Am Fam Physician. 2003;67(11):2382-2384
Patients with peripheral arterial disease (PAD) have a threefold to fivefold risk of cardiovascular morbidity and mortality compared with patients without PAD, and PAD carries a cardiovascular risk comparable to that of coronary artery disease. Studies have shown, however, that risk factors for atherosclerotic disease are undertreated in patients with PAD, even though the American Heart Association and the National Cholesterol Education Program recommend the same degree of risk-factor reduction in patients with coronary artery disease or PAD. McDermott and colleagues hypothesized that physicians who treat patients with either condition are more likely to address cardiovascular risk factors in patients with coronary artery disease than in those with PAD and no other obvious cardiovascular symptoms.
Family physicians, internists, cardiologists, and vascular surgeons were asked to fill out questionnaires to assess their risk reduction behavior as well as their knowledge of and attitude toward treating risk factors in patients with PAD. The surveys contained hypothetic cases of patients with PAD only, coronary artery disease only, or no disease. The vascular surgeons were asked only about the hypothetic PAD patients, because they were unlikely to treat patients with coronary artery disease or no disease.
A total of 1,578 physicians, including 264 vascular surgeons, were eligible for the study and completed the questionnaire. Physicians were less likely to report “almost always” prescribing antiplatelet therapy or recommending aerobic exercise for the hypothetic patient with PAD than for the patient with coronary artery disease. They were also more likely to initiate diet and drug therapy at higher cholesterol levels for the patient with PAD. Physicians were significantly more likely to report the importance of initiating anti-platelet therapy and lowering cholesterol in the patient with coronary artery disease. Cardiologists used the most aggressive approach to treatment and were significantly more likely than other specialties to report “almost always” prescribing antiplatelet therapy and lowering cholesterol levels for patients with PAD, whereas the vascular surgeons were the least likely to report doing so.
Overall, physicians reported significantly lower rates of prescribing antiplatelet therapy, cholesterol-lowering therapy, and aerobic exercise for patients with PAD than for patients with coronary artery disease. Physicians also were more likely to state that antiplatelet therapy and cholesterol lowering were extremely important interventions in patients with coronary artery disease than in patients with PAD. Perception of the importance of risk factor intervention strongly correlated with reported behavior. This study suggests that even though current guidelines recommend equal risk factor intervention in patients with PAD and in patients with coronary artery disease, most physicians under-treat risk factors in patients with PAD when no other obvious cardiovascular symptoms are present.