Suboptimal Intensity of Risk Factor Modification in Peripheral Arterial Disease (PAD)

Abstract

Conclusion: There is suboptimal medical management of atherosclerotic risk factors in patients with peripheral arterial disease (PAD). Summary: The PARTNERS study (PAD Awareness, Risk and Treatment) indicated that PAD was under recognized in primary care practice and only 60% of patients with PAD were receiving lipid lowering therapy (JAMA 2001;286:1317-24). This study sought to determine if practice guidelines for patients with cardiovascular disease, developed after publication of PARTNERS, have effected current community management of PAD. The authors recruited via a media campaign conducted in a large northern California urban area patients with leg pain that limited their walking. Respondents were screened by telephone and, if eligible, offered PAD assessment. Eligibility criteria included age ≥50 years with symptomatic PAD. PAD was defined as exertional leg pain with an ankle brachial index ≤0.9. For patients with diabetes, PAD was defined as a toe pressure of <30 mmHg. Patients must have been able to walk for 2 minutes or 50 feet on an exercise treadmill and have been on a stable medication regimen. Patients with rest pain, ulceration or gangrene were excluded. Also excluded were patients with recent myocardial infarction, Type I diabetes, and active malignancy. Treatment and risk factor profiles were determined by self reported medical history and current medication lists. Patients were evaluated as to whether or not they met current treatment guidelines for lipids, hypertension, and diabetes. With respect to lipids, an LDL cholesterol <100 mg/dl was considered to have met therapeutic guidelines. Hypertension was defined as a systolic blood pressure >140 mmHg and a diastolic blood pressure >90 mmHg. Hemoglobin A1c levels (HgbA1c) ≥7% indicated suboptimal glycemic control. There were 101 subjects in this study. Dyslipidemia was recognized in 56.4%. In dyslipidemic subjects there was suboptimal therapy in 52.6%. In addition, 20.8% of the sample were previously unrecognized cases. A history of hypertension was reported in 54.5% of the study sample. Management of systolic blood pressure was sub-optimal in 74.5% of hypertensive subjects. Systolic hypertension had been previously unrecognized in 13.9% of the study subjects. Hypertensive patients were found a 81% utilization rate of antihypertensive medication. Patients on mono versus triple therapy for hypertension exhibited no significant differences in systolic or diastolic blood pressures. Diabetes was reported in 26.7% of the patients. HgbA1c was 7.9 ± 1.9 mg/dl. Glycemic control was felt to be suboptimal in 57% of patients (mean HgbA1c = 8.7 ± 1.8 mg/dl). Sixty-two percent of the study population was on anti-platelet therapy. Anticoagulation therapy was employed in 15%. About 35% of subjects (n = 36) were not taking anticoagulant or anti-platelet therapy. No patients appeared to have had a contraindication to anti-platelet therapy. Comment: The study is small and therefore subject to Type II statistical error. Nevertheless, the results are similar to PARTNERS and indicate suboptimal management of risk factors in patients with PAD. It is clear one publication, the PARTNERS publication, has not had a dramatic impact on primary care practice with respect to management of PAD. Meaningful changes in management of PAD risk factors will only occur after intensive promulgation of treatment goals for patients with PAD.