Meeting AHA/ACC secondary prevention goals in a vascular surgery practice: An opportunity we cannot afford to miss

Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study

BACKGROUND

To characterize patients with internal carotid occlusion (ICO) with respect to demographic data, associated diseases, medical management, and risk factors and to compare these patients with those with nonsignificant stenosis (NSS; less than 50% stenosis). Secondary end points were new neurologic events, progression of contralateral degree of stenosis, cardiovascular symptoms, and death during follow-up.

METHODS

Retrospective analysis was performed using data collected from clinical records and added to a prospective database. Missing data were obtained during phone interviews or requested medical appointments.

RESULTS

From 2005 to 2013, 213 patients with ICO and 172 with NSS were studied (medium follow-up 37.81 months). Among the patients with ICO, a greater proportion were men, had a history of smoking, and presented with peripheral arterial disease and a lower creatinine clearance compared with those with NSS (P < 0.05). At the time of diagnosis, 76.1% of the patients with ICO were symptomatic compared with 35.5% of those with NSS (P = 0.000001). The patients in the ICO group exhibited significant progression of contralateral stenosis compared with those in the control group with progression on any side (15.0% vs. 2.3%, P = 0.00011). In addition, 18 patients in the ICO group (8.5%) exhibited new neurological symptoms compared with 13 (7.6%) in the NSS group (P = 0.41). When the ICO and NSS groups were combined, 10.8% of the initially symptomatic patients presented with new symptoms compared with 4.3% of those who were initially asymptomatic (P = 0.0218). The number of deaths was significantly higher among the patients in the ICO group (14.1% vs. 6.4%, P = 0.0150).

CONCLUSIONS

Patients presenting with ICO have more risk factors and higher mortality by any cause. Initially, symptomatic patients will likely present with more neurological symptoms during follow-up, independent of carotid morphology, ICO, or NSS. Efforts must be made to identify those at risk before occlusion and to prevent secondary events and death.

Preoperative depression symptom severity and its impact on adherence to preoperative beta-blocker therapy

OBJECTIVES

To test the association among depression symptoms, distressed personality type, and preoperative beta-blocker nonadherence and to estimate the prevalence of untreated major depression in this population.

DESIGN

Prospective observational study.

SETTING

A veterans hospital.

PARTICIPANTS

One hundred twenty patients on outpatient beta-blocker therapy presenting for surgery.

INTERVENTIONS

The Patient Health Questionnaire (PHQ)-9, the D-Scale-14 (DS14), and Modified Morisky Scale (MMS) questionnaires.

MEASUREMENTS AND MAIN RESULTS

Of 99 participants who presented for surgery, the incidence of preoperative nonadherence was 14.1% (95% confidence interval 7%-21%), consistent with prior research. Nonadherence was 9.5% among those with no depression, 27.8% among those with mild depression, and 28.6% among those with moderate-to-severe depression (Cochran-Armitage test for trend p = 0.03). Distressed personality type was found in 35% of the cohort (95% confidence interval 26-45%) and was not associated with beta-blocker nonadherence (Fisher's exact test, p = 0.24). Among participants with symptoms of major depressive disorder (n = 25, 25.3%), more than half (n = 14, 56%) had no indication of depression listed at their most recent primary care visit.

CONCLUSIONS

Patients with symptoms of depression on chronic beta-blocker therapy are susceptible to medication nonadherence on the day of surgery. Most surgical patients with symptoms of major depression lack a diagnosis of depression. Preoperative depression screening may thus (1) identify a population at increased risk of beta-blocker withdrawal, and (2) identify patients who may benefit from anesthesiologist-initiated referral for this treatable condition.

Obesity is a risk factor for significant carotid atherosclerosis in patients aged 39 to 55 years

We compared the prevalence of risk factors between young and old individuals with significant carotid atherosclerosis. We retrospectively reviewed the records of patients aged 39 to 55 years (group I) and aged ≥ 60 years (group II) with significant atherosclerotic stenosis at the carotid bifurcation. Group I patients had significantly higher values for the following factors: weight, height, body mass index, diastolic pressure, prevalence of current smoking, total and low-density lipoprotein cholesterol and significant lower values for systolic pressure, creatinine, and prevalence of coronary artery disease. Group I patients were more symptomatic and showed higher rates of carotid occlusion and near occlusion. Atherosclerosis of the carotid bifurcation was more aggressive in the younger group, with a higher rate of occlusion and near occlusion. Obesity and smoking were significant risk factors for young patients in this sample.

Suboptimal use of risk reduction therapy in peripheral arterial disease patients at a major teaching hospital

BACKGROUND AND OBJECTIVES

Current evidence suggests that modification of atherosclerosis risk factors plays an important role in reducing adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD). This study was undertaken to determine whether patients in this high-risk group were adequately using risk factor modification therapy.

DESIGN AND SETTING

Prospective study of consecutive patients with PAD from a teaching hospital.

PATIENTS AND METHODS

The collected data included information about atherosclerotic risk factors and utilization of risk factor modification therapy

RESULTS

The 391 patients had a mean (standard deviation of 3 (1) atherosclerotic risk factors. Hypertension was identified in 56.8% of patients (222/391), of whom only 37.4% (83/222) had adequate blood pressure control (BP <140/90 mm Hg). The prevalence of diabetes mellitus (DM) was 35 % (137/391). Among patients with DM, only 49% (67/137) had adequate blood glucose control (glycosylated hemoglobin, HbA1c <7%). Statins were currently prescribed in 61% of patients (238/391), 38.7% (92/238) of whom continued to have low-density lipoprotein (LDL) >2.5 mmol/L, compared to a rate of 76.5% (117/153) among non-statin users (P<.001). The majority of patients of patients ( 72.4%; 283/391) were overweight/obese. Many patients (67.3%; 263/391) were nonsmokers; however, most (73.4%; 193/263) had a history of smoking. Antiplatelets were prescribed for 78.3% of patients (306/391), of whom 70.6% (216/306) were taking aspirin. Angiotensin converting enzyme (ACE) inhibitors were prescribed for 44.8% of patients (175/391). Among rampril users, only 36.8% of patients (53/144) were on an optimal dose.

CONCLUSION

Although atherosclerotic risk factors were prevalent in patients with PAD, we found that patients received sub-optimal use of risk reduction treatments. Effective strategies to encourage health professionals to use these adjunctive therapies need to be developed.

Uninsured South Florida vascular surgery patients are less likely to receive optimal medical management than their insured counterparts

OBJECTIVE

Vascular disease is the most prevalent condition in patients aged >60 years, leading to increasing complications associated with their comorbid conditions. Poor medical compliance could be one reason why the rate of complications may be higher in this patient population, particularly the uninsured. This study was conducted to better assess rates of medication compliance in vascular surgical patients.

METHODS

Consecutive patients seen in vascular clinics at a busy tertiary academic center were prospectively studied. Physicians and physician assistants used a standardized questionnaire to collect patient data and evaluated patients for coexisting medical conditions and medication use. Optimal medical therapy was defined according to the 2006 American Heart Association (AHA)/American College of Cardiology (ACC) "Guidelines for Secondary Prevention for Atherosclerotic Vascular Disease." Data were analyzed using multivariate regression.

RESULTS

During the 4-month study period, 180 consecutive patients (47% men) were seen in vascular surgery clinics. Most patients (79%) were nonsmokers and only 21% admitted to smoking. Comorbid conditions surveyed included hypertension in 141, diabetes mellitus in 56, coronary artery disease in 24, hypercholesterolemia in 89, and chronic renal failure in 13; of these, 61% were insured and 39% had no insurance. Overall, only 31% of all patients were receiving adequate medical therapy for their comorbid conditions, and about 66% were receiving suboptimal medical treatment for their vascular disease. Uninsured patients were less likely (19%) than insured patients (39%) to receive optimal medical therapy (P = .012). Lack of insurance was a predictor of suboptimal medical therapy for hypertension (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.20-8.16; P = .016), hypercholesterolemia (OR, 5.1; 95% CI, 1.87-13.88; P = .001), peripheral arterial disease (OR, 13.32; 95% CI, 2.84-62.54, P < .001), and any disease overall (OR, 2.43; 95% CI, 1.21-4.88, P = .012). Overall, men and women were equally likely (68%) to receive suboptimal medical therapy; however, women were significantly more likely to be undertreated for coronary artery disease (OR, 0.022; 95% CI, 0.0017-0.293; P < .001).

CONCLUSIONS

Compliance with optimal medical therapy for secondary risk factor management amongst our vascular surgery patients is low. Uninsured patients are less likely to receive optimal medical therapy than their insured counterparts. This survey provides sobering statistics regarding medical compliance in our population. This issue deserves further study and may indirectly affect outcomes in minority groups that are disproportionately represented in our uninsured patients.

Morbidity and mortality caused by cardiac adverse events after revascularization for critical limb ischemia

BACKGROUND

We assessed cardiac adverse events (AEs) after primary lower extremity arterial revascularization (LEAR) for critical lower limb ischemia (CLI) in order to evaluate the impact of cardiac AEs on the clinical outcome. We created an optimized care protocol concerning CLI patients' preoperative work-up as well as intra- and postoperative surveillance according to recent important literature and guidelines.

METHODS

We conducted a prospective analysis of clinical outcome after LEAR using patient-related risk factors, comorbidity, surgical therapy, and AEs. This cohort was divided into patients with and without AEs. AEs were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. The consequences of AEs were reoperation, additional medication, irreversible physical damage, and early death.

RESULTS

There were 106 patients (Fontaine III n=49, 46%, and Fontaine IV n=57, 56%) who underwent primary revascularization by bypass graft procedure (n=67, 63%) or balloon angioplasty (n=39, 37%). No difference in comorbidity was registered between the two groups. Eighty-four AEs were registered in 34 patients (32%). Patients experiencing AEs had significantly less antiplatelet agents (without AEs n=63, 88%, vs. with AEs n=18, 53%; p=0.000) and/or beta-blockers (without AEs n=66, 92%, vs. with AEs n=16, 47%; p=0.000) compared to patients without AEs. The two most harmful consequences of AEs were irreversible physical damage (n=3) and early death (n=8). Sixty percent (n=9) of systemic AEs were heart-related. The postprocedural mortality rate was 7.5%, with a 75% (n=6) heart-related cause of death.

CONCLUSION

AEs occur in >30% of CLI patients after LEAR. The most harmful AEs on the clinical outcome of CLI patients were heart-related, causing increased morbidity and death. Significant correlations between prescription of beta-blockers and antiplatelet agents and prevention of AEs were observed. A persistent focus on the prevention of systemic AEs in order to ameliorate the outcome after LEAR for limb salvage remains of utmost importance. Therefore, we advise the implementation of an optimized care protocol by discussing patients in a strict manner according to a predetermined protocol, to optimize and standardize the preoperative work-up as well as intra- and postoperative patient surveillance.

Current literature for evidence-based infrainguinal endovascular treatment

With the proliferation of devices and techniques for lower extremity endovascular revascularization, treatment decisions become increasingly difficult as only limited experience with these new technologies is available for review. This monograph attempts to define the current state of the literature available to guide endovascular treatment of superficial artery disease, and to provide a baseline for future studies.

Pharmacologic Risk Factor Treatment of Peripheral Arterial Disease is Lacking and Requires Vascular Surgeon Participation

The pharmacologic treatment of the cardiovascular comorbidities in patients with peripheral arterial disease (PAD) can have a profound effect on the outcomes of these patients. Guidelines for the treatment of hypertension, hyperlipidemia, diabetes, and tobacco use have been published by the American Heart Association and American College of Cardiology (AHA/ACC). Patients with PAD are often under-treated for these conditions. We sought to evaluate the adherence to these established guidelines in all new patients presenting with PAD to a vascular surgery clinic and delineate the opportunity for vascular surgeon involvement in these treatments. Consecutive new patients with symptomatic, objectively proven PAD (ankle-brachial index < 0.9) were evaluated in a vascular surgery clinic by a staff vascular surgeon. PAD risk factors, pre-visit medications, and prior cardiovascular interventions were recorded. Patients were stratified whether they were receiving appropriate preventive pharmacotherapy and whether they were meeting AHA/ACC goals. In patients without prior cardiovascular history, screening for these conditions was performed. One hundred sixty-seven new patients were evaluated over a 1-year period. Objectively diagnosed PAD included intermittent claudication in 115 (69%) and critical limb ischemia in 52 (31%) patients. Average age was 67.8 years, and 73 patients (44%) were current smokers. At initial evaluation, only 115 (69%) patients reported antiplatelet use. Patients with a recorded diagnosis of hypertension met clinical guidelines in 39 instances (71%). Eighteen patients (20%) with diabetes mellitus had poor glycemic control (Hgb-A1C > 7.0%). Seventeen (19%) of 88 patients with a history of hyperlipidemia were not adequately treated. Vascular surgeon medical interventions resulted in 31% of patients being started on antiplatelet therapy, 29% of hypertension therapies were modified, 19% of established lipid therapy was modified, and lipid therapy was initiated in 20%. A new diagnosis of hypertension was made in 10 cases (6%) and hyperlipidemia in 13 cases (7%). Despite clear guidelines for the medical community regarding cardiovascular prevention, a large percentage of patients with symptomatic PAD presenting to the vascular surgery clinic are not receiving appropriate therapy for their comorbidities or are not meeting the established goals. Vascular surgeons have an important role in promoting vascular health through the systemic prevention of ischemic events.

The rationale for using HMG-CoA reductase inhibitors ('statins') in peripheral arterial disease

Atherosclerosis is a systemic process, and the leading cause of morbidity and mortality in the developed world. HMG-CoA reductase inhibitors ('statins') are potent lipid lowering drugs, which have been shown to reduce morbidity and mortality in patients with coronary atherosclerosis.

OBJECTIVE

To present the up-to-date data concerning statin use in the prevention and treatment of extra-coronary atherosclerosis.

METHODS

Clinical trials with statins in patients with extra-coronary atherosclerosis were searched for via PUBMED.

FINDINGS AND CONCLUSIONS

The different forms of peripheral arterial disease (e.g. cerberovascular disease, lower extremity peripheral arterial disease) are associated with significant cardiovascular morbidity and mortality, and hence constitute a coronary artery disease equivalent in terms of published practice guidelines. There is some evidence from small randomized controlled trials that statin therapy decreases cardiovascular morbidity and mortality in patients with peripheral arterial disease. The mechanism of action of statins may derive from their lipid lowering properties, or from other, pleiotropic effects. Further, larger randomized controlled studies with statins are needed to evaluate the efficacy of statin therapy in patients with stable peripheral arterial disease and in those undergoing vascular or endovascular surgery.