Presentation on theme: "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."— Presentation transcript:
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 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 disease Hirsch et al, Circulation 2006
Results SCREENING DAY Persons screened6187 Analyzed 6089 Men mean age 46% 67.6 Women mean age 56% 68.4
Results ABI 1.315.4 % 0.70< ABI < 0.905.4% ABI < 0.701.8% ABI > 1.30 Uncompressible 7.7% 0.6% ABI= highest ankle pressure/ highest humeral pressure
Results ABI 1.324.7% 0.70< ABI < 0.9013% ABI < 0.704.1% ABI > 1.30 Uncompressible 7.1% 0.6% ABI= lowest ankle pressure/ highest humeral pressure
Results ABI 1.3Odds ratio95% CI Diabetes (insulin therapy)2.41.58 - 3.64 Male1.851.59 - 2.16 Smoking1.741.36 - 2.16 age > 701.581.36 - 1.84 Renal impairment1.561.04 - 2.36 Diabetes (oral antidiabetics)1.491.17 - 1.89 History of MI1.371.04 - 1.82 North vs south1.291.06 - 1.58 Hypertension medication1.171.00 - 1.37 Lipid lowering therapy1.110.92 - 1.34 Daily walking (30min)0.780.67 - 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 disease based on ABI measurement StudypopulationPAD prevalence PARTNERS U.S. Hirsch AT et al, JAMA 2001;286:1317- 1324 Primary care offices >70 years or >50 years and diabetes or smoking N= 6979 29% REGICOR Spain Ramos R. Eur J Vasc Endovasc Surg 2009 Sep;38(3):305-11 Unselected patients 65-74 years 75-79 years N=6262 Men:10.0% Women: 4.6% Men: 17.8% Women:10.6% GetABI Germany Diehm C. Atherosclerosis. 2004;175(1);183-4 Primary care offices (GP) Unselected patients >65 years N=6880 Men: 19.8% Women: 16.8% IPSILON France Cacoub 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% ELLIPSE France Mourad JJ. JVS 2009;50:572-80 Asymptomatic high risk in-patients 55-years N= 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 disease Hirsch 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