Diagnosis and management of peripheral arterial diseaseBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5208 (Published 14 August 2012) Cite this as: BMJ 2012;345:e5208
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Peach et al failed to mention the potential role of ramipril in the treatment of patients with peripheral arterial disease (PAD).
The role of ramipril in reducing cardiovascular morbidity and mortality and health economic analysis of cost effectiveness in patients with PAD with no evidence of left ventricular dysfunction or heart failure is supported by level-1 evidence [1-5]. Moreover, ramipril improved maximum walking time, pain-free walking time, ankle brachial pressure index in a cohort of 40 patients with intermittent claudication due to infrainguinal disease in a randomised, double-blind, placebo-controlled trial . In the latter, ramipril improved maximum walking time by 243% , pain-free walking time by 164%, r-ABPI by 0.07 and t-ABPI by 0.08 after a 6-month treatment period. The improvement in maximum walking time was superior to current therapeutic agents for PAD such as cilostazol and pentoxifylline (80% improvement) [7,8] and supervised exercise programme (120% improvement) . Based on the above, ramipril should be considered in the management of patients with PAD.
1. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The heart outcomes prevention evaluation study investigators. N Engl J Med. 2000;342:145-153
2. Ostergren J, Sleight P, Dagenais G, Danisa K, Bosch J, Qilong Y, Yusuf S. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J. 2004;25:17-24
3. Bjorholt I, Andersson FL, Kahan T, Ostergren J. The cost-effectiveness of ramipril in the treatment of patients at high risk of cardiovascular events: A swedish sub-study to the hope study. J Intern Med. 2002;251:508-517
4. Lamy A, Yusuf S, Pogue J, Gafni A. Cost implications of the use of ramipril in high-risk patients based on the heart outcomes prevention evaluation (hope) study. Circulation. 2003;107:960-965
5. Smith MG, Neville AM, Middleton JC. Clinical and economic benefits of ramipril: An australian analysis of the hope study. Intern Med J. 2003;33:414-419
6. Ahimastos AA, Lawler A, Reid CM, Blombery PA, Kingwell BA. Brief communication: Ramipril markedly improves walking ability in patients with peripheral arterial disease: A randomized trial. Ann Intern Med. 2006;144:660-664
7. Beebe HG, Dawson DL, Cutler BS, Herd JA, Strandness DE, Jr., Bortey EB, Forbes WP. A new pharmacological treatment for intermittent claudication: Results of a randomized, multicenter trial. Arch Intern Med. 1999;159:2041-2050
8. Dawson DL, Cutler BS, Hiatt WR, Hobson RW, 2nd, Martin JD, Bortey EB, Forbes WP, Strandness DE, Jr. A comparison of cilostazol and pentoxifylline for treating intermittent claudication. Am J Med. 2000;109:523-530
9. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995;274:975-980
Competing interests: The author have worked on a randomised controlled trial to investigate the clinical effectiveness of ramipril in patients with intermittent claudication
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.
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
Competing interests: Dr. Graham F. Cope is the inventor of a point of care cotinine test called SmokeScreen and Director of the company GFC Diagnostics which distributes the test.
Generally a well thought out and balanced review I thought.
Shame that several of the citations for the references are incorrect, I am afraid this does not reflect well on the manuscript or whoevever reviewed the paper.
Certainly references 25 and 26 are incorrectly cited,and these are important paper. After noticing this I could not be bothered to check all the rest for accuracy.
Competing interests: No competing interests