Adherence to Guideline‐Recommended Therapy Is Associated With Decreased Major Adverse Cardiovascular Events and Major Adverse Limb Events Among Patients With Peripheral Arterial Disease

Abstract

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.

Quality of care among patients undergoing lower extremity revascularization

“…A similar trend was observed by Armstrong et al, who assessed compliance with four guideline-based therapies: smoking cessation, and being placed on an aspirin, a statin, and an angiotensin-converting enzyme inhibitor. 19 From 2006 to 2011, compliance with all four therapies increased from 27% to 38%. 19 Although our dataset was not designed to address the question of why compliance with guidelines improved, we speculate that general awareness about the possible benefits of antiplatelets and statins in patients with PAD was increasing.…”

Outpatient Follow-Up of the Lower Extremities Atherosclerosis Patients From Cardiologist Point of View

“…Также при приеме статинов у больных ОЗАНК отме- чено снижение общего числа осложнений со стороны пораженных конечностей по сравнению с пациен-тами не принимавших статины (22,0% против 26,2%; ОР 0,82; 95% ДИ 0,72-0,92; р=0,0013) [3]. Тем не менее, прием других кардиопротективных препаратов у больных ОЗАНК также способен улуч-шить прогноз [8]. Так, выполнение всех четырех рекомендаций (прием аспирина, статинов, иАПФ и отказ от курения) позволило снизить у больных ОЗАНК число кардиоваскулярных осложнений (ОР 0,64; 95% ДИ 0,45-0,89; р=0,009), число осложнений со стороны конечности (ампутация, тромболизис или хирургическая реваскуляризация; ОР 0,55; 95% ДИ 0,37-0,83; р=0,005) и смертность (ОР 0,56; 95% ДИ 0,38-0,82; р=0,003) [8].…”

“…Тем не менее, прием других кардиопротективных препаратов у больных ОЗАНК также способен улуч-шить прогноз [8]. Так, выполнение всех четырех рекомендаций (прием аспирина, статинов, иАПФ и отказ от курения) позволило снизить у больных ОЗАНК число кардиоваскулярных осложнений (ОР 0,64; 95% ДИ 0,45-0,89; р=0,009), число осложнений со стороны конечности (ампутация, тромболизис или хирургическая реваскуляризация; ОР 0,55; 95% ДИ 0,37-0,83; р=0,005) и смертность (ОР 0,56; 95% ДИ 0,38-0,82; р=0,003) [8]. Однако было показано, что больные ОЗАНК существенно реже (p<0,001) полу-чают необходимую терапию, чем пациенты с ИБС: бета-блокаторы получали 34% и 74% больных, соот-ветственно, аспирин -40% и 88%, иАПФ -31% и 57% [7].…”

Vascular specialist response to medicare evidence development coverage advisory committee (MEDCAC) panel on peripheral artery disease of the lower extremities

“…A number of observational and single center studies have shown that patients with PAD and CLI are under-treated with guideline-recommended therapies (anti-platelet therapy, statins, and antihypertensive therapies) [22]. Furthermore, under-treatment with guideline-recommended therapies was associated with increased repeat revascularization and amputation in patients undergoing revascularization [23]. The role of supervised exercise training is limited in patients with CLI, given the extent of disease, associated ulcers or gangrene, and the fact that arterial perfusion is inadequate for basal metabolic requirements and not sufficient to improve the metabolic efficiency of exercising muscles.…”