National study of obliterative arterial disease of the lower limbs involving general practitioners in France: Artemio study

Cardiovascular risk profile of patients with peripheral arterial occlusive disease during nilotinib therapy

BACKGROUND

Over the past few years, data have suggested that severe peripheral arterial occlusive disease (PAOD) is associated with nilotinib exposure. However, the characteristics of this adverse drug reaction are poorly described since its frequency is low. As far as we know, no study using a spontaneous adverse drug reactions reporting system was performed to describe the characteristics of cases of PAOD related to nilotinib.

OBJECTIVE

We performed a study to describe the cardiovascular risk profile of cases of PAOD in patients treated with nilotinib spontaneously reported to the French Pharmacovigilance Database (FPVD).

PATIENTS/METHODS

We selected all cases of "vascular disorders," as the System Organ Class in MedDRA®, in which nilotinib was "suspected" and recorded in the French Pharmacovigilance Database between 2007 and 21 October 2014. We then identified cases of PAOD with a Low Level Term and through a detailed summary of the clinical description.

RESULTS

We identified 25 cases of POAD. Most of the patients were older than 60 years (84 %) or had another cardiovascular risk factor such as hypercholesterolemia, arterial hypertension, overweight/obesity, smoking, or diabetes mellitus (72 %). Females (13 cases) and males (12 cases) were equally represented, but the presence of cardiovascular risk factors was more frequent in females than in males. The mean time from initiation of nilotinib to PAOD onset was 24 months and was significantly longer in patients aged less than 60 years compared with those aged over 60 years (33.8 ± 24.6 months vs. 22.6 ± 17.5 months, p = 0.002). Pre-existing cardiovascular risk factors, especially diabetes mellitus, also seem to accelerate its occurrence.

CONCLUSIONS

The FPVD is a useful tool in describing the cardiovascular risk profile of patients with PAOD during nilotinib exposure. Physicians have to be particularly vigilant in patients older than 60 years of age; in patients younger than 60 years of age, long-term surveillance has to be maintained.

Are National Cardiac Guidelines being Applied by Vascular Surgeons?

INTRODUCTION

National cardiac guidelines recommend that patients with intermittent claudication should be managed in the same way as those with established coronary heart disease. This survey aimed to determine the attitudes of vascular consultants to risk factor management in new patients attending their out-patient clinic.

METHODS

An anonymous postal questionnaire was sent to all 394 members of the Vascular Surgical Society in June 2002. Questions were asked about the following measures: serum cholesterol levels, the presence of diabetes, antiplatelet therapy, exercise regimens, blood pressure, thrombophilia, smoking and the availability of local guidelines and expertise.

RESULTS

A response rate of 65% was obtained. Most (85%) consultants would measure a random cholesterol, but 34% would only treat claudicants if the cholesterol was greater than 5.5 mmol/l. Furthermore, 23% would inappropriately use diet alone as initial cholesterol lowering therapy. Over a quarter of consultants would not screen for diabetes or measure blood pressure. Nearly all (99%) would recommend aspirin and 66% would recommend nicotine replacement therapy. Only 55% had access to a smoking cessation clinic, and 34% to a formal exercise program. The majority (56%) did not have local risk factor management guidelines, only 16% had access to a vascular physician, and 65% would prefer to have this expertise available for difficult cases.

DISCUSSION

Management of major risk factors was found to be sub-optimal. Thus guidelines for the prevention of coronary disease in clinical practice are not being applied to claudicants.

Management of secondary risk factors in patients with intermittent claudication

OBJECTIVES

The first line management of patients with intermittent claudication is "best medical therapy" i.e., smoking cessation, exercise, antiplatelet therapy and risk factors modification. The aim of this study was to assess the current management of risk factors in primary care and to compare General Practitioner (GP) attitudes and actual management.

DESIGN AND METHODS

Postal questionnaire of all 336 GPs in the referral area (Grampian, Scotland). Questionnaire and measurement of serum cholesterol, blood glucose and HbA1c of new clinic patients (n = 104) with claudication referred by general practitioners.

RESULTS

A 73% GP response rate was obtained. Ninety-five percent of GPs would treat risk factors. The vast majority would prescribe aspirin, yet 28% of patients were on no anti-platelet therapy. Eighty-nine percent of GPs would advise an increase in exercise but only 14% of patients recalled being told to do so. One in seven of the GPs would not check serum cholesterol, 18% considered cholesterol lowering therapy to be primary prevention and 41% would only treat levels above 5.5 mmol/l. Eighty-five percent of patients were on a statin or had a cholesterol above 5 mmol/L. Seventy-seven percent of GPs would check glucose levels, and 14% of patients were found to be previously undiagnosed diabetics.

CONCLUSIONS

Risk factors in claudicants are suboptimally managed. Urgent guidelines for the specific management of claudicants by general practitioners, as well as strategies to ensure their implementation, are required.

[Diagnostic and therapeutic stragegies in peripheral obliterative arteriopathy: non-drug treatment]

The therapeutic management of patients with peripheral arterial disease relies initially on the assessment of the severity of arterial insufficiency. At this stage, measurement of ankle systolic pressure plays a particularly important role, and is an essential part of the clinical examination. When the severity of ischaemia jeopardises the survival of a limb, the limitations associated with medical treatment clearly justify all steps being taken to enable the patient to benefit from revascularisation. In this often fragile host environment, endovascular techniques play an important part. As first-line procedures, they have a place within a multidisciplinary management approach, particularly since further surgical procedures, such as distal bypass, often prove necessary. For patients at the intermittent claudication stage, treatment indications become more complex. They include the functional repercussions of peripheral arterial occlusive disease and the cardiovascular prognosis for the patient, which is determined by assessing the extent of the arterial disease. Ultrasonography provides a topographical evaluation of the lesions and their haemodynamic repercussions. This investigation is crucial for screening patients who present with a lesion that may be appropriate for endovascular surgery. Ultrasonography is often programmed at the same time as arteriography. For patients with intermittent claudication, surgical revascularisation is considered only after a minimum 3-month period of medical treatment, for those who have significant functional impairment. In some instances, ultrasonographic evaluation, or even arteriography, may reveal lesions associated with a real risk of deterioration, such as arterial or popliteal aneurysm, and this constitutes the basis of the indication. The development of endovascular techniques has broadened the indications for surgical revascularisation to include patients with intermittent claudication. As a result, there has been a radical change with regard to the management of these patients, limiting the number for whom medical treatment is the only feasible solution.