BackgroundCurrent guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin‐converting enzyme (ACE) inhibitors. The combined effects of multiple guideline‐recommended therapies in patients with symptomatic PAD have not been well characterized.Methods and ResultsWe analyzed a comprehensive database of all patients with claudication or critical limb ischemia (CLI) who underwent diagnostic or interventional lower‐extremity angiography between June 1, 2006 and May 1, 2013 at a multidisciplinary vascular center. Baseline demographics, clinical data, and long‐term outcomes were obtained. Inverse probability of treatment propensity weighting was used to determine the 3‐year risk of major adverse cardiovascular or cerebrovascular events (MACE; myocardial infarction, stroke, or death) and major adverse limb events (MALE; major amputation, thrombolysis, or surgical bypass). Among 739 patients with PAD, 325 (44%) had claudication and 414 (56%) had CLI. Guideline‐recommended therapies at baseline included use of aspirin in 651 (88%), statin medications in 496 (67%), ACE inhibitors in 445 (60%), and smoking abstention in 528 (71%) patients. A total of 237 (32%) patients met all four guideline‐recommended therapies. After adjustment for baseline covariates, patients adhering to all four guideline‐recommended therapies had decreased MACE (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.89; P=0.009), MALE (HR, 0.55; 95% CI, 0.37 to 0.83; P=0.005), and mortality (HR, 0.56; 95% CI, 0.38 to 0.82; P=0.003), compared to patients receiving less than four of the recommended therapies.ConclusionsIn patients with claudication or CLI, combination treatment with four guideline‐recommended therapies is associated with significant reductions in MACE, MALE, and mortality.
Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are recommended for secondary prevention in peripheral artery disease, but their effectiveness in patients with critical limb ischemia (CLI) is uncertain. We reviewed 464 patients with CLI who underwent diagnostic angiography or endovascular intervention from 2006-2013 at a multidisciplinary vascular center. ACEI or ARB use was assessed at the time of angiography. Major adverse cardiovascular events (MACE), mortality, and major adverse limb events (MALE) were assessed during three-year follow-up. Propensity weighting was used to adjust for baseline differences between patients taking and not taking ACEIs or ARBs. ACEIs or ARBs were prescribed to 269 (58%) patients. Patients prescribed ACEIs or ARBs had more baseline comorbidities including diabetes and hypertension (p<0.05). Patients prescribed ACEIs or ARBs had lower three-year unadjusted rates of MACE (40% versus 47%) and mortality (33% versus 43%). After propensity weighting, ACEI or ARB use was associated with significantly lower rates of MACE (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.58-0.99, p=0.04) and overall mortality (HR 0.71, 95% CI 0.53-0.95, p=0.02). There was no significant association between ACEI or ARB use and MALE (HR 0.97, 95% CI 0.69-1.35, p=0.2) or major amputation (HR 0.74, 95% CI 0.47-1.18, p=0.1). ACEI/ARB use is associated with lower MACE and mortality in patients with CLI, but there was no effect on limb-related outcomes.
BackgroundCurrent guidelines recommend aspirin, statins, angiotensin-converting enzyme inhibitors (ACEIs), and smoking abstinence for all patients with vascular disease. There is little data on the variation in adherence to guideline-recommended therapies among patients with different clinical manifestations of vascular disease.PurposeTo analyze the variation in adherence to guideline-recommended therapies among patients with diverse manifestations of vascular disease.MethodsWe analyzed a comprehensive database of all patients with critical limb ischemia, claudication, acute limb ischemia, carotid artery stenosis, subclavian artery stenosis, renal artery stenosis, or mesenteric ischemia who underwent angiography between 2006 and 2013 at a multidisciplinary vascular center.ResultsAmong 1,114 patients with vascular disease, adherence to guideline-recommended therapy at time of angiography included use of aspirin in 936 (84%), statins in 753 (68%), ACEIs in 673 (60%), and smoking abstinence in 788 (71%). A total of 335 (30%) patients utilized all four guideline-recommended therapies. Adherence to four guideline-recommended therapies was lowest among patients with acute limb ischemia (14%) and highest among patients with renal artery stenosis (37%). Among all patients with vascular disease, the range of adherence to individual guidelines was 64%–91% for aspirin, 43%–83% for statins, 49%–66% for ACEIs, and 47%–78% for smoking abstention.ConclusionThe majority of patients with diverse manifestations of vascular disease take aspirin and abstain from smoking while fewer patients are prescribed ACEIs and statins. Among the current recommendations, statins have the widest variation in adherence. Less than one-third of patients with diverse manifestations of vascular disease are prescribed all four guideline-recommended therapies.
IntroductionMultiple barriers, including time constraints, a demanding teaching environment, and lack of longitudinal relationships with residents, make it challenging for fellows and learners to engage in effective teaching during consultation.MethodsThe Fellow as Clinical Teacher (FACT) curriculum was developed to overcome such barriers and improve fellow teaching in the setting of inpatient consultation. The FACT curriculum consists of two 45- to 60-minute small-group sessions designed for subspecialty fellows. The first session focuses on overcoming barriers to teaching and application of the principles of adult learning theory. The second introduces the PARTNER (partner with resident, assess the learner, reinforce positives, teaching objectives, new knowledge, execute recommendations, review) framework for teaching during consultation and uses video examples to model the application of this framework, allowing fellows to practice its implementation through role-play.ResultsPreviously, the FACT curriculum was shown to improve teaching skills of rheumatology and pulmonary/critical care fellows as evaluated by objective structured teaching exercises. Here, the curriculum has been expanded to 51 internal medicine and pediatrics fellows in 15 different training programs. The curriculum improved fellow teaching skills as assessed by self-assessment surveys. It was highly rated by participants, and fellows reported being more likely to teach during consultation following this educational intervention.DiscussionThe FACT curriculum can be integrated into subspecialty training programs to improve the teaching skills of internal medicine and pediatrics fellows in the setting of inpatient consultation. Ultimately, improved teaching from fellows may have broad-reaching effects for residents, patients, and the fellows themselves.
Clopidogrel HoTPR was significantly associated with TVR, while aspirin HoTPR was not associated with adverse clinical outcomes in patients with PAD.
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