Preventative medical Preventative medical practices in patients practices in patients with vascular occlusive with vascular occlusive disease at Royal Perth disease at Royal Perth HospitalHospital

Lip Gen Teh MBBS

Kishore Sieunarine MBBS FRCSE FRACS

John Eikelboom MBBS FRACP FRCPA

BackgroundBackground

• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease

BackgroundBackground

• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease– increased mortalityincreased mortality

BackgroundBackground

• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease– increased mortalityincreased mortality

• 50% in patients operated for critical 50% in patients operated for critical limb ischaemialimb ischaemia

BackgroundBackground

• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease– increased mortalityincreased mortality

• 50% over 5years in patients operated 50% over 5years in patients operated for critical limb ischaemiafor critical limb ischaemia

• 2.7x increased risk with asymptomatic 2.7x increased risk with asymptomatic carotid artery stenosiscarotid artery stenosis

• 60% over 5 years following a first stroke60% over 5 years following a first stroke

BackgroundBackground

• Preventive MedicinePreventive Medicine– Antiplatelet therapyAntiplatelet therapy

• 25% reduction in vascular events in 25% reduction in vascular events in high risk groupshigh risk groups

– Beta BlockersBeta Blockers• 34% reduction in all-cause mortality in 34% reduction in all-cause mortality in

patients with class II-III heart failurepatients with class II-III heart failure

BackgroundBackground

• Preventive MedicinePreventive Medicine– AntilipidAntilipid

• 40% reduction in vascular events in 40% reduction in vascular events in high risk groups (4S)high risk groups (4S)

– Antihypertensive therapyAntihypertensive therapy• 40% reduction in major cardiovascular 40% reduction in major cardiovascular

eventsevents

BackgroundBackground

• Preventive MedicinePreventive Medicine– Glucose LoweringGlucose Lowering

• 6% reduction in all cause mortality6% reduction in all cause mortality

• mainly microvascular benefits (UKPDS)mainly microvascular benefits (UKPDS)

– WarfarinWarfarin• ?50% reduction in all cause mortality in ?50% reduction in all cause mortality in

5 years5 years

Study AimStudy Aim

• Investigate the pattern of Investigate the pattern of preventive practices in a high risk preventive practices in a high risk group of patients.group of patients.– 2 groups: (1) PVD (2) carotid disease2 groups: (1) PVD (2) carotid disease

• Examine possible reasons for low Examine possible reasons for low rates of preventive practicesrates of preventive practices

DesignDesign

• Restrospective case note reviewRestrospective case note review

• InclusionInclusion– all first inpatient admissions all first inpatient admissions

undergoing a diagnostic or therapeutic undergoing a diagnostic or therapeutic procedure for vascular occlusive procedure for vascular occlusive disease in the year 2000disease in the year 2000

ResultsResults

• 262 cases identified262 cases identified

• 6 (2.3%) case notes unavailable6 (2.3%) case notes unavailable

DemographicsDemographics

Overall PVD CarotidN 256 189 67

Age (years) mean 70.2 70.2 70.1 median 71.0 71.0 41.0 range 35-98 35-98 86.0 std dev 10.9 11.4 9.1

Sex males 68.4% 66.7% 73.5% females 31.6% 33.3% 26.5%

LOS (days) mean 9.3 10.6 5.7 median 6.0 7.0 4.0 range 1-70 1-70 1-20 std dev 10.0 11.0 4.0

Risk factorsRisk factors

Cardiovascular disease risk factor prevalence

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Hypertension

Hyperlipidaemia

Smoker

Diabetic

Carotid

PVD

Overall

Risk factors:SmokingRisk factors:Smoking

Smoking History

0.0% 20.0% 40.0% 60.0% 80.0%

All

PVD

Carotid

current smokerex smoker

Multiple Risk factorsMultiple Risk factorsCumulative Risk Factors

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

0 1 2 3 4

Number of Risk Factors

Overall

PVD

Carotid

Vascular ComorbiditiesVascular Comorbidities

0

10

20

30

40

50

60

Angina MI PTA CABG TIA CVA

IndicationsIndications

• 26% (n=67) carotid26% (n=67) carotid– 33% asymptomatic33% asymptomatic

– 87% endarterectomies87% endarterectomies

– 10% carotid angiogram10% carotid angiogram

IndicationsIndications

• 74% (n=189) PVD74% (n=189) PVD

PVD Proceduresbypass 19.6%endarterectomy 3.7%profundaplasty 0.5%amputation 16.4%angioplasty/stent 28.0%angiogram 21.7%debridement 2.1%sympathectomy 1.1%other 6.9%

ComplicationsComplications

• 6 deaths6 deaths

• 2% angina, 2% MI2% angina, 2% MI

• 6 TIAs and 1 stroke overall6 TIAs and 1 stroke overall– 4 TIAs in carotid endarterectomies (7%)4 TIAs in carotid endarterectomies (7%)

– all in symptomatic patients (10.3%)all in symptomatic patients (10.3%)

Antiplatelet TherapyAntiplatelet Therapy

• Overall, 29.7% not on any form of Overall, 29.7% not on any form of antiplatelet therapyantiplatelet therapy– carotid group 6% not on antiplateletcarotid group 6% not on antiplatelet

– PVD group 38.1% not on antiplateletPVD group 38.1% not on antiplatelet

WarfarinWarfarin

• 16% on warfarin16% on warfarin

• 6% in carotid group6% in carotid group

• 20% in PVD group20% in PVD group

• 19.5% not on antiplatelet or 19.5% not on antiplatelet or antithrombotic therapyantithrombotic therapy

Antiplatelet TherapyAntiplatelet TherapyAntithrombotic therapy

0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0%

Aspirin

Ticlopidine

Clopidogrel

Dipyridamole

Warfarin

Antiplatelet

Antithrombotic

Carotid

PVD

ALL

At Risk SubgroupAt Risk Subgroup

• in PVD patients with no vascular co-in PVD patients with no vascular co-morbidities (n=115)morbidities (n=115)

• 51.4% were on antiplatelet versus 51.4% were on antiplatelet versus 75.6% in those with vascular co-75.6% in those with vascular co-morbiditiesmorbidities

AntihypertensivesAntihypertensives

• 72% on antihypertensives72% on antihypertensives– 83% in carotid patients83% in carotid patients

– 68% in PVD patients68% in PVD patients

– (chi sq=4.7, p=0.03)(chi sq=4.7, p=0.03)

• beta blockersbeta blockers– 34% in carotid34% in carotid

– 18% in PVD18% in PVD

AnticholesterolAnticholesterol

• 43% on cholesterol lowering therapy43% on cholesterol lowering therapy– 63% in carotid63% in carotid

– 36% in PVD36% in PVD

– (chi sq=14.4, p<0.001)(chi sq=14.4, p<0.001)

HypoglycaemicsHypoglycaemics

• 76.9% of diabetics on glucose 76.9% of diabetics on glucose lowering medications overalllowering medications overall– 83% in carotid83% in carotid

– 75% in PVD75% in PVD

DiscussionDiscussion

0

10

20

30

40

50

60

70

Perth Copenhagen Ontario

AntiplateletAntilipid

DiscussionDiscussion

• Rate of preventive practices are 2x Rate of preventive practices are 2x higher for antiplatelet and antilipid higher for antiplatelet and antilipid therapies.therapies.

• Long term prognosis of claudicants Long term prognosis of claudicants is poor and mortality approaches is poor and mortality approaches that of those with carotid disease.that of those with carotid disease.

DiscussionDiscussion

• compared to carotid patients, use of compared to carotid patients, use of preventive therapies are suboptimal in preventive therapies are suboptimal in PVD patients.PVD patients.

• Subgroup most neglected are those Subgroup most neglected are those with no coexistent coronary or with no coexistent coronary or cerebrovascular comorbiditiescerebrovascular comorbidities

– main medical contact are vascular main medical contact are vascular surgeonssurgeons