In a recent clinical update on Peripheral Arterial Disease (PAD) Professor Jonathan Golledge, vascular surgeon and head of the Queensland Research Centre of Peripheral Vascular Disease, emphasised the importance of acknowledging PAD as a systemic disease requiring intensive medical management.

We sat down with Professor Golledge and asked his perspectives on management priorities and education needs of both healthcare professionals and their patients.

What has the data shown in terms of rates of major cardiovascular events in patients with PAD?

Patients with PAD are at a high risk of major cardiovascular events¹, reflecting the systemic nature of this disease. Essentially, PAD can be regarded as a high-risk presentation of cardiovascular disease.

Despite the need for lipid-lowering in PAD, you presented figures suggesting that around 30% of patients are not prescribed a lipid lowering therapy. Can you comment on this?

Not only are there a significant proportion of patients who are not on a statin, but those who are on a statin are often not on a sufficiently high dose. My interpretation of data from trials such as FOURIER¹ is that all patients with PAD should be on a high-intensity treatment.

What are some of the reasons for suboptimal management?

PAD management tends to focus on interventions (i.e. revascularisation) rather than on medical management. In addition, general practitioners are often concerned about the use of high-dose statins. Patients themselves have been misinformed on the safety of statins and are also reluctant to take high doses. There needs to be more education on the benefit of high-intensity lipid lowering treatment for PAD.

Patients tend to focus on leg pain as their major concern. What do you recommend for this?

There has been limited study on the effect of intense medical management, such as LDL- cholesterol lowering, on leg symptoms with the focus usually on interventional management. The FOURIER trial¹ showed reduced leg events with intense LDL-cholesterol lowering. Although leg events are not the same as leg symptoms, I would suspect that treating the disease systemically will improve the symptoms in the leg.

Exercise is important for PAD patients to improve muscle strength and encourage angiogenesis, and structured exercise programs have been demonstrated to increase walking distance. Low activity is also a marker for mortality in PAD patients, so increasing patient activity is very important. Unfortunately, exercise programs are not well funded on Medicare, despite the fact that the cost of providing an exercise program is likely significantly less than the cost of revascularisation.

What’s the role of patient education in better management of PAD?

Some patients mistakenly believe that the PAD is a short-term fixable issue that will be resolved with stenting. They don’t appreciate the long-term sequelae of the condition. They also think that walking is detrimental to their health because it results in pain. Re-education is very important.

What are the order of priorities for GPs in diagnosing and managing PAD?

GPs need to diagnose the condition more readily. They can screen high risk patients for PAD by performing a simple ankle-brachial index test (which is reimbursed on Medicare when a hard-copy Doppler tracing is provided).

Critical limb ischaemia needs urgent referral for revascularisation. It presents with rest pain and tissue loss with associated ischemia. Rest pain is often not correctly diagnosed: it’s pain in the foot that keeps a patient awake at night and is relieved when the patient hangs their leg down (for example out of the bed).

In non-limb-threatening ischemia, optimal management includes a lipid lowering medication, blood pressure under 140/90, an exercise program, and anti-platelet medication.

The FOURIER trial¹ showed that there was a reduction in both major adverse cardiovascular events and major adverse limb events. Can you comment on this?

These results reinforce the importance of lowering LDL-cholesterol in these patients and emphasise the high risk of events in this subset of patients. If we were to focus on any particular patient group for lipid lowering therapy, PAD patients would result in the greatest ‘bang for buck’ due to their high risk of CV events.

Professor Golledge provided a clinical update on Peripheral Arterial Disease (PAD) at a recent meeting in Melbourne of cardiologists and endocrinologists held by Amgen.

Reference

1. Bonaca MP, et al. Low-density lipoprotein cholesterol lowering with evolocumab and outcomes in patients with peripheral artery disease. Circulation. 2018;137:338-50. https://www.ncbi.nlm.nih.gov/pubmed/29133605