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Drexel H, Lewis BS, Rosano GMC, Saely CH, Tautermann G, Huber K, Dopheide JF, Kaski JC, Mader A, Niessner A, Savarese G, Schmidt TA, Semb A, Tamargo J, Wassmann S, Per Kjeldsen K, Agewall S, Pocock SJ. The age of randomized clinical trials: three important aspects of randomized clinical trials in cardiovascular pharmacotherapy with examples from lipid, diabetes, and antithrombotic trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:453-459. [PMID: 33135079 DOI: 10.1093/ehjcvp/pvaa126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/24/2020] [Accepted: 10/16/2020] [Indexed: 11/13/2022]
Abstract
This review article aims to explain the important issues that data safety monitoring boards (DSMB) face when considering early termination of a trial and is specifically addressed to the needs of clinical and research cardiologists. We give an insight into the overall background and then focus on the three principal reasons for stopping trials, i.e. efficacy, futility, and harm. The statistical essentials are also addressed to familiarize clinicians with the key principles. The topic is further highlighted by numerous examples from lipid trials and antithrombotic trials. This is followed by an overview of regulatory aspects, including an insight into industry-investigator interactions. To conclude, we summarize the key elements that are the basis for a decision to stop a randomized clinical trial (RCT).
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Affiliation(s)
- Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, Feldkirch 6800, Austria.,Private University of the Principality of Liechtenstein, Dorfstr. 24, Triesen 9495, Liechtenstein.,Drexel University College of Medicine, 2900 W Queen Lane, Philadelphia, PA 19129, USA
| | - Basil S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center, Michal Str. 7, 34362 Haifa, Israel.,Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Efron Str. 1, 31096 Haifa, Israel
| | - Giuseppe M C Rosano
- Department of Medical Sciences, IRCCS San Raffaele Hospital, Via delle Pisana 249, Rome 00163, Italy
| | - Christoph H Saely
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, Feldkirch 6800, Austria.,Private University of the Principality of Liechtenstein, Dorfstr. 24, Triesen 9495, Liechtenstein.,Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, Feldkirch 6800, Austria
| | - Gerda Tautermann
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, Feldkirch 6800, Austria.,Private University of the Principality of Liechtenstein, Dorfstr. 24, Triesen 9495, Liechtenstein.,Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, Feldkirch 6800, Austria
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Montleartstr. 37, Vienna 1160, Austria.,Medical School, Cardiology, Sigmund Freud University, Freudplatz 3, Vienna 1020, Austria
| | - Joern F Dopheide
- Division of Angiology, Swiss Cardiovascular Center, University Hospital Bern, Freiburgstr. 4, 3010 Bern, Switzerland
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Res. Inst, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Arthur Mader
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Carinagasse 47, Feldkirch 6800, Austria.,Private University of the Principality of Liechtenstein, Dorfstr. 24, Triesen 9495, Liechtenstein.,Department of Medicine I, Academic Teaching Hospital Feldkirch, Carinagasse 47, Feldkirch 6800, Austria
| | - Alexander Niessner
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska University Hospital D1:04, Stockholm 171 76, Sweden
| | - Thomas A Schmidt
- Department of Emergency Medicine, North Zealand University Hospital, Dyrehavevey, Hillerød 3400, Denmark
| | - AnneGrete Semb
- Department of Rheumatology, Preventive Cardio-Rheuma Clinic, Diakonhjemmet Hospital, Diakonveien 12, Oslo 0370, Norway
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Plaza de Ramón s/n, Madrid 28040, Spain
| | - Sven Wassmann
- Cardiology Pasing, Institutstr. 14, Munich 81241, Germany.,Medical Faculty, Clinical Medicine, University of the Saarland, Kirrbergerstr. 100, Homburg/Saar 66421, Germany
| | - Keld Per Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Amager-Hvidovre), Italiensvej 1, 2300 Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 7D2, 9220 Aalborg, Denmark
| | - Stefan Agewall
- Department of Cardiology, Ullevål, Oslo University Hospital, Kirkeveien 166, Oslo 0450, Norway.,Institute of Clinical Sciences, Søsterhjemmet, University of Oslo, Kirkeveien 166, Oslo 0450, Norway
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK
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Djerf H, Svensson M, Nordanstig J, Gottsäter A, Falkenberg M, Lindgren H. Editor's Choice - Cost Effectiveness of Primary Stenting in the Superficial Femoral Artery for Intermittent Claudication: Two Year Results of a Randomised Multicentre Trial. Eur J Vasc Endovasc Surg 2021; 62:576-582. [PMID: 34454817 DOI: 10.1016/j.ejvs.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/02/2021] [Accepted: 07/11/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Invasive treatment of intermittent claudication (IC) is commonly performed, despite limited evidence of its cost effectiveness. IC symptoms are mainly caused by atherosclerotic lesions in the superficial femoral artery (SFA), and endovascular treatment is performed frequently. The aim of this study was to investigate its cost effectiveness vs. non-invasive treatment. METHODS One hundred patients with IC due to lesions in the SFA were randomised to treatment with primary stenting, best medical treatment (BMT) and exercise advice (stent group), or to BMT and exercise advice alone (control group). Patients were recruited at seven hospitals in Sweden. For this analysis of cost effectiveness after 24 months, 84 patients with data on quality adjusted life years (QALY; based on the EuroQol Five Dimensions EQ-5D 3L™ questionnaire) were analysed. Patient registry and imputed cost data were used for accumulated costs regarding hospitalisation and outpatient visits. RESULTS The mean cost per patient was €11 060 in the stent group and €4 787 in the control group, resulting in a difference of €6 273 per patient between the groups. The difference in mean QALYs between the groups was 0.26, in favour of the stent group, which resulted in an incremental cost effectiveness ratio (ICER) of € 23 785 per QALY. CONCLUSION The costs associated with primary stenting in the SFA for the treatment of IC were higher than for exercise advice and BMT alone. With concurrent improvement in health related quality of life, primary stenting was a cost effective treatment option according to the Swedish national guidelines (ICER < €50 000 - €70 000) and approaching the UK's National Institute for Health and Care Excellence threshold for willingness to pay (ICER < £20 000 - £30 000). From a cost effectiveness standpoint, primary stenting of the SFA can, in many countries, be used as an adjunct to exercise training advice, but it must be considered that successful implementation of structured exercise programmes and longer follow up may alter these findings.
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Affiliation(s)
- Henrik Djerf
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mikael Svensson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department for Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Vascular Centre, Skåne University Hospital, Malmö, Sweden
| | - Mårten Falkenberg
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Lindgren
- Vascular Centre, Skåne University Hospital, Malmö, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
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Maudgil DD. Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology. Clin Radiol 2020; 76:185-192. [PMID: 33081990 PMCID: PMC7568486 DOI: 10.1016/j.crad.2020.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/16/2020] [Indexed: 12/12/2022]
Abstract
Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.
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Affiliation(s)
- D D Maudgil
- Radiology Department, Wexham Park Hospital, Frimley Health Foundation Trust, Wexham Street, Slough, Berks, SL2 4HL, UK.
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Levenberg K, Proctor DN, Maman SR, Luck JC, Miller AJ, Aziz F, Radtka JF, Muller MD. A prospective community engagement initiative to improve clinical research participation in patients with peripheral artery disease. SAGE Open Med 2020; 8:2050312120930915. [PMID: 32587692 PMCID: PMC7294489 DOI: 10.1177/2050312120930915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 05/11/2020] [Indexed: 01/04/2023] Open
Abstract
Objective: Patients diagnosed with peripheral artery disease are difficult to recruit into clinical trials. However, there is currently no high-quality, patient-centered information explaining why peripheral artery disease patients choose to participate or not participate in clinical research studies. Methods: The current study was a prospective community engagement initiative that specifically asked patients with and without peripheral artery disease: (1) what motivates them to participate in clinical research studies, (2) their willingness to participate in different research procedures, (3) the barriers to participation, (4) preferences about study design, and (5) demographic and disease-related factors influencing participation. Data were gathered through focus groups (n = 19, participants aged 55–79 years) and mailed questionnaires (n = 438, respondents aged 18–85 years). Results: More than half of the respondents stated that they would be willing to participate in a study during evening or weekend time slots. Peripheral artery disease patients (n = 45) were more willing than those without peripheral artery disease (n = 360) to participate in drug infusion studies (48% versus 18%, p < 0.001) and trials of investigational drugs (44% versus 21%, p < 0.001). Motivating factors and barriers to participation were largely consistent with previous studies. Conclusion: Adults in our geographic region are interested in participating in clinical research studies related to their health; they would like their doctor to tell them what studies they qualify for and they prefer to receive a one-page advertisement that has color pictures of the research procedures. Peripheral artery disease patients are more willing than those without peripheral artery disease to participate in drug infusion studies, trials of investigational drugs, microneurography, and spinal/epidural infusions.
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Affiliation(s)
- Kate Levenberg
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA.,Noll Laboratory, Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA
| | - David N Proctor
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA.,Noll Laboratory, Department of Kinesiology, The Pennsylvania State University, University Park, PA, USA
| | - Stephan R Maman
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA
| | - J Carter Luck
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA
| | - Amanda J Miller
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA
| | - Faisal Aziz
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA
| | - John F Radtka
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA
| | - Matthew D Muller
- Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA, USA.,Department of Anesthesiology and Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Master of Science in Anesthesia Program, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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5
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Abstract
PURPOSE OF REVIEW This paper provides a concise update on the management of peripheral artery disease (PAD). RECENT FINDINGS PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group. Structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs will improve. Finally, ensuring more patients with PAD receive aspirin therapy and statins may improve long-term survival, while further research will help determine if adding newer antiplatelet or anticoagulant medications may reduce leg amputations in selected patients. Clinicians should have a low threshold to obtain an angiogram and to pursue revascularization in patients with foot ulcers, gangrene, or foot infections. In patients with claudication, clinicians should maximize the benefits derived from exercise therapy and medical management before offering percutaneous or surgical revascularization.
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Affiliation(s)
- Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112),, Houston, TX, 77030, USA.
| | - Courtney L Grant
- Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112),, Houston, TX, 77030, USA
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Lindgren HIV, Qvarfordt P, Bergman S, Gottsäter A. Primary Stenting of the Superficial Femoral Artery in Patients with Intermittent Claudication Has Durable Effects on Health-Related Quality of Life at 24 Months: Results of a Randomized Controlled Trial. Cardiovasc Intervent Radiol 2018; 41:872-881. [PMID: 29520431 PMCID: PMC5937864 DOI: 10.1007/s00270-018-1925-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/28/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intermittent claudication (IC) is commonly caused by lesions in the superficial femoral artery (SFA), yet invasive treatment is still controversial and longer term patient-reported outcomes are lacking. This prospective randomized trial assessed the 24-month impact of primary stenting with nitinol self-expanding stents compared to best medical treatment (BMT) alone in patients with stable IC due to SFA disease on health-related quality of life (HRQoL). METHODS One hundred patients with stable IC due to SFA disease treated with BMT were randomized to either stent (n = 48) or control (n = 52) group. HRQoL assessed by Short Form 36 Health Survey (SF-36) and EuroQoL 5-dimensions (EQ5D) 24 months after treatment were primary outcome measures. Walking Impairment Questionnaire, ankle-brachial index (ABI), and walking distance were secondary outcomes. RESULTS Significantly better SF-36 Physical Component Summary (P = 0.024) and physical domain scores such as Physical Function (P = 0.012), Bodily Pain (P = 0.002), General Health (P = 0.037), and EQ5D (P = 0.010) were reported in intergroup comparison between the stent and the control group. Both ABI (from 0.58 ± 0.11 to 0.85 ± 0.18; P < 0.001 in the stent group and from 0.63 ± 0.17 to 0.69 ± 0.18; P = 0.036 in the control group) and walking distance (from 170 ± 90 m to 616 ± 375 m; P < 0.001 in the stent group and from 209 ± 111 m to 331 ± 304 m; P = 0.006 in the control group) improved significantly in intragroup comparisons. CONCLUSIONS In patients with IC caused by lesions in the SFA, primary stenting compared to BMT alone was associated with significant improvements in HRQoL, ABI, and walking distance durable up to 24 months of follow-up. Clinical Trial Registration http://www.clinicaltrials.gov . Unique Identifier: NCT01230229.
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Affiliation(s)
- Hans I V Lindgren
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Interventional Radiology and Surgery, Helsingborg Hospital, 251 87, Helsingborg, Sweden.
| | - Peter Qvarfordt
- Department of Interventional Radiology and Surgery, Helsingborg Hospital, 251 87, Helsingborg, Sweden
| | - Stefan Bergman
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Vascular Centre, Skåne University Hospital, 205 02, Malmö, Sweden
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7
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Fakhry F, Fokkenrood HJP, Spronk S, Teijink JAW, Rouwet EV, Hunink MGM. Endovascular revascularisation versus conservative management for intermittent claudication. Cochrane Database Syst Rev 2018; 2018:CD010512. [PMID: 29518253 PMCID: PMC6494207 DOI: 10.1002/14651858.cd010512.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intermittent claudication (IC) is the classic symptomatic form of peripheral arterial disease affecting an estimated 4.5% of the general population aged 40 years and older. Patients with IC experience limitations in their ambulatory function resulting in functional disability and impaired quality of life (QoL). Endovascular revascularisation has been proposed as an effective treatment for patients with IC and is increasingly performed. OBJECTIVES The main objective of this systematic review is to summarise the (added) effects of endovascular revascularisation on functional performance and QoL in the management of IC. SEARCH METHODS For this review the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). The CIS also searched trials registries for details of ongoing and unpublished studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing endovascular revascularisation (± conservative therapy consisting of supervised exercise or pharmacotherapy) versus no therapy (except advice to exercise) or versus conservative therapy (i.e. supervised exercise or pharmacotherapy) for IC. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data, and assessed the methodological quality of studies. Given large variation in the intensity of treadmill protocols to assess walking distances and use of different instruments to assess QoL, we used standardised mean difference (SMD) as treatment effect for continuous outcome measures to allow standardisation of results and calculated the pooled SMD as treatment effect size in meta-analyses. We interpreted pooled SMDs using rules of thumb (< 0.40 = small, 0.40 to 0.70 = moderate, > 0.70 = large effect) according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated the pooled treatment effect size for dichotomous outcome measures as odds ratio (OR). MAIN RESULTS We identified ten RCTs (1087 participants) assessing the value of endovascular revascularisation in the management of IC. These RCTs compared endovascular revascularisation versus no specific treatment for IC or conservative therapy or a combination therapy of endovascular revascularisation plus conservative therapy versus conservative therapy alone. In the included studies, conservative treatment consisted of supervised exercise or pharmacotherapy with cilostazol 100 mg twice daily. The quality of the evidence ranged from low to high and was downgraded mainly owing to substantial heterogeneity and small sample size.Comparing endovascular revascularisation versus no specific treatment for IC (except advice to exercise) showed a moderate effect on maximum walking distance (MWD) (SMD 0.70, 95% confidence interval (CI) 0.31 to 1.08; 3 studies; 125 participants; moderate-quality evidence) and a large effect on pain-free walking distance (PFWD) (SMD 1.29, 95% CI 0.90 to 1.68; 3 studies; 125 participants; moderate-quality evidence) in favour of endovascular revascularisation. Long-term follow-up in two studies (103 participants) showed no clear differences between groups for MWD (SMD 0.67, 95% CI -0.30 to 1.63; low-quality evidence) and PFWD (SMD 0.69, 95% CI -0.45 to 1.82; low-quality evidence). The number of secondary invasive interventions (OR 0.81, 95% CI 0.12 to 5.28; 2 studies; 118 participants; moderate-quality evidence) was also not different between groups. One study reported no differences in disease-specific QoL after two years.Data from five studies (n = 345) comparing endovascular revascularisation versus supervised exercise showed no clear differences between groups for MWD (SMD -0.42, 95% CI -0.87 to 0.04; moderate-quality evidence) and PFWD (SMD -0.05, 95% CI -0.38 to 0.29; moderate-quality evidence). Similarliy, long-term follow-up in three studies (184 participants) revealed no differences between groups for MWD (SMD -0.02, 95% CI -0.36 to 0.32; moderate-quality evidence) and PFWD (SMD 0.11, 95% CI -0.26 to 0.48; moderate-quality evidence). In addition, high-quality evidence showed no difference between groups in the number of secondary invasive interventions (OR 1.40, 95% CI 0.70 to 2.80; 4 studies; 395 participants) and in disease-specific QoL (SMD 0.18, 95% CI -0.04 to 0.41; 3 studies; 301 participants).Comparing endovascular revascularisation plus supervised exercise versus supervised exercise alone showed no clear differences between groups for MWD (SMD 0.26, 95% CI -0.13 to 0.64; 3 studies; 432 participants; moderate-quality evidence) and PFWD (SMD 0.33, 95% CI -0.26 to 0.93; 2 studies; 305 participants; moderate-quality evidence). Long-term follow-up in one study (106 participants) revealed a large effect on MWD (SMD 1.18, 95% CI 0.65 to 1.70; low-quality evidence) in favour of the combination therapy. Reports indicate that disease-specific QoL was comparable between groups (SMD 0.25, 95% CI -0.05 to 0.56; 2 studies; 330 participants; moderate-quality evidence) and that the number of secondary invasive interventions (OR 0.27, 95% CI 0.13 to 0.55; 3 studies; 457 participants; high-quality evidence) was lower following combination therapy.Two studies comparing endovascular revascularisation plus pharmacotherapy (cilostazol) versus pharmacotherapy alone provided data showing a small effect on MWD (SMD 0.38, 95% CI 0.08 to 0.68; 186 participants; high-quality evidence), a moderate effect on PFWD (SMD 0.63, 95% CI 0.33 to 0.94; 186 participants; high-quality evidence), and a moderate effect on disease-specific QoL (SMD 0.59, 95% CI 0.27 to 0.91; 170 participants; high-quality evidence) in favour of combination therapy. Long-term follow-up in one study (47 participants) revealed a moderate effect on MWD (SMD 0.72, 95% CI 0.09 to 1.36; P = 0.02) in favour of combination therapy and no clear differences in PFWD between groups (SMD 0.54, 95% CI -0.08 to 1.17; P = 0.09). The number of secondary invasive interventions was comparable between groups (OR 1.83, 95% CI 0.49 to 6.83; 199 participants; high-quality evidence). AUTHORS' CONCLUSIONS In the management of patients with IC, endovascular revascularisation does not provide significant benefits compared with supervised exercise alone in terms of improvement in functional performance or QoL. Although the number of studies is small and clinical heterogeneity underlines the need for more homogenous and larger studies, evidence suggests that a synergetic effect may occur when endovascular revascularisation is combined with a conservative therapy of supervised exercise or pharmacotherapy with cilostazol: the combination therapy seems to result in greater improvements in functional performance and in QoL scores than are seen with conservative therapy alone.
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Affiliation(s)
- Farzin Fakhry
- Erasmus MCDepartments of Epidemiology & RadiologyDr Molewaterplein 40PO Box 2040RotterdamNetherlands3015 GD
| | | | - Sandra Spronk
- Erasmus MCDepartments of Epidemiology & RadiologyDr Molewaterplein 40PO Box 2040RotterdamNetherlands3015 GD
- Dutch Health Care InspectorateDepartment of Research and InnovationUtrechtNetherlands
| | - Joep AW Teijink
- Catharina HospitalDepartment of Vascular Surgeryvisiting address: Michelangelolaan 2, 5623 EJ, Eindhovenpostal address: P.O. Box 1350EindhovenNetherlands5602 ZA
| | - Ellen V Rouwet
- Erasmus MCDepartment of Vascular SurgeryRotterdamNetherlands
| | - M G Myriam Hunink
- Erasmus MCDepartment of EpidemiologyPO Box 2040RotterdamNetherlands3000 CA
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed-effect model unless we identified significant heterogeneity, in which case we used a random-effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow-up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty-seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre-existing limitations to their exercise capacity.Meta-analysis from nine studies with 391 participants showed overall improvement in pain-free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high-quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high-quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years.Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate-quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate-quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low-quality evidence).Researchers measured quality of life using Short Form (SF)-36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta-analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate-quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate-quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF-36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains - 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' - did not show improvement at six months.Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants.Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes - over 300 participants for most outcomes - using reproducible methods. AUTHORS' CONCLUSIONS High-quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.
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Affiliation(s)
- Risha Lane
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Amy Harwood
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Lorna Watson
- NHS FifeCameron House, Cameron BridgeWindygatesLevenUKKY8 5RG
| | - Gillian C Leng
- National Institute for Health and Care Excellence10 Spring GardensLondonUKSW1A 2BU
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9
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Lindgren H, Qvarfordt P, Åkesson M, Bergman S, Gottsäter A, Jansson I, Litterfeldt E, Lindgren H, Qvarfordt P, Fransson T, Öjersjö A, Hilbertson A, Röjlar T, Åkesson M, Gottsäter A, Gruber G, Hörer T, Larzon T, Jonasson T, Strandberg C, Andersson P, Bergman S, Lundell L, Svensson A, Warvsten M. Primary Stenting of the Superficial Femoral Artery in Intermittent Claudication Improves Health Related Quality of Life, ABI and Walking Distance: 12 Month Results of a Controlled Randomised Multicentre Trial. Eur J Vasc Endovasc Surg 2017; 53:686-694. [DOI: 10.1016/j.ejvs.2017.01.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
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10
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Patterson RB. A modest proposal. J Vasc Surg 2017; 65:594-602. [PMID: 28236913 DOI: 10.1016/j.jvs.2016.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/07/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Robert B Patterson
- Department of Surgery, Division of Vascular Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.
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11
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McDermott MM. The importance and challenge of recruitment for peripheral artery disease randomized clinical trials. Vasc Med 2016; 21:352-4. [DOI: 10.1177/1358863x16651506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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12
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Popplewell M, Bradbury A. Why Do Health Systems Not Fund Supervised Exercise Programmes for Intermittent Claudication? Eur J Vasc Endovasc Surg 2014; 48:608-10. [DOI: 10.1016/j.ejvs.2014.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/21/2014] [Indexed: 11/29/2022]
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13
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)). This is an update of a review first published in 1998. OBJECTIVES The prime objective of this review was to determine whether an exercise programme in people with intermittent claudication was effective in alleviating symptoms and increasing walking treadmill distances and walking times. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events and improving quality of life. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2013) and CENTRAL (2013, Issue 8). SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy in people with IC due to peripheral arterial disease. Any exercise programme or regimen used in the treatment of intermittent claudication was included, such as walking, skipping and running. Inclusion of trials was not affected by the duration, frequency or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximal walking distance), ankle brachial index (ABI), quality of life, morbidity or amputation; if none of these were reported the trial was not included in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. MAIN RESULTS Eleven additional studies were included in this update making a total of 30 trials which met the inclusion criteria, involving a total of 1816 participants with stable leg pain. The follow-up period ranged from two weeks to two years. The types of exercise varied from strength training to polestriding and upper or lower limb exercises; generally supervised sessions were at least twice a week. Most trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was moderate, mainly due to an absence of relevant information. The majority of trials were small with 20 to 49 participants. Twenty trials compared exercise with usual care or placebo, the remainder of the trials compared exercise to medication (pentoxifylline, iloprost, antiplatelet agents and vitamin E) or pneumatic calf compression; people with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Overall, when taking the first time point reported in each of the studies, exercise significantly improved maximal walking time when compared with usual care or placebo: mean difference (MD) 4.51 minutes (95% confidence interval (CI) 3.11 to 5.92) with an overall improvement in walking ability of approximately 50% to 200%. Walking distances were also significantly improved: pain-free walking distance MD 82.29 metres (95% CI 71.86 to 92.72) and maximum walking distance MD 108.99 metres (95% CI 38.20 to 179.78). Improvements were seen for up to two years, and subgroup analyses were performed at three, six and 12 months where possible. Exercise did not improve the ABI (MD 0.05, 95% CI 0.00 to 0.09). The effect of exercise, when compared with placebo or usual care, was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data. No data were given on non-fatal cardiovascular events.Quality of life measured using the Short Form (SF)-36 was reported at three and six months. At three months, physical function, vitality and role physical all significantly improved with exercise, however this was a limited finding as this measure was only reported in two trials. At six months five trials reported outcomes of a significantly improved physical summary score and mental summary score secondary to exercise. Only two trials reported improvements in other domains, physical function and general health.Evidence was generally limited for exercise compared with antiplatelet therapy, pentoxifylline, iloprost, vitamin E and pneumatic foot and calf compression due to small numbers of trials and participants. AUTHORS' CONCLUSIONS Exercise programmes are of significant benefit compared with placebo or usual care in improving walking time and distance in people with leg pain from IC who were considered to be fit for exercise intervention.
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Affiliation(s)
- Risha Lane
- Vascular Unit, Hull Royal Infirmary, Anlaby Road, Hull, UK, HU3 2JZ
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14
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Guidon M, McGee H. Recruitment to clinical trials of exercise: challenges in the peripheral arterial disease population. Physiotherapy 2013; 99:305-10. [PMID: 23537882 DOI: 10.1016/j.physio.2012.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 12/22/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe recruitment to a randomised controlled trial of a 12-week (twice-weekly) supervised exercise programme for patients with peripheral arterial disease (PAD). PAD is a chronic, progressive disease with a significant cardiovascular and cerebrovascular risk burden, and exercise is an effective primary management approach. METHOD Potential patients were identified from the Non-Invasive Vascular Laboratory records and invited to participate in the study. On successful completion of an incremental treadmill exercise test, patients were allocated at random to a control (usual care) or an exercise group. RESULTS Between November 2006 and June 2009, 548 patients were identified. Of the 156 patients who met the inclusion criteria, 40 (26%) declined to participate. Of the 71 patients who underwent exercise testing, 23 (32%) did not complete the test. The final enrolment number was 44 (44/156; 28%). Eleven patients (11/28; 39%) subsequently withdrew from the exercise programme. CONCLUSION Recruitment to clinical trials of exercise presents significant challenges in the PAD population due to the presence of co-existing cardiovascular and cerebrovascular disease, a reluctance to exercise due to leg pain, and an acceptance of reduced mobility as part of ageing. Early identification in primary care before the onset of significant comorbidity may ameliorate some of these issues.
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Affiliation(s)
- M Guidon
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
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15
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16
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A meta-analysis of the outcome of endovascular and noninvasive therapies in the treatment of intermittent claudication. J Vasc Surg 2011; 54:1511-21. [DOI: 10.1016/j.jvs.2011.06.106] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/13/2011] [Accepted: 06/19/2011] [Indexed: 11/22/2022]
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17
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Saetre T, Enoksen E, Lyberg T, Stranden E, Jørgensen J, Sundhagen J, Hisdal J. Supervised Exercise Training Reduces Plasma Levels of the Endothelial Inflammatory Markers E-Selectin and ICAM-1 in Patients With Peripheral Arterial Disease. Angiology 2011; 62:301-5. [DOI: 10.1177/0003319710385338] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Elevated plasma levels of vascular inflammatory markers have been reported in patients with peripheral arterial disease (PAD). We assessed the effect of supervised exercise training (ET) on vascular inflammation, hypothesizing that ET reduces plasma levels of the endothelial adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1). Twenty-nine patients with PAD underwent a supervised ET program for 8 weeks. Before and after ET, walking distances (pain-free, PWD; maximal, MWD) were determined by a standard treadmill test. Plasma levels of E-selectin and ICAM-1 were significantly reduced (E-selectin: 45.5-40.4 ng/mL, P = .013); ICAM-1: 342.0-298.0 ng/mL, P = .016). VCAM-1 levels were unchanged. Walking distances increased significantly (PWD: median 77-150 m, P < .001; MWD: median 306-535 m, P < .001). In conclusion, 8 weeks of ET in patients with PAD reduces plasma levels of the specific endothelium-derived inflammatory markers E-selectin and ICAM-1.
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Affiliation(s)
- T. Saetre
- Oslo Vascular Centre, Oslo University Hospital, Aker, Oslo, Norway,
| | - E. Enoksen
- The Norwegian School of Sport Sciences, Oslo, Norway
| | - T. Lyberg
- Center for Clinical Research, Oslo University Hospital, Ulleval, Oslo, Norway
| | - E. Stranden
- Oslo Vascular Centre, Oslo University Hospital, Aker, Oslo, Norway, University of Oslo, Oslo, Norway
| | - J.J. Jørgensen
- Oslo Vascular Centre, Oslo University Hospital, Aker, Oslo, Norway, University of Oslo, Oslo, Norway
| | - J.O. Sundhagen
- Oslo Vascular Centre, Oslo University Hospital, Aker, Oslo, Norway
| | - J. Hisdal
- Oslo Vascular Centre, Oslo University Hospital, Aker, Oslo, Norway
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18
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McDermott MM, Domanchuk K, Dyer A, Ades P, Kibbe M, Criqui MH. Recruiting participants with peripheral arterial disease for clinical trials: experience from the Study to Improve Leg Circulation (SILC). J Vasc Surg 2009; 49:653-659.e4. [PMID: 19135834 DOI: 10.1016/j.jvs.2008.10.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 10/09/2008] [Accepted: 10/15/2008] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe the success of diverse recruitment methods in a randomized controlled clinical trial of exercise in persons with peripheral arterial disease (PAD). METHODS An analysis of recruitment sources conducted for the 746 men and women completing a baseline visit for the study to improve leg circulation (SILC), a randomized controlled trial of exercise for patients with PAD. For each recruitment source, we determined the number of randomized participants, the rate of randomization among those completing a baseline visit, and cost per randomized participant. RESULTS Of the 746 individuals who completed a baseline visit, 156 were eligible and randomized. The most frequent sources of randomized participants were newspaper advertising (n = 67), mailed recruitment letters to patients with PAD identified at the study medical center (n = 25), and radio advertising (n = 18). Costs per randomized participant were $2750 for television advertising, $2167 for Life Line Screening, $2369 for newspaper advertising, $3931 for mailed postcards to older community dwelling men and women, and $5691 for radio advertising. Among those completing a baseline visit, randomization rates ranged from 10% for those identified from radio advertising to 32% for those identified from the Chicago Veterans Administration and 33% for those identified from posted flyers. CONCLUSION Most participants in a randomized controlled trial of exercise were recruited from newspaper advertising and mailed recruitment letters to patients with known PAD. The highest randomization rates after a baseline visit occurred among participants identified from posted flyers and mailed recruitment letters to PAD patients.
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Affiliation(s)
- Mary M McDermott
- Northwestern University Feinberg School of Medicine, Chicago, Ill. 60611, USA.
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19
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)). OBJECTIVES To determine the effects of exercise programmes on IC, particularly in respect of reduction of symptoms on walking and improvement in quality of life. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last search February 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2008, Issue 1. SELECTION CRITERIA Randomised controlled trials of exercise regimens in people with IC due to peripheral arterial disease. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed trial quality. MAIN RESULTS Twenty-two trials met the inclusion criteria involving a total of 1200 participants with stable leg pain. Follow-up period was from two weeks to two years. There was some variation in the exercise regimens used, all recommended at least two sessions weekly of mostly supervised exercise. All trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was good, though the majority of trials were small with 20 to 49 participants. Fourteen trials compared exercise with usual care or placebo; patients with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Compared with usual care or placebo, exercise significantly improved maximal walking time: mean difference (MD) 5.12 minutes (95% confidence interval (CI) 4.51 to 5.72;) with an overall improvement in walking ability of approximately 50% to 200%; exercise did not affect the ankle brachial pressure index (ABPI) (MD -0.01, 95% CI -0.05 to 0.04). Walking distances were also significantly improved: pain-free walking distance MD 82.19 metres (95% CI 71.73 to 92.65) and maximum walking distance MD 113.20 metres (95% CI 94.96 to 131.43). Improvements were seen for up to two years. The effect of exercise compared with placebo or usual care was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data.Evidence was generally limited for exercise compared with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression due to small numbers of trials and participants. Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained. AUTHORS' CONCLUSIONS Exercise programmes were of significant benefit compared with placebo or usual care in improving walking time and distance in selected patients with leg pain from IC.
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Affiliation(s)
- Lorna Watson
- Cameron House, Cameron Bridge, Windygates, Leven, UK, KY8 5RG.
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Lower extremity angioplasty for claudication: A population-level analysis of 30-day outcomes. J Vasc Surg 2007; 45:762-7. [DOI: 10.1016/j.jvs.2006.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 12/01/2006] [Indexed: 11/21/2022]
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22
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Adam DJ, Bradbury AW. TASC II Document on the Management of Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2007; 33:1-2. [PMID: 17161778 DOI: 10.1016/j.ejvs.2006.11.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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