Evaluation de l’impact de l’artériopathie oblitérante des membres inférieurs sur la qualité de vie

Abstract

Assessment of the Quality-of-Life Implications of Peripheral Arterial Occlusive Disease

Peripheral arterial occlusive disease is a common condition with possible serious consequences. It is usually diagnosed at the intermittent claudication stage. There are 2 objectives of treatment: to prevent ischaemic attacks and to improve quality of life. Treatment efficacy is, however, usually evaluated only in terms of walking distance. When making medical decisions, it is now generally accepted that patients are as much concerned by quality of life as by life expectancy, particularly with regard to chronic diseases for which the aim of therapy is not only to treat the disease but also to relieve pain or restore function. Quality-of-life evaluation is therefore necessary to assess treatment efficacy, guiding clinicians in their choice of therapy and manufacturers in their choice of new molecules for development. Three types of instruments can be used to evaluate quality of life. Currently, those most often used are health status and health-related quality-of-life scales. These scales can be nonspecific, giving information on both health status and quality of life independently of any particular condition [the Medical Outcomes Study (MOS) Short Form-36 items (SF-36), for example], or they may be relevant to one disease. Specific scales are usually more sensitive than nonspecific ones. When the ARTEMIS® scale, which is specific to peripheral arterial occlusive disease, was developed in 1993, there were 400 scales in existence. However, none were specific to peripheral arterial occlusive disease. The ARTEMIS® scale is a self-administered questionnaire, composed of a general (SF-36) and a specific instrument. It comprises 64 items covering the 8 dimensions of the SF-36, 5 specific dimensions and 2 differential dimensions (perception of health status evolution and perception of the future). The ARTEMIS® questionnaire was validated in 177 patients with intermittent claudication (phases IIa and IIb of the Leriche and Fontaine classification). Results obtained with the ARTEMIS® questionnaire are presented and compared with those obtained by other authors using nonspecific or specific scales for quality-of-life evaluation. All results showed that intermittent claudication has a significant effect on the various dimensions of quality of life (except in one study). Nevertheless, the relationship between walking distance (or other functional measures) and quality of life did not prove to be as close as had been expected, indicating that functional measures do not reflect the patient’s overall perception of the disease. The ARTEMIS® questionnaire showed that quality-of-life scores were significantly higher (better quality of life) in patients with walking distances greater than 500 metres than in those with shorter walking distances (less than 500 metres). Moreover, quality-of-life scores were both high and similar in patients with walking distances greater than 500 metres, while in patients with shorter walking distances quality-of-life scores ranged from high (good quality of life) to low (bad quality of life). In the absence of curative treatment, the patient’s perception of quality of life must therefore be evaluated prior to any treatment. Treatment will help to prevent ischaemic attacks in patients with walking distances greater than 500 metres, and will have a preventive effect and improve functional measures in patients with low quality-of-life scores, regardless of walking distance. The ARTEMIS® questionnaire can therefore assist clinicians in their choice of therapeutic strategy and in the evaluation of treatment efficacy.

Résumé

L’artériopathie oblitérante des membres inférieurs est une pathologie fréquente dont les conséquences peuvent être graves. Elle est généralement diagnostiquée au stade de la claudication intermittente. Son traitement a deux objectifs: réduire les accidents ischémiques et améliorer la qualité de vie du patient. Pourtant, la mesure de l’efficacité des traitements visant à améliorer la qualité de vie des patients repose généralement sur la simple évaluation du périmètre de marche. Depuis une vingtaine d’années, des outils de mesure de la qualité de vie ont été développés et l’impact de l’artériopathie sur la qualité de vie a pu être mesuré à l’aide de questionnaires généraux ou spécifiques comme le questionnaire ARTEMIS®. Les études ont permis de démontrer l’association globale entre qualité de vie et claudication intermittente: plus le périmètre de marche est faible, plus les répercussions sur la qualité de vie sont importantes en moyenne. Mais elles ont surtout révélé la grande dispersion des scores de qualité de vie pour des niveaux voisins de limitations fonctionnelles. La dispersion des scores est d’autant plus grande que la claudication est sévère. Ces résultats suggèrent que la prise en charge du malade atteint d’artériopathie oblitérante des membres inférieurs devrait tenir compte du score de qualité de vie, en particulier pour orienter les traitements fonctionnels vers les patients ayant des scores dégradés indépendamment de leur périmètre de marche.