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International Angiology 2017 June;36(3):203-15

DOI: 10.23736/S0392-9590.16.03716-0

Copyright © 2016 EDIZIONI MINERVA MEDICA

lingua: Inglese

Prioritization of treatments for lower extremity peripheral artery disease in low- and middle-income countries

Gerald F., FOWKES 1, Rachel B. FORSTER 2, Carol E. LEVIN 3, Nadraj G. NAIDOO 4, Ambuj ROY 5, Chang SHU 6, John SPERTUS 7, Kun FANG 8, Luis BECHARA-ZAMUDIO 9, Mariella CATALANO 10, Adriana VISONÀ 11, Sigrid NIKOL 12, John P. FLETCHER 13, Michael R. JAFF 14, 15, William R. HIATT 16, Lars NORGREN 17

1 Department of Epidemiology, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; 2 Cochrane Collaboration Review Group on Peripheral Vascular Diseases, University of Edinburgh, Edinburgh, UK; 3 Disease Control Priorities Network, School of Public Health, University of Washington, Seattle, WA, USA; 4 Unit of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; 5 Unit of Cardiology, Cardiothoracic Department, All India Institute of Medical Sciences, New Delhi, India; 6 Department of Vascular Surgery, The Second Xiangya Hospital, Central Southern University, Hunan, China; 7 Department of Outcomes Research, St. Luke’s Mid America Heart Institute, Kansas City, MO, USA; 8 Department of Vascular Surgery, The Second Xiangya Hospital, Central Southern University, Hunan, China; 9 Department of Vascular Surgery, University of Buenos Aires, Buenos Aires, Argentina; 10 Research Centre on Vascular Diseases and Angiology Unit, L. Sacco Hospital, Milan, Italy; 11 Unit of Angiology, San Giacomo Hospital, Castelfranco Veneto, Treviso, Italy; 12 Unit of Clinical and Interventional Angiology, Department of Medicine, Asklepios Clinic St. Georg, Hamburg, Germany; 13 Department of Surgery, Westmead Research Centre for Evaluation of Surgical Outcomes, Westmead Hospital, University of Sydney, Sydney, Australia; 14 Department of Medicine, Harvard Medical School, Boston, MA, USA; 15 Paul and Phyllis Fireman Endowed Chair in Vascular Medicine, Massachusetts General Hospital, Boston, MA, USA; 16 Division of Cardiology, Department of Medicine, CPC Clinical Research, University of Colorado School of Medicine, Aurora, CO, USA; 17 Unit of Surgery, Department of Surgery, Faculty of Medicine and Health, Ӧrebro University, Ӧrebro, Sweden



INTRODUCTION: Lower extremity peripheral artery disease (PAD) is increasing in prevalence in low- and middle-income countries creating a large health care burden. Clinical management may require substantial resources but little consideration has been given to which treatments are appropriate for less advantaged countries.
EVIDENCE ACQUISITION: The aim of this review was to systematically appraise published data on the costs and effectiveness of PAD treatments used commonly in high-income countries, and for an international consensus panel to review that information and propose a hierarchy of treatments relevant to low- and middle-income countries.
EVIDENCE SYNTHESIS: Pharmacotherapy for intermittent claudication was found to be expensive and improve walking distance by a modest amount. Exercise and endovascular therapies were more effective and exercise the most cost-effective. For critical limb ischemia, bypass surgery and endovascular therapy, which are both resource intensive, resulted in similar rates of amputation-free survival. Substantial reductions in cardiovascular events occurred with use of low cost drugs (statins, ACE inhibitors, anti-platelets) and smoking cessation.
CONCLUSIONS: The panel concluded that, in low- and middle-income countries, cardiovascular prevention is a top priority, whereas a lower priority should be given to pharmacotherapy for leg symptoms and revascularisation, except in countries with established vascular units.


KEY WORDS: Peripheral artery disease - Poverty - Cardiovascular disease - Prevention and control

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