Improving the use of even minimal medical therapy may boost outcomes in patients with Peripheral arterial disease (PAD), researchers found.
At admission, about two-thirds (69%) of patients with PAD who were about to undergo elective peripheral vascular interventions were receiving both aspirin and a statin, according to P. Michael Grossman, MD, of the University of Michigan in Ann Arbor, and colleagues.
During 6 months of follow-up after the intervention, those who were taking both agents when they entered the hospital were less likely to have an adverse outcome (7.3% versus 15.8%; odds ratio 0.45, 95% CI 0.29 to 0.71), defined as a repeat peripheral vascular intervention, amputation, or limb salvage surgery, the researchers reported online in Circulation: Cardiovascular Interventions.
“The fundamental elements of medical therapy in patients with lifestyle-limiting claudication are often underutilized before referral for revascularization,” they wrote.
“Strategies, such as collaborative continuous quality improvement programs,” they wrote, “need to be explored and expanded, with the goal of improving the quality of medical therapy in this patient population.”
Grossman and colleagues examined the use and impact of recommended medical therapy in patients who underwent percutaneous interventions for lifestyle-limiting claudication using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention database.
- Improving the use of even minimal medical therapy may improve outcomes in patients with Peripheral arterial disease (PAD).
- Note that there was no difference in cardiovascular events among those taking an aspirin and a statin on admission and those who were not.
The analysis included 1,357 patients with aorto-iliac or femoropopliteal disease who underwent elective interventions at 11 hospitals from 2007 through 2009.
PAD is short for Peripheral Artery Disease. People have PAD when the arteries in their legs become narrowed or clogged with fatty deposits, or plaque. The buildup of plaque causes the arteries to harden and narrow, which is called atherosclerosis. When leg arteries are hardened and clogged, blood flow to the legs and feet is reduced. Some people call this poor circulation.
PAD occurs most often in the arteries in the legs, but it also can affect other arteries that carry blood outside the heart. This includes arteries that go to the aorta, the brain, the arms, the kidneys and the stomach. When arteries inside the heart are hardened or narrowed, it is called coronary artery disease or cardiovascular disease.
The good news is that like other diseases related to the arteries, PAD can be treated by making lifestyle changes, by taking medicines, or by having endovascular or surgical procedures, if needed.
Is PAD serious?
Lower-extremity PAD is a serious disease that affects about 8 million Americans. The hardened arteries found in people with PAD are a sign that they are likely to have hardened and narrowed arteries to the heart and the brain. That is why people with PAD are at high risk for having a heart attack or a stroke.
When the blood flow to the legs is greatly (or severely) reduced, people with PAD may have pain when walking. PAD may cause other problems that can lead to amputation. People with PAD may become disabled and not be able to go to work. As time goes on, they may have a very poor quality of life.
Before the intervention, 85% of the patients were using aspirin, 76% were using a statin, 65% did not smoke, and 47% met all three criteria. By discharge, aspirin and statin use had increased to 92% and 81%, respectively. The percentage of patients using both aspirin and a statin increased to 77%.
The only modest improvement in statin use from admission to discharge “signifies a missed opportunity to provide a life-saving intervention for PAD patients,” according to the authors.
PAD risk factors you can control
Certain risk factors for PAD can’t be controlled. These uncontrollable risk factors include aging, personal or family history of PAD, cardiovascular disease or stroke. However, you can control the following risk factors:
Cigarette smoking - You can stop smoking. Smoking is a major risk factor for PAD. Smokers may have four times the risk of PAD than nonsmokers.
Obesity - You can reduce your weight. People with a Body Mass Index (BMI) of 25 or higher are more likely to develop heart disease and stroke even if they have no other risk factors.
Diabetes mellitus - You can manage diabetes and blood sugar levels. Having diabetes puts you at greater risk of developing PAD as well as other cardiovascular diseases.
Physical inactivity - You can get moving. Physical activity increases the distance that people with PAD can walk without pain and also helps decrease the risk of heart attack or stroke.
High blood cholesterol - You can manage your cholesterol levels. High cholesterol contributes to the build-up of plaque in the arteries, which can significantly reduce the blood’s flow. This condition is known as atherosclerosis. Managing your cholesterol levels is essential to prevent or treat PAD.
High blood pressure - You can manage your blood pressure. It’s sometimes called “the silent killer” because it has no symptoms. Work with your healthcare professionals to monitor and control your blood pressure.
You can choose more than one target to improve! Taking care of only one risk factor is not as effective as taking care of all those that you can control. Learn the facts. Develop a heart-healthy lifestyle and cooperate with your healthcare professionals. Your heart will thank you by functioning better and lasting longer.
Of the current smokers at admission, 77% received tobacco cessation counseling.
Use of medical therapy at baseline was less likely among nonwhite individuals, patients with chronic obstructive pulmonary disease, the very young, and the very old, and more likely among those with diabetes, coronary artery disease, and a history of previous peripheral revascularization.
After adjustment for age, race, sex, current smoking, diabetes, prior cardiovascular events, previous peripheral vascular interventions, and renal failure requiring dialysis, the 6-month rate of cardiovascular events (all-cause death, myocardial infarction, stroke, or transient ischemic attack) was no different between those who were using both aspirin and a statin at baseline and those who were using neither (3.2% versus 2%, P=0.76).
“Our population size and limited follow-up window preclude the ability to discern differences in hard cardiovascular outcomes,” the authors noted. “However, data from the Heart Protection Study suggest that use of statins reduces the rate of major cardiovascular events in patients with PAD.”
There was a significant reduction in the rate of adverse peripheral vascular outcomes with use of both aspirin and a statin, driven primarily by a significantly lower rate of repeat peripheral interventions (5.1% versus 9.9%, P=0.04). Rates were nonsignificantly lower for limb salvage surgery and amputation.
The researchers acknowledged some limitations of the study, including the lack of data on lifestyle interventions like supervised exercise programs; the lack of information on blood pressure control or lipid levels; and insufficient patient numbers, which precluded a look at the association between improved medication use and outcomes.
The study was supported by Blue Cross Blue Shield of Michigan.
Grossman and one of his co-authors were supported by funding from Blue Cross Blue Shield of Michigan and the NIH.
Primary source: Circulation: Cardiovascular Interventions
Source reference: Ardati A, et al “The quality and impact of risk factor control in patients with stable claudication presenting for peripheral vascular interventions” Circ Cardiovasc Interv 2012; DOI: 10.1161/CIRCINTERVENTIONS.112.975862.