Transcript Prevalence of PAD

Peripheral Arterial Disease in
Saudi Arabia :
Where Do We Stand?
Mohammed Al-Omran, MD, MSc, FRCSC
Associate Professor & Vascular Surgeon, King Saud University
Scientist, LKSKI- St’ Michael’s Hospital, University of Toronto
Why it is important to recognize patients with PAD?
100
Life expectancy reduced by
10 years in patients with PAD
Survival (%)
80
Controls
60
Mortality rate
~ 25% at 5 years
~ 50% at 10 years
~ 75% at 15 years
40
20
IC
CLI
0
0
5
10
15
Follow-up (years)
CLI=critical limb ischemia.
IC=intermittent claudication.
Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.
2
Why it is important to recognize patients with PAD?
PAD places individuals at high short and long term risk of
MI, Stroke & Death
3
Management of PAD
What are the Goals of treating patients with PAD?
Relief symptoms
Improve quality of life
Limb salvage
Prolong survival
5
Strategies in treating patients with PAD
Improve Lower Limb Circulation
Risk Factors Modification
6
Strategies in treating patients with PAD
Risk Factors Modification
• Diet and weight control
• Exercise
• Antiplatlets
• Hypertension control
• Diabetes control
• Lipid control
• Smoking Cessation
7
Strategies in treating patients with PAD
Improve Lower Limb Circulation
• Conservative (Exercise Program)
• Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Surgical Bypass
8
Summary of the Evidence
Goals
Blood pressure
Recommendation
Systolic
<140 mm Hg in all patients
<130 mm Hg in diabetic patients
Diastolic
<90 mm Hg in all patients
<80 mm Hg in diabetic patients
Class of
recommendation
Level of
evidence
I
A
LDL-C
LDL< 2.5 mmol/l in all patients
I
A
Diabetes
HbA1c<7% in diabetic patients
I
B
Smoking
Complete cessation in all patients
I
B
18.5-24.9 kg/m2 in all patients
I
B
30 minutes (5 days/week)
I
B
BMI
Physical Activity
9
Summary of the Evidence
Medications
Recommendation
Antiplatlets
All patients
Statins
All patients
ACE inhibitors
Symptomatic patients
Asymptomatic patients
Class of
recommendation
Level of evidence
I
A
I
A
I
IIa
B
B
10
Where Do We Stand in Saudi Arabia?
What Should We Know?
What Should we Know?
Is PAD a public health issue?
Health Care Provider:
Is there a knowledge gap?
Is there an action gap?
Is there a care gap?
Is there a missed opportunity in using PAD (ABI) as a predictor
in order to prevent the adverse cardiovascular outcomes?
Population:
Is there a public awareness about PAD?
12
What Do We Know?
Is PAD a Public Health Issue ?
14
Prevalence of and Risk Factors for Peripheral Arterial Disease in Saudi
Arabia: A Pilot Cross-sectional Study
- 11.7 % (95% CI 8.9% to 14.9%)
Alshaekh et al. SMJ. 2007;28:412-414
D
- 92.7% were asymptomatic
C
A
D
M
- Male 68%
Prevalence
C
VD
- Mean age 57
hy
H
pe
TN
rli
pi
de
m
i
Sm a
ok
in
g
- 471 patients
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Prevalence of PAD
European Data
19.1%
19.8%
29.0%
US Data
Saudi Data
11.7
%
14.5%
11.7%
4.3%
Rotterdam1
Age >55
1.
2.
3.
4.
5.
Diehm2
Age ≥65
6
Pilot Study
Age >45
NHANES3
Age >40
Prevalence was estimated using different methods
Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.
Diehm C et al. Atherosclerosis. 2004;172:95-105.
Selvin E et al. NHANES. Circulation. 2004;110:738-743.
Criqui MH et al. Circulation. 1985;71:510-515.
Hirsch AT et al. JAMA. 2001;286:1317-1324.
San Diego4
Mean Age=66
NHANES3
Age ≥70
PARTNERS5
Age >70, or between
50–69 with history of
diabetes or smoking
6. Alshaekh et al. SMJ. 2007;28:412-414
16
Is there a knowledge and action gaps
in managing patients with PAD?
17
Atherosclerotic Risk Reduction Therapy in Peripheral Arterial Disease
Compared to Coronary Artery Disease: Perception and Knowledge of
Physicians in Saudi Arabia
-
897 physicians (Internists/ GPs/ Cardiologists/ Vascular Surgeons)
-
Response rate 59 % (529 physicians)
450
413
400
350
300
279
53%
250
219
200
53%
148
150
100
50
162
66%
107
85%
65 55
0
Vascular
Al-Omran et al. In press
Cardio
GP
Internists
distributed
responders
Knowledge of the current recommended target of:
PAD
CAD
%
%
LDL-Cholesterol
(<2.5mmol/l)
36
40
Blood Pressure
(<130/85 mmHg)
28
32
Blood Glucose
(Hb 1Ac<7%)
66
68
19
Attitude towards routine evaluation of risk factors:
PAD
CAD
%
%
Lipid profile measurement
95
98
Blood pressure measurement
99
99
Blood glucose measurement
96
99
Asking about smoking
99
99
20
Attitude towards routine patients counseling with
regards to the importance of:
PAD
CAD
%
%
LDL- Cholesterol reduction
96
98
Blood pressure control
99
99
Blood glucose control
97
98
Smoking Cessation
97
98
21
Attitude towards routine initiating/modifying risk
reduction pharmacotherapy:
PAD
CAD
%
%
86.3
94.1
Statins
56
61
ACE- inhibitors
34
52
Anti-hypertensive Medications
58
63
Referral to
Smoking Cessation Clinic
37
42
Nicotine replacement therapy
43
50
Anti-platelets
22
Conclusion
Despite a considerable effort to evaluate and counsel
patients for their atherosclerotic risk factors
The perception towards risk reduction
in PAD/CAD identify
glaring knowledge and action gaps
23
Is there a care gap in managing patients
with PAD?
24
Risk Reduction Status in Patients with
Peripheral Arterial Disease Presenting to a
Major Teaching Hospital
- 140 consecutive symptomatic PAD patients presented
to KKUH over 1 year (Jan 2006 – Dec 2006)
MALE:FEMALE
24%
-Mean age 62
76%
MALE
FEMALE
Risk Reduction Status in Patients with Peripheral Arterial Disease
Presenting to a Major Teaching Hospital
Risk Reduction
Risk Factor
Therapy
%
Optimal
% Optimal Control
Control (%)
(%)
Sex (male)
Statin
Hypertension
40.0
75
59
64.0
37
Diabetes
Mellitus
Anti-thrombotic
Hypercholesterolemia
80.0 85
40
- 15
64
Smoking
ACE-I
Obesity/Overweight
37.0 32
68
40.026
How about the rest of the World?
Study
# of
patients
Setting
Antiplatlet s
use %
Statin
use %
ACE
BP
LDL-C
HbA1c
BMI
Nonsmokers
<140/90 mm Hg
%
< 2.5 mmol/l
(%)
<7%
< 25 kg/m2
%
(%)
(%)
(%)
inhibitors
use
(%)
Anand et al, 1999
195
Canada
38
16
NA
NA
NA
NA
NA
NA
Mukherjee et al,
2002
66
USA
89
57
42
NA
NA
NA
NA
73
Teh et al, 2003
189
Australia
62
35
38
NA
NA
NA
NA
NA
Brown et al, 2004
281
Canada
44
66
62
NA
NA
NA
NA
NA
Sukhija et al,
2005
561
USA
89
79
54
46
54
NA
NA
78
Rehring et al,
2005
1733
USA
NA
31
29
NA
23
40
NA
NA
Hackam et al,
2006
1507
Canada
90
76
58
NA
67
NA
NA
79
Bradley&Kirker,
2006
107
UK
60
47
NA
NA
NA
NA
NA
NA
Kinikini et al ,
2006
200
USA
79
61
48
54
36
24
33
73
AlOmran et al,
2006
391
Canada
78
61
45
35
47
49
27
67
Current study,
2008
140
KSA
80
40
37
37
64
15
32
78
27
Conclusion
The control of risk factors in
patients with PAD is
suboptimal
28
Is there a missed opportunity in using PAD (ABI) as a predictor in order to
prevent the adverse cardiovascular outcomes?
29
Peripheral Arterial Disease in SPACE registry: A
Preliminary Analysis
Objectives
To identify the prevalence of PAD in patients
presenting with acute coronary events
To identify the prevalence of PAD in patients
presenting with acute coronary events and do not
have history of CAD (missed opportunity)
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Peripheral Arterial Disease in SPACE registry:
- 545 patients with PAD (2479 ACS patients)
- Mean age 63
- Male 72%
Prevalence of PAD 22
Patients %
%
28%
Symptomatic
Asymptomatic
72%
Prevalence of PAD in patient with no history of CAD
38%
Risk Reduction Pharmacotherapy in patients with PAD (SPACE registry):
Risk Reduction
Therapy
All PAD patients
%
Symptomatic PAD
%
Asymptomatic PAD
%
Aspirin
65.0
70.0
55.0
Statin
55.0
60.0
47.0
ACE-I
43.0
45.0
34.0
32
Conclusion
There is a great opportunity in preventing
acute coronary events that we are missing
We can simply utilize this opportunity by recognizing
patients with PAD (symptomatic or asymptomatic)
and aggressively control their risk factors
33
Is there a public awareness about PAD?
34
Is there a public awareness about PAD?
- A cross-sectional interview-based survey during a
4 day campaign that was organized at KKUH
outpatient clinics and 3 shopping centers in
Riyadh, Saudi Arabia.
- Sample Size: 866 out of 923 , Response (93.8%)
35
Is there a public awareness about PAD?
36
Is there a public awareness about PAD?
37
Is there a public awareness about PAD?
38
Conclusion
The awareness of public
towards PAD is
suboptimal
39
So, Let’s wrap-up
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What Should we Know?
Is PAD a public health issue?
Health Care Provider:
Is there a knowledge gap?
Is there an action gap?
Is there a care gap?
Is there a missed opportunity in using PAD (ABI) as a predictor
in order to prevent the adverse cardiovascular outcomes?
Population:
Is there a public awareness about PAD?
41
Future Direction
- Increase public and Physicians awareness
- Disseminating the guidelines
- PAD registry and Practice auditing
Task Force
- Physicians awareness
Outreach CME program
43
Task Force
- Public awareness
Campaigns in shopping centres
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Task Force
- PAD registry and Practice auditing
King Khalid University Hospital
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Conclusions
A call to action to implement effective strategies to
diagnose and mange patients with PAD, to
encourage health professionals to use risk
reduction therapy and to increase the public
awareness are needed
Different strategies can help
which are very much at the beginning and have a
long way to develop
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“The journey of a thousand miles
begins with one step”
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Thank You
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