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Peripheral arterial disease: why screen in primary care?

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Vascular nurses have joined doctors and patient groups in condemning a decision to exclude peripheral arterial dise...

Vascular nurses have joined doctors and patient groups in condemning a decision to exclude peripheral arterial disease (PAD) from next year's GMS quality and outcome framework, although coronary heart disease and stroke have been included.

The reasons for this are not clear, as patients with ischaemic heart disease usually have diseased arteries throughout their body and would therefore benefit from an assessment of their peripheral arterial circulation.

Patients who survive an atherothrombotic event such as a myocardial infarction or stroke are at high risk of having another at the same site or elsewhere in the arterial tree. Symptomatic PAD carries a 30% risk of death within five years (60% of patients die of a myocardial infarction and 12% from a stroke) (Tierney et al, 2000).

Despite being a vascular disease in its own right as well as a marker for other cardiovascular disease, PAD remains under-diagnosed and under-treated in the majority of patients. It is estimated that 16% of patients on general practice registers over the age of 55 have PAD, but that the actual number may never be known, as one of the common clinical signs - reduced mobility - is often regarded as a natural part of the ageing process or a consequence of arthritis (Belch et al, 2003).

At any one time, a GP will have on average six to eight patients with symptoms of PAD (Eccles et al, 1998) and these patients will have reduced quality of life, with reduced mobility owing to intermittent claudication or, in more severe cases, critical limb ischaemia that may lead to amputation.

Patients with PAD frequently have co-morbidities, as the disease is associated with smoking, advancing age, diabetes and obesity. Their care, therefore, needs to be carefully coordinated so that associated conditions are identified and managed (Box 1).

In 1998, Fowkes et al estimated that simple screening of people over 50 could potentially prevent around 60,000 major cardiovascular events in Britain over five years and that about 85,000 new cases of angina and intermittent claudication could also be prevented. However, little progress has since been made in providing routine screening.

Because the under-management of PAD is such a major concern in the UK, GPs, vascular physicians, surgeons and nurses and clinicians concerned with the care of older people have joined forces to form a multidisciplinary group - Target PAD - with the shared aim of increasing and improving the management of PAD in primary care.

Groups such as Target PAD have now identified a need for formal clinical guidelines for early detection and treatment of this major health problem. Including PAD in the GMS contract would be a step in the right direction. Campaigners are lobbying parliament in the hope of influencing the GMS contracting policy. They are arguing that PAD does not need to be a separate category of the quality and outcomes framework but that as a manifestation of atherothrombosis it should be affiliated to the categories of stroke/transient ischaemic attacks or coronary heart disease.

The inclusion of PAD in the GMS contract would encourage doctors to investigate leg pain as part of their patient review, along with other forms of ischaemic vascular disease. This could be achieved by taking ankle brachial pressure index (ABPI) measurements, which is a highly sensitive diagnostic measure that specifically indicates the presence of PAD.

Patients with PAD should be treated as if they have coronary heart disease. For example, an antiplatelet agent should be prescribed to reduce the risk of a further atherothrombotic event, and they should be given lifestyle advice, such as giving up smoking or losing weight.

Nurse-led intermittent claudication clinics have already been set up in many vascular secondary care departments (Box 2), but parts of this service could be provided in primary care.

Conclusion

Detection of peripheral arterial disease is not a priority for primary care. If treatment for PAD began in primary care, the nurse-led service could follow-up these patients at regular intervals to assess both their quality of life and their peripheral arterial disease, along with other risk factors such as blood pressure, diabetes and hyperlipidaemia. However, until this condition is included in the GMS contract, diagnosis and management will remain a lottery.

Further information

Target PAD - PADlolbbying@avenuehkm.com.

Society for Vascular Nursing - www.svnnet.org.

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