Symptoms and quality of life are important in guiding treatment of peripheral arterial disease (PAD) or AOMI

Why a scientific statement?
In the United States, 8.5 million people have peripheral arterial disease (PAD), which we more commonly refer to as Obliterative Arterial Disease of the Lower Limbs (AOMI), corresponding to narrowing or obstruction of the arteries of the legs by atherosclerotic plaques. Treatment decisions and success criteria should be guided by the symptoms and quality of life reported by patients.
The American Heart Association (AHA) has published a new scientific statement in its leading journal Circulation, which is an expert analysis of current research to inform future treatment directions. The statement, "Advancing quality of care and outcomes in peripheral arterial disease through patient-reported health assessment", highlights how managing PAD based on a person's experience of symptoms can lead to more patient-centered care and outcomes, focusing on value of care rather than relying on clinical measures such as leg artery diameters or blood flow velocities.
According to the principal editor, Kim G. Smolderen clinical psychologist, Professor of Medicine and Psychiatry and co-director of the Vascular Medicine Research Laboratory...: "The person living with peripheral arterial disease is the one who has authority over the impact it has on their daily life. Our treatment must be based on their lived experiences and go beyond clinical measurements of the quality of blood flow in the arteries." "We have spent years developing and validating standardized instruments to gather patient experiences in a reliable and sensitive way. We are now at a point where we can begin to integrate this information into real-world care, through pilot programs that can develop quality benchmarks for PAD patients and types of treatment by taking into account their point of view."






Painful legs and other patient experiences:
Although the majority of people living with peripheral arterial disease are over 40, AOMI also occurs in younger people . More and more women are affected by AOMI. These people have "blockages" in the arteries that supply the legs and feet, often creating pain, cramps or weakness when they walk, forcing them to stop and rest temporarily until the pain disappears. Some people experience no symptoms at all; however, many patients can remain pain-free simply by limiting their activities. Studies show that their health and functioning are also affected. When blood flow is severely restricted (known as critical ischemia), patients can experience pain even at rest, fail to heal when they sustain an injury, or develop gangrene that can lead to amputation. AOMI is also strongly associated with coronary events (myocardial infarction) and stroke.
"All these manifestations have a considerable impact on people's daily functioning and quality of life, with a greater impact as disease severity increases. Outcomes are also affected by other health problems common in people with AOMI, such as type 2 diabetes, coronary heart disease, kidney failure or mental health problems such as depression or stress-related disorders," Prof. Smolderen also said.

Patient-directed treatment
When the healthcare team is better informed and recognizes the burden of disease on quality of life, care coordination for risk factors and patient concerns come to the fore. The statement advocates improving and individualizing care for these patients by gathering feedback on their experience throughout treatment.

Patient Reported Outcomes Measures (PROMs)are systematic and validated ways of asking patients directly to assess the impact of their disease on their symptoms, functioning (physical, social and emotional) and quality of life. The feedback provided by PROMs can more reliably and objectively assess the quality of care for people with AOMI.







The main benefits of using PROMs are:
- improve understanding of the patient's experience;
- improve self-management of patient symptoms and medical needs;
- standardize quality performance criteria for practices caring for people with OSA;
- provide relevant feedback to determine treatment changes or needs.
Thus, involving patients as experts in their own experiences draws more attention to quality-of-life issues or cardiovascular risk factors. This perspective can lead to conversations that modify treatment or direct patients to other resources such as behavioral management, wound care or smoking cessation. Patient-centered care can also enhance self-management and shared decision-making between patients and physicians. All these benefits are possible as long as patient-reported outcome measures are assessed using tools that the patient understands, regardless of literacy levels, language barriers and cultural norms. It is also important that PROMs are conducted by experts who have the qualifications and understanding to administer the tools, interpret the results and refer patients to additional resources. The statement includes examples of PROMs to measure leg pain and function (including gait disorders), AOMI-specific health status, general health status and depressive symptoms.

Performance measures to improve quality of care.
PROMs can also be an integral part of assessing the quality of care provided by programs for people with AOMI, and are increasingly being incorporated into definitions of what it means to provide high-quality, patient-centered clinical care.
The use of PROMs makes it possible to:
- provide measurable objectives for programs to improve quality of care ;
- encourage the development of training and expertise in health systems to administer, interpret and ethically use PRO-PMs to improve patient care;
- reduce disparities in care and promote health equity;
- help create national standards for quality care.






"This roadmap highlights a paradigm shift that puts the patient experience first. It is provocative to now place the lived experience with disease at the forefront, engaging people with AOMI to provide information that holds healthcare systems and practitioners accountable for delivering high-quality care, in addition to evaluating the safe and effective delivery of current evidence-based treatments," concluded Pr. Smolderen.

In conclusion
- A new scientific statement from the American Heart Association proposes an updated roadmap for integrating patient-reported symptoms and quality-of-life assessments into routine care for people with OSA.
- Patient-reported outcome measures (PROMs) are systematic, validated ways of asking people with AOMI to rate their symptoms and share how their functioning (physical, social and emotional) and quality of life are affected.
- PROMs have been used as important endpoints for studies (clinical trials) evaluating treatments for OAMI.
- According to the new statement, PROMs can also be used to assess the quality of programs offering continuing care for people with OAMI.

Comment by Dr Jean-François Renucci:
This text discovers that the patient is the "expert" in the experience of his or her illness, a notion dear to Therapeutic Patient Education (TPE), places him or her at the center of concerns and insists on dialogue and the notion of shared decision-making, all things insufficiently implemented in France for various reasons. Let's hope things change, and these recommendations can help. Finally, let's not forget that we're living in an era of chronic diseases. If a cure is illusory, let's concentrate on accepting the disease and improving quality of life by offering care programs adapted to people with AOMI.

Reference: Symptoms, quality of life important to guide treatment for peripheral artery disease (PAD). The American Heart Association: Circulation, October 13, 2022. https://newsroom.heart.org/news/symptoms-quality-of-life-important-to-guide-treatment-for-peripheral-artery-disease-pad?preview=948f