PAD must be included alongside CHD when the GP contract is revised, argue Dr Alan Begg and Ms Julie Brittenden
Standard 3 of the National Service Framework for CHD recommends that patients with established CHD or other occlusive arterial diseases such as peripheral arterial disease (PAD) should be identified and offered comprehensive advice and treatment to reduce their risk.1
In 1998, the Joint British Societies recommended that patients with PAD should be managed in the same way as those with CHD, because PAD patients are as likely as those who have survived a first myocardial infarction to die from CHD.2 It is therefore important that PAD, despite not being included as a specific disease category in the new GMS contract, is managed in a similar way to the vascular diseases that are included.
A practice of 10 000 patients with an average prevalence of occlusive vascular disease can expect to have 77 patients with PAD; of these, 21 will not be covered by the clinical indicators unless they have hypertension. A survey of patients with intermittent claudication attending a PAD clinic revealed that 24% did not have CHD, diabetes or hypertension.3
Only 10% of patients presenting with intermittent claudication have normal coronary arteries, and up to 50% have disease in their carotid arteries. Nearly a quarter of all patients presenting with intermittent claudication will die from a cardiovascular event within 5 years.
Of all deaths in patients with PAD, 50% will be caused by CHD, 17% by cardiovascular disease and 10% by other vascular diseases such as ruptured aortic aneurysm. Therapeutic intervention in patients presenting with intermittent claudication may not improve symptoms but will improve long-term survival.
In patients who present with a typical history of intermittent claudication and absent peripheral pulses, the presence of atherosclerotic narrowing of the arteries of the legs can be confirmed by an ankle brachial pressure index measurement of <0.9%.
Overweight PAD patients should be encouraged to lose weight and adopt a healthy diet. Alcohol intake should be moderated, to <21 units per week in men and <14 in women. Supervised exercise programmes, ideally of walking to near maximal pain endurance for up to three sessions per week, can improve walking distance. Stopping smoking for good can improve the long-term outcome.
Initially, reducing blood pressure in patients with PAD can exacerbate symptoms, but as patients are at high risk of an occlusive coronary or cerebral vascular event there are proven benefits in lowering blood pressure. The use of the ACE inhibitor ramipril in the HOPE trial led to a significant reduction in cardiovascular morbidity and mortality in patients with PAD.4
The Heart Protection Study showed that in patients without previous CHD but with peripheral vascular disease simvastatin reduced further vascular events such as fatal and nonfatal CHD or stroke. It also showed for the first time that cholesterol-lowering therapy reduces the need for peripheral artery revascularisation.5
The benefits of anti-platelet therapy in vascular outcomes in patients with PAD are clear from the meta-analysis of the Antithrombotic Trialists’ Collaboration.6 Low dose aspirin is the drug of choice, with clopidogrel an appropriate alternative. The CAPRIE trial showed that patients with PAD appear to have benefited the most from taking clopidogrel.7
Including PAD in the first revision of the quality and outcomes framework must be a top priority.
- Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, 2000.
- Wood D, Durrington P, Poulter N et al. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998; 80(Suppl 2): S1- S29.
- Cassar K, Coull R, Bachoo P et al. Management of secondary risk factors in patients with intermittent claudication. Eur J Vasc Endovasc Surg 2003; 26: 262-6.
- Yusuf S, Sleight P, Pogue J et al. Effects of an angiotensinconverting- 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.
- 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.
- Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death,myocardial infarction, and stroke in high risk patients. Br Med J 2002; 324: 71-86.
- A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348: 1329-39.