Invited commentary
Article Outline
The American Heart Association has estimated that 8 to 12 million Americans are afflicted with peripheral arterial disease (PAD) and that nearly 75% of PAD patients are asymptomatic.1 We, as vascular specialists, know all to well that the presence of PAD is associated with an increased risk of cardiovascular morbidity and mortality and that improvements in risk-factor profiles with behavior modification and pharmacotherapy can decrease the adverse outcomes of stroke, myocardial infarction, and limb loss. The key issue is the identification of persons at risk before symptomatic or critical disease becomes present. For that reason, unrecognized PAD constitutes an enormous public health problem with the potential for serious, if not fatal, consequences.
Many health organizations, including many professional vascular societies as well as governmental agencies, have recognized the importance of early screening and thus have joined groups such as The Peripheral Arterial Disease Coalition to improve both public and health professional awareness about the disease. It is well known that a simple ankle-brachial index measurement may provide an indication of the presence of subclinical atherosclerotic disease, therefore identifying patients who warrant aggressive education and risk-factor management.
As an example, the PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program, a multicenter, cross-sectional study conducted at 27 sites in 25 cities and 350 primary care practices throughout the United States (US), demonstrated a prevalence of PAD in 29% of patients screened in a primary care setting, only 11% of whom had classic symptoms of claudication.2 Furthermore, many persons had been previously undiagnosed, and as a result of this unawareness, the rate of intensive treatment for risk factors was low. In addition in this study, screening tests discovered patients who also, not uncommonly, had concomitant cardiac, cerebrovascular, or abdominal aortic aneurysmal disease.
Martin and colleagues have taken community PAD screening programs to a new level and have established a new standard to which all should be upheld. In their unique Dare to C.A.R.E. program, they have successfully developed a screening program which include noninvasive testing for vascular disease, glucose and cholesterol measurements, and blood pressure determination. The most amazing, and perhaps important, aspect of the program is the involvement of community physicians and health care providers in providing educational lectures to each participant. By keeping meticulous records, the authors are able report herein on the results of the first 6 years of more than 12,000 screenings.
It is unfortunate that the US Preventative Services Task Force reiterated in 2005 their 1996 recommendations against PAD screening except for a single ultrasound scan for abdominal aortic aneurysms in men aged older than 65 years who have ever smoked.3 The belief of this Task Force that “screening-associated” harm may occur in the form of unnecessary interventions may actually contribute to the under-recognition and treatment of PAD. Martin et al have shown that not only can the tests be beneficial, regardless of whether or not they lead to interventions, but that the resultant education and disease awareness and institution of medical therapy from the screenings may avoid the public health problem of undetected PAD and resultant adverse cardiovascular events. I congratulate his group on their success and ability to unite their community around the program.
References
- American Heart Association. PAD Quick Facts. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3020248. Accessed Apr 30, 2007.
- Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–1324
- . The United States preventive services task force recommendation statement on screening for peripheral arterial disease: more harm than benefit?. Circulation. 2006;114:861–866
PII: S0741-5214(07)00770-7
doi:10.1016/j.jvs.2007.05.001
© 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Results of a single center vascular screening and education program
