[The best of vascular medicine in 2006].
Peripheral arterial disease (PAD) remains an under-diagnosed affection, and the ankle-brachial index (ABI), a simple diagnostic method, is poorly known and seldom used, and the vascular patient's prescription list is frequently insufficient regarding results obtained in large trials with good methodology. The French ATTEST study underlines the fact that ABI is measured in less than 1 out of 3 patients with PAD. In ATTEST study, less than 10% have the triple therapy validated in PAD : antiplatelet drugs, statins and ACE-inhibitors. The international REACH registry included more than 60 000 patients suffering from atherosclerosis, including 8 000 cases with PAD. This survey evidences that in PAD patients, the annual cardiovascular complication rate is significantly higher than in patients with coronary artery disease (18 vs 13%); again PAD appears systematically under-treated when compared to CAD. These epidemiological surveys highlight the importance of screening of atherosclerotic lesions with the aim of setting an active prevention of CV complications. The new guidelines insist on the screening of PAD in patients at risk, as well as on the importance of the global management after initiating the triple therapy, independent of the CV risk factors. In a 5-year longitudinal study from an initial cohort of 2265 subjects, Aboyans et al. studied the progression of PAD by repeated measurements of ABI at the level of ankles and toes. Factors of progression for large-vessels PAD were active smoking, the total/HDL-cholesterol ratio, Lp(a) and CRP. Importantly, diabetes was not associated to the PAD progression in large vessels, but in contrast, it was the sole factor associated to the progression of PAD in small vessels. In an Austrian study published this year in the NEJM, Schillinger et al. compared balloon angioplasty versus the use of Nitinol stent for the treatment of long stenoses of the superficial femoral artery. In case of claudication, these lesions are usually treated medically, whereas surgery is required for more severe cases. The fact that stenting these long lesions of the superficial femoral artery provides benefits in terms of restenosis opens a approach for the endovascular therapy, to be confirmed by larger trials.
Mounier-Vehier
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Service de médecine vasculaire et HTA, Hôpital cardiologique, CHRU, 59037 Lille Cedex. cmouniervehier@chru-lille.fr
Stephan
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D
Aboyans
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Beregi
J P
JP
Lacroix
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P
Léger
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Long
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A
Sevestre
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MA
D000800:Angioplasty, Balloon; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D050197:Atherosclerosis / Q000453:epidemiology; D002309:Cardiology / Q000592:standards / Q000639:trends; D002986:Clinical Trials as Topic; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D016491:Peripheral Vascular Diseases / Q000188:drug therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D014652:Vascular Diseases / Q000628:therapy
D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors