Peripheral Arterial Disease in Peripheral Arterial Disease in Saudi ArabiaSaudi Arabia : :

Where Do We Stand? Where Do We Stand?

Mohammed Al-Omran,Mohammed Al-Omran, MD, MSc, FRCSC MD, MSc, FRCSCAssociate Professor & Vascular Surgeon, King Saud University Associate Professor & Vascular Surgeon, King Saud University Scientist, LKSKI- St’ Michael’s Hospital, University of Toronto Scientist, LKSKI- St’ Michael’s Hospital, University of Toronto

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Why it is important to recognize patients with PAD?Why it is important to recognize patients with PAD? S

urv

ival

(%

)

Follow-up (years)

Controls

IC

CLI

0 5 10 150

20

40

60

80

100

CLI=critical limb ischemia.IC=intermittent claudication.Norgren L et al. Eur J Vasc Endovasc Surg. 2007;33(suppl 1):S1-S75.

Life expectancy reduced by Life expectancy reduced by 10 years10 years in patients with PAD in patients with PAD

Mortality rateMortality rate~ 25% at 5 years~ 25% at 5 years

~ 50% at 10 years~ 50% at 10 years~ 75% at 15 years~ 75% at 15 years

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Why it is important to recognize patients with PAD?Why it is important to recognize patients with PAD?

PAD places individuals at high short and long term risk of MI, Stroke & Death

Management of PADManagement of PAD

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What are the Goals of treating patients with PAD?What are the Goals of treating patients with PAD?

Relief symptomsRelief symptoms

Improve quality of lifeImprove quality of life

Limb salvageLimb salvage

Prolong survivalProlong survival

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Strategies in treating patients with PADStrategies in treating patients with PAD

Improve Lower Limb CirculationImprove Lower Limb Circulation

Risk Factors Modification

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Strategies in treating patients with PADStrategies in treating patients with PAD

Risk Factors Modification• Diet and weight controlDiet and weight control• ExerciseExercise• Antiplatlets Antiplatlets • Hypertension controlHypertension control• Diabetes controlDiabetes control• Lipid controlLipid control• Smoking CessationSmoking Cessation

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Improve Lower Limb CirculationImprove Lower Limb Circulation• Conservative (Exercise Program)Conservative (Exercise Program)• Intervention ( Revascularization)Intervention ( Revascularization)

- Angioplasty +/- Stenting- Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass

Strategies in treating patients with Strategies in treating patients with PADPAD

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Summary of the Evidence

GoalsGoals

RecommendationRecommendationClass of Class of

recommendationrecommendationLevel of Level of evidenceevidence

Blood pressureBlood pressure

SystolicSystolic <140 mm Hg in all patients<140 mm Hg in all patients <130 mm Hg in diabetic patients<130 mm Hg in diabetic patientsDiastolic Diastolic <90 mm Hg in all patients<90 mm Hg in all patients <80 mm Hg in diabetic patients<80 mm Hg in diabetic patients

II AA

LDL-CLDL-C LDL< 2.5 mmol/l in all patientsLDL< 2.5 mmol/l in all patients II AA

DiabetesDiabetes HbA1c<7% in diabetic patientsHbA1c<7% in diabetic patients II BB

SmokingSmoking Complete cessation in all patientsComplete cessation in all patients II BB

BMIBMI 18.5-24.918.5-24.9 kg/mkg/m22 in all patients in all patients II BB

Physical ActivityPhysical Activity 3030 minutes (5 days/week)minutes (5 days/week) II BB

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Summary of the Evidence

Medications Medications RecommendationRecommendation

Class of Class of recommendationrecommendation

Level of Level of evidenceevidence

AntiplatletsAntiplatlets All patientsAll patientsII AA

StatinsStatins All patientsAll patients II AA

ACE inhibitorsACE inhibitors Symptomatic patientsSymptomatic patientsAsymptomatic patientsAsymptomatic patients

II IIaIIa

BB BB

What Should We Know?What Should We Know?

Where Do We Stand in Saudi Arabia?Where Do We Stand in Saudi Arabia?

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What Should we Know?What Should we Know?

Is PAD a Is PAD a public healthpublic health issue? issue?

Health Care Provider:Health Care Provider:

Is there a Is there a knowledge knowledge gap?gap?

Is there an Is there an action action gap?gap?

Is there a Is there a care care gap?gap?

Is there a Is there a missed opportunitymissed opportunity in using PAD (ABI) as a predictor in using PAD (ABI) as a predictor

in order to prevent the adverse cardiovascular outcomes?in order to prevent the adverse cardiovascular outcomes?

Population:Population:

Is there a Is there a public awareness public awareness about PAD? about PAD?

What Do We Know?What Do We Know?

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Is PAD a Public Health Issue ?Is PAD a Public Health Issue ?

Prevalence of and Risk Factors for Peripheral Arterial Disease in Saudi Prevalence of and Risk Factors for Peripheral Arterial Disease in Saudi Arabia: A Pilot Cross-sectional StudyArabia: A Pilot Cross-sectional Study

- - 471 patients471 patients

- Mean age 57- Mean age 57

- Male 68% - Male 68%

Prevalence Prevalence

- - 11.7 %11.7 % (95% CI 8.9% to 14.9%) (95% CI 8.9% to 14.9%)

- 92.7% were asymptomatic - 92.7% were asymptomatic 00.5

11.5

22.5

33.5

44.5

Alshaekh et al. SMJ. 2007;28:412-414

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19.1% 19.8%

Prevalence was estimated using different methods1. Meijer WT et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 2. Diehm C et al. Atherosclerosis. 2004;172:95-105. 3. Selvin E et al. NHANES. Circulation. 2004;110:738-743.4. Criqui MH et al. Circulation. 1985;71:510-515.5. Hirsch AT et al. JAMA. 2001;286:1317-1324.

Prevalence of PADPrevalence of PAD

14.5%

29.0%

11.7%

4.3%

PARTNERSPARTNERS55

Age >70, or between 50–69 with history of diabetes or smoking

San DiegoSan Diego44

Mean Age=66DiehmDiehm22

Age ≥65RotterdamRotterdam11

Age >55NHANESNHANES33

Age ≥70NHANESNHANES33

Age >40

European Data US Data

11.7%

Saudi Data

Pilot StudyPilot Study66

Age >45

6. Alshaekh et al. SMJ. 2007;28:412-414

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Is there a knowledge and action gaps in managing patients with PAD?

Atherosclerotic Risk Reduction Therapy in Peripheral Arterial Disease Atherosclerotic Risk Reduction Therapy in Peripheral Arterial Disease Compared to Coronary Artery Disease: Perception and Knowledge of Compared to Coronary Artery Disease: Perception and Knowledge of

Physicians in Saudi ArabiaPhysicians in Saudi Arabia

- 897 physicians (Internists/ GPs/ Cardiologists/ Vascular Surgeons) 897 physicians (Internists/ GPs/ Cardiologists/ Vascular Surgeons)

- Response rate 59 % (529 physicians)Response rate 59 % (529 physicians)

65 55

279

148162

107

413

219

0

50

100

150

200

250

300

350

400

450

Vascular Cardio GP Internists

distributed

responders

85%

53%

66%

53%

Al-Omran et al. In press

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PADPAD

%%

CADCAD

%%

LDL-Cholesterol LDL-Cholesterol (<2.5mmol/l)(<2.5mmol/l) 3636 4040

Blood Pressure Blood Pressure (<130/85 mmHg)(<130/85 mmHg) 2828 3232

Blood Glucose Blood Glucose (Hb 1Ac<7%)(Hb 1Ac<7%) 6666 6868

Knowledge of the current recommended target of:

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PADPAD

%%

CADCAD

%%

Lipid profile measurementLipid profile measurement 9595 9898

Blood pressure measurementBlood pressure measurement 9999 9999

Blood glucose measurementBlood glucose measurement 9696 9999

Asking about smokingAsking about smoking 9999 9999

Attitude towards routine evaluation of risk factors:Attitude towards routine evaluation of risk factors:

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PADPAD

%%

CADCAD

%%

LDL- Cholesterol reductionLDL- Cholesterol reduction 9696 9898

Blood pressure controlBlood pressure control 9999 9999

Blood glucose controlBlood glucose control 9797 9898

Smoking CessationSmoking Cessation 9797 9898

Attitude towards routine patients counseling with Attitude towards routine patients counseling with regards to the importance of:regards to the importance of:

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PADPAD

%%

CADCAD

%%

Anti-plateletsAnti-platelets 86.386.3 94.194.1

StatinsStatins 5656 6161

ACE- inhibitorsACE- inhibitors 3434 5252

Anti-hypertensive MedicationsAnti-hypertensive Medications 5858 6363

Referral to Referral to Smoking Cessation ClinicSmoking Cessation Clinic 3737 4242

Nicotine replacement therapy Nicotine replacement therapy 4343 5050

Attitude towards routine initiating/modifying risk Attitude towards routine initiating/modifying risk reduction pharmacotherapy:reduction pharmacotherapy:

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ConclusionConclusion

Despite a considerable effort to Despite a considerable effort to evaluateevaluate and and counselcounsel patients for their atherosclerotic risk factorspatients for their atherosclerotic risk factors

The perception towards risk reduction The perception towards risk reduction in PAD/CAD identify in PAD/CAD identify

glaring knowledge and action gapsglaring knowledge and action gaps

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Is there a care gap in managing patients with PAD?

Risk Reduction Status in Patients with Risk Reduction Status in Patients with Peripheral Arterial Disease Presenting to a Peripheral Arterial Disease Presenting to a

Major Teaching HospitalMajor Teaching Hospital

- - 140 consecutive symptomatic PAD patients presented 140 consecutive symptomatic PAD patients presented to KKUH over 1 year to KKUH over 1 year (Jan 2006 – Dec 2006)(Jan 2006 – Dec 2006)

-Mean age 62-Mean age 62

MALE:FEMALE

76%

24%

MALE FEMALE

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Risk FactorRisk Factor %%Optimal Optimal Control Control

(%) (%)

Sex (male)Sex (male) 7575 --

HypertensionHypertension 5959 3737

Diabetes MellitusDiabetes Mellitus 8585 1515

HypercholesterolemiaHypercholesterolemia 4040 6464

SmokingSmoking 3232 --

Obesity/OverweightObesity/Overweight 6868 --

Risk Reduction Risk Reduction

TherapyTherapy%%

Optimal Control (%) Optimal Control (%)

StatinStatin 40.040.0 64.064.0

Anti-thromboticAnti-thrombotic 80.080.0 --

ACE-IACE-I 37.037.0 40.040.0

Risk Reduction Status in Patients with Peripheral Arterial Disease Risk Reduction Status in Patients with Peripheral Arterial Disease Presenting to a Major Teaching HospitalPresenting to a Major Teaching Hospital

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Study # of patients

Setting Antiplatlet s use %

Statin use %

ACE inhibitors

use (%)

BP LDL-C HbA1c BMI Non-

smokers %<140/90 mm Hg

%< 2.5 mmol/l

(%)<7% < 25 kg/m2

  ( % ) (%) (%)

 

Anand et al, 1999 195 Canada 38 16 NA NA NA NA NA NA

Mukherjee et al, 2002

66 USA 89 57 42 NA NA NA NA 73

Teh et al, 2003 189 Australia 62 35 38 NA NA NA NA NA

Brown et al, 2004 281 Canada 44 66 62 NA NA NA NA NA

Sukhija et al, 2005

561 USA 89 79 54 46 54 NA NA 78

Rehring et al, 2005

1733 USA NA 31 29 NA 23 40 NA NA

Hackam et al, 2006

1507 Canada 90 76 58 NA 67 NA NA 79

Bradley&Kirker, 2006

107 UK 60 47 NA NA NA NA NA NA

Kinikini et al , 2006

200 USA 79 61 48 54 36 24 33 73

AlOmran et al,2006

391 Canada 78 61 45 35 47 49 27 67

Current study, 2008

140 KSA 80 40 37 37 64 15 32 78

How about the rest of the World?How about the rest of the World?

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ConclusionConclusion

The control of risk factors in

patients with PAD is

suboptimal

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Is there a missed opportunity in using PAD (ABI) as a predictor in order to prevent the adverse cardiovascular outcomes?

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Peripheral Arterial Disease in SPACE registry: A Peripheral Arterial Disease in SPACE registry: A Preliminary AnalysisPreliminary Analysis

Objectives Objectives

To identify the prevalence of PAD in patients To identify the prevalence of PAD in patients presenting with acute coronary eventspresenting with acute coronary events

To identify the prevalence of PAD in patients To identify the prevalence of PAD in patients presenting with acute coronary events and do not presenting with acute coronary events and do not have history of CAD have history of CAD (missed opportunity)(missed opportunity)

- - 545 patients with PAD (2479 ACS patients)545 patients with PAD (2479 ACS patients)

- Mean age 63- Mean age 63

- Male 72% - Male 72%

Prevalence of PADPrevalence of PAD 22 %22 % Patients %

28%

72%

Symptomatic

Asymptomatic

Prevalence of PAD in patient with no history of CADPrevalence of PAD in patient with no history of CAD

38%38%

Peripheral Arterial Disease in SPACE registry:Peripheral Arterial Disease in SPACE registry:

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Risk Reduction Risk Reduction

TherapyTherapy

All PAD patientsAll PAD patients

%%

Symptomatic PAD Symptomatic PAD

%%

Asymptomatic PADAsymptomatic PAD

%%

AspirinAspirin 65.065.0 70.070.0 55.055.0

StatinStatin 55.055.0 60.060.0 47.047.0

ACE-IACE-I 43.043.0 45.045.0 34.034.0

Risk Reduction Pharmacotherapy in patients with PAD (SPACE registry):Risk Reduction Pharmacotherapy in patients with PAD (SPACE registry):

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ConclusionConclusion

We can simply utilize this opportunity by recognizing We can simply utilize this opportunity by recognizing patients with patients with PAD PAD (symptomatic or asymptomatic) (symptomatic or asymptomatic)

and aggressively control their risk factorsand aggressively control their risk factors

There is a great opportunity in preventing There is a great opportunity in preventing acute coronary events that we are acute coronary events that we are missingmissing

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Is there a public awareness about PAD? a public awareness about PAD?

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Is there a public awareness about PAD? a public awareness about PAD?

- A cross-sectional interview-based survey during A cross-sectional interview-based survey during a 4 day campaign that was organized at KKUH a 4 day campaign that was organized at KKUH outpatient clinics and 3 shopping centers in outpatient clinics and 3 shopping centers in Riyadh, Saudi Arabia.Riyadh, Saudi Arabia.

- Sample Size: 866 out of 923 , Response (93.8%)- Sample Size: 866 out of 923 , Response (93.8%)

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Is there a public awareness about PAD? a public awareness about PAD?

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Is there a public awareness about PAD? a public awareness about PAD?

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Is there a public awareness about PAD? a public awareness about PAD?

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ConclusionConclusion

suboptimal

The awareness of public The awareness of public towards PAD is towards PAD is

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So, Let’s wrap-up

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What Should we Know?What Should we Know?

Is PAD a Is PAD a public healthpublic health issue? issue?

Health Care Provider:Health Care Provider:

Is there a Is there a knowledge knowledge gap?gap?

Is there an Is there an action action gap?gap?

Is there a Is there a care care gap?gap?

Is there a Is there a missed opportunitymissed opportunity in using PAD (ABI) as a predictor in using PAD (ABI) as a predictor

in order to prevent the adverse cardiovascular outcomes?in order to prevent the adverse cardiovascular outcomes?

Population:Population:

Is there a Is there a public awareness public awareness about PAD? about PAD?

Future DirectionFuture Direction

- Increase public and Physicians awareness- Increase public and Physicians awareness

- Disseminating the guidelines- Disseminating the guidelines

- PAD registry and Practice auditing- PAD registry and Practice auditing

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Task ForceTask Force

- Physicians awareness- Physicians awareness

Outreach CME program Outreach CME program

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Task ForceTask Force - Public awareness- Public awareness

Campaigns in shopping centres Campaigns in shopping centres

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Task ForceTask Force

- PAD registry and Practice auditingPAD registry and Practice auditing

King Khalid University HospitalKing Khalid University Hospital

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A call to action to implement effective strategies to A call to action to implement effective strategies to diagnose and mange patients with PAD, to diagnose and mange patients with PAD, to encourage health professionals to use risk encourage health professionals to use risk

reduction therapy and to increase the public reduction therapy and to increase the public awareness are neededawareness are needed

Different strategies can help Different strategies can help which are very much at the beginning and have a which are very much at the beginning and have a

long way to developlong way to develop

ConclusionsConclusions

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“The journey of a thousand miles begins with one step”

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