Mortality in Peripheral Arterial Disease: A Comparison of Patients Managed by Vascular Specialists and General Practitioners

Abstract

BACKGROUND: Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical management is unknown. OBJECTIVE:To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular specialist).DESIGN: Prospective study. SETTING:Primary care practice and academic vascular laboratory.PARTICIPANTS: GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n =82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrolment period of the PACE study.MEASUREMENTS: All-cause and cardiovascular mortality. RESULTS:After 32 months of follow-up, specialist management was associated with a lower rate of allcause mortality (RR=0.04; 95% CI 0.01-0.34; p =.003) and cardiovascular mortality (RR=0.07; 95% CI 0.01-0.65; p =.020), after adjustment for patients' characteristics. Specialists were more likely to use antiplatelet agents (93% vs 73%, p <.001), statins (62% vs 25%, p <.001) and beta blockers (28% vs 3%, p <.001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced risk of all-cause mortality (RR= 0.02; 95% CI 0.01-0.73, p =.034) and cardiovascular mortality (RR=0.02; 95% CI 0.01-0.71, p =.033).CONCLUSIONS: Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect appears to be mainly caused by the more frequent use of effective medicines by specialists.

Long-term safety of intramuscular gene transfer of non-viral FGF1 for peripheral artery disease

“…The non-vascular death rate has approximated 25-30% in published literature in patients with CLI. 14,15 In summary, the rates and causes of death in patients with PAD treated by either NV1FGF or placebo was comparable with reported values.…”

“…This may be because of a more shortterm effect, which is not apparent at later time points. An amputation rate of 13.8% at 2 years has been reported in patients with CLI, 14 which is little lower than the rate reported in this PAD registry over 3 years (21.9% versus 28%, NV1FGF versus placebo). Amputation risk always remains high in the index leg despite study enrollment (8.75% in the NF1FGF group versus 71.4% in the placebo group).…”

“…16 TALISMAN PM 201 (n¼118) was a phase II, double-blind, placebo-controlled, multicenter, safety and efficacy trials comparing intramuscular injections of four times 4 mg of NV1FGF versus placebo in patients with CLI and at least one non-healing ulcer and no option for revascularization in Europe. 11,14 TALISMAN PM 201 demonstrated a significant reduction in all amputations and 55% risk reduction of major amputations as well as a delay in time to major amputation or death in CLI patients. 14 There was no difference in ulcer healing, probably because of the severity of the baseline lesions.…”

“…11,14 TALISMAN PM 201 demonstrated a significant reduction in all amputations and 55% risk reduction of major amputations as well as a delay in time to major amputation or death in CLI patients. 14 There was no difference in ulcer healing, probably because of the severity of the baseline lesions. 12 PM 202 was a phase II, doubleblind, placebo-controlled, dose finding study assessing the effect of several doses and regimens of NV1FGF versus placebo on transcutaneous oxygen pressure.…”

“…Published rates of stroke mortality in this population are approximately 7-10% in patients with CLI. 12,14,15 Finally, nine patients (19.2%) of the NV1FGF group and three patients (12%) of the placebo group died from non-vascular causes, such as pneumonia, kidney failure and intracerebral hemorrhage, or for unknown reasons. The non-vascular death rate has approximated 25-30% in published literature in patients with CLI.…”