A new clinical update summarizing the literature on the assessment and management of Peripheral Artery Disease (PAD) has just been published in the prestigious British Medical Journal (BMJ). Like we try to do here at DFA, BMJ clinical updates aim to provide practical clinical summaries of the latest evidence on how to assess and manage particular conditions according to the world’s leading authorities. This new BMJ clinical update on PAD is no different and is authored by global PAD expert Professor Hinchliffe and colleagues.
Professor Hinchcliffe is well known to many in the diabetic foot world as the lead author of the International Working Group on the Diabetic Foot PAD guidance and systematic review documents. This update essentially targets a primary care physician audience and briefly summarises the PAD literature according to the authors. It is a very useful practical refresher on all things PAD, covers the following sections when it comes to what is currently known about PAD and includes some very interesting facts:
o Epidemiology. Did you know 60% of people with PAD will also have ischaemic heart disease and 30% will have cerebrovascular disease?
o Risk factors. Did you know smoking and diabetes are the leading risk factors for PAD?
o Prognosis. Did you know the 5-year mortality for PAD is 20% and for critical ischaemia is 50%?
o Symptoms. Did you know most patients with PAD are asymptomatic?
o Assessments. Did you know the lack of a palpable pulse is the most sensitive clinical sign of PAD? Whereas other clinical signs such as capillary refill and hair loss have little diagnostic importance? And ABIs should be performed for patients with reduced pulses, with TBIs for those with diabetes?
o Management of risk factors. Did you know risk factor management for PAD typically involves smoking cessation, antiplatelet and statin therapy, glycaemic and blood pressure control?
o Management of symptoms. Did you know people with claudication pain get a similar benefit in improved walking ability and quality of life via a supervised exercise therapy (such as 30 minutes walking to near maximal pain 3 times per week) as they do after an angioplasty?
o Referral for vascular surgery. Did you know patients presenting with critical ischaemia (ABI <0.5, rest pain or tissue loss) or patients with PAD (ABI <0.9) and a diabetic foot ulcer should be urgently referred for vascular surgery assessment?
o Surgical options. Did you know patients with a small, singular stenosis typically undergo endovascular surgery (such as an angioplasty) as a first surgical option? Yet, those with stenosis or occlusions below the knee, large or multiple stenoses typically undergo open bypass surgery?
o Future of PAD. Did you know new developments targeting improved endovascular techniques, drug eluting technologies and endovascular devices that remove atheroma are being trialed?
This update really does serve its purpose of providing a very quick, succinct and useful practical update on what clinicians should be doing in 2018 to assess, manage and refer PAD according to the evidence. Furthermore this update includes a nice pathway further summarizing these requirements and contains more interesting facts in addition to the aforementioned examples.
Whilst this update is a very worthwhile document to quickly update clinicians on PAD, it does come with some limitations. These limitations include it is essentially a narrative review of the literature according to the authors which always introduces potential bias from the authors unlike systematic reviews, and it mainly targets a primary care physician-like audience so it potentially doesn’t include any new information about PAD for the vascular surgeon or very experienced foot disease clinician.
In conclusion, this BMJ clinical update is definitely worth a read as it provides a very quick and useful refresher on PAD for any clinician of any discipline and particularly those regularly managing people with foot disease. And the more clinicians we have understanding and following what we should be doing to assess, manage and refer people with PAD according to best evidence must be another small step towards all of us ending avoidable amputations in a generation in this country.