Good PAD Treatment Cuts Poor Vascular Outcomes

December 14, 2012

ANN ARBOR, Michigan — Around half of patients presenting for elective percutaneous revascularization because of lifestyle-limiting peripheral arterial disease (PAD) are not getting optimum medical therapy and/or following recommended lifestyle changes such as smoking cessation, a new study shows [1].

The study, published online December 11, 2012 in Circulation Cardiovascular Interventions, also found that patients taking both aspirin and a statin before their intervention had a large reduction in risk of having to undergo another revascularization within the following six months.

Senior author, Dr Michael Grossman (University of Michigan, Ann Arbor) told heartwire that the results were quite surprising given the short follow-up period. He commented: "It appears that use of aspirin and statins before the revascularization procedure, as well as quitting smoking, translates into better vascular outcomes in the medium term. They should also be associated with better cardiovascular outcomes in the long term."

Grossman noted that all patients having a vascular invention should be referred by a vascular specialist who should prescribe aspirin and statins and recommend quitting smoking, but many patients don't get the message. "They often don't cash their prescriptions, and many don't understand that they have to take these drugs for the rest of their life. They think they can take them for a few months and then stop," he said.

"Opportunity for Education"

Grossman pointed out that hospitalization or a revascularization procedure presents an ideal opportunity to address a patient's medical therapy. "This is a great opportunity for education. The patient is lying in a hospital bed, the family is often also there, and it is a good time to tell them that they must do everything possible to avoid having to be in the same situation again."

For the study, Grossman and colleagues used the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention database to identify 1357 patients with claudication undergoing peripheral revascularization between 2007 and 2009.

Before the intervention, 85% of patients were taking aspirin, 76% were taking a statin, 65% were not smoking, and 47% were complying with all three recommendations. There was no difference in cardiovascular events among those taking an aspirin and statin on admission and those who were not.

However, in both an unadjusted and multivariable analysis, the odds of an adverse peripheral vascular outcome (repeat peripheral intervention, amputation, or limb salvage surgery) within six months decreased by more than half in patients who received aspirin and statin therapy before peripheral vascular intervention compared with those who received neither (OR 0.45, 95% CI 0.29-0.71).

The authors say that: "Overall we have shown that patients presenting for elective invasive management of lifestyle-limiting PAD often do not receive the basic elements of medical therapy." Noting that the use of statin therapy only improved modestly at discharge, they point out that this is a missed opportunity to provide a life-saving intervention for PAD patients.

They further note that the prescription of secondary prevention medications in a hospital setting has been shown to improve long-term compliance in a coronary artery disease population, and while there has been a considerable effort focused on improving uptake of guideline-recommended medications in patients with MI and heart failure, there are currently no such programs for patients with PAD.

They conclude that future research should focus on identifying barriers to accessing care in this patient population, adding that: "Efforts to improve the quality of medical therapy are needed in this high-risk patient population to reduce both peripheral and major cardiovascular clinical complications."