Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care

Hirsch, Alan T.; Criqui, Michael H.; Treat‐Jacobson, Diane; Regensteiner, Judith G.; Creager, Mark A.; Olin, Jeffrey W.; Krook, Susan H.; Hunninghake, Donald B.; Comerota, Anthony J.; Walsh, M. Eileen; McDermott, Mary M.; Hiatt, William R.

doi:10.1001/jama.286.11.1317

Cited by 2,370 publications

(1,209 citation statements)

References 34 publications

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“…Our main source of missingness was the exposure of interest (ie, race and SES), thus we chose complete case analysis over imputation techniques. Another limitation is a high number of patients with unspecified disease severity (59%); this may reflect weaknesses of the ICD‐9 coding scheme in chronic disease41 or underrecognition of disease severity as a prognostic factor in PAD 42, 43. However, the amputation risk estimates for the unspecified category are <1 (HR: 0.88), suggesting mostly less severe disease, including asymptomatic PAD or minor symptoms.…”

Section: Discussionmentioning

confidence: 99%

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

Arya

Binney

Khakharia

et al. 2018

JAHA

147

109

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BackgroundBlack race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients.Methods and ResultsPatients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155 647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low‐SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30–1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06–1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation.ConclusionsBlack race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.

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Section: Discussionmentioning

confidence: 99%

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

Arya

Binney

Khakharia

et al. 2018

JAHA

147

109

View full text Add to dashboard Cite

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“…There are a number of proven therapies to reduce mortality among patients with PAD including antiplatelet agents, lipid‐lowering therapy with the statins, and aggressive cardiovascular risk factor modification 6. Unfortunately, lifesaving medications are underprescribed among patients with PAD, particularly in comparison with patients with CAD,23 and also the true atherosclerosis burden and mortality risk of PAD are underestimated 9, 10. In contrast, the overall rate of use of cardioprotective medication for secondary prevention in our study cohort was relatively high; at baseline 70% were on statins, 76% on aspirin, 69% on β‐blockers, and 60% on angiogensin‐converting enzyme inhibitor/angiotensin‐receptor blockers.…”

Section: Discussionmentioning

confidence: 99%

“…An estimated 8.5 million Americans aged ≥40 years carry the diagnosis of PAD 8. Despite its association with high prevalence and extremely poor prognosis, PAD remains undiagnosed and rarely receives attention in the scientific literature compared to patients with coronary artery disease (CAD) and other atherosclerotic conditions 7, 9. To date, predictors of mortality and underlying pathophysiology in patients with PAD are not well defined, which may be a contributing factor to why the mortality risk and ischemic amputations in PAD patients remained high 10.…”

Section: Introductionmentioning

confidence: 99%

Trimethylamine N ‐Oxide and Mortality Risk in Patients With Peripheral Artery Disease

Senthong

Wang

Fan

et al. 2016

JAHA

136

102

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BackgroundProduction of the proatherogenic metabolite, trimethylamine N‐oxide (TMAO), from dietary nutrients by intestinal microbiota enhances atherosclerosis development in animal models and is associated with atherosclerotic coronary artery disease in humans. The utility of studying plasma levels of TMAO to risk stratify in patients with peripheral artery disease (PAD) has not been reported.Methods and ResultsWe examined the relationship between fasting plasma TMAO and all‐cause mortality (5‐year), stratified by subtypes of PAD and presence of coronary artery disease in 935 patients with PAD who underwent elective angiography for cardiac evaluation at a tertiary care hospital. Median plasma TMAO was 4.8 μmol/L (interquartile range, 2.9–8.0 μmol/L). Elevated TMAO levels were associated with 2.7‐fold increased mortality risk (fourth versus first quartiles, hazard ratio 2.86, 95% CI 1.82–3.97, P<0.001). Following adjustments for traditional risk factors, inflammatory biomarkers, and history of coronary artery disease, the highest TMAO quartile remained predictive of 5‐year mortality (adjusted hazard ratio 2.06, 95% CI 1.36–3.11, P<0.001). Similar prognostic value for elevated TMAO was seen for subjects with carotid artery, non–carotid artery, or lower extremity PAD. TMAO provided incremental prognostic value for all‐cause mortality (net reclassification index, 40.22%; P<0.001) and improvement in area under receiver operator characteristic curve (65.7% versus 69.4%; P=0.013).Conclusions TMAO, a pro‐atherogenic metabolite formed by gut microbes, predicts long‐term adverse event risk and incremental prognostic value in patients with PAD. These findings point to the potential for TMAO to help improve selection of high‐risk PAD patients with or without significant coronary artery disease, who likely need more aggressive and specific dietary and pharmacologic therapy.

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“…For example, 70% (almost all of the remaining patients were on anticoagulants) and 84% of patients included in the recently published Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra‐arterial Supplementation (JUVENTAS) trial were on antiplatelet and statin therapy, respectively 44. The relatively poor incorporation of PAD guidelines probably results from a relative lack of public awareness about PAD, its unappreciated implications on overall cardiovascular risk, and the fact that the benefits of treatment are not well appreciated 45, 46, 47. Furthermore, overestimation of the treatment given by others, lack of education, training, and organizational facilities to implement guidelines properly play a role,48 as well as the beliefs of the physician themselves 49.…”

Section: Trends In Medical Therapy For Padmentioning

confidence: 99%