since his operation, his intake of alcohol and salt was moderate, and he was about 2 kg overweight. Apart from a raised blood pressure of 154/92 mm Hg and absent pedal pulses bilaterally without notable tropic changes, clinical examination was unremarkable. Positive investigations were: fasting cholesterol 8·4 mmol/L; triglycerides 1·6 mmol/L; HDL fraction 1·50 mmol/L; LDL fraction 6·90 mmol/L; blood pressure in the clinic 168/102 mm Hg; ambulatory daytime blood pressure 152/91 mm Hg; and night-time blood pressure 132/84 mm Hg. Renal function, electrocardiography, and echocardiography were normal. This case is not unusual and many doctors who run cardiovascular clinics will be familiar with many such patients. However, on further investigation, this patient’s hospital notes from the time of femeropopliteal bypass showed some notable findings. Blood pressure was recorded as at or just above 150/90 mm Hg on three occasions, although normal on others. He had also a fasting serum cholesterol of 6·9 mmol/L. Although the patient was generally well and symptom-free 5 years after his bypass, the state of his graft might have been healthier if the risk factors of mild hypertension and hypercholes- terolaemia had been aggressively managed from the outset, but borderline hypertension and hypercholesterolaemia did not then attract the same attention they do now. Therefore, after thought about this patient’s disorder and the state of his arterial system, the concept of the ADAPT clinic developed. The facility was seen as one that would enable assessment, management, and treatment of all cardiovascular patients, whatever their presentation, according to a common protocol. Selling the concept The ADAPT clinic was conceived to coordinate the management of arterial disease, irrespective of the The arterial tree is one of the most intriguing and, undoubtedly, the most ubiquitous, of the body’s organs. It is not, however, commonly thought of as an organ at all, but considered in isolation according to the specialty best suited to managing the presenting symptoms, such as cardiology, nephrology, or neurology. The reality, however, is that an insult to any part of the circulatory system is a threat to the arterial organ as a whole, and management of disease in one part should be common to management of that in another, although the local symptoms may require interventional skills peculiar to the affected area. For example, the cardiac surgeon tends to direct his skills to coronary-artery bypass surgery, whereas the vascular surgeon develops skills in reparative procedures for the aorta and major blood vessels. With the development of radiological skills in angioplastic and stenting techniques, these barriers are starting to break down, but the management of the underlying central disease process, generally atherosclerosis in one form or another, is commonly haphazard and dependent on which of the cardiovascular routes the patient has taken. Superlative interventional procedures are often successfully performed without attention being given to the continuing need for risk-factor management and therapy to protect the arterial organ as a whole and maintain reparative processes. 1 Each specialty works on a particular organ, and generally ignores the likelihood that other organs may be threatened by occlusive disease of the arterial system elsewhere. Logical practice should, however, demand comprehensive assessment of the entire circulatory system. We established the arterial disease assessment, prevention, and treatment (ADAPT) clinic to try to achieve these goals. The concept A man aged 55 years was referred to our unit because his family physician had recorded a blood pressure of 160/95 mm Hg during a check-up. The patient had not been seen by a doctor for 5 years. Previously, he had developed calf pain when playing golf and had been referred by his family physician to a vascular surgeon with a diagnosis of intermittent claudication. A femeropopliteal bypass cured his symptoms and, after one postoperative visit, he had been discharged back to the care of his family physician. He had not attended for follow-up until his wife urged him to have the check-up, which resulted in the present referral. The patient denied any cardiovascular symptoms. He managed a small business and played 18 holes of golf at least twice a week. He had not smoked The arterial organ in cardiovascular disease: ADAPT (arterial disease assessment, prevention, and treatment) clinic Eoin O’Brien, David Bouchier-Hayes, Desmond Fitzgerald, Neil Atkins VIEWPOINT 1700 THE LANCET • Vol 352 • November 21, 1998 Lancet 1998; 352: 1700–02 The Blood Pressure Unit, Beaumont Hospital, Dublin 9, Ireland (E O’Brien FRCP, D Bouchier-Hayes FRCSI, D Fitzgerald MD, N Atkins MA) Viewpoint ADAPT clinic arterial disease Family physician Assessment Prevention Treatment Nephrologist Neurologist Cardiologist Lipid clinic Hypertension clinic Ophthalmology Diabetic clinic Vascular surgeon Figure 1: Referral sources to ADAPT clinic