Background

1. Screening for PAD in the general population» Des pas pour la vie«  -   »steps for life«  Lessons of a French screening program Böge G, Laroche JP, Benshali Y , Lorin C , Brisot D , Perez-Martin A , Dauzat M , P Carpentier , JL Bosson , C Rolland , C Genty , Becker F , Quéré I.

2. Background • PAD indicates general atherosclerosis and is associated with increased mortality • ABI is correlated • with severity of PAD • and with elevated general and cardiovascular mortality (ABI < 0.9 or > 1.3) • With diminished QoL • PAD is frequent, underdiagnosed, although medical therapy is known to reduce morbidity and mortality rates in these patients - Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Resnick HE, Lindsay RS, McDermott MM, Devereux RB, Jones KL, Fabsitz RR, Howard BV. Circulation. 2004 Feb 17;109(6):733-9 - A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life. Alison MA, Hiatt WR, Hirsch AT, Coll JR, Criqui MH, J Am Coll Cardiol.2008;51(13):1292-8 Feringa H et al, Cardioprotective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol. 2006;47:1182-1187

3. Methods • National screening campaign • general population with no known PAD • Presenting cardiovascular risk factors • Over 60 years old • One day in France • 58 communities • 79 centers • 350 physicians • 3 month follow up

4. Methods • Questionnaire • Medical history • Cardiovascular risk factors • ABI measurement • Vascular specialist • Continuous wave Doppler 8 MHz probe • systolic blood pressure • in both upper extremities • In both lower extremities (posterior and anterior tibial artery) • ABI calculation • Method 1: ABI= highest ankle pressure/ highest humeral pressure • Method 2: ABI= lowest ankle pressure/ highest humeral pressure

5. ABI: methods of calculation • ABI= highest ankle pressure/ highest humeral pressure • Correlated with the hemodynamic severity of peripheral arterial involvement • Diagnostic accuracy for PAD (vs angiography) 98% • Usually recommended measurement method • ABI= lowest ankle pressure/ highest humeral pressure • Cardiovascular risk similar • Higher sensibility: more PAD detected • May bee a better screening tool ACC/AHA Guidelines for the Management of patients with peripheral arterial disease Hirsch et al, Circulation 2006 Different calculations of ankle-brachial index and their impact on cardiovascular risk prediction. Espinola-Klein C, Rupprecht HJ, Bickel C, Lackner K, Savvidis S, Messow CM, Munzel T, Blankenberg S; AtheroGene Investigators. Circulation. 2008 Aug 26;118(9):961-7.

6. Results

7. Results ABI= highest ankle pressure/ highest humeral pressure

8. Results ABI= lowest ankle pressure/ highest humeral pressure

9. Results Abnormal ABI (< 0.9 or > 1.3) 1 2 3 4 5 6 7 Risk factors

10. Results

11. Three month follow-up • 692/1500 patients: telephone follow up at 3 months • 42% of them had have a complete duplex scan of the lower extremities, confirming the PAD. • 30% lifestyle correction (diet, physical activity) • Only 2% had modified medical treatment

12. Screening of peripheral arterial diseasebased on ABI measurement

13. Effectiveness of screening The potential benefit depends of • 1) Disease prevalence (15% -41% in high risk populations) • 2) PAD mortality (3.9%-8.2%/year) • 3) Screening test available (ABI) • 4) Mortality rate reduction by appropriate therapy ( 25%-50%) Hooi et al, asymptomatic peripheral arterial disease predicted cardiovascular morbidity and mortality in a 7 year-follw-up study. J Clin Epidemiol. 2004;57:294-300. Caro J et al, The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database. BMC cardiovasc Disor.2005;5:14 Feringa H et al, Cardio protective medication is associated with improved survival in patients with peripheral arterial disease. J Am Coll Cardiol. 2006;47:1182-1187.

14. Effectiveness of screening Reduction of mortality rates about 2-9 lives/ 100 patients screened/ follow up of 7 years • “individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ankle-brachial-index (ABI) so that therapeutic interventions known to diminish their increased risk of myocardial infarction (MI), stroke, and death may be offered” Beckman JA et al, The United States Preventive Services Task Force Recommendation statement on screening for peripheral artery disease. More harm than benefit? Circulation 2006;114:861-866 Class I indication ACC/AHA Guidelines for the Management of patients with peripheral arterial disease Hirsch et al, Circulation 2006; 113:1474-1547

15. Conclusion • Screening of asymptomatic PAD in high risk patients is possible, sure and inexpensive by ABI measurement • Asymptomatic PAD in the general population > 60 years, presenting CV risk factors, is frequent with a prevalence of about 25% • PAD is still underdiagnosed, and an undertreated disease • Screening of asymptomatic PAD is effective and life-saving if therapeutic interventions (lifestyle correction and medical treatment) known to diminish their increased cardiovascular risk are offered