International ABI awareness as the next
step in the PAD campaign
Coronary artery disease, cerebrovascular disease are well known
in the society as the cause for heart attack (MI) and brain attack (stroke).
Peripheral artery disease is the third most common manifestation of the
atherosclerosis and one can lose lower limb if the critical ischemia is
precipitated by other factors. The awareness of peripheral vascular disease is
not adequate enough among the people in our society or general practioners to
avoid complications and toe or limb loss in India and many other countries.
Peripheral artery disease (PAD) is common, underdiagnosed,
and undertreated. Owing to the systemic nature of atherosclerosis, PAD patients
are at risk for polyvascular disease. For example, 63% of patients with PAD
have concomitant symptomatic cerebrovascular or coronary disease. Accordingly,
PAD patients are at significantly increased risk for myocardial infarction,
stroke, and vascular death over a 5-year period compared to age-matched
cohorts.
The ankle–brachial index (ABI) is the preferred initial test
for PAD screening and diagnosis. It is relatively inexpensive, sensitive, and
specific. Current guidelines provide clear recommendations on the indications
for ABI testing. However, these guidelines may not have been fully
implemented among practitioners.
In our practice we rarely see patients getting referred
based on the ABI recorded in the clinics. The clinicians ask for Colour Doppler
study (both legs costing Rs 2000 to 3000) and then send them with a report
saying diffuse peripheral vascular disease in the diabetic and smoking population.
Then we are doing the ankle brachial index in our clinic to classify degree of
ischemia. One should practice checking the ankle brachial index routinely in
patients with suspected peripheral arterial disease.
In a survey conducted in Australia, it was found that strikingly
low 6% of GPs were aware of evidence-based guidelines on PAD screening, and
only 5% were aware of guidelines on PAD diagnosis. The majority of GPs (58%)
never perform ABIs. Most notably, 70% of the respondents choose arterial duplex
(which is more costly and time-consuming) as the initial diagnostic tool in a
patient with a history and physical exam consistent with PAD; younger GPs were
more likely to choose the ABI. I think we are no better than the GPs in Australia
in the evaluation of Peripheral vascular disease in the community.
The most common ‘moderate to major’ barriers to PAD
screening and testing were (1) equipment availability, (2) time constraints,
(3) lack of training and skills, and (4) staff availability. The time
constraint barrier is not surprising, given that the time for an ABI could
approach the 15-minute length of a typical primary care office visit. Other
studies have also identified limited reimbursement and time as primary barriers
to widespread use of the ABI in primary care practices.
I think, by increasing the awareness and improving staff
ability more and more GPs will make an attempt to record the ABI in their
practice and follow their patients for the CV events and extend better
protection measures to avoid the amputations.
