Peripheral arterial disease detection, awareness, and treatment in primarycare

Context Peripheral arterial disease (PAD) is a manifestation of systemic at herosclerosis that is common and is associated with an increased risk of de ath and ischemic events, yet may be underdiagnosed in primary care practice . Objective To assess the feasibility of detecting PAD in primary care clinic s, patient and physician awareness of PAD, and intensity of risk factor tre atment and use of antiplatelet therapies in primary care clinics. Design and Setting The PAD Awareness, Risk, and Treatment: New Resources fo r Survival (PARTNERS) program, a multicenter, cross-sectional study conduct ed at 27 sites in 25 cities and 350 primary care practices throughout the U nited States in June-October 1999. Patients A total of 6979 patients aged 70 years or older or aged 50 through 69 years with history of cigarette smoking or diabetes were evaluated by h istory and by measurement of the ankle-brachial index (ABI). PAD was consid ered present if the ABI was 0.90 or less, if it was documented in the medic al record, or if there was a history of limb revascularization. Cardiovascu lar disease (CVD) was defined as a history of atherosclerotic coronary, cer ebral, or abdominal aortic aneurysmal disease. Main Outcome Measures Frequency of detection of PAD; physician and patient awareness of PAD diagnosis; treatment intensity in PAD patients compared wi th treatment of other forms of CVD and with patients without clinical evide nce of atherosclerosis. Results PAD was detected in 1865 patients (29%); 825 of these (44%) had PAD only, without evidence of CVD. Overall, 13% had PAD only, 16% had PAD and CVD, 24% had CVD only, and 47% had neither PAD nor CVD (the reference group ). There were 457 patients (55%) with newly diagnosed PAD only and 366 (35% ) with PAD and CVD who were newly diagnosed during the survey. Eighty-three percent of patients with prior PAD were aware of their diagnosis, but only 49% of physicians were aware of this diagnosis. Among patients with PAD, c lassic claudication was distinctly uncommon (11%). Patients with PAD had si milar atherosclerosis risk factor profiles compared with those who had CVD. Smoking behavior was more frequently treated in patients with new (53%) an d prior PAD (51%) only than in those with CVD only (35%; P<.001). Hypertens ion was treated less frequently in new (84%) and prior PAD (88%) only vs CV D only (95%; P<.001) and hyperlipidemia was treated less frequently in new (44%) and prior PAD (56%) only vs CVD only (73%, P<.001). Antiplatelet medi cations were prescribed less often in patients with new (33%) and prior PAD (54%) only vs CVD only (71%, P<.001). Treatment intensity for diabetes and use of hormone replacement therapy in women were similar across all groups . Conclusions Prevalence of PAD in primary care practices is high, yet physic ian awareness of the PAD diagnosis is relatively low. A simple ABI measurem ent identified a large number of patients with previously unrecognized PAD. Atherosclerosis risk factors were very prevalent in PAD patients, but thes e patients received less intensive treatment for lipid disorders and hypert ension and were prescribed antiplatelet therapy less frequently than were p atients with CVD. These results demonstrate that underdiagnosis of PAD in p rimary care practice may be a barrier to effective secondary prevention of the high ischemic cardiovascular risk associated with PAD.