preventative medical practices in patients with vascular occlusive disease at royal perth hospital...
TRANSCRIPT
Preventative medical Preventative medical practices in patients practices in patients with vascular occlusive with vascular occlusive disease at Royal Perth disease at Royal Perth HospitalHospital
Lip Gen Teh MBBS
Kishore Sieunarine MBBS FRCSE FRACS
John Eikelboom MBBS FRACP FRCPA
BackgroundBackground
• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease
BackgroundBackground
• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease– increased mortalityincreased mortality
BackgroundBackground
• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease– increased mortalityincreased mortality
• 50% in patients operated for critical 50% in patients operated for critical limb ischaemialimb ischaemia
BackgroundBackground
• Peripheral Vascular Occlusive Peripheral Vascular Occlusive DiseaseDisease– increased mortalityincreased mortality
• 50% over 5years in patients operated 50% over 5years in patients operated for critical limb ischaemiafor critical limb ischaemia
• 2.7x increased risk with asymptomatic 2.7x increased risk with asymptomatic carotid artery stenosiscarotid artery stenosis
• 60% over 5 years following a first stroke60% over 5 years following a first stroke
BackgroundBackground
• Preventive MedicinePreventive Medicine– Antiplatelet therapyAntiplatelet therapy
• 25% reduction in vascular events in 25% reduction in vascular events in high risk groupshigh risk groups
– Beta BlockersBeta Blockers• 34% reduction in all-cause mortality in 34% reduction in all-cause mortality in
patients with class II-III heart failurepatients with class II-III heart failure
BackgroundBackground
• Preventive MedicinePreventive Medicine– AntilipidAntilipid
• 40% reduction in vascular events in 40% reduction in vascular events in high risk groups (4S)high risk groups (4S)
– Antihypertensive therapyAntihypertensive therapy• 40% reduction in major cardiovascular 40% reduction in major cardiovascular
eventsevents
BackgroundBackground
• Preventive MedicinePreventive Medicine– Glucose LoweringGlucose Lowering
• 6% reduction in all cause mortality6% reduction in all cause mortality
• mainly microvascular benefits (UKPDS)mainly microvascular benefits (UKPDS)
– WarfarinWarfarin• ?50% reduction in all cause mortality in ?50% reduction in all cause mortality in
5 years5 years
Study AimStudy Aim
• Investigate the pattern of Investigate the pattern of preventive practices in a high risk preventive practices in a high risk group of patients.group of patients.– 2 groups: (1) PVD (2) carotid disease2 groups: (1) PVD (2) carotid disease
• Examine possible reasons for low Examine possible reasons for low rates of preventive practicesrates of preventive practices
DesignDesign
• Restrospective case note reviewRestrospective case note review
• InclusionInclusion– all first inpatient admissions all first inpatient admissions
undergoing a diagnostic or therapeutic undergoing a diagnostic or therapeutic procedure for vascular occlusive procedure for vascular occlusive disease in the year 2000disease in the year 2000
ResultsResults
• 262 cases identified262 cases identified
• 6 (2.3%) case notes unavailable6 (2.3%) case notes unavailable
DemographicsDemographics
Overall PVD CarotidN 256 189 67
Age (years) mean 70.2 70.2 70.1 median 71.0 71.0 41.0 range 35-98 35-98 86.0 std dev 10.9 11.4 9.1
Sex males 68.4% 66.7% 73.5% females 31.6% 33.3% 26.5%
LOS (days) mean 9.3 10.6 5.7 median 6.0 7.0 4.0 range 1-70 1-70 1-20 std dev 10.0 11.0 4.0
Risk factorsRisk factors
Cardiovascular disease risk factor prevalence
0.0% 20.0% 40.0% 60.0% 80.0% 100.0%
Hypertension
Hyperlipidaemia
Smoker
Diabetic
Carotid
PVD
Overall
Risk factors:SmokingRisk factors:Smoking
Smoking History
0.0% 20.0% 40.0% 60.0% 80.0%
All
PVD
Carotid
current smokerex smoker
Multiple Risk factorsMultiple Risk factorsCumulative Risk Factors
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
0 1 2 3 4
Number of Risk Factors
Overall
PVD
Carotid
Vascular ComorbiditiesVascular Comorbidities
0
10
20
30
40
50
60
Angina MI PTA CABG TIA CVA
IndicationsIndications
• 26% (n=67) carotid26% (n=67) carotid– 33% asymptomatic33% asymptomatic
– 87% endarterectomies87% endarterectomies
– 10% carotid angiogram10% carotid angiogram
IndicationsIndications
• 74% (n=189) PVD74% (n=189) PVD
PVD Proceduresbypass 19.6%endarterectomy 3.7%profundaplasty 0.5%amputation 16.4%angioplasty/stent 28.0%angiogram 21.7%debridement 2.1%sympathectomy 1.1%other 6.9%
ComplicationsComplications
• 6 deaths6 deaths
• 2% angina, 2% MI2% angina, 2% MI
• 6 TIAs and 1 stroke overall6 TIAs and 1 stroke overall– 4 TIAs in carotid endarterectomies (7%)4 TIAs in carotid endarterectomies (7%)
– all in symptomatic patients (10.3%)all in symptomatic patients (10.3%)
Antiplatelet TherapyAntiplatelet Therapy
• Overall, 29.7% not on any form of Overall, 29.7% not on any form of antiplatelet therapyantiplatelet therapy– carotid group 6% not on antiplateletcarotid group 6% not on antiplatelet
– PVD group 38.1% not on antiplateletPVD group 38.1% not on antiplatelet
WarfarinWarfarin
• 16% on warfarin16% on warfarin
• 6% in carotid group6% in carotid group
• 20% in PVD group20% in PVD group
• 19.5% not on antiplatelet or 19.5% not on antiplatelet or antithrombotic therapyantithrombotic therapy
Antiplatelet TherapyAntiplatelet TherapyAntithrombotic therapy
0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0%
Aspirin
Ticlopidine
Clopidogrel
Dipyridamole
Warfarin
Antiplatelet
Antithrombotic
Carotid
PVD
ALL
At Risk SubgroupAt Risk Subgroup
• in PVD patients with no vascular co-in PVD patients with no vascular co-morbidities (n=115)morbidities (n=115)
• 51.4% were on antiplatelet versus 51.4% were on antiplatelet versus 75.6% in those with vascular co-75.6% in those with vascular co-morbiditiesmorbidities
AntihypertensivesAntihypertensives
• 72% on antihypertensives72% on antihypertensives– 83% in carotid patients83% in carotid patients
– 68% in PVD patients68% in PVD patients
– (chi sq=4.7, p=0.03)(chi sq=4.7, p=0.03)
• beta blockersbeta blockers– 34% in carotid34% in carotid
– 18% in PVD18% in PVD
AnticholesterolAnticholesterol
• 43% on cholesterol lowering therapy43% on cholesterol lowering therapy– 63% in carotid63% in carotid
– 36% in PVD36% in PVD
– (chi sq=14.4, p<0.001)(chi sq=14.4, p<0.001)
HypoglycaemicsHypoglycaemics
• 76.9% of diabetics on glucose 76.9% of diabetics on glucose lowering medications overalllowering medications overall– 83% in carotid83% in carotid
– 75% in PVD75% in PVD
DiscussionDiscussion
0
10
20
30
40
50
60
70
Perth Copenhagen Ontario
AntiplateletAntilipid
DiscussionDiscussion
• Rate of preventive practices are 2x Rate of preventive practices are 2x higher for antiplatelet and antilipid higher for antiplatelet and antilipid therapies.therapies.
• Long term prognosis of claudicants Long term prognosis of claudicants is poor and mortality approaches is poor and mortality approaches that of those with carotid disease.that of those with carotid disease.
DiscussionDiscussion
• compared to carotid patients, use of compared to carotid patients, use of preventive therapies are suboptimal in preventive therapies are suboptimal in PVD patients.PVD patients.
• Subgroup most neglected are those Subgroup most neglected are those with no coexistent coronary or with no coexistent coronary or cerebrovascular comorbiditiescerebrovascular comorbidities
– main medical contact are vascular main medical contact are vascular surgeonssurgeons