Peripheral arterial disease (PAD) is underdiagnosed and undertreated. This is despite the high vascular morbidity and mortality rates associated with PAD. There is also evidence that quitting smoking, improving the lipid profile, lowering the blood pressure, and administering antiplatelet drugs reduce the risk of vascular events in these patients. Secondary prevention for patients with PAD is yet to meet the standard of care for those with ischemic heart disease. The authors surveyed 200 claudicants attending a vascular clinic with additional follow-up in a risk modification clinic. After a median follow-up of 28 months (range: 6-65) there was a significant (p=0.001) improvement in walking distance; 34 patients (17%) had a vascular ischemic event. Of those, 11 patients (5.5%) had worsening intermittent claudication and 9 had a stroke/transient ischemic attack; 9 events (4.5%) were fatal. The lipid targets were met in 76% the patients. Half the smokers quit smoking and 94% of the patients were taking antiplatelet drugs or anticoagulants. Blood pressure reached the accepted target in 87% of the patients. Secondary prevention in patients with PAD may reduce the risk of vascular events. Aggressive risk modification is therefore recommended.
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References
1.
Donnelly R, Yeung JM: Management of intermittent claudication: The importance of secondary prevention. Eur J Vasc Endovasc Surg23:100-107, 2002.
2.
Robinson JG, Boland LL, McGovern PG, et al: A comparison of NCEP and absolute risk stratification methods for lipid-lowering therapy in middle-aged adults: The ARIC Study. The ARIC Investigators. Prev Cardiol4:148-157, 2001.
3.
McLafferty RB, Dunnington GL, Mattos MA, et al: Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral. J Vasc Surg31:870-879, 2000.
4.
Dieter RS, Chu WW, Pacanowski JP Jr, et al: The significance of lower extremity peripheral arterial disease. Clin Cardiol25:3-10, 2002.
5.
Leng GC, Papacosta O, Whincup P, et al: Femoral atherosclerosis in an older British population: Prevalence and risk factors. Atherosclerosis152:167-174, 2000.
6.
Karnegis JN, Matts JP, Tuna N, et al: Correlation of coronary with peripheral arterial stenosis. The POSCH Group. Atherosclerosis92:25-30, 1992.
7.
Hirsch AT, Hiatt WR, and the PARTNERS Steering Committee: PAD awareness, risk, and treatment: New resources for survival—the USA PARTNERS program. Vasc Med6:9-12, 2001.
8.
Burns P, Lima E, Bradbury AW: Second best medical therapy. Eur J Vasc Endovasc Surg24:400-404, 2002.
9.
Dawson DL, Hiatt WR, Creager MA, et al: Peripheral arterial disease: Medical care and prevention of complications. Prev Cardiol5:119-130, 2002.
10.
Hirsch AT, Treat-Jacobson D, Lando HA, et al: The role of tobacco cessation, antiplatelet and lipid-lowering therapies in the treatment of peripheral arterial disease. Vasc Med2:243-251, 1997.
11.
Luther M, Lepantalo M, Alback A, et al: Amputation rates as a measure of vascular surgical results. Br J Surg83:241-244, 1996.
12.
Endean ED, Sloan DA, Veldenz HC, et al: Performance of the vascular physical examination by residents and medical students. J Vasc Surg19:149-154, 1994.
13.
McKenna M, Wolfson S, Kuller L: The ratio of ankle and arm arterial pressure as an independent predictor of mortality. Atherosclerosis87:119-128, 1991.
14.
Gardner AW, Poehlman ET: Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA274:975-980, 1995.
15.
Izquierdo-Porrera AM, Gardner AW, Powell CC, et al: Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease. J Vasc Surg31:670-677, 2000.
16.
Treat-Jacobson D, Walsh ME: Treating patients with peripheral arterial disease and claudication. J Vasc Nurs21:5-14, 2003.
17.
Goldhaber SZ, Manson JE, Stampfer MJ, et al: Low-dose aspirin and subsequent peripheral arterial surgery in the Physicians’ Health Study. Lancet340:143-145, 1992.
18.
Robless P, Mikhailidis DP, Stansby G: Systematic review of antiplatelet therapy for the prevention of myocardial infarction, stroke or vascular death in patients with peripheral vascular disease. Br J Surg88:787-800, 2001.
19.
Antithrombotic Trialists’ Collaboration: Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ324:71-86, 2002.
20.
Schillinger M, Exner M, Mlekusch W, et al: Statin therapy improves cardiovascular outcome of patients with peripheral artery disease. Eur Heart J25:742-748, 2004.
21.
Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: A randomised placebo-controlled trial. Lancet360:7-22, 2002.
22.
Aronow WS, Ahn C: Frequency of new coronary events in older persons with peripheral arterial disease and serum low-density lipoprotein cholesterol ≥ 125 mg/dL treated with statins versus no lipid-lowering drug. Am J Cardiol90:789-791, 2002.
23.
Pedersen TR, Wilhelmsen L, Faergeman O, et al: Follow-up study of patients randomized in the Scandinavian Simvastatin Survival Study (4S) of cholesterol lowering. Am J Cardiol86:257-262, 2000.
24.
Mohler ER, Hiatt WR, Creager MA: Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. Circulation108:1481-1486, 2003.
25.
McDermott MM, Mehta S, Ahn H, et al: Atherosclerotic risk factors are less intensively treated in patients with peripheral arterial disease than in patients with coronary artery disease. J Gen Intern Med12:209-215, 1997.
26.
Youssef F, Seifalian AM, Jagroop IA, et al: The early effect of lipid-lowering treatment on carotid and femoral intima media thickness (IMT). Eur J Vasc Endovasc Surg23:358-364, 2002.
27.
Dupuis J, Tardif JC, Cernacek P, et al: Cholesterol reduction rapidly improves endothelial function after acute coronary syndromes. The RECIFE (reduction of cholesterol in ischaemia and function of the endothelium) trial. Circulation99:3227-3233, 1999.
28.
Ubels FL, Muntinga JH, van Doormaal JJ, et al: Effects of initial and long-term lipid-lowering therapy on vascular wall characteristics. Atherosclerosis154:155-161, 2001.
29.
Meade T, Zuhrie R, Cook C, et al: Bezafibrate in men with lower extremity arterial disease: Randomised controlled trial. BMJ325:1139-1143, 2002.
30.
Adler AI, Stevensen RJ, Neil A, et al: UKPDS 59: Hyperglycaemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes. Diabetes Care25:994-999, 2002.
31.
Daskalopoulou SS, Mikhailidis DP, Elisaf M: Prevention and treatment of the metabolic syndrome. Angiology20:1835-1838, 2004.
32.
Murabito JM, D’Agostino RB, Silbershatz H, et al: Intermittent claudication. A risk profile from The Framingham Heart Study. Circulation96:44-49, 1997.
33.
PROGRESS Collaborative Group: Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet358:1033-1041, 2001.
34.
Lindholm LH, Ibsen H, Dahlof B, et al: The LIFE Study Group. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): A randomised trial against atenolol. Lancet359:1004-1010, 2002.
35.
Varnauskas E: Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med319:332-337, 1988.
36.
Elam MB, Hunninghake DB, Davis KB, et al: Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: The ADMIT study: A randomized trial. Arterial Disease Multiple Intervention Trial. JAMA284:1263-1270, 2000.
37.
Garg R, Elam MB, Crouse JR III, et al: Effective and safe modification of multiple atherosclerotic risk factors in patients with peripheral arterial disease. Am Heart J140:792-803, 2000.
Wood D, Durrington P, Poulter N, et al: Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart80(suppl 2):S1-S52, 1998.
40.
Kaplan R, Heckbert S, Furberg C, et al: Predictors of subsequent coronary events, stroke, and death among survivors of first hospitalized myocardial infarction. J Clin Epidemiol55:654-664, 2002.
41.
Bowlin SJ, Medalie JH, Flocke SA, et al: Intermittent claudication in 8,343 men and 21-year specific mortality follow-up. Ann Epidemiol7:180-187, 1997.
Vogt MT, McKenna M, Anderson SJ, et al: The relationship between ankle-arm index and mortality in older men and women. J Am Geriatr Soc41:523-530, 1993.
44.
McDermott MM, Greenland P, Liu K, et al: Leg symptoms in peripheral arterial disease: Associated clinical characteristics and functional impairment. JAMA286:1599-1606, 2001.
45.
Nicoloff AD, Taylor LM Jr, Sexton GJ, et al: Homocysteine and Progression of Atherosclerosis Study Investigators. Relationship between site of initial symptoms and subsequent progression of disease in a prospective study of atherosclerosis progression in patients receiving long-term treatment for symptomatic peripheral arterial disease. J Vasc Surg35:38-46, 2002.
46.
Wilt TJ, Davis BR, Meyers DG, et al: Prevalence and correlates of symptomatic peripheral atherosclerosis in individuals with coronary heart disease and cholesterol levels less than 240 mg/dL: Baseline results from the Cholesterol and Recurrent Events (CARE) Study. Angiology47:533-541, 1996.
47.
Mukherjee D, Lingam P, Chetcuti S, 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). Circulation106:1909-1912, 2002.
48.
Buchwald H, Bourdages HR, Campos CT, et al: Impact of cholesterol reduction on peripheral arterial disease in the Program on the Surgical Control of the Hyperlipidemias (POSCH). Surgery120:672-679, 1996.
49.
The UK HDL-C Consensus group: Role of fibrates in reducing coronary risk: A UK consensus. Curr Med Res Opin20:241-247, 2004.
50.
Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA285:2486-2497, 2001.
51.
Elisaf M, Mikhailidis DP: Statins and renal function. Angiology53:493-502, 2002.
52.
Youssef F, Gupta P, Seifalian AM, et al: The effect of short-term treatment with simvastatin on renal function in patients with peripheral arterial disease. Angiology55:53-62, 2004.
53.
Athyros VG, Elisaf M, Papageorgiou AA, et al, and the GREACE Study Collaborative Group: Effect of statins versus untreated dyslipidemia on serum uric acid levels in patients with coronary heart disease: A subgroup analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study. Am J Kidney Dis43:589-599, 2004.
54.
Athyros VG, Mikhailidis DP, Papageorgiou AA, et al: The effect of statins versus untreated dyslipidaemia on renal function in patients with coronary heart disease: A subgroup analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study. J Clin Pathol57:728-734, 2004.
55.
Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 5,963 people with diabetes: A randomised placebo-controlled trial. Lancet361:2005-2016, 2003.
56.
Zanchetti A, Hansson L, Dahlof B, et al: Effects of individual risk factors on the incidence of cardiovascular events in the treated hypertensive patients of the Hypertension Optimal Treatment Study. HOT Study Group. J Hypertens19:1149-1159, 2001.
57.
Hittel N, Donnelly R:Treating peripheral arterial disease in patients with diabetes. Diabetes Obes Metab4(suppl 2):S26-S31, 2002.
58.
Prior M, Arosio E, Ferrari M, et al: Lipoprotein (a) and general risk factors in patients with angiographically assessed peripheral arterial disease. Int Angiol14:357-363, 1995.
59.
Mikhailidis DP, Ganotakis ES, Spyropoulos KA, et al: Prothrombotic and lipoprotein variables in patients attending a cardiovascular risk management clinic: Response to ciprofibrate or lifestyle advice. Int Angiol17:225-233, 1998.
60.
Bhatnagar D, Anand IS, Durrington PN, et al: Coronary risk factors in people from the Indian subcontinent living in west London and their siblings in India. Lancet18:405-409, 1995.
61.
Milionis HJ, Rizos E, Mikhailidis DP: Smoking diminishes the beneficial effects of statins: Observations from the landmark trials. Angiology52:575-587, 2001.
62.
Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: Results of the GISSI-Prevenzione trail. Lancet354:447-455, 1999.
