Diagnosis and management of peripheral arterial disease

In their review of diagnosis and management of peripheral arterial disease (PAD) Peach et al identified smoking as the most important modifiable risk factor for developing PAD and cited evidence that smokers have a four times greater risk of developing intermittent claudication than non-smokers; and those who continue to smoke are more likely to need intervention or amputation than their non-smoking counterparts(1). Although they state smoking is important and preventable they made no mention of their method of assessment of smoking habit nor how they advised and support patients to quit.

The recently published NICE guidelines on PAD recommend the provision of information, advice, support and treatment for secondary prevention of cardiovascular disease, including smoking cessation. However, it states there are currently barriers to implementing this advice(2).

One barrier is obtaining reliable information about smoking habit. This cannot be obtained by simply asking the patient, because self-reported smoking habit is unreliable and subject to bias. Biochemical analysis of cotinine, the major metabolite of nicotine showed at least 15% of smokers with PAD denied smoking when questioned(3). Patients who smoke are constantly advised to quit, but they are not given any information about the reasons for this action, they are not helped in their attempts to quit, nor are they monitored and supported throughout their treatment.

In practice, smokers should be identified at the earliest opportunity and their nicotine intake monitored at regular intervals by cotinine measurement, and given personalised advice based on this result(4). They should be given literature and verbal advice about their need to quit smoking given details on where and how they get expert advice to quit, including the use of NRT and other pharmaceutical agents. This could be supplemented with an arranged appointment with the local smoking cessation advisory service.

There is convincing evidence that integrated smoking cessation strategies, carried out by vascular surgeons, which includes the monitoring of continued abstinence and assistance and support to avoid relapse, are successful and cost effective; with the suggestion that vascular specialists should engage in a comprehensive approach to promote smoking cessation in their patients(5).

Great emphasis and resources should be applied to identifying, monitoring and preventing cigarette smoking among patients with PAD. And this will in turn improve treatment, shorten recovery times and reduce NHS costs.

References
1. Peach G, Griffin M, Jones KG, Thompson MM, Hinchliffe RJ. Diagnosis and management of peripheral arterial disease. BMJ 2012; 345: e5208

2. Layden J, Michaels J, Bermingham S, Higgins B. Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ 2012; 345: e4947

3. Hobbs SD, Wilmink ABM, Adam DJ, Bradbury AW. Assessment of smoking status in patients with peripheral arterial disease. J Vasc Surg 2005; 41: 451-6.

4. Cope GF, Nayyar P, Holder R. Feedback from a point of care test for nicotine intake to reduce smoking during pregnancy. Ann Clin Biochem 2003; 40: 674-679.

5. Black JH. Evidence base and strategies for successful smoking cessation. J Vasc Surg 2010; 51: 1529-37