We should check the ABI in all patients at risk of peripheral arterial disease!

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.