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Canadian Journal of Cardiology
Letters to the Editor| Volume 37, ISSUE 10, P1677, October 2021

The Time Has Come for Vascular Medicine in Canada

Published:January 18, 2021DOI:https://doi.org/10.1016/j.cjca.2021.01.011
      To the Editor:
      Peripheral artery disease (PAD) affects > 800,000 Canadians, and is increasing globally.
      • Fowkes F.G.
      • Aboyans V.
      • Fowkes F.J.
      • McDermott M.M.
      • Sampson U.K.
      • Criqui M.H.
      Peripheral artery disease: epidemiology and global perspectives.
      Compared with coronary artery disease (CAD) patients, PAD patients are at higher risk for future cardiovascular and limb events,
      • Smolderen K.G.
      • Bell A.
      • Lei Y.
      • et al.
      One-year costs associated with cardiovascular disease in Canada: insights from the Reduction of Atherothrombosis for Continued Health (REACH) registry.
      and their annual medications and in-hospital care is more costly.
      • Smolderen K.G.
      • Bell A.
      • Lei Y.
      • et al.
      One-year costs associated with cardiovascular disease in Canada: insights from the Reduction of Atherothrombosis for Continued Health (REACH) registry.
      PAD is underdiagnosed and undertreated,
      • Makowsky M.
      • McMurtry M.S.
      • Elton T.
      • et al.
      Prevalence and treatment patterns of lower extremity peripheral arterial disease among patients at risk in ambulatory health settings.
      and the landscape of effective PAD therapies is rapidly evolving, adding to the challenges of optimally managing this patient population.
      In Canada, various practitioners care for PAD patients. However, primary care physicians are well-positioned to identify them because PAD is highly prevalent and easily identified.
      • Hirsch A.T.
      • Criqui M.H.
      • Treat-Jacobson D.
      • et al.
      Peripheral arterial disease detection, awareness, and treatment in primary care.
      Unfortunately, PAD awareness is low, little time is devoted to PAD education in medical school or family medicine residency, and there are no primary care guidelines regarding screening, nor are there PAD billing incentives.
      PAD patients referred to vascular surgeons typically receive surgical management but are less commonly prescribed life-saving medical therapies. Barriers to medication prescription include surgeons’ low level of comfort, absence of vascular medicine specialists, and a belief that this role is best fulfilled by general practitioners or internal medicine specialists. This often leads to suboptimal management and higher-than-necessary associated morbidity and mortality among PAD patients.
      Postgraduate trainees in family or internal medicine rarely spend time on a vascular service, and, after residency, there are few continuing medical education opportunities on PAD management. Vascular surgery trainees have limited time to spend on cardiology or vascular medicine rotations, and optimal medical management topics are not commonly presented in vascular surgery continuing medical education. Furthermore, there are few general internists or cardiologists with a special interest or experience managing PAD patients, and there are few formally trained vascular medicine specialists. Canada does not have vascular medicine speciality certification, although vascular medicine fellowship training programs do exist in Ontario and Québec. Other centres across Canada should consider initiating vascular medicine clinical services and training programs to improve the care we provide to PAD patients.
      Because PAD patients are high risk and costly to the health-care system, they would ideally be served by close collaboration between surgical and medical specialists and primary care, and this care can be integrated by vascular medicine specialists to optimise PAD care.
      Finally, the Canadian Cardiovascular Society Consensus guidelines on PAD diagnosis and management are scheduled for completion by the end of 2021, and should serve as an up-to-date evidence synthesis upon which regional development of vascular medicine training and service provision in medical schools and hospitals across the country can be built.

      Funding Sources

      S.S.A. holds the Michael G. DeGroote Heart and Stroke Foundation Chair in Population Health Research, and a Canada Research Chair Tier 1, in Ethnicity and Cardiovascular Disease.

      Disclosures

      S.S.A. receives consulting and speaker fees from Bayer and Janssen. A.D.B. has received honoraria for consulting, speaking, or conducting research for the following commercial organizations: Amgen, Bristol Myers Squibb, Janssen, AstraZeneca, Novartis, Pfizer, Bayer, Lilly, Boehringer Ingelheim, HLS Therapeutics, Spectrum Therapeutics, Sanofi, and Bausch Health. D.S. receives honoraria or compensation for consulting, speaking, proctorship, or conducting research from Bayer, Cook Canada (Medical Devices), and Medtronic Canada (Medical Devices).

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        One-year costs associated with cardiovascular disease in Canada: insights from the Reduction of Atherothrombosis for Continued Health (REACH) registry.
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