and prevalence of peripheral arterial disease" . J Vasc Surg. 2004; 40:1158-65. Google Scholar8. In: Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA , et al.. "Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study" . BMJ. 2000; 321:405-12. Google Scholar9. In: Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. "Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators" . N Engl J Med. 2000; 342:145-53. Google Scholar10. "Heart Protection Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: A randomised placebo-controlled trial" . Lancet. 2002; 360:7-22. Google Scholar11. "Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients" . BMJ. 2002; 324:71-86. Google Scholar12. In: Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL , et al.. "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation" . Circulation. 2006; 113:e463-654. Google Scholar13. In: Abramson BL, Huckell V, Anand S, Forbes T, Gupta A, Harris K , et al.. "Canadian Cardiovascular Society Consensus Conference: Peripheral arterial disease - executive summary" . Can J Cardiol. 2005; 21:997-1006. Google Scholar14. In: Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC , et al.. "AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute" . Circulation. 2006; 113:2363-72. Google Scholar15. In: Kinikini D, Sarfati MR, Mueller MT, Kraiss LW. "Meeting AHA/ACC secondary prevention goals in a vascular surgery practice: An opportunity we cannot afford to miss" . J Vasc Surg. 2006; 43:781-7. Google Scholar16. In: Hackam DG, Tan MK, Lin PJ, Mehta PG, Jaffer S, Kates M , et al.. "Supporting a call to action for peripheral artery disease: insights from two prospective clinical registries" . J Vasc Surg. 2006; 44:776-81. Google Scholar17. In: Anand SS, Kundi A, Eikelboom J, Yusuf S. "Low rates of preventive practices in patients with peripheral vascular disease" . Can J Cardiol. 1999; 15:1259-63. Google Scholar18. In: Brown LC, Johnson JA, Majumdar SR, Tsuyuki RT, McAlister FA. "Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis" . CMAJ. 2004; 171:1189-92. Google Scholar19. In: Gen TL, Sieunarine K, Eikelboom J, Prendergast FJ, Goodman MA, Joesbury K , et al.. "Suboptimal preventive practices in patients with carotid and peripheral vascular occlusive disease in a tertiary referral setting" . ANZ J Surg. 2003; 73:932-7. Google Scholar20. In: Rehring TF, Sandhoff BG, Stolcpart RS, Merenich JA, Hollis HW. "Atherosclerotic risk factor control in patients with peripheral arterial disease" . J Vasc Surg. 2005; 41:816-22. Google Scholar21. In: Sukhija R, Yalamanchili K, Aronow WS, Kakar P, Babu S. "Clinical characteristics, risk factors, and medical treatment of 561 patients with peripheral arterial disease followed in an academic vascular surgery clinic" . Cardiol Rev. 2005; 13:108-10. Google Scholar22. In: Bradley L, Kirker SG. "Secondary prevention of arteriosclerosis in lower limb vascular amputees: A missed opportunity" . Eur J Vasc Endovasc Surg. 2006; 32:491-3. Google Scholar23. In: Mukherjee D, Lingam P, Chetcuti S, Grossman PM, Moscucci M, Luciano AE , et al.. "Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: Insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-QI2)" . Circulation. 2002; 106:1909-12. Google Scholar24. "World Health Organization" . The world health report 2004Last Accessed on 2006 Aug 25Available from: http://www.who.int/features/qa/18/en. Google Scholar25. "CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee" . Lancet. 1996; 348:1329-39. Google Scholar26. In: Psaty BM, Smith NL, Siscovick DS, Koepsell TD, Weiss NS, Heckbert SR , et al.. "Health outcomes associated with antihypertensive therapies used as first-line agents.A systematic review and meta-analysis" . JAMA. 1997; 277:739-45. Google Scholar27. In: Hirsch AT, Gloviczki P, Drooz A, Lovell M, Creager MA. "Mandate for creation of a national peripheral arterial disease public awareness program: an opportunity to improve cardiovascular health" . J Vasc Surg. 2004; 39:474-81. Google Scholar28. In: Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW , et al.. "Peripheral arterial disease detection, awareness, and treatment in primary care" . JAMA. 2001; 286:1317-24. Google Scholar29. In: Al Omran M, Lindsay TF, Major J, Jawas A, Leiter LA, Verma S. "Perceptions of Canadian Vascular Surgeons toward Pharmacological Risk Reduction in Patients with Peripheral Arterial Disease" . Ann Vasc Surg. 2006; 20:555-63. Google Scholar30. In: McDermott MM, Hahn EA, Greenland P, Cella D, Ockene JK, Brogan D , et al.. "Atherosclerotic risk factor reduction in peripheral arterial disease: Results of a national physician survey" . J Gen Intern Med. 2002; 17:895-904. Google Scholar31. In: Cassar K, Belch JJ, Brittenden J. "Are national cardiac guidelines being applied by vascular surgeons?" Eur J Vasc Endovasc Surg. 2003; 26:623-8. 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