Physical Activity in Patients with Symptomatic Peripheral Artery Disease: Insights from the PORTRAIT Registry

Prognostic impact of optimal lifestyle advice and medical therapy in patients with peripheral arterial disease

Background: Secondary prevention remains under-implemented in patients with peripheral arterial disease (PAD). In the present study, we sought to assess the extent, the predictors and the prognostic impact of optimal lifestyle advice (OLA) and optimal medical therapy (OMT) given at discharge to patients with PAD undergoing invasive peripheral procedures. Patients and methods: We included consecutive patients with PAD undergoing invasive peripheral procedures, between 2012 and 2013. Data were obtained from a mandatory fill-in clinical pathway. The primary outcome was all-cause mortality, verified using the National Mortality Registry. Results: A total of 2014 participants were included (mean age 70±11 years, 38.1% women). OLA was given to 279 (14%), OMT to 1186 (59%) participants. Male gender and absence of chronic limb-threatening ischaemia were significant predictors of OLA and OMT. During the median follow-up of 729 days (interquartile range 645) 392 (19.5%) participants died giving an overall mortality rate of 97/1000 patient years. On multivariate analysis both OLA and OMT emerged as independent predictors of survival (HR for all-cause mortality: 0.59; 95% CI: 0.42-0.82, p 0.005 and HR: 0.41; 95% CI: 0.22-0.76, p 0.002). Conclusions: OLA and OMT are associated with better long-term prognosis in patients with PAD, however they are still under-implemented, suggesting a considerable potential for improvement, especially in women.

The effects of sedentary behaviour on patients with peripheral arterial Disease: A systematic review

Sedentary behavior has recently emerged as a risk factor for cardiometabolic diseases. The objective of this review was to assess the relationship between sedentary behavior and peripheral arterial disease (PAD). Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we performed an electronic search across databases including Cochrane Central Register of Controlled Trials, Embase, MEDLINE (Ovid), CINHAL and PubMed to identify studies focusing on sedentary behavior and PAD. A total of 678 records fulfilled eligibility; 166 duplicates were removed, 487 were excluded at the title and abstract level and 15 studies were excluded at the full article level. Thus, our review comprised 10 studies of 20,064 patients with mean age 67.4 years. The average sedentary time was 544.9 min/day. The current review findings indicate that patients with PAD exhibited prolonged periods of sedentary behavior. Furthermore, sedentary behavior among patients with PAD was associated with lower survival rates. The included studies also reported varied outcomes regarding walking distance with some showing an association between reduced sedentary behavior and increased total walking distance. A randomized controlled trial in this review highlighted that reducing sedentary time among patients with PAD improved walking distance. Therefore, the connection between sedentary behavior and PAD seems to be bidirectional. Sedentary time could contribute to PAD development, and PAD-related symptoms may lead to prolonged sedentary behavior. A call for research investigating the link between PAD and sedentary time. Additionally, intervention studies are needed to target the reduction of sedentary time in patients with PAD.

Longitudinal Pathways Between Physical Activity, Depression, and Perceived Stress in Peripheral Artery Disease

BACKGROUND

One-fifth of the patients with peripheral artery disease (PAD) experience depression and stress. Depression and stress may impact patients' abilities to be physically active, a key recommendation for supporting overall PAD management to improve symptoms and reduce the risk of cardiovascular events. We aimed to study interrelationships between 1-year longitudinal trajectories of depression, stress, and physical activity following a PAD diagnosis.

METHODS

Patients with new or worsening PAD symptoms enrolled at 10 US PORTRAIT study (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) vascular specialty clinics (CT, LA, MI, MO, NC, OH, and RI) were assessed at baseline, 3, 6, and 12 months between June 2, 2011 and December 3, 2015. Depressive symptoms were measured with the 8-item Patient Health Questionnaire, perceived stress with the 4-item Perceived Stress Scale and physical activity with items from the INTERHEART study. Path analysis was used to examine the longitudinal relationship between depression and physical activity and perceived stress and physical activity.

RESULTS

A total of 766 patients were included (mean age of 68.2 [±9.4] years; 57.7% male). Overall, 17.8% reported significant depressive symptoms, 36.0% experienced increased perceived stress, and 44.1% were sedentary upon PAD diagnosis. A decrease in physical activity preceded a rise in subsequent depressive symptoms (β ranges -0.45 [95% CI, -0.80 to -0.09]; -0.81 [95% CI, -1.19 to 0.42]) over the course of 1 year. Low physical activity scores at the initial presentation were followed by high perceived stress at 3 months (β=-0.44 [95% CI, -0.80 to -0.07]).

CONCLUSIONS

In symptomatic PAD, a decrease in physical activity was followed by an increased risk of depressive symptoms and perceived stress at subsequent intervals over the course of 1 year following PAD diagnosis and treatment. Integrated behavioral health approaches for PAD, addressing physical activity and managing depression or distress, are indicated as collective PAD treatment goals.

A cross-sectional study explores the association of physical activity with the severity of peripheral arterial disease from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Engaging in physical activity (PA) has been proved to reduce the risk of developing cardiovascular diseases. In patients with peripheral arterial disease (PAD), diminished PA predicts high overall mortality. However, the extent of the association of participation in PA with PAD severity is unknown. Therefore, the overarching aim of this study was to investigate the association between PAD severity, PA levels and patterns using the Hispanic Community Health Study/Study of Latinos. This was a cross-sectional cohort study that included 495 participants with PAD and a total of 12,281 participants without PAD from the Hispanic Community Health Study/Study of Latinos database. The Global Physical Activity Questionnaire was administered to assess the time spent weekly in performing moderate-to-vigorous PA (MVPA) during work, leisure time, and transportation. The ankle-brachial index (ABI) was used to measure PAD. PA status was categorized on the basis of MVPA as follows: physically active and physically inactive to insufficient. In addition, all participants were classified as follows: those with normal ABI who were physically active, those with normal ABI but who were physically inactive, those with PAD but were physically active, and those with PAD who were physically inactive. Complex sample for regression models were used to investigate the association between PA and the severity of PAD. Of the participants, 235 (47.5%) were physically inactive to insufficient, and 260 participants (52.5%) engaged in at least 150 min/wk of MVPA, which is the recommended PA level according to the guidelines of World Health Organization. Compared with who were highly active, the participants who engaged in low PA were twice as likely to have moderately severe ABI and 4 times as likely to have severe ABI, after adjustment for the covariates (age, smoking status, and body mass index). Hispanic/Latino adults with sever PAD in the US showed pattern of physical inactivity. Findings of this study highlight the association between PA and severity of PAD. These findings highlight the necessity of interventions in increasing PA in these participants. Future studies are required to identify appropriate exercise regimens or home-based programs to help patients with severe PAD meet the current PA recommendations.

The Nevada Peripheral Artery Disease Screening Effort in a Medicare Advantage Population and Subsequent Mortality and Major Adverse Cardiovascular Event Risk

INTRODUCTION

There is a lack of contemporary estimates of undetected asymptomatic lower-extremity peripheral artery disease (PAD) in the community and its association with adverse outcomes in the population. We aimed to study the long-term association between previously undetected PAD and subsequent all-cause mortality and major adverse cardiovascular events (MACE) in Medicare advantage beneficiaries 65 years and older in a large metropolitan area characterized by concentrations of atherosclerotic risk factors along with a more vulnerable socio-economic risk profile.

METHODS

Data was derived from electronic medical records and linked with claims outcomes data for 13,971 Medicare advantage beneficiaries 65 years and older who underwent PAD screening in 2016 as part of patients' routine annual health assessment in the greater Las Vegas, Nevada metropolitan area. PAD screenings were performed with their primary care provider using volume plethysmography system (VPS) methods. The association between PAD screen status and one-year and 3-year all-cause mortality and MACE rates was documented.

RESULTS

The cohort had a mean age of 75.3±6.6 years and 57.7% of them were female. A total of 4,351 out of 13,768 (31.6%) had a positive PAD screening result. Almost 60% had a lower socio-economic income level, with 15.1% living under the poverty level. The risk estimates associated with a positive vs. a negative PAD screening for both all-cause mortality and MACE was (unadjusted HR mortality=2.17, 95% Confidence Interval, 95%CI 1.79-2.63; unadjusted HR MACE=2.00, 95%CI 1.15-3.49) at 1 year, and (unadjusted HR mortality=2.04, 95%CI 1.84-2.26; unadjusted HR MACE=1.67, 95%CI 1.37-2.02) at 3 year, respectively. Following multivariable adjustment, all associations persisted (P-values <.001) ranging from 1.41-1.69, except for 1-year MACE (similar risk estimate, but P=0.09).

CONCLUSION

A positive screening result of previously undetected lower extremity PAD was independently associated with short-term and long-term increased risks for mortality and MACE in individuals aged 65 years and older living in a large, metropolitan area.

Real World Practice Deviation from Nationwide Guidelines in Patients with Intermittent Claudication

OBJECTIVE

Patients with intermittent claudication (IC) are initially treated with supervised exercise therapy (SET), as advised by national and international guidelines. Dutch health insurance companies and the Dutch National Health Care Institute suggested an 87% compliance rate with these guidelines in the Netherlands in 2017 and judged this to be undesirably low. The aim of this study was to evaluate compliance with IC guidelines and to elaborate on the reasons for deviating from them (practice variation) in a large teaching hospital.

METHODS

A retrospective single centre cohort study was conducted at a large teaching hospital in the Netherlands. In total, 420 patients with newly diagnosed IC between 1 January 2017 and 31 December 2018 were analysed. Data included risk profiles and prescribed therapies.

RESULTS

For all 420 included patients, the compliance rate with the guidelines for SET was 80.5%. The rate of adequately motivated and defensible practice variation was 15.7%; the rate of unjustified practice variation was 3.8%. Meaningful care was seen in 96.2% of cases.

CONCLUSION

Deviation from IC guidelines was found in 19.5% of patients. Almost three quarters of this deviation can be explained by the decision to provide personalised, meaningful care.