Toronto, ON - Despite playing a central role in the treatment of patients with peripheral arterial disease (PAD), vascular surgeons may not be prescribing the drugs needed to reduce the risk of cardiovascular disease (CVD) in these patients, new research suggests [1].

Writing in the July 27, 2006 issue of the Annals of Vascular Surgery, Dr Mohammed Al-Omran (Toronto General Hospital, ON) and colleagues report that the rate at which surgeons recommended evidence-based medication in PAD patients varied considerably among surgeons and between drugs.

"If you have disease in your arterial tree, or PAD, you're at very high risk for CVD as well," senior author on the study, Dr Subodh Verma (St Michael's Hospital, Toronto, ON), told heartwire. "As a result, all of those standard risk-reduction therapies such as aspirin, clopidogrel, statins, and ACE inhibitors in people who have CAD also apply to those people who have PAD. In Canada, the main delivery of care for people who have PAD rests with the vascular surgeons—they are sort of the top of the pyramid when it comes to delivery of vascular care. And we found that there were significant knowledge and action gaps with respect to recommending and instituting risk-reduction therapy."

Al-Omran et al conducted a cross-sectional survey of 79 vascular surgeons at the 2004 annual meeting of the Canadian Society for Vascular Surgery; a total of 52 completed the survey. According to survey results, knowledge of LDL-cholesterol, blood-pressure, and blood glucose targets was low. While routine initiation of antiplatelet therapy was high, less than 50% of respondents knew that ACE inhibitors could be prescribed for PAD patients as an antiatherosclerotic therapy (regardless of blood-pressure level). Similarly, only 19% and 5.8% of surgeons surveyed said they would recommend statin and ACE-inhibitor therapy, respectively.

Strikingly, while surgeons overwhelmingly agreed that risk-reduction therapy should be recommended or initiated by vascular surgeons, less than two thirds of surgeons said they routinely counseled patients about LDL-cholesterol reduction and blood-pressure control, and the majority admitted that their self-assessment of risk reduction in PAD was average or below average.

"What we think is happening is that vascular surgeons may actually believe that this is not their mandate and that the mandate rests with other practitioners, be it general practitioners or an internist," Verma stated.

Part of the problem may be that, unlike in cardiovascular disease, where patients found to be at risk are typically referred by a family physician first to a cardiologist and then to a surgeon, patients with presumed or proven PAD are usually referred directly from the family doctor to the surgeon. "So there's no intermediate, cardiologist-type person who will actually catch these patients and make sure they receive the appropriate risk-reduction therapy."

Also commenting on the results, coauthor and vascular surgeon Dr Thomas Lindsay (Toronto General Hospital) told heartwire that most surgeons have little experience prescribing the types of medications tracked in the study. "I think that most surgeons are uncomfortable with the side effects of risk-reduction medications and being responsible for these side effects."

He continued: "I believe that if [surgeons] were given guidelines plus information that they might give to patients about the side effects and how to manage them, they might be more willing to prescribe these drugs." Very few sales representatives from drug companies that make these agents actually visit surgeons to provide them with prescribing and monitoring information, he added. "I do believe most surgeons are aware of the latest cardiovascular guidelines, but since they rarely prescribe these medications, the unfamiliarity makes them uncomfortable."

Asked why surgeons appear to be more comfortable prescribing some drugs more than others, Lindsay responded that it is likely "a mix of the safety of the medications, the side-effect profiles, and what type of ongoing monitoring is necessary." In Canada, he points out, there are very few vascular internists who would be specialists in this sort of information.

"More education of the vascular surgeons is required regarding side effects, safety profiles, and monitoring guidelines," Lindsay stated. "If they were familiar and comfortable with these, I do believe it would increase the rates at which they prescribed these medications."