Primary and Secondary Prevention of Lower Extremity Arterial Disease in Chinese Type 2 Diabetes Patients: Current Status and Future Prospects
Xiaomei Zhang1, Zhangrong Xu2, Xingwu Ran3, Linong Ji4, on behalf of China DIA-LEAD Study Investigators
1.	Department of Endocrinology, Peking University International Hospital, Beijing 102206, China
2.	Diabetes Center, Department of Endocrinology, The 306th Hospital of PLA, Beijing, China
3.	Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu610041, China
4.	Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing 100044, China

Background:
Lower extremity arterial disease (LEAD) is associated with a 5.9-fold increased risk of cardiovascular mortality in type 2 diabetes patients, but often neglected because of asymptomatic intermittent claudication in real practices. Furthermore, there is a paucity of data regarding the spectrums of preventing LEAD in Chinese diabetes patients in real-life setting.

Aims:
The present study is designed to determine the manifestations of primary and secondary prevention for LEAD in Chinese diabetes patients. We also tried to identify the treatment gaps relative to the guidelines recommendations and opportunities for LEAD management.

Methods:
Patients from China DIA-LEAD study, which consecutively enrolled 7,113 inpatients and 3,568 outpatients aged 50 years and older who had been diagnosed with diabetes from 30 hospitals across China between June 2016 and January 2017, were included in present analysis and stratified into the groups of primary and secondary prevention by the existence of LEAD. Data regarding patient demographics, cardiovascular risk profiles, pharmacotherapies, lipid parameters and blood glucose measurements were recorded and analyzed. LEAD was defined as patients with established LEAD or newly diagnosed at the time of study visit by the Ankle-Brachial Index (ABI) and/or lower limb ultrasonography according to the Chinese Diabetes Society 2013 Guidelines on LEAD screening and management. 

Results: 
Of the total 1,0681 patients, 78.8% (n=8,416) were in primary prevention group and 21.2% (n=2,265) were in secondary prevention group. Of the secondary prevention group, 10.6% (n=1,134) were diagnosed with LEAD before enrollment and 11.8% (n=1,131) newly diagnosed at the present visit. Patients in secondary prevention group were older than in primary group (68.0 vs. 63.2, p<0.001). There were no differences in the gender, BMI, alcohol consumption status, and family history of premature CVD between the primary prevention group and secondary prevention group. However, the proportions of patients smoking, comorbid with marcrovascular diseases and microvascular diseases in secondary prevention group were higher than those in the primary prevention group. The anti-hypertensive agents, lipid lowering therapies, anti-platelet agents, and vasodilator therapies were underused in both groups, compared with guidelines recommendations; even the percentages were higher in secondary prevention group compared with primary prevention group (44.1% vs. 55.3%, p<0.001; 46.2% vs. 52.0%, p<0.001; 35.3% vs. 45.6%, p<0.001; 31.3% vs. 47.0%, p<0.001). The goal attainment of blood pressure (<130/80mmHg) is significantly higher in primary prevention group than the secondary prevention group (57.3% vs. 46.3%, p<0.001) .The goal attainment of blood lipid (LDL-C<2.60mmol/L, 42.9% vs.41.1%, p=0.156) and glucose (HbA1c<7.0%, 28.6% vs. 26.7%, 0.078) were sub-optimal in both groups. 

Discussion:
The current treatment approach is suboptimal in both primary and secondary prevention of LEAD in diabetes patients. Initiatives to improve multifactorial risk management may be mandated before designing primary and secondary prevention-specific strategies. Efforts are needed to optimize both therapy and risk factors control to further bridge the gap between guideline recommendations and real practice.

No conflict of interest

Primary and secondary prevention of lower extremity arterial disease in Chinese type 2 diabetes patients