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Maeda K, Kobayashi T, Emura S, Okazaki T, Mochizuki S, Sato T, Taniguchi M, Futagami D, Inoue R, Tomota M, Hiraoka T, Shimonaga T, Tachibana H, Shimizu H, Takahashi S. Medium-Term Outcomes of Treatment with a VIABAHN VBX Covered Stent for Aortoiliac Occlusive Lesions in Patients with Peripheral Artery Disease. Ann Vasc Surg 2024; 105:201-208. [PMID: 38604500 DOI: 10.1016/j.avsg.2023.12.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/07/2023] [Accepted: 12/31/2023] [Indexed: 04/13/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) for aortoiliac (AI) occlusive lesions is now conducted worldwide, but there are challenges in EVT for complex AI lesions. The VIABAHN VBX (W.L. Gore & Associates, Flagstaff, AZ) is a next-generation balloon-expandable covered stent designed for use with complex AI lesions. The purpose of this study is to evaluate the medium-term outcomes of VIABAHN VBX for such lesions. METHODS Symptomatic patients who underwent EVT with VIABAHN VBX for an AI lesion from 2018 to 2020 at 7 Japanese centers were reviewed retrospectively. The primary endpoints were primary patency and freedom from target lesion revascularization (TLR). RESULTS A total of 95 EVT procedures with VIABAHN VBX for AI occlusive lesions were performed in 71 patients. The patients had high rates of dyslipidemia (53%) and chronic kidney disease (61%), and 22% had chronic limb-threatening ischemia (CLTI). The Transatlantic Inter-Society Consensus (TASC Ⅱ) class was A in 12 patients (17%), B in 12 (17%), C in 10 (14%), and D in 37 (52%). Severe calcification (360°) of the treated lesion was present in 31 patients (33%). The median procedure time was 84 (49-158) min, with a technical success rate of 100%. The median follow-up period was 36 (32-43) months. The 3-year primary and secondary patency of VIABAHN VBX were 91% and 99%, the 3-year freedom from TLR was 92%, and the 3-year freedom from major adverse limb event (MALE) was 98%. No limbs required major amputation. Lesion severity (TASC Ⅱ C or D) and severe calcification did not affect the primary patency or freedom from TLR. CONCLUSIONS Medium-term outcomes after EVT with VIABAHN VBX for AI lesions were acceptable regardless of lesion severity and calcification. These results suggest that VIABAHN VBX may be suitable for AI occlusive lesions with severe anatomical complexity and/or severe calcification.
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Affiliation(s)
- Kazuki Maeda
- Department of Cardiovascular Surgery, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima-shi, Hiroshima, Japan.
| | - Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shogo Emura
- Department of Cardiovascular Surgery, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima-shi, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shingo Mochizuki
- Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Tomoyasu Sato
- Department of Radiology, Akane-Foundation Tsuchiya General Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Masato Taniguchi
- Department of Cardiology, Fukuyama Cardiovascular Hospital, Fukuyama-shi, Hiroshima, Japan
| | - Daisuke Futagami
- Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Fukuyama-shi, Hiroshima, Japan
| | - Risa Inoue
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Toshifumi Hiraoka
- Department of Cardiovascular Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure-shi, Hiroshima, Japan
| | - Takashi Shimonaga
- Department of Cardiology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure-shi, Hiroshima, Japan
| | - Hitoshi Tachibana
- Department of Cardiovascular Surgery, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Haruna Shimizu
- Department of Cardiovascular Surgery, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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3
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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4
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Uwumiro F, Okpujie V, Nebuwa C, Umoudoh U, Asobara E, Aniaku E, Makata G, Olukorode J. Emerging trends in nationwide mortality, limb loss, and resource utilization for critical limb ischemia in young adults. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00155-6. [PMID: 38616461 DOI: 10.1016/j.carrev.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND/OBJECTIVES Recent trends indicate a rise in the incidence of critical limb ischemia (CLI) among younger adults. This study examines trends in CLI hospitalization and outcomes among young adults with peripheral arterial disease (PAD) in the United States. METHODS Adult hospitalizations (18-40 years) for PAD/CLI were analyzed from the 2016-2020 nationwide inpatient sample database using ICD-10 codes. Rates were reported per 1000 PAD or 100,000 cardiovascular disease admissions. Outcomes included trends in mortality, major amputations, revascularization, length of hospital stay (LOS), and hospital costs (THC). We used the Jonckheere-Terpstra tests for trend analysis and adjusted costs to the 2020 dollar using the consumer price index. RESULTS Approximately 63,045 PAD and 20,455 CLI admissions were analyzed. The mean age of the CLI cohort was 32.7 ± 3 years. The majority (12,907; 63.1 %) were female and white (11,843; 57.9 %). Annual CLI rates showed an uptrend with 3265 hospitalizations (227 per 1000 PAD hospitalizations, 22.7 %) in 2016 to 4474 (252 per 1000 PAD hospitalizations, 25.2 %) in 2020 (Ptrend<0.001), along with an increase in PAD admissions from 14,405 (188 per 100,000, 0.19 %) in 2016 to 17,745 (232 per 100,000, 0.23 %%) in 2020 (Ptrend<0.0001). Annual in-hospital mortality increased from 570 (2.8 %) in 2016 to 803 (3.9 %) in 2020 (Ptrend = 0.001) while amputations increased from 1084 (33.2 %) in 2016 to 1995 (44.6 %) in 2020 (Ptrend<0.001). Mean LOS increased from 5.1 (SD 2.7) days in 2016 to 6.5 (SD 0.9) days in 2020 (Ptrend = 0.002). The mean THC for CLI increased from $50,873 to $69,262 in 2020 (Ptrend<0.001). The endovascular revascularization rates decreased from 11.5 % (525 cases) in 2016 to 10.7 % (635 cases) in 2020 (Ptrend = 0.025). Surgical revascularization rates also increased from 4.9 % (225 cases) in 2016 to 10.4 % (600 cases) in 2020 (Ptrend = 0.041). CONCLUSION Hospitalization and outcomes for CLI worsened among young adults during the study period. There is an urgent need to enhance surveillance for risk factors of PAD in this age group.
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Affiliation(s)
- Fidelis Uwumiro
- Department of Internal Medicine, University of Benin Teaching Hospital, Benin, Nigeria.
| | - Victory Okpujie
- Department of Internal Medicine, University of Benin Teaching Hospital, Benin, Nigeria
| | - Chikodili Nebuwa
- Department of Internal Medicine, Nuvance Health, Vassar Brothers Medical Center, Poughkeepsie, NY, USA
| | - Uwakmfonabasi Umoudoh
- Department of Internal Medicine, Southport District Hospital, Southport, Merseyside, UK
| | - Evaristus Asobara
- Department of Internal Medicine, Nnamdi Azikiwe University Teaching Hospital, Awka, Nigeria
| | - Emmanuel Aniaku
- Department of Internal Medicine, Al-darb General Hospital, Jazan Region, Saudi Arabia
| | - Golibe Makata
- Department of Internal Medicine, Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria
| | - John Olukorode
- Department of Internal Medicine, Benjamin S Carson College of Health and Medical Sciences, Babcock University, Ogun State, Nigeria
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5
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. Eur Heart J 2024; 45:1303-1321. [PMID: 38461405 DOI: 10.1093/eurheartj/ehad734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2024] Open
Abstract
All guidelines worldwide strongly recommend exercise as a pillar of the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended for clinicians to promote and assist for the set-up of comprehensive exercise programmes to best advice in patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are narratively described based on the current best evidence. The document ends by highlighting disparities in access to supervised exercise programmes across Europe and the series of gaps for evidence requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Center of Cardiology, Department of Cardiology III-Angiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France
- INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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6
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Abumoawad A, Okazaki RA, Behrooz L, Eberhardt RT. Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00160-2. [PMID: 38582206 DOI: 10.1016/j.avsg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 04/08/2024]
Abstract
Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.
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Affiliation(s)
| | - Ross A Okazaki
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Leili Behrooz
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Robert T Eberhardt
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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7
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. VASA 2024; 53:87-108. [PMID: 38461401 DOI: 10.1024/0301-1526/a001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Finland
- University of Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, France
- INSERM CIC 1414, Université de Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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8
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Moras E, Khan MI, Song DD, Syed M, Prabhakaran SY, Gandhi KD, Lavie CJ, Alam M, Sharma R, Krittanawong C. Pharmacotherapy and revascularization strategies of peripheral artery disease. Curr Probl Cardiol 2024; 49:102430. [PMID: 38309544 DOI: 10.1016/j.cpcardiol.2024.102430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.
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Affiliation(s)
- Errol Moras
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Mohammad Ishrak Khan
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - David D Song
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | - Moinuddin Syed
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | | | - Kruti D Gandhi
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Raman Sharma
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
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9
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Ravindhran B, Lim AJM, Kurian T, Walshaw J, Hitchman LH, Lathan R, Smith GE, Carradice D, Chetter IC, Pymer S. Supervised Exercise Therapy for Intermittent Claudication: A Propensity Score Matched Analysis of Retrospective Data on Long Term Cardiovascular Outcomes. Eur J Vasc Endovasc Surg 2024; 67:480-488. [PMID: 38040103 DOI: 10.1016/j.ejvs.2023.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/18/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE This study aimed to explore the long term outcomes of patients with intermittent claudication (IC) who completed supervised exercise therapy (SET) vs. those who declined or prematurely discontinued SET, focusing on the incidence of chronic limb threatening ischaemia (CLTI), revascularisation, major adverse limb events (MALE), and major adverse cardiovascular events (MACE). METHODS A retrospective registry analysis of consecutive patients with IC who were referred for SET between March 2015 and August 2016 and followed up for a minimum of five years. Serial univariable analysis and logistic regression were performed to identify the statistically significant clinical variables that were independent predictors of each outcome measure. The resulting statistically significant variables were used to guide 1:1 propensity score matching (PSM) using the nearest neighbour method with a calliper of 0.2. Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the association between SET and the outcomes of interest. RESULTS Two hundred and sixty-six patients were referred to SET between March 2015 and August 2016. Of these, 64 patients completed SET and 202 patients did not. After PSM, 49 patients were analysed in each cohort. The Cox proportional hazards analysis revealed a significant association between completion of SET and revascularisation requirement (HR 0.46 95% CI 0.25 - 0.84; p = .011), completion of SET and progression to CLTI (HR 0.091, 95% CI 0.04 - 0.24; p < .001), completion of SET and MACE (HR 0.52; 95% CI 0.28 - 0.99; p = .05) and completion of SET and MALE (HR 0.28, 95% CI 0.13 - 0.65; p = .003). The Harrell's C index for all of these models was greater than 0.75, indicating good predictive accuracy. CONCLUSION Completion of SET is associated with better outcomes in patients who completed SET compared with patients who declined or discontinued SET with respect to clinically important cardiovascular outcomes over seven years.
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Affiliation(s)
- Bharadhwaj Ravindhran
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK.
| | - Arthur J M Lim
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Thomas Kurian
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Josephine Walshaw
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Louise H Hitchman
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Ross Lathan
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
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Breen TJ, McGinigle K, Strosberg D, Dardik A, Altin SE. Anatomic patterns in claudicants who fail supervised exercise therapy. J Vasc Surg 2024; 79:679-684.e1. [PMID: 37984757 DOI: 10.1016/j.jvs.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Patients with intermittent claudication (IC) from peripheral arterial disease (PAD) have significant improvement with supervised exercise therapy (SET). However, many patients have progressive disease that will ultimately require revascularization. We sought to determine whether the anatomic patterns of PAD were associated with response to SET. METHODS We prospectively enrolled patients with IC at the West Haven, Connecticut Veterans Health Administration between June 2019 and June 2022. Patients were classified based on the level of their arterial disease with >50% obstruction. SET failure was defined as progressive symptoms or development of critical limb-threatening ischemia (CLTI) requiring revascularization. RESULTS Thirty-eight patients with PAD were included. Thirteen patients (34.2%) had significant common femoral artery (CFA) disease, and 25 (65.8%) had non-CFA disease. Over a median follow-up of 1407 days, 11 patients (84.6%) with CFA disease failed SET as compared with three patients (12.0%) with non-CFA disease (P < .001). Patients with CFA disease were more likely to develop CLTI (46.2% vs 4.0%; P = .001) and have persistent symptoms (38.5% vs 8.0%; P = .02). Patients with CFA disease had significantly lower post-SET ankle-brachial index (0.58 ± 0.14 vs 0.77 ± 0.19; P = .03). In multivariate analysis, the only variable associated with SET failure was CFA disease location (odds ratio, 68.75; 95% confidence interval, 5.05-936.44; P = .001). CONCLUSIONS Patients with IC from high-grade CFA atherosclerosis are overwhelmingly likely to fail SET, potentially identifying a subset of patients who benefit from upfront revascularization.
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Affiliation(s)
- Thomas J Breen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Katharine McGinigle
- Division of Vascular Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David Strosberg
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - S Elissa Altin
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Department of Internal Medicine, Section of Cardiovascular Medicine, West Haven Veterans Affairs Medical Center, West Haven, CT.
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise Therapy for Chronic Symptomatic Peripheral Artery Disease: A Clinical Consensus Document of the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases in Collaboration With the European Society of Vascular Medicine and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2024; 67:S1078-5884(24)00011-X. [PMID: 38467522 DOI: 10.1016/j.ejvs.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland.
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Helsinki; Department of Vascular Surgery, University of Helsinki, Helsinki
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital; EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University; National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France; INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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12
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Aronow WS, Avanesova AA, Frishman WH, Shamliyan TA. Inconsistent Benefits From Mobile Information Communication Technology in Adults With Peripheral Arterial Disease. Cardiol Rev 2024; 32:12-17. [PMID: 35674708 DOI: 10.1097/crd.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Quality of evidence regarding telemedicine in adults with peripheral arterial disease has not been systematically appraised. OBJECTIVES To explore benefits and harms from mobile information communication technology devices and applications in peripheral arterial disease. METHODS Systematic rapid evidence review and appraisal with the grading of recommendations assessment, development, and evaluation working group approach. RESULTS Sixteen randomized controlled clinical trials (RCT) examined various self-monitoring devices, telemedicine platforms, and individualized telephone counseling. Low-quality evidence suggested that the odds of treatment failure (pooled Peto odds ratio 0.8; 95% CI, 0.4-1.7; 5 RCTs), adverse effects (pooled Peto odds ratio 0.9; 95% CI, 0.5-1.5; 2 RCTs), and physical performance (standardized mean difference in 6-minute walking test 0.2; 95% CI, -0.3-0.7; 4 RCTs) did not differ between mobile interventions and usual care. Single RCTs suggested large but inconsistent improvement in the quality of life: EuroQol5D standardized mean difference = 5.0 (95% CI, 4.4-5.7; 1 RCT) after telehealth program for promoting patient self-management and standardized mean difference = 1.4 (95% CI, 0.4-2.3; 1 RCT) after structured rehabilitation with mobile self-monitoring. Inconsistent reporting of patient-centered outcomes and small sample sizes hampered the quality of evidence. CONCLUSIONS Improved quality of life after specific mobile applications should be confirmed in powered RCTs and large postmarketing studies.
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Affiliation(s)
- Wilbert S Aronow
- From the Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Anna A Avanesova
- North-Caucasus Federal University, Stavropol, Russian Federation
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13
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Kharawala A, Nagraj S, Pargaonkar S, Seo J, Kokkinidis DG, Altin SE. Hypertension Management in Peripheral Artery Disease: A Mini Review. Curr Hypertens Rev 2024; 20:1-9. [PMID: 38083897 DOI: 10.2174/0115734021267004231122061712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 06/01/2024]
Abstract
Lower extremity peripheral artery disease (PAD) affects over 230 million adults globally, with hypertension being one of the major risk factors for the development of PAD. Despite the high prevalence, patients with hypertension who have concomitant PAD are less likely to receive adequate therapy. Through this review, we present the current evidence underlying hypertension management in PAD, guideline-directed therapies, and areas pending further investigation. Multiple studies have shown that both high and relatively lower blood pressure levels are associated with worse health outcomes, including increased morbidity and mortality. Hence, guideline-directed recommendation involves cautious management of hypertensive patients with PAD while ensuring hypotension does not occur. Although any antihypertensive medication can be used to treat these patients, the 2017 American Heart Association/American College of Cardiology (AHA/ACC), 2017 European Society of Cardiology (ESC), and 2022 Canadian guidelines favor the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) as the initial choice. Importantly, data on blood pressure targets and treatment of hypertension in PAD are limited and largely stem from sub-group studies and post-hoc analysis. Large randomized trials in patients with PAD are required in the future to delineate hypertension management in this complex patient population.
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Affiliation(s)
- A Kharawala
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - S Nagraj
- Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - S Pargaonkar
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - J Seo
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - D G Kokkinidis
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - S E Altin
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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14
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Alsheikh S, Altoijry A, Alokayli S, Alkhalife SI, Alsahil SJ, AlGhofili H. Exploring Understanding of Peripheral Artery Disease among Patients at High-Risk in Saudi Arabia: Results from an Interview-Based Study. Clin Pract 2023; 14:13-23. [PMID: 38391398 PMCID: PMC10887943 DOI: 10.3390/clinpract14010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/29/2023] [Accepted: 12/13/2023] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND The level of awareness of peripheral artery disease (PAD) in Saudi Arabia, especially among populations at high risk, is not currently well known. Therefore, our objective was to assess the existing level of awareness among patients who are at high risk of PAD, as well as their comprehension of the disease. METHOD An interview-based cross-sectional study included 1035 participants with risk factors for PAD and collected data on demographics and knowledge domains related to PAD. RESULTS The statistical analysis was performed using t-tests and ANOVA. Overall, participants exhibited poor knowledge, with a mean score of 5.7 out of 26. The highest scores were observed in the risk factor and preventive measure domains, with means of 1.8 out of 7 and 1.8 out of 6, respectively. The factors associated with higher knowledge scores included older age, male gender, higher education, healthcare profession, interviews in vascular settings, previous awareness of PAD, and prior cardio-cerebrovascular interventions. CONCLUSION This study underscores the inadequate knowledge of PAD among high-risk individuals. Targeted educational initiatives are essential to bridge this knowledge gap, potentially reducing the burden of PAD-related complications and improving patient outcomes. Efforts should focus on raising awareness about PAD, particularly among high-risk populations.
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Affiliation(s)
- Sultan Alsheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Shirin Alokayli
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Sarah Ibrahim Alkhalife
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Shahad Jamal Alsahil
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Hesham AlGhofili
- Vascular Surgery Department, King Salman Heart Center, King Fahad Medical City, Riyadh 11525, Saudi Arabia
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
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15
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Coca-Martinez M, Girsowicz E, Doonan RJ, Obrand DI, Bayne JP, Steinmetz OK, Mackenzie KS, Carli F, Martinez-Palli G, Gill HL. Multimodal prehabilitation for peripheral arterial disease patients with intermittent claudication - A pilot randomized controlled trial. Ann Vasc Surg 2023:S0890-5096(23)00767-7. [PMID: 37949167 DOI: 10.1016/j.avsg.2023.09.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/10/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To establish the feasibility and safety of multimodal prehabilitation (MP), and to obtain pilot data on the change in quality of life, functional walking capacity, and the need for surgery for a full-scale trial. DESIGN Pilot randomized controlled trial that included patients older than 50 years old suffering from moderate to severe intermittent claudication and who were candidates for endovascular revascularization (ER). Participants were excluded if they presented with ischemic rest pain, gangrene or ulceration of the index leg, significant lesions in the iliac vessels, planned surgical bypass, comorbidities in which exercise was contraindicated or if they were unable to speak English or French. METHODS Participants were randomized in a 1:1 ratio to 12 weeks of MP or institutional standard of care (unsupervised walking advice). MP consisted of i)1 weekly supervised exercise session; ii) home-based exercise prescription; iii) nutritional counseling and supplementation iv) smoking cessation therapy and v) psychosocial support. Feasibility and safety were measured with recruitment and retention rates, as well as the occurrence of any adverse events. In addition, barriers to attend supervised sessions and compliance to each component were assessed. Change in functional walking capacity, health-related quality of life, and the rates of patients deciding not to undergo ER were collected and analyzed throughout the follow-up period of 12 months. RESULTS Of the 37 patients referred for eligibility, 27 (73%) accepted to participate in the trial and were randomized. Of the 27 patients included, 24 completed the 12-week program. Adherence to each prehabilitation component was 83% IQR [72,93] for supervised exercise, 90% [83,96] for home-based exercise and 69% [45,93] for nutritional sessions. 50% of patients were referred for and underwent psychosocial intervention and 40% of the active smokers enrolled in the smoking cessation program. No adverse events were observed during the program. The two main barriers for not fully adhering to the intervention were excessive pain while performing the exercises and the difficulty to keep up with the prescribed exercises. A statistically significant mean change (SD) was seen in the MP group vs standard of care for functional capacity, mean (SD) 6MWT 60 (74) vs -11 (40) meters p<0.05, and quality of life mean (SD) VascuQol 1.15 (0.54) vs -0.3 (1.09) points p<0.05. There was no statistically significant difference between groups in the rates of patients deciding to undergo ER during the 1-year follow-up period. CONCLUSIONS The results of this pilot trial demonstrate that MP is safe and feasible. A 12-week MP program seems to improve quality of life and functional walking capacity to a greater extent than unsupervised walking advice. There is a need for a large-scale trial to investigate the effectiveness of MP at improving quality of life and assessing its impact on the rates of patients deciding not to undergo or delay ER. The long-term functional and quality of life outcomes of the patients deciding to undergo ER after prehabilitation also needs to be assessed.
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Affiliation(s)
- Miquel Coca-Martinez
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada; Department of Anesthesia and Intensive Care, Universitat de Barcelona, Barcelona, Spain; Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Elie Girsowicz
- Department of Vascular Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Robert J Doonan
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Daniel I Obrand
- Department of Vascular Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jason P Bayne
- Department of Vascular Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Oren K Steinmetz
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Kent S Mackenzie
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | | | - Heather L Gill
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada.
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16
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Smolderen KG, Samaan Z, Decker C, Collins T, Lazar RM, Itoga NK, Mena-Hurtado C. Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1511-1528. [PMID: 37781785 DOI: 10.1161/cir.0000000000001178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.
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17
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Søgaard M, Nielsen PB, Eldrup N, Behrendt CA, Nicolajsen CW, Lip GYH, Skjøth F. Epidemiological Trends and Projections of Incidence, Prevalence, and Disease Related Mortality Associated With Peripheral Arterial Disease: Observations Using Nationwide Danish Data. Eur J Vasc Endovasc Surg 2023; 66:662-669. [PMID: 37567342 DOI: 10.1016/j.ejvs.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 06/27/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE Peripheral arterial disease (PAD) trends remain unclear because contemporary data are sparse and conflicting. This nationwide cohort study quantified changes in PAD incidence, prevalence, and all cause mortality, and projected prevalence development through to 2040. METHODS Population based registries covering the entire Danish population aged ≥ 40 years from 2000 to 2018 were linked to assess trends in PAD incidence, prevalence, and all cause mortality, overall and by sex and age groups. Based on observed trends in incidence and mortality, and estimated future annual age distribution and population mortality, the PAD prevalence through to 2040 was projected. RESULTS The Danish population aged 40 - 99 years in 2000 - 2018 included 4 811 281 individuals, among whom 145 870 incident PAD diagnoses were identified. The age and sex standardised PAD incidence decreased from 2.26 per 1 000 person years in 2000 to 1.65 in 2018 (incidence RR 0.74, 95% CI 0.72 - 0.77). The incidence was approximately 20% higher in men than women but declined similarly over time. Concurrently, PAD prevalence in the Danish adult population increased from 1.3% to 1.6% (prevalence ratio 1.28, 95% CI 1.26 - 1.30). Among patients aged ≥ 80 years, the prevalence reached 5.7% in women and 7.9% in men. The age and sex standardised annual mortality among patients with PAD decreased from 9.8% in 2000 to 7.2% in 2018 (mortality ratio 0.75, 95% CI 0.72 - 0.78). Projections of PAD prevalence demonstrated that the rising PAD prevalence will continue until around 2030, followed by a decline towards 2040. Among individuals aged ≥ 80 years, the prevalence was projected to plateau at 8.9% for men and 6.2% for women before declining. CONCLUSION Within an unselected nationwide population, the incidence and all cause mortality of PAD have declined over the last two decades. Concurrently, prevalence increased and is projected to increase further over the coming decade, emphasising the growing burden of this common atherosclerotic disease in ageing populations.
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Affiliation(s)
- Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Chalotte W Nicolajsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Surgery, Unit of Vascular Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Unit for Clinical Biostatistics, Aalborg University Hospital, Denmark
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18
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Kapadia S, Huang H, Parise H, Ismayl M, Ahmed Z, Tirziu D, Altin SE. Supervised Exercise Therapy Versus Percutaneous Transluminal Angioplasty for Claudication by Level of Disease: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:403-405. [PMID: 37659260 DOI: 10.1016/j.amjcard.2023.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/04/2023]
Affiliation(s)
- Sohum Kapadia
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Haocheng Huang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Helen Parise
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Mahmoud Ismayl
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Zain Ahmed
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Daniela Tirziu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - S Elissa Altin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Deparmtent of Cardiology, West Haven VA Medical Center, West Haven, Connecticut.
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19
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Ulfsdottir H, Bäck M, Cider Å, Jivegård L, Sandberg A, Nordanstig J, Svensson M. Cost-Effectiveness of Exercise Therapy in Patients with Intermittent Claudication-A Comparison of Supervised Exercise, Home-Based Structured Exercise, and Walk Advice from the SUNFIT Trial. J Clin Med 2023; 12:5277. [PMID: 37629318 PMCID: PMC10455939 DOI: 10.3390/jcm12165277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/19/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Hospital-based supervised exercise (SEP) is a guideline-recommended intervention for patients with intermittent claudication (IC). However, due to the limited availability of SEP, home-based structured exercise programs (HSEP) have become increasingly popular alongside the "go home and walk" advice. We evaluated the cost-effectiveness of walk advice (WA) with Nordic pole walking vs. SEP combined with WA or HSEP combined with WA. We used data from the SUNFIT RCT (NCT02341716) to measure quality-adjusted life-years (QALYs) over a 12-month follow-up, and economic costs were obtained from a hospital cost-per-patient accounting system. Incremental cost-effectiveness ratios (ICERs) were calculated, and uncertainty was assessed using nonparametric bootstrapping. The average health-care-cost per patient was similar in the WA (EUR 1781, n = 51) and HSEP (EUR 1820, n = 48) groups but higher in the SEP group (EUR 4619, n = 50, p-value < 0.01). Mean QALYs per patient during the follow-up were similar with no statistically significant differences. The findings do not support SEP as a cost-effective treatment for IC, as it incurred significantly higher costs without providing additional health improvements over WA with or without HSEP during the one-year observation period. The analysis also suggested that HSEP may be cost-effective compared to WA, but only with a 64% probability.
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Affiliation(s)
- Hildigunnur Ulfsdottir
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Sidekick Health, 413 90 Gothenburg, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Åsa Cider
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Lennart Jivegård
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Health Technology Assessment Centre Region Västra Götaland, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden
| | - Anna Sandberg
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Department of Vascular Surgery, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA
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20
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Schenck CS, Strand E, Smolderen KG, Romain G, Nagpal S, Cleman J, Blume PA, Mena-Hurtado C. Community distress and risk of adverse outcomes after peripheral vascular intervention. J Vasc Surg 2023; 78:166-174.e3. [PMID: 36944389 PMCID: PMC11146282 DOI: 10.1016/j.jvs.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION Community distress is associated with adverse outcomes in patients with cardiovascular disease; however, its impact on clinical outcomes after peripheral vascular intervention (PVI) is uncertain. The Distressed Communities Index (DCI) is a composite measure of community distress measured at the zip code level. We evaluated the association between community distress, as measured by the DCI, and 24-month mortality and major amputation after PVI. METHODS We used the Vascular Quality Initiative database, linked with Medicare claims data, to identify patients who underwent initial femoropopliteal PVI between 2017 and 2018. DCI scores were assigned using patient-level zip code data. The primary outcomes were 24-month mortality and major amputation. We used time-dependent receiver operating characteristic curve analysis to determine an optimal DCI value to stratify patients into risk categories for 24-month mortality and major amputation. Mixed Cox regression models were constructed to estimate the association of DCI with 24-month mortality and major amputation. RESULTS The final cohort consisted of 16,864 patients, of whom 4734 (28.1%) were classified as having high community distress (DCI ≥70). At 24 months, mortality was elevated in patients with high community distress (30.7% vs 29.5%, P = .02), as was major amputation (17.2% vs 13.1%, P <.001). After adjusting for demographic and clinical characteristics, a 10-point higher DCI score was associated with increased risk of mortality (hazard ratio: 1.01; 95% confidence interval: 1.00-1.03) and major amputation (hazard ratio: 1.02; 95% confidence interval: 1.00-1.04). CONCLUSIONS High community distress is associated with increased risk of mortality and major amputation after PVI.
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Affiliation(s)
| | - Eric Strand
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Sameer Nagpal
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Peter A Blume
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
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21
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Kennedy MA, Potiaumpai M, Maitin-Shepard M, Wilson CM, Campbell A, Schwartz AL, Gorzelitz J, Caru M, Grimmett C, Schmitz KH. Looking back: a review of policy implications for exercise oncology. J Natl Cancer Inst Monogr 2023; 2023:140-148. [PMID: 37139975 PMCID: PMC10501465 DOI: 10.1093/jncimonographs/lgad002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/16/2022] [Accepted: 01/13/2023] [Indexed: 05/05/2023] Open
Abstract
The evidence to support the benefits of exercise for people living with and beyond cancer is robust. Still, exercise oncology interventions in the United States are only eligible for coverage by third-party payers within the restrictions of cancer rehabilitation settings. Without expanded coverage, access will remain highly inequitable, tending toward the most well-resourced. This article describes the pathway to third-party coverage for 3 programs that address a chronic disease and utilize exercise professionals: the Diabetes Prevention Program, Supervised Exercise Training for Peripheral Artery Disease, and Cancer Rehabilitation. Lessons learned will be applied toward expanding third-party coverage for exercise oncology programming.
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Affiliation(s)
- Mary A Kennedy
- Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Melanie Potiaumpai
- Milton S. Hershey College of Medicine, Public Health Sciences, Pennsylvania State University, Hershey, PA, USA
| | | | - Christopher M Wilson
- Physical Therapy Program, School of Health Sciences, Oakland University, Rochester, MI, USA
| | - Anna Campbell
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Anna L Schwartz
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jessica Gorzelitz
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA, USA
| | - Maxime Caru
- Milton S. Hershey College of Medicine, Public Health Sciences, Pennsylvania State University, Hershey, PA, USA
| | - Chloe Grimmett
- School of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Kathryn H Schmitz
- Division of Hematology and Oncology, University of Pittsburgh, Pittsburgh, PA, USA
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22
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Bethel M, Annex BH. Peripheral arterial disease: A small and large vessel problem. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 28:100291. [PMID: 38511071 PMCID: PMC10945902 DOI: 10.1016/j.ahjo.2023.100291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2024]
Abstract
Peripheral arterial disease (PAD) is one clinical manifestation of systemic atherosclerosis and is very common. Despite its prevalence, PAD remains underdiagnosed, undertreated, and understudied. The most common symptom in patients with PAD is intermittent claudication (IC), or pain in the lower extremities with walking or exertion, which is relieved after a short period of rest. Many patients with confirmed PAD are asymptomatic or have symptoms other than IC. Regardless of symptoms, patients with PAD have poor cardiovascular outcomes. PAD has largely been viewed a disease of large vessel atherosclerosis but what is becoming clear is that arterial plaques and occlusions are only one piece of the puzzle. Recent work has shown that abnormalities in the microvasculature contribute to the outcome of patients with PAD. From the perspective of the leg, limitation in blood flow is not the only problem as patients have a myriad of other problems, including muscle fibrosis, neuropathic changes, changes in the cellular respiration machinery and dysfunction of the small vessels that perfuse skeletal muscle and the supporting structures. Supervised exercise training remains one of the most effective tool to treat patients with PAD, however, the mechanisms behind its effectiveness are still being elucidated and use of structured exercise programs is not widespread. Medical therapy to treat systemic atherosclerosis is underutilized in patients with PAD. Invasive therapies are used only when patients with PAD have reached an advanced stage. While invasive strategies are effective in some patients with PAD, these strategies are costly, carry risk, and many patients are not amenable to invasive therapy. Appreciating the complex pathophysiology of PAD will hopefully spur new research and development of effective therapies for PAD.
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Affiliation(s)
- Monique Bethel
- Department of Medicine, Division of Cardiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Brian H. Annex
- Department of Medicine, Division of Cardiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
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23
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Association between home-based exercise using a pedometer and clinical prognosis after endovascular treatment in patients with peripheral artery disease. J Cardiol 2023; 81:222-228. [PMID: 36126908 DOI: 10.1016/j.jjcc.2022.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/20/2022] [Accepted: 08/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Exercise therapy following endovascular treatment (EVT) is important for patients with peripheral artery disease (PAD); however, continuous exercise therapy is difficult to be performed in clinical practice. This study aimed to investigate the association between the implementation of home-based exercise using pedometers after EVT and 1-year clinical outcomes. METHODS This multicenter observational prospective cohort registry included patients with PAD complaining of intermittent claudication who underwent EVT for aortoiliac and/or femoropopliteal artery lesions between January 2016 and March 2019. Patients were instructed to perform home-based exercises using a specific pedometer after EVT. The study population was divided into good and poor recording groups according to the frequency of the pedometer measurements. The good recording group was defined as those who completed ≥50 % of the prescribed daily pedometer recording during the follow-up period. The poor recording group was defined as those with an inability to use a pedometer and/or who completed <50 % of the prescribed daily pedometer recordings. The primary outcome was 1-year major adverse events (MAE), defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, target vessel revascularization, and major amputation of the target limb. RESULTS The mean age was 74.4 years; 78 % were male. A total of 623 lesions were analyzed (58.7 % aortoiliac, 41.3 % femoropopliteal). At 1 year, a lower cumulative incidence of MAE was observed in the good recording group compared to that in the poor recording group [10/233 (4.3 %) vs. 35/267 (13.7 %) patients, respectively; p < 0.001]. Multivariate Cox regression analysis showed that patients in the good recording group had a lower hazard ratio for 1-year MAE (0.33; 95 % confidence interval, 0.16-0.68; p = 0.004) than that in the poor recording group. CONCLUSIONS Good self-recording of pedometer measurements was associated with favorable prognosis in patients with PAD following EVT.
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Reitz KM, Althouse AD, Forman DE, Zuckerbraun BS, Vodovotz Y, Zamora R, Raffai RL, Hall DE, Tzeng E. MetfOrmin BenefIts Lower Extremities with Intermittent Claudication (MOBILE IC): randomized clinical trial protocol. BMC Cardiovasc Disord 2023; 23:38. [PMID: 36681798 PMCID: PMC9862509 DOI: 10.1186/s12872-023-03047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC. METHODS 200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol. DISCUSSION MOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC. TRIAL REGISTRATION The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | | | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Wolff Center, UPMC, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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25
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Sieland J, Niederer D, Engeroff T, Vogt L, Troidl C, Schmitz-Rixen T, Banzer W, Troidl K. Changes in miRNA expression in patients with peripheral arterial vascular disease during moderate- and vigorous-intensity physical activity. Eur J Appl Physiol 2023; 123:645-654. [PMID: 36418750 PMCID: PMC9684818 DOI: 10.1007/s00421-022-05091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Walking is the preferred therapy for peripheral arterial disease in early stage. An effect of walking exercise is the increase of blood flow and fluid shear stress, leading, triggered by arteriogenesis, to the formation of collateral blood vessels. Circulating micro-RNA may act as an important information transmitter in this process. We investigated the acute effects of a single bout of 1) aerobic walking with moderate intensity; and 2) anaerobic walking with vigorous intensity on miRNA parameters related to vascular collateral formation. METHODS Ten (10) patients with peripheral arterial disease with claudication (age 72 ± 7 years) participated in this two-armed, randomized-balanced cross-over study. The intervention arms were single bouts of supervised walking training at (1) vigorous intensity on a treadmill up to volitional exhaustion and (2) moderate intensity with individual selected speed for a duration of 20 min. One week of washout was maintained between the arms. During each intervention, heart rate was continuously monitored. Acute effects on circulating miRNAs and lactate concentration were determined using pre- and post-intervention measurement comparisons. RESULTS Vigorous-intensity walking resulted in a higher heart rate (125 ± 21 bpm) than the moderate-intensity intervention (88 ± 9 bpm) (p < 0.05). Lactate concentration was increased after vigorous-intensity walking (p = 0.005; 3.3 ± 1.2 mmol/l), but not after moderate exercising (p > 0.05; 1.7 ± 0.6 mmol/l). The circulating levels of miR-142-5p and miR-424-5p were up-regulated after moderate-intensity (p < 0.05), but not after vigorous-intensity training (p > 0.05). CONCLUSION Moderate-intensity walking seems to be more feasible than vigorous exercises to induce changes of blood flow and endurance training-related miRNAs in patients with peripheral arterial disease. Our data thus indicates that effect mechanisms might follow an optimal rather than a maximal dose response relation. Steady state walking without the necessity to reach exhaustion seems to be better suited as stimulus.
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Affiliation(s)
- Johanna Sieland
- Department of Sports Medicine, Institute of Sports Sciences, Goethe University, Ginnheimer Landstraße 39, 60487, Frankfurt, Germany.
| | - Daniel Niederer
- grid.7839.50000 0004 1936 9721Department of Sports Medicine, Institute of Sports Sciences, Goethe University, Ginnheimer Landstraße 39, 60487 Frankfurt, Germany ,grid.7839.50000 0004 1936 9721Division of Preventive and Sports Medicine, Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Tobias Engeroff
- grid.7839.50000 0004 1936 9721Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Division Health and Performance, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Lutz Vogt
- grid.7839.50000 0004 1936 9721Department of Sports Medicine, Institute of Sports Sciences, Goethe University, Ginnheimer Landstraße 39, 60487 Frankfurt, Germany
| | - Christian Troidl
- grid.8664.c0000 0001 2165 8627Department of Experimental Cardiology, Medical Faculty, Justus-Liebig-University, 35392 Giessen, Germany ,grid.419757.90000 0004 0390 5331Department of Cardiology, Kerckhoff Heart and Thorax Center, 61231 Bad Nauheim, Germany ,grid.452396.f0000 0004 5937 5237German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt Am Main, Germany
| | - Thomas Schmitz-Rixen
- grid.411088.40000 0004 0578 8220Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Winfried Banzer
- grid.7839.50000 0004 1936 9721Division of Preventive and Sports Medicine, Institute for Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Kerstin Troidl
- grid.411088.40000 0004 0578 8220Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany ,grid.449744.e0000 0000 9323 0139Department of Life Sciences and Engineering, TH Bingen, Berlinstrasse 109, 55411 Bingen Am Rhein, Germany
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26
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Makita S, Yasu T, Akashi YJ, Adachi H, Izawa H, Ishihara S, Iso Y, Ohuchi H, Omiya K, Ohya Y, Okita K, Kimura Y, Koike A, Kohzuki M, Koba S, Sata M, Shimada K, Shimokawa T, Shiraishi H, Sumitomo N, Takahashi T, Takura T, Tsutsui H, Nagayama M, Hasegawa E, Fukumoto Y, Furukawa Y, Miura SI, Yasuda S, Yamada S, Yamada Y, Yumino D, Yoshida T, Adachi T, Ikegame T, Izawa KP, Ishida T, Ozasa N, Osada N, Obata H, Kakutani N, Kasahara Y, Kato M, Kamiya K, Kinugawa S, Kono Y, Kobayashi Y, Koyama T, Sase K, Sato S, Shibata T, Suzuki N, Tamaki D, Yamaoka-Tojo M, Nakanishi M, Nakane E, Nishizaki M, Higo T, Fujimi K, Honda T, Matsumoto Y, Matsumoto N, Miyawaki I, Murata M, Yagi S, Yanase M, Yamada M, Yokoyama M, Watanabe N, Ito H, Kimura T, Kyo S, Goto Y, Nohara R, Hirata KI. JCS/JACR 2021 Guideline on Rehabilitation in Patients With Cardiovascular Disease. Circ J 2022; 87:155-235. [PMID: 36503954 DOI: 10.1253/circj.cj-22-0234] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Hitoshi Adachi
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University of Medicine
| | - Shunichi Ishihara
- Department of Psychology, Bunkyo University Faculty of Human Sciences
| | - Yoshitaka Iso
- Division of Cardiology, Showa University Fujigaoka Hospital
| | - Hideo Ohuchi
- Department of Pediatrics, National Cerebral and Cardiovascular Center
| | | | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus
| | - Koichi Okita
- Graduate School of Lifelong Sport, Hokusho University
| | - Yutaka Kimura
- Department of Health Sciences, Kansai Medical University Hospital
| | - Akira Koike
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Kazunori Shimada
- Department of Cardiology, Juntendo University School of Medicine
| | | | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Tetsuya Takahashi
- Department of Physical Therapy, Faculty of Health Science, Juntendo University
| | - Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | | | - Emiko Hasegawa
- Faculty of Psychology and Social Welfare, Seigakuin University
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Sumio Yamada
- Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine
| | - Yuichiro Yamada
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital
| | | | | | - Takuji Adachi
- Department of Physical Therapy, Nagoya University Graduate School of Medicine
| | | | | | | | - Neiko Ozasa
- Cardiovascular Medicine, Kyoto University Hospital
| | - Naohiko Osada
- Department of Physical Checking, St. Marianna University Toyoko Hospital
| | - Hiroaki Obata
- Division of Internal Medicine, Niigata Minami Hospital.,Division of Rehabilitation, Niigata Minami Hospital
| | | | - Yusuke Kasahara
- Department of Rehabilitation, St. Marianna University Yokohama Seibu Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kentaro Kamiya
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Yuji Kono
- Department of Rehabilitation, Fujita Health University Hospital
| | - Yasuyuki Kobayashi
- Department of Medical Technology, Gunma Prefectural Cardiovascular Center
| | | | - Kazuhiro Sase
- Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University
| | - Shinji Sato
- Department of Physical Therapy, Teikyo Heisei University
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Norio Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Daisuke Tamaki
- Department of Nutrition, Showa University Fujigaoka Hospital
| | - Minako Yamaoka-Tojo
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University
| | - Michio Nakanishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Mari Nishizaki
- Department of Rehabilitation, National Hospital Organization Okayama Medical Center
| | - Taiki Higo
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Kanta Fujimi
- Department of Rehabilitation, Fukuoka University Hospital
| | - Tasuku Honda
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Shioya Hospital, International University of Health and Welfare
| | | | - Ikuko Miyawaki
- Department of Nursing, Kobe University Graduate School of Health Sciences
| | - Makoto Murata
- Department of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Masanobu Yanase
- Department of Transplantation, National Cerebral and Cardiovascular Center
| | | | - Miho Yokoyama
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Syunei Kyo
- Tokyo Metropolitan Geriatric Medical Center
| | | | | | - Ken-Ichi Hirata
- Department of Internal Medicine, Kobe University Graduate School of Medicine
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27
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Franklin BA, Eijsvogels TM, Pandey A, Quindry J, Toth PP. Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations. Am J Prev Cardiol 2022; 12:100425. [PMID: 36281325 PMCID: PMC9586849 DOI: 10.1016/j.ajpc.2022.100425] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 09/05/2022] [Accepted: 10/06/2022] [Indexed: 11/11/2022] Open
Abstract
The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.
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Affiliation(s)
- Barry A. Franklin
- Preventive Cardiology and Cardiac Rehabilitation, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Thijs M.H. Eijsvogels
- Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ambarish Pandey
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - John Quindry
- Integrative Physiology and Athletic Training, University of Montana, Missoula, MT, USA
- International Heart Institute – St. Patrick's Hospital, Providence Medical Center, Missoula, MT, USA
| | - Peter P. Toth
- CGH Medical Center, Sterling, IL, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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DHRUVA SANKETS, BACHHUBER MARCUSA, SHETTY ASHWIN, GUIDRY HAYDEN, GUDUGUNTLA VINAY, REDBERG RITAF. A Policy Approach to Reducing Low-Value Device-Based Procedure Use. Milbank Q 2022; 100:1006-1027. [PMID: 36573334 PMCID: PMC9836248 DOI: 10.1111/1468-0009.12595] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.
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Affiliation(s)
- SANKET S. DHRUVA
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
| | - MARCUS A. BACHHUBER
- Louisiana State University Health Sciences Center School of Medicine
- Louisiana Department of Health
| | - ASHWIN SHETTY
- Louisiana State University Health Sciences Center School of Medicine
| | - HAYDEN GUIDRY
- Louisiana State University Health Sciences Center School of Medicine
| | | | - RITA F. REDBERG
- University of California, San Francisco School of Medicine
- Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan Francisco
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29
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Bellomo TR, Tsao NL, Johnston-Cox H, Borkowski K, Shakt G, Judy R, Moore J, Ractcliffe SJ, Fiehn O, Floyd TF, Wehrli FW, Mohler E, Newman JW, Damrauer SM. Metabolite patterns associated with individual response to supervised exercise therapy in patients with intermittent claudication. JVS Vasc Sci 2022; 3:379-388. [PMID: 36568282 PMCID: PMC9772856 DOI: 10.1016/j.jvssci.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 10/01/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
Objective Supervised exercise therapy (SET) is the first line treatment for intermittent claudication owing to peripheral arterial disease. Despite multiple randomized controlled trials proving the efficacy of SET, there are large differences in individual patient's responses. We used plasma metabolomics to identify potential metabolic influences on the individual response to SET. Methods Primary metabolites, complex lipids, and lipid mediators were measured on plasma samples taken at before and after Gardner graded treadmill walking tests that were administered before and after 12 weeks of SET. We used an ensemble modeling approach to identify metabolites or changes in metabolites at specific time points that associated with interindividual variability in the functional response to SET. Specific time points analyzed included baseline metabolite levels before SET, dynamic metabolomics changes before SET, the difference in pre- and post-SET baseline metabolomics, and the difference (pre- and post-SET) of the dynamic (pre- and post-treadmill). Results High levels of baseline anandamide levels pre- and post-SET were associated with a worse response to SET. Increased arachidonic acid (AA) and decreased levels of the AA precursor dihomo-γ-linolenic acid across SET were associated with a worse response to SET. Participants who were able to tolerate large increases in AA during acute exercise had longer, or better, walking times both before and after SET. Conclusions We identified two pathways of relevance to individual response to SET that warrant further study: anandamide synthesis may activate endocannabinoid receptors, resulting in worse treadmill test performance. SET may train patients to withstand higher levels of AA, and inflammatory signaling, resulting in longer walking times. Clinical Relevance This manuscript describes the use of metabolomic techniques to measure the interindividual effects of SET in patients with peripheral artery disease (PAD). We identified high levels of AEA are linked to CB1 signaling and activation of inflammatory pathways. This alters energy expenditure in myoblasts by decreasing glucose uptake and may induce an acquired skeletal muscle myopathy. SET may also help participants tolerate increased levels of AA and inflammation produced during exercise, resulting in longer walking times. This data will enhance understanding of the pathophysiology of PAD and the mechanism by which SET improves walking intolerance.
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Affiliation(s)
- Tiffany R. Bellomo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Noah L. Tsao
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Hillary Johnston-Cox
- Division of Cardiovascular Medicine, Department of Medicine, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamil Borkowski
- West Coast Metabolomics Center, University of California Davis, Davis, CA
| | - Gabrielle Shakt
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Renae Judy
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Jonni Moore
- Department of Pathology, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Oliver Fiehn
- West Coast Metabolomics Center, University of California Davis, Davis, CA
| | - Thomas F. Floyd
- Departments of Anesthesiology and Pain Management, Cardiovascular Surgery, and Radiology, University of Texas Southwestern, Dallas, TX
| | - Felix W. Wehrli
- Department of Radiology, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emile Mohler
- Division of Cardiovascular Medicine, Department of Medicine, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John W. Newman
- West Coast Metabolomics Center, University of California Davis, Davis, CA,Department of Nutrition, University of California, Davis, CA,Obesity and Metabolism Research Unit, USDA-ARS-Western Human Nutrition Research Center, Davis, CA
| | - Scott M. Damrauer
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Correspondence: Scott M. Damrauer, MD, Division of Vascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 4 Silverstein, Philadelphia, PA 19104
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30
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Lanzi S, Belch J, Brodmann M, Madaric J, Bura-Riviere A, Visonà A, Mazzolai L. Supervised exercise training in patients with lower extremity peripheral artery disease. VASA 2022; 51:267-274. [DOI: 10.1024/0301-1526/a001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Summary: The optimal first line management of patients with symptomatic chronic lower extremity peripheral artery disease (PAD) includes secondary prevention of cardiovascular risk factors, pharmacological treatment, and supervised exercise therapy (SET). SET programs have shown to be effective in improving walking performance, functional performance, and quality of life. However, despite a large body of evidence, and despite national and international guidelines recommending SET as first line therapy, SET remains largely underused in patients with chronic PAD. This position paper aims to describe how SET is perceived, its accessibility and structure through Europe. An anonymous web-based survey was used. It comprised 21 questions developed in conjunction with an angiologist and a clinical exercise physiologist specialist in vascular rehabilitation. We had 131 responders from 17 countries. For patients with PAD, SET programs exist only in 59% of European countries. SET reimbursement is available in 41% of countries. SET programs showed to be heterogeneous across countries. Thirty-four percent of the SET programs are PAD-dedicated, while 23% are part of a cardiac rehabilitation program. In addition, among existing SET programs, 65% are dedicated to symptomatic patients with PAD only, 9% to both asymptomatic and symptomatic, 8% to post-revascularized patients only, and 1% to asymptomatic patients with PAD only. Finally, 17% reported not knowing which patients are eligible for enrolment in a SET program. Duration, frequency, and modality of SET also varied from country to country. Overall, these data indicate that a large variability of SET availability and characteristics exists across Europe. Therefore, there is an urgent need to provide detailed guidance to deliver optimal exercise therapeutic care in patients with PAD.
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Affiliation(s)
- Stefano Lanzi
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Juraj Madaric
- Clinic of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | | | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Italy
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Switzerland
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31
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Englund EK, Langham MC, Wehrli FW, Fanning MJ, Khan Z, Schmitz KH, Ratcliffe SJ, Floyd TF, Mohler ER. Impact of supervised exercise on skeletal muscle blood flow and vascular function measured with MRI in patients with peripheral artery disease. Am J Physiol Heart Circ Physiol 2022; 323:H388-H396. [PMID: 35802515 PMCID: PMC9359664 DOI: 10.1152/ajpheart.00633.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/21/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Supervised exercise is a common therapeutic intervention for patients with peripheral artery disease (PAD), however, the mechanism underlying the improvement in claudication symptomatology is not completely understood. The hypothesis that exercise improves microvascular blood flow is herein tested via temporally resolved magnetic resonance imaging (MRI) measurement of blood flow and oxygenation dynamics during reactive hyperemia in the leg with the lower ankle-brachial index. One hundred and forty-eight subjects with PAD were prospectively assigned to standard medical care or 3 mo of supervised exercise therapy. Before and after the intervention period, subjects performed a graded treadmill walking test, and MRI data were collected with Perfusion, Intravascular Venous Oxygen saturation, and T2* (PIVOT), a method that simultaneously quantifies microvascular perfusion, as well as relative oxygenation changes in skeletal muscle and venous oxygen saturation in a large draining vein. The 3-mo exercise intervention was associated with an improvement in peak walking time (64% greater in those randomized to the exercise group at follow-up, P < 0.001). Significant differences were not observed in the MRI measures between the subjects randomized to exercise therapy versus standard medical care based on an intention-to-treat analysis. However, the peak postischemia perfusion averaged across the leg between baseline and follow-up visits increased by 10% (P = 0.021) in participants that were adherent to the exercise protocol (completed >80% of prescribed exercise visits). In this cohort of adherent exercisers, there was no difference in the time to peak perfusion or oxygenation metrics, suggesting that there was no improvement in microvascular function nor changes in tissue metabolism in response to the 3-mo exercise intervention.NEW & NOTEWORTHY Supervised exercise interventions can improve symptomatology in patients with peripheral artery disease, but the underlying mechanism remains unclear. Here, MRI was used to evaluate perfusion, relative tissue oxygenation, and venous oxygen saturation in response to cuff-induced ischemia. Reactive hyperemia responses were measured before and after 3 mo of randomized supervised exercise therapy or standard medical care. Those participants who were adherent to the exercise regimen had a significant improvement in peak perfusion.
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Affiliation(s)
- Erin K Englund
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michael C Langham
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Molly J Fanning
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zeeshan Khan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State University, University Park, Pennsylvania
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, Virginia
| | - Thomas F Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Emile R Mohler
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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32
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Bearne LM, Delaney N, Nielsen M, Sheehan KJ. Inequity in exercise-based interventions for adults with intermittent claudication due to peripheral arterial disease: a systematic review. Disabil Rehabil 2022:1-10. [PMID: 35931094 DOI: 10.1080/09638288.2022.2102255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine the equity in access to trials of exercise interventions for adults with intermittent claudication due to peripheral arterial disease. METHODS Systematic electronic database searches of MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Clinical Trials, PEDRO, Opengrey, ISRCTN and ClinincalTrials.gov for randomised controlled trials of exercise interventions for adults with intermittent claudication were conducted. Data extraction was informed by Cochrane's PROGRESS-Plus framework. RESULTS Searches identified 6412 records. Following the screening of 262 full texts, 49 trials including 3695 participants were included. All trials excluded potential participants on at least one equity factor. This comprised place of residence, language, sex, personal characteristics (e.g., age and disability), features of relationships (e.g., familial risk factors) and time-dependent factors, (e.g., time since revascularisation). Overall, 1839 of 7567 potential participants (24.3%) were excluded based on equity factors. Disability was the most frequently reported factor for exclusions. CONCLUSION Trialists endeavour to enrol a representative sample in exercise trials whilst preserving the safety profile of the intervention. This review highlights that these efforts can inadvertently lead to inequities in access as all trials excluded potential participants on at least one equity factor. Future exercise trials should optimise participation to maximise generalisability of findings. PROSPERO registration no. CRD42020189965.Implications for rehabilitationEquity factors influence health opportunities and outcomes.All trials of exercise for people with intermittent claudication excluded adults on at least one equity factor.Disability was the predominant factor for exclusions from trials.Trials should optimise participation to maximise generalisability of results as these findings are used to inform treatment and service design.
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Affiliation(s)
- Lindsay Mary Bearne
- School of Life Course and Population Sciences, King's College London, London, United Kingdom.,Centre for Applied Health and Social Care Research, Kingston University and St George's, University of London, London, United Kingdom
| | - Nancy Delaney
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Mae Nielsen
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
| | - Katie Jane Sheehan
- School of Life Course and Population Sciences, King's College London, London, United Kingdom
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33
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Angraal S, Hejjaji V, Tang Y, Gosch KL, Patel MR, Heyligers J, White CJ, Tutein Nolthenius R, Mena-Hurtado C, Aronow HD, Moneta GL, Fitridge R, Soukas PA, Abbott JD, Secemsky EA, Spertus JA, Smolderen KG. One-Year Health Status Outcomes Following Early Invasive and Noninvasive Treatment in Symptomatic Peripheral Artery Disease. Circ Cardiovasc Interv 2022; 15:e011506. [PMID: 35579010 DOI: 10.1161/circinterventions.121.011506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Lifestyle changes and medications are recommended as the first line of treatment for claudication, with revascularization considered for treatment-resistant symptoms, based on patients' preferences. Real-world evidence comparing health status outcomes of early invasive with noninvasive management strategies is lacking. METHODS In the international multicenter prospective observational PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry, disease-specific health status was assessed by the Peripheral Artery Questionnaire in patients with new-onset or worsening claudication at presentation and 3, 6, and 12 months later. One-year health status trajectories were compared by early revascularization versus noninvasive management on a propensity-matched sample using hierarchical generalized linear models for repeated measures adjusted for baseline health status. RESULTS In a propensity-matched sample of 1000 patients (67.4±9.3 years, 62.8% male, and 82.4% White), 297 (29.7%) underwent early revascularization and 703 (70.3%) were managed noninvasively. Over 1 year of follow-up, patients who underwent early invasive management reported significantly higher health status than patients managed noninvasively (interaction term for time and treatment strategy; P<0.001 for all Peripheral Artery Questionnaire domains). The average 1-year change in Peripheral Artery Questionnaire summary scores was 30.8±25.2 in those undergoing early invasive, compared with 16.7±23.4 in those treated noninvasively (P<0.001). CONCLUSIONS Patients with claudication undergoing early invasive treatment had greater health status improvements over the course of 1 year than those treated noninvasively. These data can be used to support shared decision-making with patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01419080.
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Affiliation(s)
- Suveen Angraal
- Department of Internal Medicine, University of Missouri Kansas City School of Medicine (S.A.)
| | - Vittal Hejjaji
- Department of Cardiology, Saint Luke's Mid America Heart Institute (V.H., J.A.S.), University of Missouri-Kansas City
| | - Yuanyuan Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., K.L.G.)
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., K.L.G.)
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P.)
| | - Jan Heyligers
- Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands (J.H.)
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland, AU, and Ochsner Health, New Orleans, LA (C.J.W.)
| | - Rudolf Tutein Nolthenius
- Department of (vascular) Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands (R.T.N.)
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (C.M.-H., K.G.S.)
| | - Herbert D Aronow
- Division of Cardiology, Lifespan Cardiovascular Institute, Alpert Medical School of Brown University, Providence, RI (H.D.A.)
| | - Gregory L Moneta
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland (H.D.A., G.L.M.)
| | - Robert Fitridge
- Departments of Vascular Surgery, Royal Adelaide and The Queen Elizabeth Hospital, Australia (R.F.)
| | - Peter A Soukas
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (P.A.S., J.D.A.)
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (P.A.S., J.D.A.)
| | - Eric A Secemsky
- Division of Cardiology (E.A.S.), Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (E.A.S.), Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute (V.H., J.A.S.), University of Missouri-Kansas City
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (C.M.-H., K.G.S.)
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Geronemus A, Niekamp A, Russell E. Techniques for successful vessel crossing. Tech Vasc Interv Radiol 2022; 25:100838. [DOI: 10.1016/j.tvir.2022.100838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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35
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Hogan SE, Nehler MR, Anand S, Patel MR, Debus S, Jackson MT, Buchanan C, King RW, Hess C, Muehlhofer E, Haskell LP, Bauersachs RM, Berkowitz SD, Hsia J, Bonaca MP. Improvement in walking impairment following surgical and endovascular revascularization: Insights from VOYAGER PAD. Vasc Med 2022; 27:343-349. [PMID: 35467452 DOI: 10.1177/1358863x221085606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) affects 200 million people worldwide and is associated with impaired quality of life, increased morbidity, and mortality. Supervised exercise therapy (SET) and lower-extremity revascularization (LER) are both proven strategies to improve patient symptoms. Short and long-term functional outcomes after LER for symptomatic PAD in a large, international cohort have not previously been described. METHODS The VOYAGER PAD trial (ClinicalTrials.gov identifier: NCT02504216) enrolled subjects after LER for symptomatic PAD (Rutherford category 2-6). Participants completed the Walking Impairment Questionnaire (WIQ) at baseline, 1, 3 and 6 months, and every 6 months thereafter. The primary outcome analysis was degree of difficulty walking two blocks at each of the aforementioned time points. Difficulty walking three blocks and climbing one flight of stairs at these time points was also analyzed. Data about supervised and home exercise therapy before or after revascularization were not collected in the VOYAGER PAD trial. RESULTS Of the 5614 VOYAGER PAD participants completing the WIQ at baseline, three-quarters presented with claudication and one-quarter with critical limb ischemia. Of these, the majority (62% with claudication and 74% with CLI) reported inability or much difficulty walking two blocks prior to LER. Walking improved after LER regardless of revascularization strategy, but one-fifth with claudication and one-third with CLI reported continued inability or much difficulty walking two blocks 1 month after LER. Participants who reported improved walking ability 1 month after LER experienced a durable functional result out to 3 years. Although the proportion of participants reporting significant baseline difficulty climbing one flight of stairs or walking three blocks differed, the trend in immediate and sustained improvement after LER was similar to that observed for walking two blocks. CONCLUSION In this large, international cohort undergoing LER for symptomatic PAD, nearly two-thirds reported inability or much difficulty walking two blocks at baseline. Although many participants reported improved walking ability after LER, a substantial proportion remained severely disabled. These observations may help motivate providers, patients, and medical systems to improve awareness and engagement in SET referral after LER.
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Affiliation(s)
- Shea E Hogan
- CPC Clinical Research, Aurora, CO, USA.,Denver Health, Denver, CO, USA
| | - Mark R Nehler
- CPC Clinical Research, Aurora, CO, USA.,Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Sonia Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Sebastian Debus
- University Heart & Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Cullen Buchanan
- CPC Clinical Research, Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
| | - R Wilson King
- CPC Clinical Research, Aurora, CO, USA.,Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Connie Hess
- CPC Clinical Research, Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | | | - Rupert M Bauersachs
- Cardiovascular Center Bethanien, Frankfurt, Germany.,Department of Medicine, University of Mainz, Mainz, Germany
| | - Scott D Berkowitz
- CPC Clinical Research, Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
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36
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Süss JD, Gawenda M. Primärtherapie der Claudicatio intermittens – Anspruch und Wirklichkeit. Zentralbl Chir 2022; 147:453-459. [DOI: 10.1055/a-1798-0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie narrative Übersichtsarbeit fasst die Studienlage zum Thema Gehtraining bei Patienten mit Claudicatio intermittens (CI) zusammen. Eindringlich wird auf die evidenzbasierten
Leitlinienempfehlungen und die dahinterstehenden Studien eingegangen. Aspekte zum angiomorphologischen Befund, zu Patientenadhärenz, Langzeitwirkung, Studienqualität und ihre
Vergleichbarkeit werden diskutiert. Der Problematik in der Versorgungsrealität mit Abweichungen von den Leitlinien und der oftmals invasiven Erstlinientherapie des PAVK-IIb-Patienten werden
besondere Bedeutung geschenkt. Dabei wird die Rolle des Rehasports und die gesundheitspolititsche Bedeutung von Gehtraining in Deutschland erörtert. Gründe für die fehlende Leitlinientreue
und deren Umsetzung im Gesundheitssystem werden analysiert. Dementsprechend werden Handlungsempfehlungen, in Anlehnung an internationale Erfahrungen (Niederlande, Dänemark), zur Besserung
der Situation in Deutschland formuliert.
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Affiliation(s)
- Jan David Süss
- Gefäßchirurgie, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
| | - Michael Gawenda
- Gefäßchirurgie, St-Antonius-Hospital gGmbH, Eschweiler, Deutschland
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37
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Intensive exercise therapy for restenosis after superficial femoral artery stenting: the REASON randomized clinical trial. Heart Vessels 2022; 37:1596-1603. [PMID: 35396952 PMCID: PMC9349080 DOI: 10.1007/s00380-022-02060-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/18/2022] [Indexed: 11/20/2022]
Abstract
Endovascular treatment (EVT) is the main treatment for peripheral artery disease (PAD). Despite advances in device development, the restenosis rate remains high in patients with femoropopliteal lesions (FP). This study aimed to evaluate the effectiveness of exercise training in reducing the 1-year in-stent restenosis rate of bare metal nitinol stents for FPs. This prospective, randomized, open-label, multicenter study was conducted from January 2017 to March 2019. We randomized 44 patients who had claudication with de novo stenosis or occlusion of the FP into an intensive exercise group (n = 22) and non-intensive exercise group (n = 22). Non-intensive exercise was defined as walking for less than 30 min per session, fewer than three times a week. We assessed exercise tolerance using an activity meter at 1, 3, 6, and 12 months, and physiotherapists ensured maintenance of exercise quality every month. The primary endpoint was instant restenosis defined as a peak systolic velocity ratio > 2.5 on duplex ultrasound imaging. Kaplan–Meier analysis was used to evaluate the data. There were no significant differences in background characteristics between the groups. Six patients dropped out of the study within 1 year. In terms of the primary endpoint, intensive exercise significantly improved the patency rate of bare nitinol stents at 12 months. The 1-year freedom from in-stent restenosis rates were 81.3% in the intensive exercise group and 47.6% in the non-intensive exercise group (p = 0.043). No cases of stent fracture were observed in the intensive exercise group. Intensive exercise is safe and reduces in-stent restenosis in FP lesions after endovascular therapy for PAD. Clinical trial registration: University Hospital Medical Information Network Clinical Trials Registry (No. UMIN 000025259).
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Dittman JM, Amendola MF, Lavingia KS. Medical Optimization of the PAD Patient. Semin Vasc Surg 2022; 35:113-123. [DOI: 10.1053/j.semvascsurg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
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Elissa Altin S, Schneider MD, Parise H, Banerjee S, Wu WC, Meadows JL, Pfau S, Keefe H, Armstrong EJ. Implementation of supervised exercise therapy in a veteran population with symptomatic claudication. Vasc Med 2022; 27:136-141. [PMID: 35225695 DOI: 10.1177/1358863x211073622] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: Real-world implementation of supervised exercise therapy (SET) referral for symptomatic intermittent claudication has been limited by poor provider awareness around reimbursement and low patient adherence owing to factors including limited center availability and long travel distances to sites. Methods: In this study, 76 of 77 consecutive male veteran patients with intermittent claudication managed at a single-center vascular specialty clinic were referred to SET prior to revascularization. Pre- and post-SET submaximal exercise treadmill testing was performed for assessment of exercise capacity in metabolic equivalents (METs). Results: In the 48.7% of subjects who completed 36 sessions of SET ( n = 37), the average improvement in METs was 60.3%, reflecting improvement from baseline average of 3.4 METs to 5.5 METs after SET. Another 14 patients pursued self-guided exercise therapy and 25 patients declined any participation in exercise therapy. Reasons for declining participation in SET included inadequate transportation, cost of copayment, and interference with full-time work schedules. There was a nonsignificant numeric trend toward improved change in ankle–brachial index in the combined SET and self-guided exercise groups compared to those that declined exercise therapy (0.011 ± 0.124 vs –0.040 ± 0.105, p = 0.156). Conclusion: High acceptance of referral to SET is possible, despite the limitations to implementation. Incorporation of novel pre- and post-SET submaximal exercise treadmill testing allows for assessment of change in exercise capacity and aids in risk stratification and management of intermittent claudication symptoms.
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Affiliation(s)
- S Elissa Altin
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- West Haven VA Medical Center, West Haven, CT, USA
| | - Marabel D Schneider
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Helen Parise
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Subhash Banerjee
- Divison of Cardiology, University of Texas Southwestern Medical School, Dallas, TX, USA
- VA North Texas Health Care System, Dallas, TX, USA
| | - Wen-Chih Wu
- Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI, USA
- VA Providence Healthcare System, Providence, RI, USA
| | - Judith L Meadows
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- West Haven VA Medical Center, West Haven, CT, USA
| | - Steven Pfau
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- West Haven VA Medical Center, West Haven, CT, USA
| | - Heidi Keefe
- West Haven VA Medical Center, West Haven, CT, USA
| | - Ehrin J Armstrong
- Adventist Heart and Vascular Institute at Adventist Health, St Helena, CA, USA
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Bronas UG, Regensteiner JG. Connecting the past to the present: A historical review of exercise training for peripheral artery disease. Vasc Med 2022; 27:174-185. [DOI: 10.1177/1358863x211073620] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Peripheral artery disease (PAD), a prevalent manifestation of atherosclerosis, is associated with increased cardiovascular morbidity and mortality as well as decreased functional ability. Exercise training for PAD is acknowledged to be a highly effective treatment, which improves walking ability and cardiovascular risk. The historical development of this treatment has not been the focus of a report. Therefore, we present a historical review of research on exercise training for PAD. Overall, this body of knowledge has provided strong evidence of the efficacy of supervised exercise training (SET) to improve walking ability for patients with claudication due to PAD. SET, using intermittent bouts of walking exercise to moderate claudication pain on a treadmill, is considered the most efficacious mode of exercise to improve walking ability in patients with claudication. This compelling evidence published over the past 60 years was evaluated by the Centers for Medicare & Medicaid Services in 2017, which culminated in a national coverage determination for SET to improve symptomatic PAD. Future directions include determining optimal delivery strategies for SET and further elucidation of the mechanisms of improvement in walking ability resulting from SET. In addition, alternative forms of exercise should be evaluated and effective home- and community-based exercise interventions should be assessed. There is an enormous need to increase the inclusion of women and racial and ethnic minority groups in studies. It is to be hoped that researchers will continue with new innovative research and persistence in the treatment of claudication due to PAD.
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Affiliation(s)
- Ulf G Bronas
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois – Chicago, Chicago, IL, USA
| | - Judith G Regensteiner
- Ludeman Family Center for Women’s Health Research; Divisions of General Internal Medicine and Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Powell AC, Lugo CT, Dietrich CL, Lucas ER, Long JW, DeFrance A, Simmons JD. A Description of Outcomes Experienced by Patients Whose Orders for Peripheral Artery Revascularization Were Reviewed by a Nondenial Prior Authorization Program. Vasc Endovascular Surg 2022; 56:393-400. [DOI: 10.1177/15385744211055911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective After a nondenial prior authorization program evaluates orders for peripheral artery revascularization (PAR), ordering physicians sometimes withdraw their orders based upon program recommendations. Some patients with withdrawn orders receive PAR if claudication does not resolve. To characterize patient outcomes under this program, we evaluated whether associations existed between the withdrawal of patients’ initial PAR orders and the presence of claims for PAR and claims mentioning intermittent claudication (IC) in the following 16 weeks. Methods Orders for PAR placed from 1/1/19 to 9/30/19 for patients with Medicare Advantage health plans were extracted from a national healthcare organization’s database. Claims data from 0 to 16 weeks following the order were reviewed to determine if patients had downstream PAR claims, or if they had emergency department or hospital claims mentioning IC. Chi-square tests were used to assess the association between order withdrawal and downstream PAR, as well as claims mentioning IC. Multivariate logistic regressions were run to assess the same, controlling for patient age, sex, urbanicity, local median income, state obesity rate, type of PAR, ordering physician specialty, and whether PAR was ordered in a hospital setting. Results Of 1588 orders meeting inclusion criteria, 71.9% (1038/1444) of authorized orders and 61.1% (88/144) of withdrawn orders were followed by PAR within 16 weeks, a significant difference ( P < .01). Relatedly, 69.8% (1008/1444) of authorized orders and 70.8% (102/144) of withdrawn orders were followed by IC claims, an insignificant difference. Multivariate logistic regressions showed patients with withdrawn PAR orders had significantly lower adjusted odds of PAR (OR: 0.63; 95% CI: 0.44–0.91), but an insignificant difference in their adjusted odds of IC (OR: 1.10; CI: 0.76–1.64). Conclusions Although patients with withdrawn PAR orders were significantly less likely to receive PAR in the subsequent 16 weeks, no association was found between withdrawn PAR orders and subsequent claims mentioning IC.
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van Reijen NS, van Dieren S, Frans FA, Reekers JA, Metz R, Buscher HCJL, Koelemay MJW. Cost Effectiveness of Endovascular Revascularisation vs. Exercise Therapy for Intermittent Claudication Due to Iliac Artery Obstruction. Eur J Vasc Endovasc Surg 2022; 63:430-437. [PMID: 35148946 DOI: 10.1016/j.ejvs.2021.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/13/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare cost effectiveness of endovascular revascularisation (ER) and supervised exercise therapy (SET) as primary treatment for patients with intermittent claudication (IC) due to iliac artery obstruction. METHODS Cost utility analysis from a restricted societal perspective and time horizon of 12 months. Patients were included in a multicentre randomised controlled trial (SUPER study, NCT01385774, NTR2648) which compared effectiveness of ER and SET. Health status and health related quality of life (HRQOL) were measured using the Euroqol 5 dimensions 3 levels (EQ5D-3L) and VascuQol-25-NL. Incremental costs were determined per allocated treatment and use of healthcare during follow up. Effectiveness of treatment was determined in quality adjusted life years (QALYs). The difference between treatment groups was calculated by an incremental cost utility ratio (ICER). RESULTS Some 240 patients were included, and complete follow up was available for 206 patients (ER 111 , SET 95). The mean costs for patients allocated to ER were €4 031 and €2 179 for SET, a mean difference of €1 852 (95% bias corrected and accelerated [bca] bootstrap confidence interval 1 185 - 2 646). The difference in QALYs during follow up was 0.09 (95% bcaCI 0.04 - 0.13) in favour of ER. The ICER per QALY was €20 805 (95% bcaCI 11 053 - 45 561). The difference in VascuQol sumscore was 0.64 (95% bcaCI 0.39 - 0.91), again in favour of ER. CONCLUSION ER as a primary treatment, results in slightly better health outcome and higher QALYs and HRQOL during 12 months of follow up. Although these differences are statistically significant, clinical relevance must be discussed due to the small differences and relatively high cost of ER as primary treatment.
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Affiliation(s)
- Nick S van Reijen
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Franceline A Frans
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jim A Reekers
- Department of Radiology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Roderik Metz
- Department of Vascular Surgery, Spaarne Gasthuis, Haarlem, the Netherlands
| | | | - Mark J W Koelemay
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Ibeggazene S, Pymer S, Birkett ST, Caldow E, Harwood AE. A systematic review of exercise intervention reporting quality and dose in studies of intermittent claudication. Vascular 2022; 31:477-488. [PMID: 35130092 DOI: 10.1177/17085381211070700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Exercise therapy is an important treatment option for people with intermittent claudication (IC). Appropriate reporting of exercise interventions in populations with IC within randomised controlled trials (RCTs) is important to ensure that research can be translated into clinical practice. Therefore, the purpose of our review is to evaluate the reporting of exercise interventions in RCTs of exercise therapy in patients with IC. METHODS A systematic search was performed to identify relevant trials in patients with IC published until May 2020. Studies including only participants with critical limb ischaemia or asymptomatic peripheral artery disease were excluded. Each trial was scored using the recently developed 'Consensus on Exercise Reporting Template' (CERT) which has a maximum obtainable score of 19. RESULTS Of 1489 unique records identified from the search, 73 trials were included, reporting 107 exercise interventions. Overall, the average CERT score was 10/19. The exercise equipment used, the use of supervision and a description of whether the exercise prescription was tailored or generic were the most frequently reported intervention components. The motivational strategies used, intervention adherence and intervention fidelity were the most underreported CERT components. There was no trend indicating that CERT scores were higher in more recent publications. CONCLUSIONS We have identified that important details about exercise interventions are frequently missing from the published literature. These missing data hinder replication of research findings and limit the translation of evidence into clinical practice.
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Affiliation(s)
- Saïd Ibeggazene
- College of Health, Wellbeing and Life Sciences, 7314Sheffield Hallam University, Sheffield, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, 12195Hull York Medical School, Hull, UK
| | - Stefan T Birkett
- School of Sport and Health Sciences, 6723University of Central Lancashire, Preston, UK
| | - Edward Caldow
- School of Health and Society, 7046University of Salford, Salford, UK
| | - Amy E Harwood
- Centre for Sports, Exercise and Life Sciences, 120958Coventry University, Coventry, UK
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Randomised Clinical Trial of Supervised Exercise Therapy vs. Endovascular Revascularisation for Intermittent Claudication Caused by Iliac Artery Obstruction: The SUPER study. Eur J Vasc Endovasc Surg 2022; 63:421-429. [DOI: 10.1016/j.ejvs.2021.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/20/2022]
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Building your Peripheral Artery Disease Tool Kit: Medical Management of PAD in 2022. Can J Cardiol 2022; 38:634-644. [DOI: 10.1016/j.cjca.2022.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 12/24/2022] Open
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Gray WA, Griffiths RI, Elroy PWM, Amorosi SL, McGovern AM, Jaff MR, Akehurst R, Müller-Hülsbeck S. Cost-effectiveness of a paclitaxel-eluting stent (Eluvia) compared to Zilver PTX for endovascular femoropopliteal intervention. J Med Econ 2022; 25:880-887. [PMID: 35703041 DOI: 10.1080/13696998.2022.2088965] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Antiproliferative therapies based on paclitaxel have been developed to extend the durability of endovascular interventions for lower-extremity atherosclerotic peripheral artery disease, resulting in improved primary vessel patency and fewer target lesion revascularizations. This study evaluated the cost-effectiveness of the sustained-release, paclitaxel-eluting Eluvia stent (Boston Scientific, Marlborough, MA) versus the paclitaxel-coated Zilver PTX stent (Cook Medical, Bloomington, IN) for endovascular intervention in the superficial femoral or proximal popliteal artery. DESIGN A microsimulation model was constructed from a United States Medicare perspective with a 24-month time horizon. Patients entering the model were assigned to initial endovascular intervention with either Eluvia or Zilver PTX. Each month patients were exposed to the risks of primary vessel patency loss, target lesion revascularization, amputation, and death. Clinical input parameters were taken from a randomized trial (IMPERIAL) comparing the two interventions at 24-months follow-up. Cost parameters were obtained from analyses of Medicare administrative and claims data. Cost-effectiveness analysis entailed sampling a complete set of clinical and cost parameters from their respective distributions, and then running cohorts of 10,000 patients through each intervention arm of the model. One-way and probabilistic sensitivity analyses were performed. RESULTS In the base case microsimulation, at 24 months, the modeled target lesion revascularization was 11.6% for Eluvia and 19.0% for Zilver PTX, and the mean total direct costs were $20,010 and $21,356, respectively (Eluvia average savings=$1,346). In probabilistic sensitivity analyses, Eluvia was cost-effective in 87.8% of all simulations at a willingness-to-pay threshold of $10,000 per target lesion revascularization prevented. Eluvia was more effective and less costly (dominant) than Zilver PTX in 73.6% of simulations. CONCLUSIONS In this comparison of a paclitaxel-eluting to a paclitaxel-coated stent for endovascular femoropopliteal intervention, Eluvia was more effective and less costly (dominant) than Zilver PTX from a US Medicare perspective. These findings should be considered when formulating reimbursement policy and clinical practice guidelines.
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Affiliation(s)
- William A Gray
- Division of Cardiovascular Diseases, Lankenau Heart Institute, Philadelphia, PA, USA
| | | | | | | | | | | | - Ron Akehurst
- BresMed Health Solutions, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Jansen SCP, Hoeks SE, Nyklíček I, Scheltinga MRM, Teijink JAW, Rouwet EV. Supervised Exercise Therapy is Effective for Patients With Intermittent Claudication Regardless of Psychological Constructs. Eur J Vasc Endovasc Surg 2021; 63:438-445. [PMID: 34887208 DOI: 10.1016/j.ejvs.2021.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE According to current guidelines, supervised exercise therapy (SET) is the treatment of choice for intermittent claudication (IC). Little is known about the potential consequences of psychological factors on the effectiveness of treatment. The aim of this study was to determine possible associations between a set of psychological constructs and treatment outcomes, and to investigate whether self efficacy increased after SET. METHODS This was a substudy of the ELECT Registry, a multicentre Dutch prospective cohort study in patients with IC receiving primary SET. A complete set of validated questionnaires scoring extraversion, neuroticism, conscientiousness, anxiety, depression, self control, optimism, and self efficacy was obtained in 237 patients (median age 69 years, 40% female). Anxiety and depression were dichotomised using established cutoff scores, whereas other scores were analysed as continuous measures. Multiple linear regression analyses determined possible associations between these independent variables and maximum and functional walking distances (MWD and FWD, respectively), Six Minute Walk Test (6MWT), and VascuQol-6 (dependent variables). Self efficacy during 12 months of SET was analysed using a linear mixed model. RESULTS Neuroticism and anxiety were associated with lower overall VascuQol-6 scores (estimate -1.35 points [standard error (SE) 0.57; p = .018] and -1.98 points [SE 0.87, p = .023], respectively). Optimism and self efficacy demonstrated higher overall 6MWT (5.92 m [SE 2.34; p = .012] and 1.35 m [SE 0.42; p = .001], respectively). Self control was associated with lower overall log MWD (-0.02 [SE 0.01; p = .038] and log FWD (-0.02 [SE 0.01; p = .080), whereas self efficacy had a higher overall log MWD (0.01 [SE 0.003; p = .009]) and log FWD (0.01 [SE 0.003; p = .011]). Depressive patients with IC demonstrated a greater improvement in 6MWT during follow up (17.56 m [SE 8.67; p = .044]), but this small effect was not confirmed in sensitivity analysis. Self efficacy did not increase during follow up (0.12% [SE 0.49; p = .080]). CONCLUSIONS The beneficial effects of SET occur regardless of the psychological constructs, supporting current guidelines recommending a SET first strategy in each patient with IC.
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Affiliation(s)
- Sandra C P Jansen
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; CAPHRI Research School, Maastricht University, the Netherlands
| | - Sanne E Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Ivan Nyklíček
- Centre of Research on Psychological and Somatic disorders (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands
| | - Marc R M Scheltinga
- Department of Vascular Surgery, Maxima Medical Centre, Veldhoven, the Netherlands
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; CAPHRI Research School, Maastricht University, the Netherlands.
| | - Ellen V Rouwet
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Yasu T. Comprehensive cardiac rehabilitation program for peripheral arterial diseases. J Cardiol 2021; 80:303-305. [PMID: 34857431 DOI: 10.1016/j.jjcc.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
Peripheral arterial disease (PAD) is a phenotype of atherosclerotic disease often associated with cerebrovascular or coronary artery disease. The incidence of cardiovascular events in patients with PAD is 5.4% per year, which is higher than that of cerebrovascular or coronary artery disease. The most useful screening method for PAD is the ankle brachial pressure index (ABI). The ABI should be measured in (1) all patients with lower limb symptoms such as claudication, (2) all patients aged 65 years and over, and (3) those aged 50 to 65 years who have risk factors such as smoking and diabetes mellitus. PAD is diagnosed if the ABI is <0.9. A comprehensive cardiac rehabilitation program includes complete smoking cessation, blood pressure control with antihypertensive medications and salt reduction for hypertension, glycemic control for diabetes mellitus, and appropriate medications such as antiplatelet agents and statins. A multidisciplinary team approach is effective in comprehensive cardiac rehabilitation for patients with PAD, even those with critical limb ischemia (CLI). Exercise therapy is a crucial and essential treatment for PAD, except in CLI. Exercise therapy is contraindicated in patients with acute arterial occlusion and CLI with infection. PAD is often associated with other atherosclerotic diseases; the patient should be monitored for ischemic heart disease during the initial exercise stress test using the Gardner treadmill protocol. Supervised exercise therapy is highly recommended (Class I, Level of Evidence A). Alternatively, a home-based exercise program is feasible (Class IIa, Level of Evidence A). The exercise type (treadmill, track walking, ergometer), frequency (3 to 5 days per week), intensity (speed and incline), and duration (30 minutes) are determined based on the exercise stress test results for each patient. Exercise should be continued at least 3 times a week for at least 12 weeks. Cilostazol is highly recommended (Class I, Level of Evidence A).
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Affiliation(s)
- Takanori Yasu
- Department of Cardiovascular Medicine & Nephrology, Dokkyo Medical University.
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Scierka LE, Jelani QUA, Smolderen KG, Gosch K, Spertus JA, Mena-Hurtado C, Jones P, Dreyer RP. Patient representativeness of a peripheral artery disease cohort in a randomized control trial versus a real-world cohort: The CLEVER trial versus the PORTRAIT registry. Contemp Clin Trials 2021; 112:106624. [PMID: 34793986 DOI: 10.1016/j.cct.2021.106624] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/23/2021] [Accepted: 11/11/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is a burdensome disease. It is unclear whether PAD cohorts enrolled in contemporary randomized control trials (RCT) are representative of the real-world PAD populations in terms of their patient characteristics. METHODS We compared baseline patient characteristics and health status (as measured by the Peripheral Artery Questionnaire [PAQ]) between the randomized CLEVER study, and the real-world PORTRAIT registry. CLEVER was an RCT of PAD patients enrolled from 29 centers across the US and Canada comparing revascularization with stenting versus optimal medical therapy (OMT) and supervised exercise therapy (SET) plus OMT. PORTRAIT was a multicenter, prospective study of patients with new or worsening PAD symptoms across ten sites in the US. RESULTS The final cohort consisted of 879 patients (n = 119 from CLEVER, n = 760 from PORTRAIT (24.5% black, 41.4% women). While CLEVER enrolled patients with aortoiliac disease, only 16.0% of the PORTRAIT cohort had isolated aortoiliac disease. Compared with CLEVER, patients from PORTRAIT were older (64.0 ± 9.5 versus 68.9 ± 9.5 yrs., p ≤0.001), had more severe disease as measured by the ankle brachial index (0.7 ± 0.2 versus 0.9 ± 0.2, p ≤0.001) and a higher prevalence of cardiovascular risk factors including hyperlipidemia and diabetes (all p values<0.05). Both cohorts had similar disease-specific health status as measured by the PAQ summary score (47.4 ± 21.9 versus 43.6 ± 18.4, p = 0.07). CONCLUSION In this comparative study, real-world patients with PAD were older and sicker when compared to an RCT with similar indications. This gap may be bridged by improving enrollment of underrepresented high-risk patients in PAD trials testing strategies for PAD symptom relief. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01419080?term=portrait&rank=1NCT01419080.
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Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Qurat-Ul-Ain Jelani
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-, Kansas City, MO, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Philip Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Rachel P Dreyer
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT, USA.
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Byskosh N, Pamulapati V, Xu S, Vavra AK, Hoel AW, Tian L, McDermott MM, Butt Z, Ho KJ. Identifying Gaps in Disease Knowledge among Patients with Peripheral Artery Disease. J Vasc Surg 2021; 75:1358-1368.e5. [PMID: 34793926 DOI: 10.1016/j.jvs.2021.11.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION An individual's understanding of disease risk factors and outcomes is important for the ability to make healthy lifestyle choices and decisions about disease treatment. Peripheral artery disease (PAD) is a condition with increasing global prevalence and high risk of adverse patient outcomes. This study seeks to understand the adequacy of disease understanding in patients with PAD. METHODS This was an observational study of patients with PAD recruited from vascular surgery outpatient clinic and PAD clinical studies at a single academic medical center over an 8-month period. A 44-item paper survey assessed demographic and socioeconomic information, knowledge of personal medical history, PAD risk factors, consequences of PAD, and health education preferences. Patients with documented presence of PAD were offered the survey. Patients unable to complete the survey or provide informed consent were not considered eligible. Disease "awareness" was defined as correct acknowledgement of the presence or absence of a disease, including PAD, in the personal medical history. "PAD knowledge score" was the percentage of correct responses to questions on general PAD risk factors and consequences. Of 126 eligible patients, 109 participated. Bivariate analysis was used to study factors associated with awareness of PAD diagnosis. Factors associated with the PAD knowledge score were studied using the Pearson correlation coefficient, two-sample T-test, or one-way ANOVA. P value < .05 was considered statistically significant. RESULTS Mean participant age was 69.4 ± 11.0 years and 39.4% (N=43) were female. Most participants (78.9%; N=86) had critical limb-threatening ischemia. Only 65.4% (N=70) of participants were aware of a diagnosis of PAD, which was less than their awareness of related comorbidities. Factors positively associated with PAD diagnosis awareness were female sex (81.4% vs. 54.7%; P=.004) and history of percutaneous leg revascularization (78.6% vs. 47.9%; p=.001). Among 17 patients who had undergone major leg amputation, 35% (N=6) were unaware of a diagnosis of PAD. PAD knowledge scores correlated positively with an awareness of PAD diagnosis (59.1% vs. 48.7%; P=.02) and negatively with a history of hypertension (53.4% vs. 68.1%; P=.001). Most participants (86.5%; N=90) expressed a desire to be further educated on PAD. The most popular education topics were dietary recommendations, causes, and treatment for PAD. CONCLUSION Patients with PAD have deficits in their awareness of this diagnosis and general knowledge about PAD. Future research priorities should further define these deficits and their causes in order to inform new strategies that foster information-seeking behavior and effective educational programs for PAD.
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Affiliation(s)
- Nina Byskosh
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vivek Pamulapati
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shujun Xu
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ashley K Vavra
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew W Hoel
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lu Tian
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Mary M McDermott
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Zeeshan Butt
- Medical Social Sciences, Psychiatry and Behavioral Sciences and Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen J Ho
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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