Protocol of Peripheral Artery Disease Screening: The Phase -1 of the Global Artery Project (GAP)

Introduction

In 2015, the prevalence of Peripheral Artery Disease (PAD) was 237 million cases worldwide, with a relative increase of 17% compared to 2010.¹ The prevalence seems to be booming in low- and middle-income countries, with a 22.6% relative increase, vs. 4.5% in high-income countries.^1,2 In addition to its high prevalence, PAD multiplies by 4 the 10-year cardiovascular mortality in men (18.7% versus 4.4%) and multiplies by 3 the 10-year cardiovascular mortality in women (12.6% versus 4.1%).³ Mortality rates for asymptomatic PAD are similar to those for intermittent claudication and have remained unchanged over the last three decades.^4,5 The main underlying causes of lower-limb PAD are smoking, diabetes, high blood pressure, and elevated blood fat (cholesterol) levels.⁶ Diabetes is a major risk factor for PAD with multiple and serious complications. Diabetic foot is undoubtedly one of the most feared complications in diabetic patients because it exposes them to the risk of amputation, which is experienced by patients as a social drama that can lead to despair, depression, anxiety, loss of self-esteem, stigmatization, isolation, and a real feeling of bodily disintegration.⁷ PAD represents more than 88% of the causes of diabetic foot, with an amputation rate of more than 26% in our country.⁸ Sensitive to this public health problem, the Institute of Continuing Medical Education (ICME) LLC, specialized in health promotion, is launching a Phase 1 of the “Global Artery Project^®” focused on the Peripheral Artery Disease. To define the objectives of Phase 1 of this project, we were inspired by the 2024 multisociety guidelines for the management of lower extremity decline in the (PAD) National Action Plan.^9,10 Thus, we retained six objectives.

Objective 1: To improve at-risk population awareness of PAD symptoms and diagnostic tools across the national territory.

Objective 2: Organization of the Continuing Medical Education for the National PAD Team.

Objective 3: Activate health care systems and development partners to provide PAD Screening programs.

Objective 4: Reduce the rates of non-traumatic lower extremity amputations related to PAD through lower extremity revascularization strategic plans (drugs, open surgery, Stent, Vascular Rehabilitation).

Objective 5: To increase and sustain research in order to better understand the prevention, diagnosis, and treatment of PAD.

Objective 6: Provide national and regional health policy decision-makers with a national and regional database based on an AOMI register and scientific publications.

This protocol will be dedicated to Objectives 1, 2, and 3. Objectives 4, 5, and 6 will be the subject of another protocol study.

Protocol

OBJECTIVE 1: Improve At-Risk Population Awareness of PAD Symptoms and Diagnosis Tools across national territory.

To achieve this goal, we plan 3 actions:

Action 1.1: Across the national territory, carry out at-risk groups’ awareness on the “prevention of diabetic feet” and explain the link between diabetic feet and PAD

Rationale: Diabetic foot is a complication of PAD that is known and feared by patients in general; PAD itself is unknown to the population. Given the non-existence of a priority region and given limited resources and for reasons of efficiency, awareness will focus on the main regions of our country and will prioritize the at-risk groups as defined in current guidelines^6,11: age ≥65 years, Age 50-64 y, with risk factors for atherosclerosis (e.g., diabetes, history of smoking, dyslipidemia, hypertension), chronic kidney disease, or family history of PAD, Age <50 years, with diabetes, and one additional risk factor for atherosclerosis.

Tactics:

1.1A: Identify the 10 major cities in the main regions of our country, which are poles of concentration of the population to reach the maximum number of people and a representative portion of the national population ( Figure 1).

Figure 1. Main Cities selected (red dots) for awareness and PAD screening days in public squares and public hospitals in Cote d'Ivoire.

PAD: Peripheral Arterial Disease.

1.1B: Organize two teams (Team A and Team B) of awareness and screening.

1.1C: Set up a local committee composed of local facilitators such as the regional chief physician, a representative of the town hall, a representative of traditional leaders, and a representative of religious leaders.

1.1D: Develop advertising and awareness posters on prevention of “diabetic feet” specifying the population at risk.

1.1E: Develop a communication plan on prevention of “diabetic feet” and its link with PAD via local radio stations, local religious worship, town hall information channels, and the organization of traditional communities.

Action 1.2: Across the national territory, carry out at-risk groups’ PAD screening during awareness days

Rationale: For reasons of inclusion and efficiency, PAD screening will focus on the main regions of our country and will prioritize the at-risk groups for messaging and screening as defined in the current guidelines^6,11: age ≥65 years, Age 50-64 y, with risk factors for atherosclerosis (e.g., diabetes, history of smoking, dyslipidemia, hypertension), chronic kidney disease, or family history of PAD, Age <50 years, with diabetes, and one additional risk factor for atherosclerosis.

Tactics:

1.2A: For PAD screening, use the same 10 major cities of the main regions Identified for awareness on prevention of “diabetic feet.”

1.2B: Take advantage of awareness days to achieve the PAD screening.

1.2C: Set up PAD screening stands at public awareness sites.

1.2D: Carry out the screening for PAD by automatic measurement of Ankle Brachial Index in subjects at risk of PAD.

1.2E: Collect screening data on a survey sheet.

Action 1.3: Secure funding to launch and sustain PAD awareness and screening initiatives

Rationale: Communication through consistent messaging on a national scale requires significant funding. However, in low- and middle-income countries (LMIC), the financial resources of the population are limited.

Tactics:

1.3A: Identify needs and assess their financial costs for both awareness raising and screening.

1.3B: Identify funders to discuss opportunities.

1.3C: Send letters requesting financial support from potential funders.

OBJECTIVE 2: Organization of the Continuing Medical Education for the National PAD Team.

To achieve this goal, a main action must be taken:

Action: Establish a National PAD Team made up of 176 members including 3 vascular physicians, 2 diabetologists, 2 radiologists, 2 biochemists, 2 orthopedic surgeons, 4 vascular surgeons, 10 patients, 50 nurses (5 nurses × 10 regions), 1 podiatrist, and 100 general practitioners (10 general practitioners × 10 regions).

Using CME, raise awareness among the PAD Team about the extent of the PAD problem, and explain to them the risk factors and diagnostic and management methods of PAD.

Rationale: Despite its prevalence and serious complications that can lead to amputation or patient death, PAD is under-recognized by clinicians due to major gaps in their knowledge and understanding of the risk factors, screening, diagnosis, and management methods of PAD. The Global Artery Project (GAP) aims to fill these gaps.

Tactics:

2.A: Establish a national PAD Team.

2.B: Organize PAD Team CME.

2.C: Present during the CME, the worldwide, African and Ivorian prevalence of PAD, the risk factors of PAD and their management methods.

2.D: Present during the CME, the diagnostic and screening methods of PAD.

2.E: Explain during the CME, the pharmacological, surgical, interventional and functional methods of managing PAD.

OBJECTIVE 3: Activate health care systems and development partners to provide PAD Screening programs.

The goal s to screen 500 people per screening site for a total of 5,000 people across the 10 screening sites. To minimize screening program costs, we plan to form two teams (Team A and Team B) that will travel to five screening sites for a total of 2,500 people screened per team. These screenings will be performed during the awareness days.

To achieve this goal, a main action must be taken:

Action: Free Screening of Peripheral Arterial Disease (PAD) by measuring the Ankle-Brachial Pressure Index (ABI) in at-risk patients.

Rationale: A pilot study conducted from January 2022 to March 2024 screened 474 diabetic patients, including 211 (44.5%) men and 263 (55.5%) women with a mean age of 59.84 ± 12 years [range: 18-91 years]. The prevalence of PAD was 15.8% (N = 75). Patients who screened positive and carried PAD were managed in a specialized environment with pharmacological medical treatment, a vascular rehabilitation program, and arterial revascularization surgery, if necessary. This specialized medical monitoring has allowed us to obtain excellent immediate results, allowing the foot to be saved and the absence of amputation in nearly 90% of cases. Considering these results, we wish to extend this screening campaign to more at-risk groups as defined in the current guidelines^6,11: age ≥65 years, Age 50-64 y, with risk factors for atherosclerosis (e.g., diabetes, history of smoking, dyslipidemia, hypertension), chronic kidney disease, or family history of PAD, Age <50 years, with diabetes, and one additional risk factor for atherosclerosis. The cost of the measurement was a limiting factor that prevented a large number of people from accessing this screening. To extend this screening to more people, the FREE measurement of the Brachial Pressure Index (ABI) could be an interesting solution, which requires funders to bear the costs of this screening.

Tactics:

3.A: Identify needs and assess their financial costs for PAD screening during awareness days.

3.B: Doing PAD screening devices during awareness days.

3.C: Identify funders to discuss opportunities.

3.D: Send letters requesting financial support from funders for the PAD screening program.

Discussion

Ethical considerations

The Ethic Committee of Bouake Teaching Hospital for Medical Care and Scientific Research gave us the institutional approval (N° 01 MSHP/CHU-B/DMS/CARDIO/K.C/22).