title: Prioritization of treatments for lower extremity peripheral artery disease in low- and middle-income countries.
abstract: BACKGROUND
  Lower extremity peripheral artery disease (PAD) is increasing in prevalence in low- and middle-income countries creating a large health care burden. Clinical management may require substantial resources but little consideration has been given to which treatments are appropriate for less advantaged countries.
  
  
  METHODS
  The aim of this review was to systematically appraise published data on the costs and effectiveness of PAD treatments used commonly in high-income countries, and for an international consensus panel to review that information and propose a hierarchy of treatments relevant to low- and middle-income countries.
  
  
  RESULTS
  Pharmacotherapy for intermittent claudication was found to be expensive and improve walking distance by a modest amount. Exercise and endovascular therapies were more effective and exercise the most cost-effective. For critical limb ischemia, bypass surgery and endovascular therapy, which are both resource intensive, resulted in similar rates of amputation-free survival. Substantial reductions in cardiovascular events occurred with use of low cost drugs (statins, ACE inhibitors, anti-platelets) and smoking cessation.
  
  
  CONCLUSIONS
  The panel concluded that, in low- and middle-income countries, cardiovascular prevention is a top priority, whereas a lower priority should be given to pharmacotherapy for leg symptoms and revascularisation, except in countries with established vascular units.
authors.affiliation: Department of Epidemiology, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK - Gerry.fowkes@ed.ac.uk.
authors.forename: F Gerald
authors.initials: FG
authors.lastname: Fowkes
authors.affiliation: Cochrane Collaboration Review Group on Peripheral Vascular Diseases, University of Edinburgh, Edinburgh, UK.
authors.forename: Rachel B
authors.initials: RB
authors.lastname: Forster
authors.affiliation: Disease Control Priorities Network, School of Public Health, University of Washington, Seattle, WA, USA.
authors.forename: Carol E
authors.initials: CE
authors.lastname: Levin
authors.affiliation: Unit of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: Nadraj G
authors.initials: NG
authors.lastname: Naidoo
authors.affiliation: Unit of Cardiology, Cardiothoracic Department, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ambuj
authors.initials: A
authors.lastname: Roy
authors.affiliation: Department of Vascular Surgery, The Second Xiangya Hospital, Central Southern University, Hunan, China.
authors.forename: Chang
authors.initials: C
authors.lastname: Shu
authors.affiliation: Department of Outcomes Research, St. Luke's Mid America Heart Institute, Kansas City, MO, USA.
authors.forename: John
authors.initials: J
authors.lastname: Spertus
authors.affiliation: Department of Vascular Surgery, The Second Xiangya Hospital, Central Southern University, Hunan, China.
authors.forename: Kun
authors.initials: K
authors.lastname: Fang
authors.affiliation: Department of Vascular Surgery, University of Buenos Aires, Buenos Aires, Argentina.
authors.forename: Luis
authors.initials: L
authors.lastname: Bechara-Zamudio
authors.affiliation: Research Centre on Vascular Diseases and Angiology Unit, L. Sacco Hospital, Milan, Italy.
authors.forename: Mariella
authors.initials: M
authors.lastname: Catalano
authors.affiliation: Unit of Angiology, San Giacomo Hospital, Castelfranco Veneto, Treviso, Italy.
authors.forename: Adriana
authors.initials: A
authors.lastname: Visonà
authors.affiliation: Unit of Clinical and Interventional Angiology, Department of Medicine, Asklepios Clinic St. Georg, Hamburg, Germany.
authors.forename: Sigrid
authors.initials: S
authors.lastname: Nikol
authors.affiliation: Department of Surgery, Westmead Research Centre for Evaluation of Surgical Outcomes, Westmead Hospital, University of Sydney, Sydney, Australia.
authors.forename: John P
authors.initials: JP
authors.lastname: Fletcher
authors.affiliation: Department of Medicine, Harvard Medical School, Boston, MA, USA.|Paul and Phyllis Fireman Endowed Chair in Vascular Medicine, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Jaff
authors.affiliation: Division of Cardiology, Department of Medicine, CPC Clinical Research, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: William R
authors.initials: WR
authors.lastname: Hiatt
authors.affiliation: Unit of Surgery, Department of Surgery, Faculty of Medicine and Health, Ӧrebro University, Ӧrebro, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Norgren
mesh_terms: D000671:Amputation, Surgical; D003362:Cost-Benefit Analysis; D004358:Drug Therapy; D057510:Endovascular Procedures; D015444:Exercise; D006801:Humans; D035002:Lower Extremity / Q000098:blood supply*; D058729:Peripheral Arterial Disease / Q000517:prevention & control* / Q000628:therapy*; D011203:Poverty / Q000191:economics; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors