Thank you, Tonio, and welcome, everyone, to this morning session. These are my acknowledgments, and the objectives of this talk will be to describe ischemic cardiovascular limb risk associated with peripheral joint disease, discuss disparities in treatment and awareness of PAD, and review strategies to improve awareness and treatment. Now, when we talk about peripheral joint disease, we commonly refer to the presence of atherosclerotic stenosis of 50% or more in the aorta, or arteries that feed the limbs. There's more than 200 million people suffering of peripheral joint disease in the world, and 6.5 million of them age 40 years or older live here in the United States. Now, when we compare patients with PAD with those without, patients with PAD have a 70% increased risk of cardiovascular events and 80% increased risk of death compared with patients without PAD or controls. The prevalence of myocardial infarctions is 2.5 times higher than in patients without PAD. In prior history of survey of vascular events in patients who have already established peripheral joint disease, it's associated with much worse outcomes and extensive coronary disease. Patients with PAD have a higher risk of subclinical and coronary artery disease, as well as cardiovascular events, when compared with controls or non-PAD patients. And the risk of death from cardiovascular events in patients with PAD is nearly 6 times higher than the general population. Now, the REACH registry that enrolled a little over 7,000 patients, about 63% of them have some sort of concomitant of CVD, CAD, or PAD, as you see in this slide. And the relative five-year mortality for patients with PAD is about 30-32% higher than prostate cancer, Hodgkin's disease, or breast cancer. If you look at this at 10 years, the 10-year survival rate for patients with PAD is around 25%. It's pretty dismal. And the answer is here. Patients with PAD have higher risk of cardiovascular mortality than patients who have established coronary artery disease. Now, these patients die of coronary artery disease, but die of other reasons as well, as you see in this slide. Certainly most of them will die of coronary artery disease. Now, why is this correlation so strong? Well, it's simple. Patients with PAD or CAD, they both share the same atherosclerotic risk factors, particularly smoking. There's also a genetic predisposition. First-degree relatives of patients with PAD have a higher risk of development of peripheral disease. And they seem to have also increased inflammatory markers. What about the cost and the impact of PAD in society? In 2015, we spent approximately $380 billion in the management of PAD, but only 12.5% of the predicted population was identified and treated. So imagine the burden to society when we try to manage PAD. And what surprised me the most is that about 150,000 to 180,000 amputations occur in the United States every year. Many of them can be avoided. Many of them have been done without a prior arterial testing. So we must raise some awareness. The problem is the accurate epidemiological information is still limited. And only 10% of patients demonstrate any sort of symptoms. Most are asymptomatic. Bear in mind that African Americans have twice the prevalence of PAD than whites or Hispanics, and one and a half to three times the likelihood of losing a limb from PAD. But there's barriers. There's barriers both for patients and barriers for physicians when we talk about PAD awareness. And barriers will include low race knowledge and screening for PAD, lack of awareness regarding risk and the consequences of an amputation, and low levels of trust to us, to physicians. What about provider-based barriers? Low disease awareness among primary care physicians, inadequate knowledge of physical diagnostic methods to manage PAD, or if they know it, they don't use it. This relative low level of compensation, as you well know, for treating asymptomatic patients. So what else can we do? Well, we've got to go to Congress. We must have unauthorized funds to establish some sort of coordinated program to cover the cost of PAD screening without any cost sharing for at-risk patients. We must require quality measures to reduce amputation related to PAD and disallow a non-emergent amputation without some sort of material testing, whether it's a doppler, whether it's an angiogram. Right now in Congress, there's a bill sitting called the Amputation Reduction and Compensation Act, the ART Act or bill, which will require Medicare, Medicaid, and group health insurance to cover preventive screening at at-risk populations. Now if this is passed, we will decrease the number of unnecessary amputations, particularly in populations of color. Why? Because we will require some sort of arterial testing prior to amputation. So what are the solutions to improve awareness and treatment? Let's develop key message and training for community leaders, let's empower patients to perform self-examination. Let's develop provider education programs to raise PAD awareness, and let's focus on improving diagnosis and treatment for populations at risk. Thank you.

PAD

treatment disparities

awareness

myocardial infarctions

amputations