SIGN has published a guideline on the diagnosis and management of peripheral arterial disease (PAD),1 which updates its 1998 guidance on drug therapy for peripheral vascular disease.2
Prevalence of PAD
Peripheral arterial disease affects 20% of those aged 65–74 years, although only one-quarter of these people have symptoms. It is a significant marker for systemic arterial damage, and carries an increased risk of a fatal or non-fatal cardiovascular event, which can be as high as twice that of the general population.1
The QOF review group estimated that a GP with 2000 patients on his/her list will be able to identify approximately 40 patients with confirmed PAD, and will see one or two new patients each year.3
Identification in general practice
Patients who present with features of intermittent claudication can have the presence of PAD confirmed in general practice. Apart from taking a thorough history, peripheral pulses should be examined and the abdomen should be palpated to exclude an aneurysm.
An ankle brachial pressure index (ABPI) cut-off point of 0.9, measured using a hand held Doppler device, has a high enough sensitivity and specificity to confirm underlying vascular disease.1 Excellent guidance is included on a method to measure ABPI. However, no evidence has been found for the usefulness of pulse oximetry in the detection of early PAD.1
Management and treatment
Risk factor modification along with actions to prevent both disease progression and the major complications of vascular events can be successfully tackled in primary care. Although stopping smoking will reduce cardiovascular risk, there is little evidence to demonstrate a change in outcome associated with smoking cessation in patients with PAD.
Optimal diabetes control is important, and although obese patients should reduce their weight, no studies have investigated the effect of weight reduction in patients with PAD.1
All patients require anti-platelet therapy. Analysis of the PAD subgroup in the CAPRIE study showed better vascular event and mortality outcomes in those on clopidogrel compared to those on aspirin.4 The cost-effectiveness of using clopidogrel in preference to, rather than as an alternative to, aspirin for PAD patients has not been shown.1
Based on the Heart Protection Study, lowering cholesterol with a statin in patients whose cholesterol is above 3.5 mmol/l will lead to outcome benefits, and may also increase the walking distance achieved.5
Effectively treating raised blood pressure will reduce the risk of a cardiovascular event; there is no strong evidence to suggest that beta-blockers should not be used in the presence of PAD.1 In the HOPE Study, ABPI was measured unconventionally,6 so the specific benefits of an angiotensin-converting enzyme inhibitor in patients with PAD can only be extrapolated from their use in trials of patients with stable coronary disease.7
Patients should be considered for a 3-month trial of cilostazol in order to improve their walking distance and quality of life, as well as being encouraged to exercise.
Naftidrofuryl is an alternative for those with poor quality of life. For the majority of patients, endovascular and surgical intervention are not recommended, and only those with severe disability or disabling symptoms need to be referred to a vascular specialist.
PAD in QOF3?
Despite a strong case, these high-risk patients were not included in the first QOF revision.2,8 Any future changes to the QOF that treat all cardiovascular diseases as one category will include PAD patients. However, adding PAD on its own would be the simplest approach, accepting there will be some horizontal overlap with other clinical areas of QOF2.
- Scottish Intercollegiate Guidelines Network. Diagnosis and management of peripheral arterial disease (SIGN 89). Edinburgh: SIGN, 2006.
- Scottish Intercollegiate Guidelines Network. Drug Therapy for Peripheral Vascular Disease (SIGN 27). Edinburgh: SIGN, 1998.
- Peripheral Artery Disease QOF Indicators Final Report, August 2005. http://www.pcpoh.bham.ac.uk/primarycare/QOF/index.htm
- A randomised blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348 (9038): 1329–1339.
- 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. Lancet 2002; 360 (9326): 7–22.
- Ostergren J, Sleight P, Dagenais G et al; HOPE study investigators. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J 2004; 25 (1): 17–24.
- Al-Mallah M, Tleyjeh I, Abdel-Latif A et al. Angiotensin-converting enzyme inhibitors in coronary artery disease and preserved left ventricular systolic function: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Cardiol 2006; 47 (8):1576-1583.
- British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.