screening for pad in the general population » des pas pour la vie« - »steps for life« lessons of...
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Screening for PAD in the general population
» Des pas pour la vie« - »steps for life«
Lessons of a French screening program
Böge G, Laroche JP , Benshali Y , Lorin C , Brisot D , Perez-Martin A , Dauzat M , P Carpentier , JL Bosson , C Rolland , C Genty , Becker F , Quéré I.
Background • PAD indicates general atherosclerosis and is associated with
increased mortality• ABI is correlated
– with severity of PAD – and with elevated general and cardiovascular mortality (ABI < 0.9 or >
1.3)– With diminished QoL
• PAD is frequent, underdiagnosed, although medical therapy is known to reduce morbidity and mortality rates in these patients
- Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Resnick HE, Lindsay RS, McDermott MM, Devereux RB, Jones KL, Fabsitz RR, Howard BV. Circulation. 2004 Feb 17;109(6):733-9- A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life. Alison MA, Hiatt WR, Hirsch AT, Coll JR, Criqui MH, J Am Coll Cardiol.2008;51(13):1292-8
Feringa H et al, Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol. 2006;47:1182-1187
Methods
• National screening campaign– general population with no known PAD– Presenting cardiovascular risk factors– Over 60 years old
• One day in France– 58 communities– 79 centers– 350 physicians
• 3 month follow up
Methods
• Questionnaire – Medical history– Cardiovascular risk factors
• ABI measurement– Vascular specialist– Continuous wave Doppler 8 MHz probe– systolic blood pressure
• in both upper extremities• In both lower extremities (posterior and anterior tibial artery)
• ABI calculation– Method 1: ABI= highest ankle pressure/ highest humeral pressure– Method 2: ABI= lowest ankle pressure/ highest humeral pressure
• ABI= highest ankle pressure/ highest humeral pressure– Correlated with the hemodynamic severity of peripheral arterial
involvement – Diagnostic accuracy for PAD (vs angiography) 98%– Usually recommended measurement method
• ABI= lowest ankle pressure/ highest humeral pressure– Cardiovascular risk similar– Higher sensibility: more PAD detected– May bee a better screening tool
ABI: methods of calculation
Different calculations of ankle-brachial index and their impact on cardiovascular risk prediction. Espinola-Klein C, Rupprecht HJ, Bickel C, Lackner K, Savvidis S, Messow CM, Munzel T, Blankenberg S; AtheroGene Investigators. Circulation. 2008 Aug 26;118(9):961-7.
ACC/AHA Guidelines for the Management of patients with peripheral arterial diseaseHirsch et al, Circulation 2006
Results SCREENING DAY
Persons screened 6187
Analyzed 6089
Men mean age
46% 67.6
Women mean age
56% 68.4
Results
ABI < 0.9 or > 1.3 15.4 %
0.70< ABI < 0.90 5.4%
ABI < 0.70 1.8%
ABI > 1.30Uncompressible
7.7%0.6%
ABI= highest ankle pressure/ highest humeral pressure
Results
ABI < 0.9 or > 1.3 24.7%
0.70< ABI < 0.90 13%
ABI < 0.70 4.1%
ABI > 1.30Uncompressible
7.1%0.6%
ABI= lowest ankle pressure/ highest humeral pressure
Results
1 2 3 4 5 6 7
Risk factors
Abnormal ABI(< 0.9 or > 1.3)
ResultsABI < 0.9 or > 1.3 Odds ratio 95% CIDiabetes (insulin therapy) 2.4 1.58 - 3.64
Male 1.85 1.59 - 2.16
Smoking 1.74 1.36 - 2.16
age > 70 1.58 1.36 - 1.84
Renal impairment 1.56 1.04 - 2.36
Diabetes (oral antidiabetics) 1.49 1.17 - 1.89
History of MI 1.37 1.04 - 1.82
North vs south 1.29 1.06 - 1.58
Hypertension medication 1.17 1.00 - 1.37
Lipid lowering therapy 1.11 0.92 - 1.34
Daily walking (30min) 0.78 0.67 - 0.91
Three month follow-up
• 692/1500 patients: telephone follow up at 3 months
• 42% of them had have a complete duplex scan of the lower extremities, confirming the PAD.
• 30% lifestyle correction (diet, physical activity)• Only 2% had modified medical treatment
Screening of peripheral arterial diseasebased on ABI measurement
Study population PAD prevalence
PARTNERSU.S.Hirsch AT et al, JAMA 2001;286:1317-1324
Primary care offices>70 years or >50 years and diabetes or smokingN= 6979
29%
REGICORSpainRamos R. Eur J Vasc Endovasc Surg 2009 Sep;38(3):305-11
Unselected patients65-74 years 75-79 years N=6262
Men:10.0% Women: 4.6% Men: 17.8% Women:10.6%
GetABIGermanyDiehm C. Atherosclerosis. 2004;175(1);183-4
Primary care offices (GP)Unselected patients >65 years N=6880
Men: 19.8%Women: 16.8%
IPSILONFranceCacoub P. Int J Clin Pract. 2009 Jan;63(1):63-70.
High risk patients presenting in a GP primary care offices(>55 years and presenting at least 2 CV risk factors or history of atherothrombosis)N=5679
27.8%
ELLIPSEFranceMourad JJ. JVS 2009;50:572-80
Asymptomatic high risk in-patients 55-yearsN= 2146
41.1%
Effectiveness of screening
The potential benefit depends of• 1) Disease prevalence (15% -41% in high risk populations)• 2) PAD mortality (3.9%-8.2%/year)
• 3) Screening test available (ABI)• 4) Mortality rate reduction by appropriate therapy ( 25%-
50%)
Hooi et al, asymptomatic peripheral arterial disease predicted cardiovascular morbidity and mortality in a 7 year-follw-up study. J Clin Epidemiol. 2004;57:294-300.Caro J et al, The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database. BMC cardiovasc Disor.2005;5:14
Feringa H et al, Cardio protective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol. 2006;47:1182-1187.
Reduction of mortality rates about 2-9 lives/ 100 patients screened/ follow up of 7 years
• “individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ankle-brachial-index (ABI) so that therapeutic interventions known to diminish their increased risk of myocardial infarction (MI), stroke, and death may be offered”
Class I indication
ACC/AHA Guidelines for the Management of patients with peripheral arterial diseaseHirsch et al, Circulation 2006; 113:1474-1547
Beckman JA et al, The United States Preventive Services Task Force Recommendation statement on screening for peripheral artery disease. More harm than benefit? Circulation 2006;114:861-866
Effectiveness of screening
Conclusion
• Screening of asymptomatic PAD in high risk patients is possible, sure and inexpensive by ABI measurement
• Asymptomatic PAD in the general population > 60 years, presenting CV risk factors, is frequent with a prevalence of about 25%
• PAD is still underdiagnosed, and an undertreated disease• Screening of asymptomatic PAD is effective and life-saving if
therapeutic interventions (lifestyle correction and medical treatment) known to diminish their increased cardiovascular risk are offered