Problems in management of patients with PAOD

K.Roztocil

IKEM, Prague

18 Eurochap Congress of the IUA and XIX Congress of the MLAVS,

Palermo, October 24-27, 2009

Questions

• Current situation in management of patients with PAD

• Less intensive treatment of risk factors in patients with PAD

• Need of improved awareness, detection and treatment of PAD

• On-going programm of the Czech Soc. of Angiology

Current situation :

• Cca 10.000 patients with PAD in a population of 100.000 inhabitants either symptomatic (in 1/3) or asymptomatic (in 2/3 of cases)

• Symptomatic patients managed by : • vascular surgeons• interventional radiologists• vascular physicians-angiologists • event. other medical branches• Asymptomatic patients : in last year increased attention by

• angiologists• primary care physicians

Revascularization proceduresduring last 3 decades enormous increase of numbers

J.Vasc.Surg 2009, 50, 54-60

Increase of revascularization

• Registry of open vascular surgery and endovascular interventions : in CZ altogether cca 200 per 100.000 inhabitants ( in 2008: surgery 47, endovascular 150)

• Increasing number of revascularization represents only small portion of overall patients with PAD

• up to 98% of patients expected in population obtained non-surgical or non-interventional therapy or no therapy because of missed diagnosis

Vascular specialists care :

Discrepancy :• While surgical vascular service (for 2% of

patients) is more or less created, with increasing numbers of revascularizations, there is insufficiency of vascular internists care (for 98% of patients)

Insufficient angiology-vascular medicine :

• Angiology-vascular medicine started to establish with a delay in comparison with other specialities

• in limited number of countries• Developing branch of internal medicine• Vascular internists network not fully created,

neither in countries with recognized angiology

Concept of angiology/vascular medicine in the CZ

• Structure of angiological care :• 1. Outpatients angiological settings –

expected 2-4 per 100.000 inhabitants (at present less than 1)

• 2. Angiological centres – University Teaching Hospitals, Regional hosp.

• Expected 1-2 centers per 1 milion of inhabitants – (10-20) at present 8 centres

Centres of angiology

• recommended to be preferably organized as an independent part of cardiovascular centres localized at University hospitals, composed from

• 1. Dept. of cardiology• 2. Dept of cardiosurgery • 3. Dept. of angiology• 4. Dept. of angiosurgery (+ Dept. of interv. radiology where endovascular

interventions are not performed by angiologists)

Specialized centres of angiology

• Composed from : out-patients clinic, nonivasive investigation lab, percutaneous interventions, standard beds and intensive care unit for angiological patients

• At least 3 angiologists• Specialized care, interdisciplinary cooperation in most

serious conditions• Aside of this :• Acreditation for postgraduate education in angiology• Leading role in ongoing and future preventive

cardiovascular programms

Current strategy in management of patients with PAD

Based on recommendations formulated by • 1. Transatlantic Inter-Society Consensus for the

management of PAD • J.Vasc.Surg. 45, S1-S68, 2007• 2. ACC/AHA Guidelines (JACC 2006)• 3. 8th ACCP Conference (Chest 2008) • 4. CEVF Consensus on Intermittent Claudication

(Intern.Angiol. 2008)

TASC II statement:

• Patients with PAD must be approached with the same intensity for secondary prevention and risk factor modification as recommended for patients with CAD or carotid artery disease.

„You are non-smoker….hm….what a pitty, because in the case of smoking it would be helpful for you to stop.“

SMOKING IS THE MOST IMPORTANT

Modification of atherosclerotic risk factors

• Typically multiple risk factors in patients with PAD :

• It needs approach on multiple levels - smoking cessation, physical activity, dietary modification, weight reduction or maintenance, blood pressure control, elevated LDL cholesterol levels, antiplatelet drugs, glycemic control in diabetics

Pharmacotherapy of risk factors

• cholesterol-lowering

• anti-platelets

• ACEi

• ca-inhibitors

Pharmacotherapy of risk factors in patients with PAD and CAD

• Mc Dermott et al.: Atheroclerotic risk factors are less intensively treated in patients with peripheral arterial disase

• J.Gen.Intern.Med. 1997, 12, 209-215

Comparison of patients with PAD and CAD

• 349 patients with PAD or CAD interviewed

• CAD PAD

• Cholesterol lower. drugs 58% 46%

• Aspirin 81% 49%

Antiplatelet treatment in getABI

• CAD or CVD diabetics 75%

• CAD or CVD non-diabetics 72.8%

• PAD diabetics 57.4%

• PAD non-diabetics 54.4%

• PAD + CAD or CVD diabetics 81.8%

• PAD + CAD or CVD nondiabetics 80.7%• Lange S. et al. Diabetes Care 2003, 26, 3357-8

PARTNERS Study

• PAD CAD

• Lipid control 44% 73%

• Antiplatelet therapy 33% 71%

• Antihypertensive 88% 95%

• Hirsch A.T. et al. JAMA 2007

Registry REACH (reduction of atherothr.for continued health)

• 68000 patients with atheroscl., 8322 PAD• Comparison of RF control in CHD and

PAD significantly worse in PAD (blood pressure, glycemia, cholesterol, smoking )

• Statins 50% - 76%• ASA 76% - 84%• ACE 33% - 50% • Cacoub P. et al. Atherosclerosis 2008

Long-term prognosis in patients with CAD and PAD

• Welten et al. 2007• 2730 PAD pacients with compared with

2730 symptom. CAD• 10-years survival in patients with PAD 2.4

times worse than in patients with CAD• Patients with PAD less treated by

antiplatelets, ACE-inhibitors, betablockers, statins

60%

Call to action Paper

International initiative : A International initiative : A Call to Action Call to Action

Belch JJF et al. Arch Intern Med 2003; 163: 884-892.

Jill J.F. BelchEric J.TopolGiancarlo AgnelliMichel BertrandRobert M.CallifDenis L.ClementMark A.CraegerDonald EastonJames R.GavinPhilip GreenlandGraeme HankeyPeter HanrathAlan T.HirschJürgen MayerSidney c.SmithFrank SullivanMichael Weber

Call to action : Main items of the document

• 1) to increase awareness of PAD and its consequences

• 2) improve the identification of patients with symptomatic and asymptomatic PAD

• 3) screening of high risk patients• 4) improve treatment of patients with

PAD• 5) early detection of asymptomatic cases

Rationale for creation of a national PAD initiatives

• High prevalence of PAD• High mortality (2-4-fold)• Nonfatal CV events (3-5-fold)• Quality of life • Patient awareness of PAD is low (less than 50%)• Physicians awareness is low (less than 1/3)• Detection of PAD is relatively simple (ABI)• Treatment is underused (pharmacotherapy of RF)

Programm of the Czech Soc. of Angiol. for patients with PAD

An answer at the national level to the Call to action document

• 1. step : education activities among vascular specialists (clinical significance of PAD, early detection of atherosclerosis)

Programm of the Czech Soc. of Angiol. for patients with PAD

• 2. step : education activities in cooperation with Society of GP

• Regional meetings

• Demonstration of ABI measurement followed by a training

• Created group of 270 first line doctors for the ongoing 3. step – Programm MOET PAD

Programm MOET PAD

• 3. step – Monitoring of effective therapy in patients with PAD

• 270 primary care physicians

• 3733 patients with PAD included and followed 1 year

• 48% newly diagnosed

Aims of programm MOET PAD:

• Increased awareness of PAD and its clinical significance

• Improved diagnosis, detection of asymptomatic

• Increase number of treated

• Preliminary analysis of results in 1240 patiens

Antiplatelet therapy

Statiny

Cholesterol

CCH interval (mmol/l) 1.visit 3 m visit 6 m visit 9 m visit 12 m visit

mean 6,1 5,4 5,2 5,1 4,9

do 4,5 6,9% 16,1% 17,8% 21,2% 31,1%

4,5-5,5 23,2% 37,4% 48,5% 48,4% 45,8%

5,5-6,5 34,5% 32,3% 26,3% 24,9% 19,9%

6,5-7,5 24,9% 11,2% 6,6% 4,9% 2,6%

>7,5 10,6% 3,0% 0,8% 0,7% 0,6%

(N) 1193 1000 848 676 502

LDL cholesterol

LDL interval (mmol/l) 1 visit 3 m visit 6 m visit 9 m visit 12 mvisit

mean 3,5 3,0 2,8 2,7 2,6

do 2,5 17,0% 29,2% 35,3% 38,3% 44,6%

2,5-3,5 31,7% 43,7% 45,2% 46,5% 45,0%

3,5-4,5 34,1% 20,8% 16,5% 12,1% 9,0%

>4,5 17,2% 6,3% 3,0% 3,1% 1,4%

HDL cholesterol

HDL interval (mmol/l) 1visit 3 m 6 m 9 m 12 m

mean 1,3 1,4 1,4 1,4 1,5

do 1 18,9% 9,3% 8,2% 7,0% 4,6%

1-1,2 27,0% 21,1% 20,0% 16,6% 11,2%

1,2-1,5 26,8% 38,6% 40,9% 38,5% 44,2%

1,5-2 20,6% 23,9% 25,4% 31,0% 33,1%

>2 6,7% 7,0% 5,6% 6,9% 7,0%

Trends in blood pressure control

CONCLUSION 1. While vascular and endovascular surgery is rather well

created with continously increasing numbers of revascularization, there is insufficiency of angiologists care, which is necessary for majority of vascular patients 2. Secondary prevention and pharmacotherapy of risk factors in patients with PAD is at present less intensive than in patients with CAD and CVD and it is related to worse prognosis of persons with PAD

3. It is generally accepted that there is a need of improved awareness, detection and treatment of patients with PAD.

4. National programm initiated in the CZ aimed at better risk factors control in patients with PAD was presented with promising preliminary findings.

Thank you for your attention