Prof. Denis Clement ,
Patients with peripheral artery disease are at high risk due to undetected coronary and/or carotid artery disease. Cardiologists need to pay full attention to control this dangerous condition.
It has been repeatedly shown that survival of patients with peripheral artery disease (PAD) is dramatically decreased compared to control populations(1); this comes out true even when the PAD is asymptomatic. Mortality is largely due to associated coronary (65%) or carotid artery disease (10%) and much less to PAD itself. Indeed, prevalence of coronary disease in PAD patients ranges between 34 and 58% and 20 to 40% have a significant carotid artery stenosis (2). The message of this is that the cardiologists need to better realise that PAD patients are at high risk and that simple non invasive techniques (such as an electrocardiogram and Duplex of the carotid arteries) should be done to timely detect the associated vascular abnormality. Such is particularly the case when any surgery is being planned (The CoCaLis document, 3). More recently, attention has been attracted on the presence of other life-threatening diseases like aortic aneurysm and renovascular diseases. All means should be used to measure and treat the risk for example with antiplatelet drugs (CAPRIE study, 4), ACE inhibitors (HOPE Study, 5), betablocking agents (DECREASE Study, 6) and statins (Heart Protection Study, 7). Studies and analyses are under way to find out on the financial implications of this condition (3).
Cardiologists have always underestimated the significant role PAD plays in the cardiovascular territory; they should focus their attention on these patients who are at severe risk and often are on their way to life-threatening complications. PAD patients are regularly seen at all sites where cardiologists are practising such as in the hospital but at least as many are seen in regular all day private practices. PAD can be seen as a strong indicator for coronary and/or carotid disease. As suggested by leading authorities, cardiologists should be aware that their field of expertise is not limited to the heart; the title of the speciality should be converted to “cardiology and vascular medicine” and training should be adequately adapted to increase knowledge and expertise in this rapidly growing field.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1. FOWKES FGR. Epidemiology of atherosclerotic arterial disease in the lower limbs. Eur J Vasc Surg 1988 ; 2 : 283 - 291. 2. DORMANDY J, MAHIR M, ASCADY G, et al. Fate of the patient with chronic leg ischaemia. J Cardiovasc Surg 1989 ; 30 : 50 – 57 3. CLEMENT DL, BOCCALON H, DORMANDY J, DURAND-ZALESKI I, FOWKES G, BROWN T. A clinical approach to the management of the patient with coronary (Co) and/or carotid (Ca) artery disease who presents with leg ischaemia (Lis). Int Angiol 1999 ; 19 : 97-125. 4. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel vs. aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996 ; 348 : 1329 – 1339. 5. The heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, Ramipril, on cardiovascular events in high- risk patients. N Engl J Med 2000 ; 342 : 145 – 153. 6. POLDERMANS D, BOERSMA E, BAX JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 1999 ; 341 – 1789 – 1794. 7. Heart protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals : a randomised placebo-controlled trial. Lancet 2002 ; 360 : 7 – 22.
Prof. D.L. Clément Ghent, Belgium C WG on Peripheral Circulation
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