Detection and management of associated atherothrombotic locations in patients with a recent atherothrombotic ischemic stroke: results of the DETECT survey.

BACKGROUND: Cerebral infarction (CI), myocardial infarction, peripheral artery disease (PAD) and aortic atheroma are the main clinical manifestations of atherothrombosis. Long-term prevention after CI of atherothrombotic origin may require preventive measures at other sites, such as specific drug therapies, surgery, or angioplasty. Therefore the detection of other locations is potentially important. OBJECTIVES: The primary objective was to describe the other locations of atherothrombosis in patients hospitalized for a recent cerebral infarct of atherothrombotic origin. Secondary objectives were to describe their vascular risk factor profiles, and their management before and after the cerebral event. METHOD: This prospective, observational, multicenter survey was conducted in France between September 2003 and July 2004, mainly in neurological departments and stroke units. RESULTS: 753 patients were included (74% men; mean age 69.3 years). Previous coronary events had occurred in 119 (16%). Previous stroke or transient ischemic attacks had occurred in 233 (31%). PAD was already known in 109 (15%). A search for other atherothrombotic locations was positive in 216 patients (29%). The minimum prevalence for any associated atherothrombotic location (either present before or identified during hospitalization) was 47.5% for any location, 33.7% for coronary artery disease, 16.6% for aortic atheroma, and 22.7% for PAD. CONCLUSION: Fifty percent of the patients with recent atherothrombotic CI have other locations of atherothrombosis. For this reason, a systematic search for these other locations is recommended because of the possible therapeutic consequences. However, the question of the most appropriate period for this search after the cerebral event remains unsettled.

[Risk factors management in 5708 ambulatory patients suffering from peripheral vascular disease followed in urban practices]. / Contrôle des facteurs de risque dans une population de 5 708 artériopathes des membres inférieurs vus en médecine de ville.

STUDY OBJECTIVE: we examined the management of risk factors in patients suffering from obliterating peripheral arterial disease (OPAD), in urban medical practice. METHODS: PRISMA, ECLAT1 and APRES are surveys based on urban medicine in France. These 3 studies have allowed a compilation of data pertaining to the control of risk factors in patients suffering from one or more clinical manifestations of atherothrombosis, including cerebral vascular accident, coronary insufficiency or OPAD. The study population was divided among patients with isolated OPAD, versus OPAD associated with coronary artery disease (CAD), versus OPAD associated with cerebral vascular disease. RESULTS: a total of 5 708 patients with stable OPAD were included among the 3 studies. Risk factors were not managed in the majority of patients, including 62.6% of hypercholesterolemic patients, 71.1% of diabetics, and 77.4% of hypertensive patients. Overall, the control of risk factors was less satisfactory in patients with OPAD than in patients with CAD. Smoking (70.6% current or past smokers) remains a major risk factor in OPAD. The proportion of current smokers was significantly higher is the group with isolated OPAD than in the other 2 groups of patients (p < 0.0001). CONCLUSIONS: The control of risk factors in patients with OPAD is suboptimal, mainly because of failure to reach the therapeutic goals, rather than because of poor medical management. It is important that recent recommendations be implemented in medical practice. Awareness of the primary physicians will be key in the optimisation of treatment prescriptions and, above all, in the achievement of a higher level of clinical performance.

[Peripheral arterial disease: what management practices for general practitioners?]. / L'artériopathie des membres inférieurs en médecine générale. Quelle prise en charge?

OBJECTIVE: The purpose of this study was to analyze the results of the ATTEST study in order to evaluate general medicine management practices for peripheral arterial disease (PAD). Our analysis was based on the guidelines for good practice which recommend measurement of the systolic pressure index (SPI), search for other localizations of atherothrombosis, treatment of risk factors including smoking, walking exercises, and long-term prescription of anti-platelets. METHODS: ATTEST is a cross-sectional multicentric observational epidemiologic study conducted in metropolitan France. The study has recruited 8.475 analyzable patients with symptomatic PAD alone (3811 patients) or associated with other atherothrombotic localizations (2416 patients) or other cardiovascular diseases (2248 patients). These patients were followed by 3020 physicians. The current analysis thus included 6227 patients (81.2% men, 18.8% women, mean age 67.2 years), including 78.8% who had reached the stage of intermittent claudication. Risk factors included current or past smoking (61%), hypercholesterolemia (66.3%), hypertension (63.1%) and diabetes mellitus (26%). RESULTS: Arterial duplex Doppler exams of the lower limbs were performed in 91.2% of the patients but measurement of the SPI for diagnostic purposes had been performed in only 17%. The majority (85.8%) of the patients with proven coronary artery disease or cervico-encephalic involvement had had an ECG and 69.3% had had a duplex Doppler of the supra-aortic trunks. Smoking continued in 39% of the patients and an aid to cease smoking had been prescribed for only 7% of the patients who were non-smokers for less than one year. Nearly two-thirds of the patients analyzed had received advice concerning physical activities. Finally, anti-platelets had been prescribed for 92.2% of the patients. CONCLUSIONS: The general practitioner plays a crucial role in the diagnosis and treatment of PAD. Although measurement of the SPI is recommended as an early diagnostic tool and for evaluation of severity, it had been performed in less than one-third of the patients. Search for another localization of atherothrombosis had been performed in more than half of the patients. The physicians generally delivered advice on physical exercise and prescribed anti-platelets. The fight against smoking was however largely insufficient. The results of this study warrant further optimization of the collaboration between general practitioners and vascular disease specialists.