DGIM: Vascular disease PAD – often not treated in accordance with guidelines

27.04.2021 09:51

The calves quickly begin to hurt, even at a normal walking pace, and you have to take breaks from walking again and again - these complaints must be taken seriously as warning signs, as they can indicate peripheral arterial disease (PAD). This serious circulatory disorder in the legs is caused by calcification and narrowing of the leg arteries and, in the worst case, can lead to vascular occlusions and make amputations necessary; The risk of a heart attack or stroke is also significantly increased for those affected. Despite these risks, PAD is still underestimated and often not treated in accordance with guidelines, criticizes the German Society for Internal Medicine. V. (DGIM).

In particular, the administration of statins falls far short of what is needed, according to the experts from the specialist society. PAD and other vascular diseases were the main topic at the 127th Internal Medicine Congress, which ended last week.

The frequency of PAOD increases significantly with age and is around 20 percent in people over 65 years of age. However, the majority of those affected know nothing about the pathological vascular changes because they do not become noticeable through pain at an early stage. “Even without the characteristic symptoms, PAD is easy to diagnose – family doctors should actively examine older patients for this disease,” says Professor Dr. med. Viola Hach-Wunderle, specialist in internal medicine with a focus on angiology, phlebology and hemostaseology at the Nordwest Hospital in Frankfurt am Main. First of all, checking the foot pulses is informative; If these are not palpable, the so-called ankle-brachial index (ABI) is determined, i.e. the ratio of the blood pressure values measured at the ankle and the upper arm. “These measurements are very simple and can be carried out in any family doctor’s office,” says the Frankfurt angiologist. Even in previously symptom-free patients, a noticeable ABI must be taken seriously as a warning signal, because the vascular changes usually affect not only the legs, but also other areas of the body. The involvement of the coronary arteries and the vessels that supply the brain is particularly critical. “Even in symptom-free patients, an abnormal ABI is associated with a doubling of the risk of heart attack and stroke,” explains Hach-Wunderle.

If exercise-dependent pain occurs (“intermittent claudication”), the risk of suffering a heart attack or stroke in the following five years is already 20 percent; If the painful circulatory problems in the legs become noticeable even at rest, the risk of death increases significantly and is then 40 to 60 percent within the next five years.

In order to reduce these risks and counteract the deterioration of the vascular condition, the PAD guidelines provide for consistent therapy with lifestyle changes and drug treatment. On the one hand, you should try to avoid known risk factors such as obesity, lack of exercise, smoking and unhealthy diet. High blood pressure, high blood fat and blood sugar levels also contribute to the arteriosclerotic changes. PAD should therefore always be treated with statins to lower blood lipids - even if the disease does not yet cause any symptoms. In more advanced stages, anticoagulants should also be added, and if necessary, blood pressure lowering drugs. “However, these medications are still far too rarely prescribed and taken by PAD patients,” says Hach-Wunderle. An evaluation of health insurance data from BARMER from 2019 showed: Only around 40 percent of PAD patients receive drug therapy in accordance with the guidelines. An evaluation of secondary data from the years 2014 to 2017 from the Westphalia-Lippe Association of Statutory Health Insurance Physicians came to a similar result: only about every second PAOD patient received at least one of the guidelines-compliant medications. Only 29 percent of this patient group received statins.

One reason could possibly be the fear of side effects, as statins can cause muscle pain and, in more severe but very rare cases, also lead to muscle damage or diabetes. “These rare side effects, which affect fewer than one in 1,000 patients, are offset by the great therapeutic benefit of statins,” emphasizes Hach-Wunderle. In the long term, the funds reduce the risk of amputation by more than a third and the risk of cardiovascular events falls by 17 percent. “Statins are frequently used, safe and inexpensive medications that are regularly used for arteriosclerosis of the cerebral or coronary arteries - just not in the secondary prophylaxis of PAD patients for reasons that are not understandable,” says Hach-Wunderle.

Although pathological changes in the blood vessels are among the most important causes of illness and death worldwide, diseases of the peripheral vessels in particular are often not taken seriously enough, emphasizes Professor Dr. med. Sebastian Schellong, President of the 127th Annual Meeting. There is still a need for clarification here. “In order to once again raise awareness of the importance of vascular diseases beyond heart attacks and strokes, as well as their diverse manifestations and their connections with other diseases, we have dedicated this topic to a focus at this year’s congress,” says Schellong. In internal medicine in particular, there is probably no disease that does not have a connection to vascular medicine through its causes or possible consequential damage.

Literature:

-Darius H, Trampisch H, Pittrow D, et al. Comparison of two coronary equivalents: Increased risk in diabetes mellitus and peripheral arterial disease. DMW 2008; 45:2317-2322

-Aboyans V, Ricco JB, Bartelink MLEL et al. Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. Eur Heart J 2018; 39(9): 763–821. doi: 10.1093/eurheartj/ehx095.

– Reinecke H et al. Peripheral arterial disease and critical limb ischemia: still poor outcomes and lack of guideline adherence. Eur Heart J 2015, online February 2, 2015, doi: 10.1093/eurheartj/ehv006

-Lawall H, Huppert P, Rümenapf G et al: AWMF S3 guidelines for the diagnosis, therapy and follow-up care of peripheral arterial occlusive disease, 2015

-Press release BARMER from January 29, 2021: https://www.barmer.de/presse/presseinformationen/pressemitteilungen/cholesterinsenker-278296

-Gebauer, K., Wintersohl, K., Kraska, R. et al. Secondary drug prevention in patients with peripheral arterial disease. Heart (2020). https://doi.org/10.1007/s00059-020-04998-w