Combination of diabetes and PAD presents clinical, financial challenges

Expert says that increasing prevalence of obesity and diabetes may replace tobacco use as nation’s most pressing health hazard.

Vascular Interventional Advances

The link between diabetes and peripheral arterial disease is both clinically significant and costly to society, according to Michael R. Jaff, DO, an associate professor of medicine at Harvard Medical School in Boston.

Patients with both diabetes and PAD not only tend to have increased risks for limb loss, negative clinical outcomes and mortality, but the cost of care is also higher when compared with those patients who have either diabetes, PAD or neither condition. In addition, Jaff cautioned, the prevalence of the conditions is increasing.

“As we go into our careers and our young trainees enter the workforce in health care, the major health hazard is no longer cigarette smoking, although one should not downplay the importance of that,” Jaff said in the keynote address at the Vascular Interventional Advances 2009 meeting in Las Vegas. “The largest health hazard is not tobacco related but is rather obesity and diabetes related.”

Jaff cited results from a number of studies and analyses that illustrated the negative relationship between diabetes, PAD and negative outcomes. A study of 474 men followed for 14 years suggested that those with PAD and diabetes had an increased risk of limb loss and death compared with patients who had either PAD alone, diabetes alone or neither (P=.001). Researchers from a meta-analysis reported a 61% prevalence of diabetes among the patient population with critical limb ischemia undergoing percutaneous transluminal angioplasty. Results from another study suggested that the presence of diabetes, indicated by higher HbA1c levels, was associated with increased risk for PAD and for limb loss.

“The truth of the matter is that all of these patients require comprehensive medical management, aggressive antiplatelet therapy and some form of antihypertensive therapy (in some cases, ACE inhibitors),” Jaff said. “It is also important to not forget the importance of aggressive lipid-lowering therapies, not only for PAD, which is a coronary heart disease equivalent, but for long-term survival.”

Treatment literature for diabetes and PAD

Jaff contended that the literature on the direct treatment of diabetes in patients with PAD, however, was limited. Citing results from the Diabetes Control and Complications Trial (DCCT), Jaff noted that when 1,441 patients with type 1 diabetes were treated with conventional glycemic control vs. intensive glycemic control, the patients receiving intensive glycemic control reduced their risk for any CV event by 42% and either nonfatal MI, stroke or CV death by 57% following a mean 6.5 years of treatment. A recent retrospective analysis of 291 patients undergoing 385 percutaneous coronary interventions suggested that more than 57% of them had diabetes and tended to have worse outcomes than those without diabetes.

Jaff also presented economic data suggesting that the most expensive patients to care for were those with both PAD and diabetes. Jaff urged his colleagues to consider undertaking more research focusing specifically on the relationship between diabetes and PAD.

“There is no question that due to the expanding prevalence of diabetes and obesity, we will all be seeing more of this, and this will be taking the place of tobacco and vascular disease as our major referral line,” Jaff concluded. “However, there are opportunities abound to stop limb loss and the mortality associated with this. It is our system-wide obligation to dedicate our lives to this pandemic in spite of all of the external pressures that may fly in the face of that.” – by Eric Raible

For more information:

Jaff M. Keynote address. Presented at: Vascular Interventional Advances; October 20-23, 2009; Las Vegas.