Excess cardiovascular mortality at 5-year, getABI study - HOTLINE 3 

Presenter report : Diehm, Curt (Germany)

Peripheral arterial disease (PAD) is widely accepted as an indicator disease for generalized atherosclerosis. The disease can be easily and reliably diagnosed in the primary care setting by determining the ratio between the systolic blood pressure in the arteries at the ankle and the arm (ankle-brachial index, which is 0.9 or above in healthy individuals).

The aim of the German Epidemiological Trial on Ankle Brachial Index (getABI) was to quantify the excess cardiovascular risk borne by symptomatic and asymptomatic PAD patients compared to those without PAD in a sample of elderly patients. Thus, the study was set up as large-scale prospective observational epidemiological trial in 344 representative family practices across Germany. A total of 6,880 unselected patients aged 65 years or older were included in 2001. To achieve optimal data quality, the study was monitored, and an unprecedented follow-up of the patients’ survival status was achieved. At the hotline session, the survival data at 5 years based on the status of 97.4% of the initial patient cohort were reported.

The study included a total of 6880 unselected patients, which underwent ABI testing by their primary care physician. Mean age of the patients at baseline was 72.5 years, 58% were females, 46% had formerly smoked or were current smokers, 74% had hypertension, 24% diabetes mellitus and 52% lipid disorders. Of all patients, 12.1% had asymptomatic PAD (pathological ABI test, but no complaints) and 8.7% had symptomatic PAD.

After a 5-year observation period, all-cause mortality was 24.1% in patients with symptomatic PAD, 19.2% with asymptomatic PAD, and 9.5% in patients without PAD. Even when all other known risk factors for cardiovascular death were accounted for by statistical means, PAD had the best ability to predict future death, stroke or myocardial infarction. There was a strong association between lower ABI categories and risk of premature death.

The authors concluded that not only symptomatic, but also asymptomatic PAD patients carry a substantially increased risk for all-cause mortality, compared to individuals without PAD.
Their data strongly support the rationale for screening for high-risk PAD patients by determination of the ABI in the primary care setting. This might ensure timely treatment of patients’ modifiable atherosclerotic risk factors.

Discussant report: Poldermans, Don (Netherlands)

In the study presented at the Hot Line III session; “Excess cardiovascular mortality in patients with peripheral arterial disease in primary care: 5-year results of the getABI study” showed a poor prognosis of peripheral arterial disease (PAD) patients. A total of 6880 patients of 65 years or older from primary care centers were evaluated by an ankle brachial index for the presence of PAD. The incidence was 18%, while more than half of the patients were asymptomatic. There was a correlation between the severity of PAD and prognosis, importantly there was no difference between asymptomatic and symptomatic PAD. In patients with severe PAD the 5-year mortality was 50%. The cause of this high event rate in PAD patients is multifactorial. The extent of atherosclerosis is related to the level of inflammation, closely correlated with coronary plaque instability and subsequently acute coronary syndromes. Furthermore patients with PAD are significantly less likely to receive cardiovascular therapy; i.e. antiplatelet therapy, statins, ACE-inhibitors, and beta-blockers. This was shown in a study presented at the scientific sessions of the ESC. In 2439 patients with symptomatic CAD, survival during 10 year follow-up was superior as compared to a matched population of cardiovascular risk factors of patients with PAD. Importantly, cardiovascular therapy adherence to guidelines recommendations for medical therapy of the ESC was superior in CAD patients1. The consultation of PAD patients by the general physician offers an unique opportunity to implement cardiovascular medical therapy according to the current guidelines

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