In previous decades, cardiologists in Europe specialised in the diagnosis and management of diseases that affected the heart and vessels. Atherosclerosis was classified as a generalised vascular disease, and the mechanisms of venous or arterial embolism were more clearly understood. However, as technology became more advanced, cardiology evolved into a hyper-specialised discipline and was divided into several subspecialties. This has forced cardiologists to stay increasingly focused on their domain of choice. Also, the consistent increase in the prevalence and burden of cardiac disease has led to a progressive loss of interest in the peripheral vessels for most cardiologists.
As this interest has declined, the gap in the care of patients with peripheral vascular disease has been filled by other physicians. For example, in the U.K. and the Scandinavian countries, patients with peripheral artery diseases are managed by vascular surgeons, and those with thromboembolic venous disease are managed by thrombosis specialists. In some countries, angiologists are taking care of these patients.
Many countries in Europe and North America have created a discipline of vascular medicine to better manage these patients and to give the same attention as patients with cardiac diseases. However, these patients are still not treated optimally because cardiologists have lost interest and are looking elsewhere. A European survey that was conducted a few years ago shows that young cardiologists have less interest and practice in peripheral vascular diseases. This trend has increased the rift between cardiologists and vascular disease. It is important to note that many patients with cardiac diseases also have vascular conditions and vice versa. Therefore, these patients require an all-around vision of their cardiovascular health, but this is often missed since cardiology, stroke centres and vascular departments are so firmly divided.
It has also been observed that many cardiologists do not palpate the peripheral pulses and also do not ask patients about vascular symptoms. They prescribe exercise tests to screen for coronary artery disease, but why some patients have submaximal efforts because of limb limitations is rarely considered. In other words, the assessment of peripheral vessels is not integrated into the typical cardiovascular check-up.
Numerous publications have demonstrated that investigating peripheral vessels can help predict cardiovascular events. This includes the assessment of endothelial function, measurement of the ankle-brachial index, carotid and femoral imaging and estimation of aortic stiffness. Also, concomitant disease in two or three vascular beds is a powerful predictor of the occurrence of adverse vascular events.
It is unfortunate that even though cancer and cardiovascular diseases are the two leading causes of death in most countries, and cancer has large screening programmes, but no screening strategies are implemented for cardiovascular diseases. There is evidence to show that screening can reduce cardiovascular deaths, as can the identification of vascular diseases. Therefore, not only hypertension but peripheral arterial disease screening can help. In patients with cardiac disease, the coexistence of peripheral arterial disease can help identify patients who are at the highest level of risk.
All cardiologists can read electrocardiogram, interpret common abnormalities, have a basic knowledge and practice in peripheral vascular medicine. ESC guidelines also recommend that vascular teams should be set up in every healthcare centre, and cardiologists should be part of a multidisciplinary team along with vascular surgeons and physicians. This can help optimise the management of cardiovascular patients. The state of peripheral vessels must be integrated into patient management as this can help improve overall patient outcomes and quality of life.
Source: European Heart Journal
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