Preventative medical practices in patients with vascular occlusive disease at Royal Perth Hospital Lip Gen Teh MBBS Kishore Sieunarine MBBS FRCSE FRACS John Eikelboom MBBS FRACP FRCPA

Background Peripheral Vascular Occlusive DiseasePeripheral Vascular Occlusive Disease

Background –increased mortality

Background Peripheral Vascular Occlusive DiseasePeripheral Vascular Occlusive Disease –increased mortality 50% in patients operated for critical limb ischaemia50% in patients operated for critical limb ischaemia

Background Peripheral Vascular Occlusive DiseasePeripheral Vascular Occlusive Disease –increased mortality 50% over 5years in patients operated for critical limb ischaemia50% over 5years in patients operated for critical limb ischaemia 2.7x increased risk with asymptomatic carotid artery stenosis2.7x increased risk with asymptomatic carotid artery stenosis 60% over 5 years following a first stroke60% over 5 years following a first stroke

Background Preventive MedicinePreventive Medicine –Antiplatelet therapy 25% reduction in vascular events in high risk groups25% reduction in vascular events in high risk groups –Beta Blockers 34% reduction in all-cause mortality in patients with class II-III heart failure34% reduction in all-cause mortality in patients with class II-III heart failure

Background Preventive MedicinePreventive Medicine –Antilipid 40% reduction in vascular events in high risk groups (4S)40% reduction in vascular events in high risk groups (4S) –Antihypertensive therapy 40% reduction in major cardiovascular events40% reduction in major cardiovascular events

Background Preventive MedicinePreventive Medicine –Glucose Lowering 6% reduction in all cause mortality6% reduction in all cause mortality mainly microvascular benefits (UKPDS)mainly microvascular benefits (UKPDS) –Warfarin ?50% reduction in all cause mortality in 5 years?50% reduction in all cause mortality in 5 years

Study Aim Investigate the pattern of preventive practices in a high risk group of patients.Investigate the pattern of preventive practices in a high risk group of patients. –2 groups: (1) PVD (2) carotid disease Examine possible reasons for low rates of preventive practicesExamine possible reasons for low rates of preventive practices

Design Restrospective case note reviewRestrospective case note review InclusionInclusion –all first inpatient admissions undergoing a diagnostic or therapeutic procedure for vascular occlusive disease in the year 2000

Results 262 cases identified262 cases identified 6 (2.3%) case notes unavailable6 (2.3%) case notes unavailable

Demographics

Risk factors

Risk factors:Smoking

Multiple Risk factors

Vascular Comorbidities

Indications 26% (n=67) carotid26% (n=67) carotid –33% asymptomatic –87% endarterectomies –10% carotid angiogram

Indications 74% (n=189) PVD74% (n=189) PVD

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

Antiplatelet Therapy Overall, 29.7% not on any form of antiplatelet therapyOverall, 29.7% not on any form of antiplatelet therapy –carotid group 6% not on antiplatelet –PVD group 38.1% not on antiplatelet

Warfarin 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 antithrombotic therapy19.5% not on antiplatelet or antithrombotic therapy

Antiplatelet Therapy

At Risk Subgroup in PVD patients with no vascular co- morbidities (n=115)in PVD patients with no vascular co- morbidities (n=115) 51.4% were on antiplatelet versus 75.6% in those with vascular co-morbidities51.4% were on antiplatelet versus 75.6% in those with vascular co-morbidities

Antihypertensives 72% on antihypertensives72% on antihypertensives –83% in carotid patients –68% in PVD patients –(chi sq=4.7, p=0.03) beta blockersbeta blockers –34% in carotid –18% in PVD

Anticholesterol 43% on cholesterol lowering therapy43% on cholesterol lowering therapy –63% in carotid –36% in PVD –(chi sq=14.4, p<0.001)

Hypoglycaemics 76.9% of diabetics on glucose lowering medications overall76.9% of diabetics on glucose lowering medications overall –83% in carotid –75% in PVD

Discussion

Discussion Rate of preventive practices are 2x higher for antiplatelet and antilipid therapies.Rate of preventive practices are 2x higher for antiplatelet and antilipid therapies. Long term prognosis of claudicants is poor and mortality approaches that of those with carotid disease.Long term prognosis of claudicants is poor and mortality approaches that of those with carotid disease.

Discussion compared to carotid patients, use of preventive therapies are suboptimal in PVD patients.compared to carotid patients, use of preventive therapies are suboptimal in PVD patients. Subgroup most neglected are those with no coexistent coronary or cerebrovascular comorbiditiesSubgroup most neglected are those with no coexistent coronary or cerebrovascular comorbidities –main medical contact are vascular surgeons