1. 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

2. 2 Why it is important to recognize patients with PAD? Survival (%) Follow-up (years) Controls IC CLI 051015 0 20 40 60 80 100 CLI=critical limb ischemia. IC=intermittent claudication. Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75. Life expectancy reduced by 10 years in patients with PAD Mortality rate ~ 25% at 5 years ~ 50% at 10 years ~ 75% at 15 years

3. 3 Why it is important to recognize patients with PAD? PAD places individuals at high short and long term risk of MI, Stroke & Death

4. Management of PAD

5. 5 What are the Goals of treating patients with PAD? Relief symptoms Improve quality of life Limb salvage Prolong survival

6. 6 Strategies in treating patients with PAD Improve Lower Limb Circulation Risk Factors Modification

7. 7 Strategies in treating patients with PAD Risk Factors Modification Diet and weight controlDiet and weight control ExerciseExercise AntiplatletsAntiplatlets Hypertension controlHypertension control Diabetes controlDiabetes control Lipid controlLipid control Smoking CessationSmoking Cessation

8. 8 Improve Lower Limb Circulation Conservative (Exercise Program)Conservative (Exercise Program) Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting - Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass Strategies in treating patients with PAD

9. 9 Summary of the Evidence Goals Recommendation Class of recommendation Level of evidence Blood pressure Blood pressureSystolic <140 mm Hg in all patients <140 mm Hg in all patients <130 mm Hg in diabetic patients <130 mm Hg in diabetic patientsDiastolic <90 mm Hg in all patients <90 mm Hg in all patients <80 mm Hg in diabetic patients <80 mm Hg in diabetic patients IA LDL-C LDL-C LDL< 2.5 mmol/l in all patients IA Diabetes HbA1c<7% in diabetic patients IB Smoking Complete cessation in all patients IB BMI 18.5-24.9 kg/m 2 in all patients IB Physical Activity 30 minutes (5 days/week) IB

10. 10 Summary of the Evidence Medications Recommendation Class of recommendation Level of evidence Antiplatlets All patients IA Statins IA ACE inhibitors Symptomatic patients Asymptomatic patients I IIa IIaB B

11. What Should We Know? Where Do We Stand in Saudi Arabia?

12. 12 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?

13. What Do We Know?

14. 14 Is PAD a Public Health Issue ?

15. Prevalence of and Risk Factors for Peripheral Arterial Disease in Saudi Arabia: A Pilot Cross-sectional Study - 471 patients - Mean age 57 - Male 68% Prevalence - 11.7 % (95% CI 8.9% to 14.9%) - 92.7% were asymptomatic Alshaekh et al. SMJ. 2007;28:412-414

16. 16 Prevalence was estimated using different methods 1. 1.Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. 2.Diehm C et al. Atherosclerosis. 2004;172:95-105. 3.Selvin E et al. NHANES. Circulation. 2004;110:738-743. 4.Criqui MH et al. Circulation. 1985;71:510-515. 5.Hirsch AT et al. JAMA. 2001;286:1317-1324. Prevalence of PAD PARTNERS 5 Age >70, or between 50–69 with history of diabetes or smoking San Diego 4 Mean Age=66 Diehm 2 Age ≥65 Rotterdam 1 Age >55 NHANES 3 Age ≥70 NHANES 3 Age >40 European Data US Data Saudi Data Pilot Study 6 Age >45 6. Alshaekh et al. SMJ. 2007;28:412-414

17. 17 Is there a knowledge and action gaps in managing patients with PAD?

18. 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) Al-Omran et al. In press

19. 19 PAD %CAD % LDL-Cholesterol (<2.5mmol/l) 3640 Blood Pressure (<130/85 mmHg) 2832 Blood Glucose (Hb 1Ac<7%) 6668 Knowledge of the current recommended target of:

20. 20 PAD %CAD % Lipid profile measurement 9598 Blood pressure measurement 9999 Blood glucose measurement 9699 Asking about smoking 9999 Attitude towards routine evaluation of risk factors:

21. 21 PAD %CAD % LDL- Cholesterol reduction 9698 Blood pressure control 9999 Blood glucose control 9798 Smoking Cessation 9798 Attitude towards routine patients counseling with regards to the importance of:

22. 22 PAD %CAD % Anti-platelets86.394.1 Statins5661 ACE- inhibitors 3452 Anti-hypertensive Medications 5863 Referral to Smoking Cessation Clinic 3742 Nicotine replacement therapy 4350 Attitude towards routine initiating/modifying risk reduction pharmacotherapy:

23. 23 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

24. 24 Is there a care gap in managing patients with PAD?

25. 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) - 140 consecutive symptomatic PAD patients presented to KKUH over 1 year (Jan 2006 – Dec 2006) -Mean age 62

26. 26 Risk Factor % Optimal Control (%) (%) Sex (male) 75- Hypertension5937 Diabetes Mellitus 8515 Hypercholesterolemia4064 Smoking32- Obesity/Overweight68- Risk Reduction Therapy% Optimal Control (%) Statin40.064.0 Anti-thrombotic80.0- ACE-I37.040.0 Risk Reduction Status in Patients with Peripheral Arterial Disease Presenting to a Major Teaching Hospital

27. 27 Study# of patients Setting Antiplatlet s use % Statin use % ACE inhibitors use (%) BPLDL-CHbA1cBMI Non- smokers % <140/90 mm Hg % < 2.5 mmol/l (%) <7%< 25 kg/m2 ( % ) Anand et al, 1999 195Canada3816NA Mukherjee et al, 2002 66USA895742NA 73 Teh et al, 2003 189Australia623538NA Brown et al, 2004 281Canada446662NA Sukhija et al, 2005 561USA8979544654NA 78 Rehring et al, 2005 1733USANA3129NA2340NA Hackam et al, 2006 1507Canada907658NA67NA 79 Bradley&Kirker, 2006 107UK6047NA Kinikini et al, 2006 200USA7961485436243373 AlOmran et al, 2006 391Canada7861453547492767 Current study, 2008 140KSA804037 64 15 3278 How about the rest of the World?

28. 28 Conclusion The control of risk factors in patients with PAD is suboptimal

29. 29 Is there a missed opportunity in using PAD (ABI) as a predictor in order to prevent the adverse cardiovascular outcomes?

30. 30 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 To identify the prevalence of PAD in patients presenting with acute coronary events and do not have history of CAD (missed opportunity) To identify the prevalence of PAD in patients presenting with acute coronary events and do not have history of CAD (missed opportunity)

31. - 545 patients with PAD (2479 ACS patients) - Mean age 63 - Male 72% Prevalence of PAD 22 % Prevalence of PAD in patient with no history of CAD Prevalence of PAD in patient with no history of CAD 38% 38% Peripheral Arterial Disease in SPACE registry:

32. 32 Risk Reduction Therapy Therapy All PAD patients % Symptomatic PAD % Asymptomatic PAD % Aspirin Aspirin65.070.055.0 Statin Statin55.060.047.0 ACE-I ACE-I43.045.034.0 Risk Reduction Pharmacotherapy in patients with PAD (SPACE registry):

33. 33 Conclusion We can simply utilize this opportunity by recognizing patients with PAD (symptomatic or asymptomatic) and aggressively control their risk factors We can simply utilize this opportunity by recognizing patients with PAD (symptomatic or asymptomatic) and aggressively control their risk factors There is a great opportunity in preventing acute coronary events that we are missing There is a great opportunity in preventing acute coronary events that we are missing

34. 34 a public awareness about PAD? Is there a public awareness about PAD?

35. 35 a public awareness about PAD? 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%)

36. 36 a public awareness about PAD? Is there a public awareness about PAD?

37. 37 a public awareness about PAD? Is there a public awareness about PAD?

38. 38 a public awareness about PAD? Is there a public awareness about PAD?

39. 39 Conclusion suboptimal The awareness of public towards PAD is

40. 40 So, Let’s wrap-up

41. 41 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?

42. Future Direction - Increase public and Physicians awareness - Increase public and Physicians awareness - Disseminating the guidelines - Disseminating the guidelines - PAD registry and Practice auditing - PAD registry and Practice auditing

43. 43 Task Force - Physicians awareness - Physicians awareness Outreach CME program Outreach CME program

44. 44 Task Force - Public awareness - Public awareness Campaigns in shopping centres Campaigns in shopping centres

45. 45 Task Force -PAD registry and Practice auditing King Khalid University Hospital King Khalid University Hospital

46. 46 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 Conclusions

47. 47 “The journey of a thousand miles begins with one step”

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