Use of angiotensin-converting enzyme inhibitors and freedom from amputation after lower extremity revascularization

Abstract

ObjectiveAngiotensin-converting enzyme inhibitors (ACEIs) have not been well evaluated in conjunction with lower extremity revascularization (LER). This study evaluated freedom from amputation in patients who underwent either an open (OPEN) or endovascular (ENDO) revascularization with and without utilization of an ACEI.Materials and methodsPatients who underwent LER were identified from 2007–2008 Medicare Provider Analysis and Review files. Demographics, comorbidities, and disease severity were obtained. Post-procedural use of an ACEI was confirmed using combining them with National Drug Codes and Part D Files. Outcomes were analyzed using chi-square analysis, Kaplan–Meier test, and Cox regression.ResultsWe identified 22,954 patients who underwent LER: 8,128 (35.4%) patients with claudication, 3,056 (13.3%) with rest pain, and 11,770 (51.3%) with ulceration or gangrene. More patients underwent ENDO (14,353) than OPEN (8,601) revascularization and 38% of the cohort was taking an ACEI. Overall, ACEI utilization compared to patients not taking ACEI was not associated with lower amputation rates at 30 days (13.5% vs. 12.6%), 90 days (17.7% vs. 17.1%), or 1 year (23.9% vs. 22.8%) (P>0.05 for all). After adjustment for comorbidities, ACEI utilization was associated with higher amputation rates for patients with rest pain (hazard ratio: 1.4; 95% confidence interval: 1.1–1.8).ConclusionACEI utilization was not associated with overall improved rates of amputation-free survival or overall survival in the vascular surgery population. However, an important finding of this study was that patients presenting with a diagnosis of rest pain and taking an ACEI who underwent a LER had statistically higher amputation rates and a lower amputation-free survival at 1 year. Further analysis is needed to delineate best medical management for patients with critical limb ischemia and taking ACEI who undergo vascular revascularization.

Global vascular guidelines on the management of chronic limb-threatening ischemia

“…316,317 Although the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and Heart Outcomes Prevention Evaluation (HOPE) study suggested that in the absence of heart failure, monotherapy with an ACEI (ramipril) reduces the rate of MACEs in high-risk patients, there is recent evidence to suggest that this class of drug may result in a higher amputation rate for patients with CLTI. 318 In an analysis of the Medicare database for 2007 to 2008, there were 22,954 patients who underwent lower extremity revascularization. Of these, 64.6% were treated for CLTI.…”

Medical therapy for cardiovascular and limb-related risk reduction in critical limb ischemia

“…50 Contemporary studies reporting on the outcomes of ACE inhibitors or ARBs among patients with CLI are presented in Table 2. 33,[50][51][52][53][54][55][56] The protective effect of renin-angiotensin system inhibitors has been well-established for patients with advanced atherosclerotic disease. However, the safety and efficacy of these antihypertensive medications for secondary prevention among patients with CLI is still unknown.…”

“…50 Contemporary studies reporting on the outcomes of ACE inhibitors or ARBs among patients with CLI are presented in Table 2. 33,50–56…”

Outcomes of Lower Extremity Endovascular Revascularization: Potential Predictors and Prevention Strategies

“…Moreover, several studies documented that angiotensin-converting enzyme inhibitors (ACEI) are associated with reduced MACE [ 47 , 48 , 49 ]. A study showed that patients with CLTI treated with ACEI and LER resulted in statistically significant more amputations, which remained significant after adjustment at 1 year [ 50 ]. Other studies found that ACEI use was associated with an increased rate of re-intervention [ 51 ].…”