In new diagnostic and treatment recommendations for peripheral artery disease, the American College of Cardiology Foundation and the American Heart Association have endeavored to eliminate a wide disparity of care in these patients who are often undiagnosed or undertreated.
In the document, the consensus of a writing committee of pertinent specialties tasked to provide performance measures for the disease, peripheral artery disease (PAD) was defined as lower extremity and abdominal aortic disease caused by atherosclerotic vascular disease. Treatment measures were developed on the basis of class I evidence and were designed to be achievable by any physician, advanced practice nurse, practice, or health care system, according to the final report to be published in the Dec. 14/21 issue of the Journal of the American College of Cardiology (J. Am. Coll. Cardiol. 2010;56:2147-81) and simultaneously in several other publications representing partners on the writing committee.
The prevalence of PAD is approximately 12% of the adult population, with men slightly more affected than women, according to the report. Above age 70 years, almost 20% of individuals have PAD. The disease often is undiagnosed because up to 50% of patients present with atypical symptoms or no symptoms at all.
For this reason, the committee was especially concerned that ankle brachial index (ABI) measurements should be performed on all patients at risk for PAD regardless of whether they have symptoms. They recognized that reimbursement for ABI in the office setting is incomplete and that performing the test would "add a burden to busy primary care physicians," according to the report, but still concluded that it was justified.
The ABI is measured with a handheld continuous wave Doppler ultrasound device and a blood pressure cuff. An ABI measurement of less than 0.90 is considered diagnostic of PAD.
"Patients with peripheral artery disease have the highest rate of heart attacks, stroke, and cardiovascular disease – higher than people with coronary artery disease – yet they remain undertreated," Dr. Jeffrey W. Olin, professor of medicine at Mount Sinai School of Medicine, New York, and chair of the writing committee, said in a published statement on the report.
As far as treatment, the committee was critical of current practice, especially among primary care physicians. "Studies have found that people with PAD are up to six times more likely to die of heart disease, compared to matched controls," but even when PAD is diagnosed, "many health care providers will often just treat the leg symptoms ... and not the heart-related risks," according to the statement.
A major goal of the guidelines is to induce practitioners to move to appropriate therapy for PAD patients once they are diagnosed, not only to improve their ability to walk further and faster without pain, but also to "lower the rate of heart attack, stroke, and death from cardiovascular disease."
Such treatment recommendations included in the measures are:
• Statin therapy to lower LDL cholesterol to less than 100 mg/dL.
• Smoking cessation intervention.
• Antiplatelet therapy with aspirin or clopidogrel for patients with a history of symptomatic PAD.
• Supervised exercise programs for patients with claudication.
• Monitoring of any existent abdominal aortic aneurysm and/or lower extremity vein bypass grafting.
The writing committee envisions that the published performance measures will be used by the Centers for Medicare and Medicaid Services and other third-party payers to assess each individual physician caring for patients with PAD.
Along with the American College of Cardiology and the American Heart Association, the Peripheral Artery Disease Performance Measures Writing Committee included representatives from the Society for Cardiac Angiography and Interventions, the American College of Radiology, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery, among others.
Dr. Olin has consulted for Genzyme, Merck, and the Sanofi/BMS partnership. Members of the writing committee had various industrial relationships but were recused from voting on recommendations for which they were deemed to have conflicts. A complete list of their disclosures is provided in each of the published versions of the report.