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Dodd JE, Hanna J, Brodmann M, Golledge J, Zeller T, Moscovic M, Dahm J, Troisi N, Tepe G, Wong J, Ward NC, Mwipatayi BP. Outcomes of drug-coated balloon angioplasty in patients with dyslipidemia in the BIOLUX P-III registry: A subgroup analysis. Vascular 2024:17085381241275795. [PMID: 39158589 DOI: 10.1177/17085381241275795] [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: 08/20/2024]
Abstract
OBJECTIVES The aim of this study was to assess the mid-term outcomes of the use of drug-coated balloons (DCBs) to treat infrainguinal peripheral arterial disease (PAD) in patients with dyslipidemia. METHODS BIOLUX P-III is a prospective, international, multicenter, all-comers registry-based study that was conducted at 44 sites with follow-ups at 6, 12 and 24 months. The present study is a subgroup analysis comparing the outcomes associated with endovascular revascularization with those associated with Passeo-18 lux DCBs in patients with and without dyslipidemia. The proportions of patients free from major adverse events (defined as device- or procedure-related mortality within 30 days, clinically driven target lesion revascularization (CD-TLR) and major target limb amputation), target vessel revascularization, and patient-reported outcomes within 24 months postintervention were compared between the two groups. RESULTS A total of 876 patients with symptomatic PAD who underwent peripheral revascularization with DCBs and had information on their dyslipidemia status were included; 588 of those patients had dyslipidemia. There was no difference in the proportion of patients free from MAEs between the groups. The percentages of patients who were 6, 12 and 24 months free from CD-TLR were significantly lower in the dyslipidemia group than in the nondyslipidemia group (86.3% vs 91.9% at 2 years, p = .0183). Similarly, the percentage of patients free from target vessel revascularization was lower in the dyslipidemia group at all timepoints (83.3% vs 89.3% at 2 years, p = .0203). There was no difference in mortality or major or minor limb amputation rates. Other secondary outcomes were similar between the groups. CONCLUSIONS Compared to those without dyslipidemia, patients with symptomatic PAD and dyslipidemia who underwent revascularization with a Passeo-18 lux DCB had greater rates of CD-TLR and TVR. However, having dyslipidemia did not increase the risk of mortality or limb amputation. CLINICAL TRIAL REGISTRATION NCT02276313.
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Affiliation(s)
- James Evan Dodd
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Joseph Hanna
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | | | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia
| | - Thomas Zeller
- Clinic Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg, Freiburg, Germany
| | - Matej Moscovic
- Department of Angiology, Institute of Cardiovascular Diseases, Kosice, Slovakia
| | - Johannes Dahm
- Department of Angiology and Cardiology, Herz- und Gefäßzentrum Neu-Bethlehem, Göttingen, Germany
| | - Nicola Troisi
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Gunnar Tepe
- Department of Diagnostic and Interventional Radiology, Klinikum Rosenheim, Rosenheim, Germany
| | - Jacqueline Wong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Natalie C Ward
- Dobney Hypertension Centre, Medical School, University of Western Australia, Perth, Australia
| | - Bibombe Patrice Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
- School of Surgery, University of Western Australia, Perth, Australia
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Seyferth ER, Song H, Vance AZ, Clark TWI. Association between statin intensity and femoropopliteal stent primary patency in peripheral arterial disease. CVIR Endovasc 2024; 7:60. [PMID: 39096322 PMCID: PMC11297851 DOI: 10.1186/s42155-024-00472-4] [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: 06/15/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Statins are widely used in coronary and peripheral arterial disease, but their impact on patency of stents placed for peripheral arterial disease is not well-studied. The purpose of this study was to evaluate femoropopliteal stent primary patency according to statin intensity at the time of stent placement and compare this effect to other covariates that may influence stent patency. MATERIALS AND METHODS A retrospective review identified 278 discrete femoropopliteal stent constructs placed in 216 patients over a 10-year period; Rutherford categories were 2 (3.6%), 3 (12.9%), 4 (21.2%), 5 (49.6%), and 6 (12.6%). Stent locations were common femoral (1.8%), common femoral/superficial femoral (0.7%), superficial femoral (50.7%), superficial femoral/popliteal (32.7%) and popliteal (14.0%) arteries; 63.3% of stents were paclitaxel-eluting. Primary patency of each stent construct was determined with duplex ultrasound, angiography, or computed tomographic angiography. Greater than 50% restenosis or stent occlusion was considered loss of patency. Cox proportional hazard and Kaplan-Meier modeling were used to assess the effect of statin use and additional covariates on stent patency. RESULTS Patients on any statin at the time of stent placement were half as likely to undergo loss of primary unassisted patency as patients on no statin therapy (hazard ratio, 0.53; 95% confidence interval, 0.19-0.87; P = .004). Moderate/high intensity statin therapy conferred 17 additional months of median stent patency compared to the no statin group. Antiplatelet therapy, anticoagulant therapy, drug-eluting stents (versus bare metal or covered stents), and Rutherford class were not predictive of stent patency (P = 0.52, 0.85, 0.58, and 0.82, respectively). CONCLUSION Use of statin therapy at the time of femoropopliteal stent placement was the most predictive examined variable influencing primary unassisted patency.
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Affiliation(s)
- Elisabeth R Seyferth
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Helen Song
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ansar Z Vance
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Timothy W I Clark
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, 19104, USA.
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Sato Y, Morishita T, Shimizu T, Kataoka T, Matsunaka Y, Uzui H, Tada H. Evaluation of nontarget lesions in femoropopliteal disease using near-infrared spectroscopy intravascular ultrasound imaging. Catheter Cardiovasc Interv 2024. [PMID: 39049486 DOI: 10.1002/ccd.31159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/28/2024] [Accepted: 07/13/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND In coronary artery disease (CAD), lipid-core-containing plaque (LCP) in nontarget lesions detected using near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) was related to increased major adverse cardiovascular events in patients with CAD. In the endovascular therapy field, few previous studies using NIRS-IVUS revealed the presence of LCPs in severe stenotic lesions of femoropopliteal disease. AIM This study aimed to assess the plaque morphology of nontarget lesions, especially LCPs, and compare it with that of target lesions using NIRS-IVUS in patients with femoropopliteal disease. METHODS This single-center prospective observational study included 14 patients who underwent endovascular therapy for FP disease. NIRS-IVUS assessment was performed on the entire FP arterial segment. Forty-one LCP lesions with a maximum lipid-core burden index in any 4-mm region (max LCBI4mm) > 100 were detected using NIRS-IVUS. We evaluated the patient and lesion characteristics. LCP lesions were divided into the target (n = 18) and nontarget (n = 23) lesion groups for comparison. RESULTS Patient characteristics were notable for advanced age (76.8 ± 6.6 years); high proportion of males (78.7%); and high incidence of hypertension (100%), dyslipidemia (78.6%), diabetes (64.3%). Regarding NIRS findings, the target lesion group exhibited a significantly smaller proportion of LCPs concerning the lesion length (25.9 ± 15.7% vs. 50.6 ± 29.2%, p = 0.002) than the nontarget lesion group. Conversely, there were no significant differences in the value of max LCBI4mm (284.4 ± 153.4 vs. 289.5 ± 113.1, p = 0.90), length of LCP lesion (9.8 ± 9.7 mm vs. 10.7 ± 6.9 mm, p = 0.74), and distribution of LCPs (p = 0.08) between the groups. In addition, the number of LCPs in the target FP artery positively correlated with max LCBI4mm in the target FP artery (r = 0.671, p = 0.008). CONCLUSIONS NIRS-IVUS findings demonstrated the presence of LCPs in nontarget lesions in patients with FP disease. Moreover, the abundance of LCPs in nontarget lesions was similar to that in target lesions in FP disease.
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Affiliation(s)
- Yusuke Sato
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | | | - Tomohiro Shimizu
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tatsuhiro Kataoka
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yuya Matsunaka
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiroyasu Uzui
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiroshi Tada
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Hess CN, Daffron A, Nehler MR, Morrison JT, Buchanan CE, Szarek M, Anderson VE, Cannon CP, Hsia J, Saseen JJ, Bonaca MP. Randomized Trial of a Vascular Care Team vs Education for Patients With Peripheral Artery Disease. J Am Coll Cardiol 2024; 83:2658-2670. [PMID: 38897676 DOI: 10.1016/j.jacc.2024.04.034] [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] [Received: 12/08/2023] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Underutilization of therapies to reduce ischemic risk in peripheral artery disease (PAD) persists. OBJECTIVES The purpose was to conduct an implementation trial of lipid management in vascular disease. METHODS The OPTIMIZE PAD-1 (Implementation of Vascular Care Team to Improve Medical Management of PAD Patients) trial randomized patients with peripheral artery disease with low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL to management via a vascular care team including a clinical pharmacist and an algorithm of intensive lipid management to achieve goal LDL-C in 1 step vs usual care plus provider education. Medications were obtained using commercial insurance. The primary endpoint was percent change in LDL-C at 12 months. RESULTS Of 166 enrolled patients, 74.2% did not have an LDL-C level at goal. Among 114 randomized patients (mean age 66 years, 36.0% women, and 15.8% Black), 50.9% received high-intensity statin, and 7.9% received ezetimibe at baseline. The mean 12-month LDL-C change was -49.1% (95% CI: -58.7% to -39.5%) with vascular care team management and -5.4% (95% CI: -15.3% to 4.6%) with usual care; the between-group least-squares mean difference was -43.7% (95% CI: -57.6% to -29.9%; P < 0.0001). Mean LDL-C was reduced in vascular care team patients from 100.6 mg/dL at baseline to 54.8 and 50.1 mg/dL by week 4 and month 12, respectively. At 12 months, vascular care team patients were >3 times as likely to achieve LDL-C <70 mg/dL and 8 times as likely to achieve LDL-C <55 mg/dL (P < 0.0001) than usual care. CONCLUSIONS OPTIMIZE PAD-1 showed that an interprofessional, algorithm-based program can achieve rapid LDL-C lowering in vascular patients using available insurance and therapies, and LDL-C targets can be met in most patients if enabled by optimized systems of care.
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Affiliation(s)
- Connie N Hess
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; CPC Clinical Research, Aurora, Colorado, USA.
| | - Ashley Daffron
- University of Colorado School of Pharmacy, Aurora, Colorado, USA
| | - Mark R Nehler
- CPC Clinical Research, Aurora, Colorado, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Michael Szarek
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; CPC Clinical Research, Aurora, Colorado, USA
| | | | - Christopher P Cannon
- CPC Clinical Research, Aurora, Colorado, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judith Hsia
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; CPC Clinical Research, Aurora, Colorado, USA
| | - Joseph J Saseen
- University of Colorado School of Pharmacy, Aurora, Colorado, USA
| | - Marc P Bonaca
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; CPC Clinical Research, Aurora, Colorado, USA.
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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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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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Srinivasan A, Miranda J, Mills JL. Appropriate care in chronic limb threatening ischemia: A review of current evidence and outcomes. Semin Vasc Surg 2024; 37:249-257. [PMID: 39152003 DOI: 10.1053/j.semvascsurg.2024.04.001] [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: 02/02/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 08/19/2024]
Abstract
Chronic limb threatening ischemia (CLTI) poses a significant treatment challenge for vascular surgeons, interventionalists, podiatrists, and associated medical specialists. The evidence for what constitutes appropriate care is rapidly evolving and new treatment options are in constant development. This review examines the current guidelines for CLTI care, as well as reported outcomes for multiple care strategies in this patient population, including revascularization and medical optimization. We performed a literature review of the PubMed database, reviewing articles that reported outcomes for CLTI care between 2000 and 2023, and described these outcomes as they relate to the current state of CLTI treatment. Significant data are still forthcoming regarding CLTI care, but widespread adoption of appropriate CLTI care is essential for the treatment of this vulnerable population.
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Affiliation(s)
- Arvind Srinivasan
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030.
| | - Jorge Miranda
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030
| | - Joseph L Mills
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030
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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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Campbell A, Alslaim H, Duson S, Rowe VL. Educating Trainees to Treat Peripheral Arterial Disease: Challenges and Opportunities. Ann Vasc Surg 2024:S0890-5096(24)00150-X. [PMID: 38582208 DOI: 10.1016/j.avsg.2023.12.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 04/08/2024]
Abstract
Educating trainees to treat Peripheral Artery Disease (PAD) carries specific contemporary challenges. The national increase of the prevalence of PAD combined with a significant shortage of vascular surgeons creates a need for concern for future management of this complex disease. Over the past 2 decades, traditional (5 + 2) and integrated (0 + 5) paradigms have fostered trainee annual growth and comparable case distribution and volumes in endovascular and open surgical treatment options have been maintained. Close evaluation into not only the absolute numbers of surgical cases, but the level of trainee involvement in each logged case is recommended. Future implementation of the Entrustable Professional Activity (EPA) modules will hopefully assist in ensuring linear development of surgical skill and judgment. Additionally, advances in individual and systems level techniques to enhance skill acquisition in the form of "off-the job training" and simulation-based training may provide an enhancement to traditional technical training methods. Finally, the possibility and role of artificial intelligence in vascular surgery skill training must not be ignored, but carefully explored and utilized to modernize cognitive and technical skill preparation for trainees in the and delivery of care for PAD patients. Overall, the training residents for the treatment of PAD patients will be associated with new challenges that vascular surgery must embrace and surmount to advance our specialty.
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Affiliation(s)
- Anthony Campbell
- Department of General Surgery, Medical College of Georgia, Augusta, GA
| | - Hossam Alslaim
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sira Duson
- University of Tennessee Health Science Center, Memphis, TN
| | - Vincent L Rowe
- Division of Vascular and Endovascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Smolderen KG, Romain G, Cleman J, Scierka L, Mena-Hurtado C. Variability in guideline-directed medical therapy across sites and operators and long-term mortality and amputation outcomes risk in patients undergoing peripheral vascular interventions. Am Heart J 2024; 270:75-85. [PMID: 38307364 DOI: 10.1016/j.ahj.2024.01.008] [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] [Received: 10/06/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation). METHODS We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects. RESULTS GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08). CONCLUSION Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.
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Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Department of Psychiatry, Psychology Section, Yale University School of Medicine, New Haven, CT.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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de Launay D, Paquet M, Kirkham AM, Graham ID, Fergusson DA, Nagpal SK, Shorr R, Grimshaw JM, Roberts DJ. Evidence for clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications among adults with peripheral artery disease: protocol for a systematic review and meta-analysis. BMJ Open 2024; 14:e076795. [PMID: 38514143 PMCID: PMC10961494 DOI: 10.1136/bmjopen-2023-076795] [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] [Received: 06/16/2023] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION International guidelines recommend that adults with peripheral artery disease (PAD) be prescribed antiplatelet, statin and antihypertensive medications. However, it is unclear how often people with PAD are underprescribed these drugs, which characteristics predict clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications, and whether underprescription and non-adherence are associated with adverse health and health system outcomes. METHODS AND ANALYSIS We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2006 onwards. Two investigators will independently review abstracts and full-text studies. We will include studies that enrolled adults and reported the incidence and/or prevalence of clinician underprescription of or patient non-adherence to guideline-recommended cardiovascular medications among people with PAD; adjusted risk factors for underprescription of/non-adherence to these medications; and adjusted associations between underprescription/non-adherence to these medications and outcomes. Outcomes will include mortality, major adverse cardiac and limb events (including revascularisation procedures and amputations), other reported morbidities, healthcare resource use and costs. Two investigators will independently extract data and evaluate study risk of bias. We will calculate summary estimates of the incidence and prevalence of clinician underprescription/patient non-adherence across studies. We will also conduct subgroup meta-analyses and meta-regression to determine if estimates vary by country, characteristics of the patients and treating clinicians, population-based versus non-population-based design, and study risks of bias. Finally, we will calculate pooled adjusted risk factors for underprescription/non-adherence and adjusted associations between underprescription/non-adherence and outcomes. We will use Grading of Recommendations, Assessment, Development and Evaluation to determine estimate certainty. ETHICS AND DISSEMINATION Ethics approval is not required as we are studying published data. This systematic review will synthesise existing evidence regarding clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications in adults with PAD. Results will be used to identify evidence-care gaps and inform where interventions may be required to improve clinician prescribing and patient adherence to prescribed medications. PROSPERO REGISTRATION NUMBER CRD42022362801.
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Affiliation(s)
- David de Launay
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Maude Paquet
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Aidan M Kirkham
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Clinical Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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12
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Krittanawong C, Escobar J, Virk HUH, Alam M, Virani S, Lavie CJ, Narayan KMV, Sharma R. Lifestyle Approach and Medical Therapy of Lower Extremity Peripheral Artery Disease. Am J Med 2024; 137:202-209. [PMID: 37980970 DOI: 10.1016/j.amjmed.2023.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
Lower extremity peripheral artery disease (PAD) is common among patients with several risk factors, such as elderly, smoking, hypertension, and diabetes mellitus. Notably, PAD is associated with a higher risk of cardiovascular complications. Non-invasive interventions are beneficial to improve morbidity and mortality among patients with PAD. Traditional risk factors like smoking, diabetes mellitus, hypertension, and dyslipidemia play a significant role in the development of PAD. Still, additional factors such as mental health, glycemic control, diet, exercise, obesity management, lipid-lowering therapy, and antiplatelet therapy have emerged as important considerations. Managing these factors can help improve outcomes and reduce complications in PAD patients. Antiplatelet therapy with aspirin or clopidogrel is recommended in PAD patients, with clopidogrel showing more significant benefits in symptomatic PAD individuals. Managing several risk factors is crucial for improving outcomes and reducing complications in patients with PAD. Further research is also needed to explore the potential benefits of novel therapies. Ultimately, a comprehensive approach to PAD management is essential for improving morbidity and mortality among patients with this condition.
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Affiliation(s)
| | - Johao Escobar
- Division of Cardiology, Harlem Cardiology, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Salim Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; The Aga Khan University, Karachi, Pakistan; Baylor College of Medicine, Houston, Texas
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, La
| | - K M Venkat Narayan
- Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University, Atlanta, Ga
| | - Raman Sharma
- Department of Medicine/Cardiology, 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
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13
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 124] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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14
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Kadoglou NPE, Stasinopoulou M, Velidakis N, Khattab E, Christodoulou E, Gkougkoudi E, Valsami G. The Complex Mechanisms and the Potential Effects of Statins on Vascular Calcification: A Narrative Review. Rev Cardiovasc Med 2024; 25:51. [PMID: 39077343 PMCID: PMC11263155 DOI: 10.31083/j.rcm2502051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 07/31/2024] Open
Abstract
Vascular calcification (VC) is a complex process of calcium deposition on the arterial wall and atherosclerotic plaques and involves interaction between vascular smooth muscle cells, inflammatory and VC mediators. The latter are independent predictors of cardiovascular morbidity and mortality and potential targets of pharmaceutical therapy. This paper is a narrative review of the complex mechanisms of VC development and in this context the potential anti-atherosclerotic effects of statins. At the initial stages of atherosclerosis VC correlates with atherosclerosis burden and in the long-term with cardiovascular morbidity and mortality. A plethora of animal and clinical studies have proposed statins as the cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease. Based on coronary computed tomography data, high doses of statins may have negligible or even positive effects on the progression of coronary artery calcification. Growing data support an increase in atherosclerotic plaque calcification in peripheral arteries (e.g., carotids), after long-term, statin-therapy. Despite the paradox of increasing VC, those effects of statins have been associated with higher plaque stability, reducing the risk of consequent adverse events. Statins seem to promote a "favorable" atherosclerotic calcification, suppressing atherosclerotic lesion expansion and their vulnerability. More studies are required to clarify the underlying mechanisms.
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Affiliation(s)
| | - Marianna Stasinopoulou
- Center of Clinical, Experimental Surgery, and Translational Research, Biomedical Research Foundation, Academy of Athens, 11527 Athens, Greece
| | | | - Elina Khattab
- Medical School, University of Cyprus, 2029 Nicosia, Cyprus
| | - Eirini Christodoulou
- Laboratory of Biopharmaceutics-Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | | | - Georgia Valsami
- Laboratory of Biopharmaceutics-Pharmacokinetics, Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
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15
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Wu YW, Wang CY, Cheng NC, Lin HJ, Huang HL, Huang JH, Chen CC, Lee JK, Chen PL, Hsu PC, Wu IH, Yeh JT, Tsai HY, Tzeng YS, Cheng CC, Lin CH, Wu SH, Tan JWH, Wu CH, Hsueh SK, Chang CH, Wu HP, Hsu CH, Yen HT, Lin PC, Lin CH, Tai HC, Chen WJ. 2024 TSOC/TSPS Joint Consensus: Strategies for Advanced Vascular Wound Management in Arterial and Venous Diseases. ACTA CARDIOLOGICA SINICA 2024; 40:1-44. [PMID: 38264067 PMCID: PMC10801419 DOI: 10.6515/acs.202401_40(1).20231220a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024]
Abstract
The Taiwan Society of Cardiology (TSOC) and Taiwan Society of Plastic Surgery (TSPS) have collaborated to develop a joint consensus for the management of patients with advanced vascular wounds. The taskforce comprises experts including preventive cardiologists, interventionists, and cardiovascular and plastic surgeons. The consensus focuses on addressing the challenges in diagnosing, treating, and managing complex wounds; incorporates the perfusion evaluation and the advanced vascular wound care team; and highlights the importance of cross-disciplinary teamwork. The aim of this joint consensus is to manage patients with advanced vascular wounds and encourage the adoption of these guidelines by healthcare professionals to improve patient care and outcomes. The guidelines encompass a range of topics, including the definition of advanced vascular wounds, increased awareness, team structure, epidemiology, clinical presentation, medical treatment, endovascular intervention, vascular surgery, infection control, advanced wound management, and evaluation of treatment results. It also outlines a detailed protocol for assessing patients with lower leg wounds, provides guidance on consultation and referral processes, and offers recommendations for various wound care devices, dressings, and products. The 2024 TSOC/TSPS consensus for the management of patients with advanced vascular wounds serves as a catalyst for international collaboration, promoting knowledge exchange and facilitating advancements in the field of advanced vascular wound management. By providing a comprehensive and evidence-based approach, this consensus aims to contribute to improved patient care and outcomes globally.
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Affiliation(s)
- Yen-Wen Wu
- Division of Cardiology, Cardiovascular Medical Center, and Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Graduate Institute of Medicine, Yuan Ze University
| | - Chao-Yung Wang
- Division of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
- Institute of Cellular and System Medicine, National Health Research Institute, Zhunan
| | - Nai-Chen Cheng
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine
| | - Hung-Ju Lin
- Division of Cardiology, Department of Internal Medicine
- Cardiovascular Center, National Taiwan University Hospital, Taipei
| | - Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien
| | - Jih-Hsin Huang
- Division of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City
| | - Chun-Chi Chen
- Division of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Jen-Kuang Lee
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine
- Division of Cardiology, Department of Internal Medicine
- Department of Internal Medicine
- Department of Laboratory Medicine, National Taiwan University College of Medicine
- Telehealth Center, National Taiwan University Hospital, Taipei
| | - Po-Lin Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Division of Cardiovascular Surgery, Department of Surgery, En Chu Kong Hospital, New Taipei City
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, Kaohsiung Medical University, Kaohsiung
| | - I-Hui Wu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
- Department of Trauma Surgery, National Taiwan University Hospital, Taipei
| | - Jiun-Ting Yeh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan
| | - Hao-Yuan Tsai
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City
| | - Yuan-Sheng Tzeng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Department of Surgery, Zuoying Armed Forces General Hospital, Kaohsiung
| | - Cheng-Chung Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Chia-Hsun Lin
- Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital
| | - Szu-Hsien Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Jimmy Wei Hwa Tan
- Department of Cardiovascular Surgery, An-Nan Hospital, China Medical University, Tainan
| | - Cheng-Hsueh Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei
| | - Shu-Kai Hsueh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Chien-Hwa Chang
- Division of Cardiovascular Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi County
| | - Hsu-Ping Wu
- Cardiovascular Center, MacKay Memorial Hospital, Taipei
| | - Chung-Ho Hsu
- Section of Peripheral Artery Disease, Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Po-Chang Lin
- Department of Internal Medicine, China Medical University Hospital, Taichung
| | - Chih-Hung Lin
- Department of Plastic Reconstructive Surgery, Chang Gung University of Science and Technology, Taoyuan
| | - Hao-Chih Tai
- Institute of Cellular and System Medicine, National Health Research Institute, Zhunan
| | - Wen-Jone Chen
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine
- Division of Cardiology, Department of Internal Medicine
- Department of Emergency Medicine, National Taiwan University College of Medicine and Hospital, Taipei
- Min-Sheng General Hospital, Taoyuan, Taiwan
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16
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Lee JH, Jeon HS, Lee JW, Youn YJ, Ahn SG, Kim H, Bae Y, Kim U, Ahn CM, Ko YG. Impact of guideline-directed medical therapy on 5-year mortality in patients with newly diagnosed peripheral artery disease. J Vasc Surg 2023; 78:1471-1478.e3. [PMID: 37597591 DOI: 10.1016/j.jvs.2023.08.103] [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: 03/14/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Current guidelines recommend that patients with peripheral artery disease (PAD) should be treated with antithrombotic agents, renin-angiotensin-system blockers, and statins. However, the clinical impact of guideline-directed medical therapy (GDMT) on long-term mortality in patients with newly diagnosed PAD remains unclear. We aimed to investigate the prevalence of GDMT and evaluate 5-year mortality according to GDMT after PAD diagnosis. METHODS This retrospective cohort study, using nationwide health insurance claims data in Korea, included patients newly diagnosed with PAD between 2006 and 2015. GDMT was defined as the use of all drugs, including antithrombotic agents, renin-angiotensin-system blockers, and statins, within 3 months of PAD diagnosis. The primary endpoint was all-cause mortality. RESULTS We investigated 19,561 newly diagnosed patients with PAD without proven cardiovascular disease. Among the study population, 4378 patients (22.4%) were categorized in the GDMT and 15,183 (77.6%) in the non-GDMT groups. During the 5-year follow-up, GDMT showed a lower incidence of all-cause mortality than that of non-GDMT (2.8% vs 4.8%; adjusted hazard ratio, 0.329; 95% confidence interval, 0.257-0.421; P < .001). Even in the propensity-matched population, GDMT showed a lower mortality rate than non-GDMT (hazard ratio, 0.283; 95% confidence interval, 0.217-0.370; P < .001). As the number of guideline-recommended drugs increased, the mortality rate decreased proportionately. CONCLUSIONS After PAD diagnosis, GDMT was associated with a lower incidence of mortality regardless of proven cardiovascular disease. This retrospective analysis showed an insufficient prevalence of GDMT among patients with PAD in real-world practice.
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Affiliation(s)
- Jung-Hee Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Ho Sung Jeon
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Young Jin Youn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Sung Gyun Ahn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Hoseob Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Yoonjong Bae
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Kentoffio K, Sun T, Xu J, Parikh RV, Hsue PY, Secemsky EA. Longitudinal outcomes following peripheral vascular intervention among older persons living with HIV. Vasc Med 2023; 28:564-570. [PMID: 37638877 DOI: 10.1177/1358863x231191822] [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] [Indexed: 08/29/2023]
Abstract
BACKGROUND Persons living with human immunodeficiency virus (HIV, PLWH) have an increased risk of peripheral artery disease (PAD) in comparison to the general population. However, a gap remains in understanding optimal management for this condition. This study assesses longitudinal outcomes associated with peripheral endovascular intervention (PVI) for PAD among PLWH. METHODS All Medicare fee-for-service patients undergoing femoropopliteal artery PVI between April 1, 2015 and December 31, 2018 were identified and stratified by HIV serostatus. The primary outcome was major adverse limb events (MALE), defined as major amputation or arterial embolism/thrombosis following an index procedure. The subdistribution hazard was used to evaluate the association between HIV serostatus and MALE, accounting for the competing risk of death. Results were adjusted for sociodemographics and major comorbidities. RESULTS Of 168,553 patients who underwent PVI, 357 (0.21%) were PLWH. The average age was 77.0 ± 7.6 years; 80.3% had hypertension, 70.3% had hyperlipidemia, and 24.6% had tobacco use disorder. Compared to those without HIV, PLWH were younger and had a higher burden of cardiovascular risk factors. MALE were substantially more frequent among PLWH, with a cumulative incidence of 24.6%, compared to 14.5% among those without HIV. The adjusted subdistribution hazard ratio was 1.26 (95% CI 1.00-1.58, p = 0.05). The use of guideline-directed statin therapy was low in both groups in the 90 days following revascularization (57.9% in PLWH vs 58.1% in those without HIV, p = 0.95). CONCLUSION Among US Medicare beneficiaries, PLWH had poorer long-term outcomes following PVI. Greater attention to the management of symptomatic PAD is warranted for the HIV population, particularly following revascularization.
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Affiliation(s)
- Katherine Kentoffio
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tianyu Sun
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jiaman Xu
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rushi V Parikh
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Priscilla Y Hsue
- Department of Medicine, Division of Cardiology, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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18
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Lu CR, Lu SY, Lin SY, Yip HT, Liu CH, Hsu KC, Chang SS. Protective Effects of Statins on Limb and Cardiovascular Outcomes in Patients with Peripheral Artery Disease and End-Stage Renal Disease. ACTA CARDIOLOGICA SINICA 2023; 39:755-764. [PMID: 37720404 PMCID: PMC10499954 DOI: 10.6515/acs.202309_39(5).20230118a] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/18/2023] [Indexed: 09/19/2023]
Abstract
Background Previous studies have reported that statins have inconsistent and marginal cardiovascular (CV) benefits in patients with end-stage renal disease (ESRD). However, whether statins play a secondary preventive role in patients with peripheral artery disease (PAD) and ESRD remains unclear. Objectives This study aimed to compare the long-term clinical outcomes between statin users and nonusers with PAD and ESRD. Methods This retrospective cohort study assessed the long-term protective effects of statins using data from the National Health Insurance Research Database in Taiwan. Propensity score matching was performed according to sex, age, index year, related comorbidities, and medications. The main outcomes were limb events and major adverse CV events (MACEs). Results The statin user group (n = 4,460) was compared with the propensity score-matched statin nonuser group (n = 4,460). The mean age of the matched patients was 64 years, and 40% of the patients were men. The baseline characteristics of the groups were well-balanced. The overall limb event and MACE rates were not different between the two groups. However, the statin user group had lower rates of limb amputation [adjusted hazard ratio (aHR): 0.85, 95% confidence interval (CI): 0.73-0.99], stroke (aHR: 0.71, 95% CI: 0.62-0.83), CV death (aHR: 0.46, 95% CI: 0.32-0.66), and all-cause death (aHR: 0.45, 95% CI: 0.42-0.48) despite having a higher rate of percutaneous transluminal angioplasty for PAD. Conclusions This population-based retrospective cohort study demonstrated that statin therapy was associated with a lower risk of limb amputation, nonfatal stroke, CV death, and all-cause death in patients with PAD and ESRD.
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Affiliation(s)
- Chiung-Ray Lu
- Division of Cardiovascular Medicine, China Medical University Hospital
| | - Shang-Yeh Lu
- Division of Cardiovascular Medicine, China Medical University Hospital
| | - Shi-Yi Lin
- School of Medicine, College of Medicine
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University
- Division of Nephrology and Kidney Institute
| | - Hei-Tung Yip
- Management Office for Health Data, China Medical University Hospital
- College of Medicine
| | - Chia-Hao Liu
- Division of Cardiovascular Medicine, China Medical University Hospital
| | - Kai-Cheng Hsu
- Artificial Intelligence Center for Medical Diagnosis, China Medical University
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Sheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital
- School of Medicine, College of Medicine
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Steiger K, Fuentes A, Erben Y. Medical Management of Cardiovascular Disease. Surg Clin North Am 2023; 103:565-575. [PMID: 37455025 DOI: 10.1016/j.suc.2023.04.019] [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: 07/18/2023]
Abstract
We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization.
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Affiliation(s)
- Kyle Steiger
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana Fuentes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Navar AM, Kolkailah AA, Gupta A, Gillard KK, Israel MK, Wang Y, Peterson ED. Gaps in Guideline-Based Lipid-Lowering Therapy for Secondary Prevention in the United States: A Retrospective Cohort Study of 322 153 Patients. Circ Cardiovasc Qual Outcomes 2023; 16:533-543. [PMID: 37529931 PMCID: PMC10527346 DOI: 10.1161/circoutcomes.122.009787] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 06/26/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Many patients with atherosclerotic cardiovascular disease (ASCVD) are not on guideline-recommended statin therapy. We evaluated utilization of statins and other lipid-lowering therapy (LLT), and changes in low-density lipoprotein cholesterol (LDL-C), among patients with ASCVD over a 1-year period. METHODS LLT and LDL-C levels at the first outpatient visit (January 1, 2017-December 31, 2018) and 1-year follow-up were evaluated using data from Cerner Real-World Data, an electronic health record-derived data set from 92 US health systems. Logistic regression was used to evaluate factors associated with high-intensity statin use. RESULTS We identified 322 153 patients with ASCVD (median age 69 years, 58.8% men, 81.8% White). Overall, 76.1% of patients were on statins, with only 39.4% on high-intensity statins. Men were more likely to receive high-intensity statins than women (multivariable-adjusted odds ratio, 1.34 [95% CI, 1.30-1.38]). Increasing age was associated with lower odds of statin use (odds ratio, 0.79 per 5-year increase at 60 years [95% CI, 0.78-0.81]). Patients with peripheral artery disease (odds ratio, 0.40 [95% CI, 0.37-0.42]) and cerebrovascular disease (odds ratio, 0.75 [95% CI, 0.70-0.80]) had lower odds of using high-intensity statins than those with coronary artery disease. At baseline, most patients (61.3%) had elevated LDL-C (≥70 mg/dL), including 59.8% of those on low/moderate-intensity statins and 76.1% on no statin; only 45.3% achieved an LDL-C <70 mg/dL at 1 year. Nonstatin LLT use was low (ezetimibe, 4.4%; proprotein convertase subtilisin/kexin type 9 inhibitors, 0.7%). Among patients on no statin or low/moderate-intensity statin at baseline, 14.8% and 13.4%, respectively, were on high-intensity statins at 1 year. CONCLUSIONS Among patients with ASCVD in routine care, high-intensity statins are underutilized, and uptitration and use of nonstatin therapy are uncommon. Women, older adults, and individuals with noncardiac ASCVD are particularly undertreated. Concerted efforts are needed to address therapeutic inertia for lipid management in patients with ASCVD.
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Affiliation(s)
- Ann Marie Navar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.M.N., A.A.K., E.D.P., A.G., Y.W.)
| | - Ahmed A Kolkailah
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.M.N., A.A.K., E.D.P., A.G., Y.W.)
| | - Anand Gupta
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.M.N., A.A.K., E.D.P., A.G., Y.W.)
| | | | - Marc K Israel
- Esperion Therapeutics, Inc, Ann Arbor, MI (K.K.G., M.K.I.)
| | - Yiqing Wang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.M.N., A.A.K., E.D.P., A.G., Y.W.)
| | - Eric D Peterson
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (A.M.N., A.A.K., E.D.P., A.G., Y.W.)
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21
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Dorn A, Dorweiler B, Ahmad W, Mylonas S, Becker I, Majd P. Low and High Ankle-Brachial Index Are Both Associated with Mortality in German Nursing Home Residents-The Five-Year Follow-Up of the "Allo-Study" Cohort. J Clin Med 2023; 12:4411. [PMID: 37445445 PMCID: PMC10343002 DOI: 10.3390/jcm12134411] [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: 05/08/2023] [Revised: 06/20/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Peripheral arterial disease (PAD) is associated with high cardiovascular morbidity and mortality. We aimed to examine this relation in a population that tends to be under-represented in research on the topic. In a prospective observational cohort study, residents of 45 nursing homes in Germany were screened for pathological ankle-brachial index (ABI) and observed for five years. Of 1333 participants (median age 84 years), 55.5% had a pathological ABI (≤0.9 or >1.4) on one or both legs. 84.7% of the probands with a low ABI (indicating PAD) had no previously known PAD diagnosis. The five-year mortality was 73.0%. Mortality was higher in individuals with a pathological ABI (76.5%) than in those with a normal ABI (68.7%, p = 0.003). An ABI > 1.4 was associated with a higher mortality (79.4%) than a reduced (74.7%) or normal ABI (68.7%, p = 0.011). Pathological ABI values were associated with an increase in mortality after correction for age, sex and all recorded comorbidities, including cardiac disease. Although PAD is highly prevalent in nursing home residents, it is underdiagnosed and undertreated. In the study cohort, both high and low ABI were important predictors of mortality. PAD deserves more attention in this high-risk population.
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Affiliation(s)
- Anna Dorn
- Vascular Surgery Department, Protestant Hospital, 51465 Bergisch Gladbach, Germany;
| | - Bernhard Dorweiler
- Vascular Surgery Department, University Hospital of Cologne, 50937 Cologne, Germany; (B.D.); (W.A.); (S.M.)
| | - Wael Ahmad
- Vascular Surgery Department, University Hospital of Cologne, 50937 Cologne, Germany; (B.D.); (W.A.); (S.M.)
| | - Spyridon Mylonas
- Vascular Surgery Department, University Hospital of Cologne, 50937 Cologne, Germany; (B.D.); (W.A.); (S.M.)
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology, University Hospital of Cologne, 50937 Cologne, Germany;
| | - Payman Majd
- Vascular Surgery Department, Protestant Hospital, 51465 Bergisch Gladbach, Germany;
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22
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Chang M, O'Brien-Irr MS, Shaw JF, Montross BC, Dosluoglu HH, Harris LM, Dryjski ML, Khan SZ. Optimal Medical Management in Patients undergoing Peripheral Vascular Interventions for Chronic Limb Threatening Ischemia is associated with Improved Outcomes. J Vasc Surg 2023:S0741-5214(23)01068-6. [PMID: 37150486 DOI: 10.1016/j.jvs.2023.04.025] [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: 01/16/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE Optimizing medical management and risk factor modification are underutilized strategies in patients with chronic limb threatening ischemia (CLTI), despite evidence of improved outcomes. The Vascular Quality Initiative (VQI) registry is a tool to improve quality of vascular care. In this study, we used the VQI to evaluate trends in medical management in CLTI patients undergoing peripheral vascular interventions (PVI), and the impact of changes in management on overall survival (OS), amputation-free survival (AFS) and limb salvage (LS). METHODS Patients undergoing index PVI for CLTI between 2012-2016, with at least 24-month follow-up were identified from the national VQI registry. Patient details including smoking status and medication use, OS, LS, and AFS were analyzed with linear-by-linear association, t-test and logistic regression. RESULTS 12,370 PVI were completed in 11,466 patients. There was a significant increase in infrapopliteal interventions (29.8% → 39.0%; P < .001) and PVI performed for tissue loss (TL) (59.1% → 66.5%; P < .001). The percentage of current smokers at time of PVI decreased (36.2% → 30.7%; P = .036). At discharge, statins were initiated in 25%, aspirin in 45% and P2Y12 therapy in 58% of patients not receiving these medications prior to PVI. Over the course of follow-up, dual antiplatelet (DAPT) (41.1% → 48.0%; P < .001), ACE-inhibitor (46.2% → 51.3%; P < .001), and statin (70.4% → 77.5%; P < .001) use increased. Combined DAPT, ACE-inhibitor and statin use increased from 33.6% → 39.6% (P=<.001). Significant improvement in 24-month OS and AFS was noted (OS, 90.9% → 93.7%; P = .002: AFS, 81.2% → 83.1%; P = .046) but not LS (89.6% → 89.0%; P = .83). Combined therapy with P2Y12 inhibitors, statins and ACE-inhibitors was an independent predictor of improved OS (HR 0.61; 0.39 - 0.96, P = .034). DAPT was independent predictor of improved LS (HR 0.83; 0.79 - 0.87, P < .007). CONCLUSION Antiplatelet, ACE-inhibitor and statin use increased over the study period and was associated with improved OS and AFS. Limb salvage trends did not change significantly over time, possibly due to inclusion of patients with higher disease burden or inadequate medical management. Medical management, although improved, remained far from optimal and represents an area for continued development.
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Affiliation(s)
- Matthew Chang
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA
| | | | - JoAnna F Shaw
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA
| | - Brittany C Montross
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA
| | - Hasan H Dosluoglu
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA
| | - Linda M Harris
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA
| | - Maciej L Dryjski
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA
| | - Sikandar Z Khan
- University at Buffalo, Department of Vascular Surgery, Buffalo, New York, USA.
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23
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Jano A, Mak AK, Reitz KM, McPhee J, Ahuja V, Goodney P, Tzeng E. Assessing the Prevalence of Medical Optimization Therapy in Vascular Surgery Clinics. JAMA Surg 2023; 158:550-552. [PMID: 36723947 PMCID: PMC10173024 DOI: 10.1001/jamasurg.2022.7659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/11/2022] [Indexed: 02/02/2023]
Abstract
This cross-sectional study uses checklist data to assess optimal medical therapy prescribed for veterans with atherosclerotic cardiovascular disease.
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Affiliation(s)
- Antalya Jano
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Allison K. Mak
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katherine M. Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - James McPhee
- VA Boston Healthcare System, Boston, Massachusetts
| | - Vanita Ahuja
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Philip Goodney
- VA White River Junction Health Care, White River Junction, Vermont
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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24
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Abstract
Peripheral artery disease (PAD) is a common type of atherosclerotic disease of the lower extremities associated with reduced quality of life and ambulatory capacity. Major adverse cardiovascular events and limb amputations are the leading cause of morbidity and mortality in this population. Optimal medical therapy is therefore critical in these patients to prevent adverse events. Risk factor modifications, including blood pressure control and smoking cessation, in addition to antithrombotic agents, peripheral vasodilators, and supervised exercise therapy are key pillars of medical therapy. Revascularization procedures represent key touch points between patients and health care providers and serve as opportunities to optimize medical therapy and improve long-term patency rates and outcomes. This review summarizes the aspects of medical therapy that all providers should be familiar with when caring for patients with PAD in the peri-revascularization period.
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Affiliation(s)
| | - Joshua A. Beckman
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
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25
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Chang M, O'Brien-Irr M, Montross B, Dosluoglu H, Harris L, Dryjski M, Rivero M, Khan SZ. Impact of Statins on Survival and Limb Salvage in Patients Undergoing Peripheral Endovascular Intervention for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2023; 91:20-27. [PMID: 36503021 DOI: 10.1016/j.avsg.2022.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/25/2022] [Accepted: 11/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Statin therapy is recommended in all patients with peripheral arterial disease (PAD). Its impact on reduction in mortality has been well-documented, yet effect on limb-specific outcomes has been less conclusive. Differences among PAD subgroups or variability of statin use may contribute to the inconsistent findings. We evaluated statin use in patients who underwent peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI) and its impact on overall survival (OS), amputation-free survival (AFS) and limb salvage (LS). METHODS The national Vascular Quality Initiative was queried for the index PVI for CLTI during the period 2010-2016; follow-up (FU) through 2020. Demographics, comorbidities, operative details, and FU status were recorded. Patients were categorized as E-Statin: statin use pre-PVI through discharge (D/C) and FU or N-Statin: No statins pre-PVI, at D/C or any time during FU. The propensity score matched model (PSM) was constructed. Groups were compared using chi-square, Kaplan-Meier survival and Cox regression analysis. RESULTS There were 9,089 index PVI in 8,402 patients; E-Statin: 7149 index PVI in 6,591 patients; and N-Statin: 1940 index PVI in 1811 patients. The mean age was 69 ± 12 years and 58% were male. Statin use was associated with improved 3-year OS-E Statin: 92.9% ± 0.9 versus N Statin: 91.1% ± 2.2%; P = 0.003; hazard ratio (HR): Exp (B) (95% confidence interval): 0.66 (0.44-0.99); P = 0.047 and remained significant following PSM: E Statin: 95.1% ± 0.2% versus 90.8% ± 0.3%; P = 0.02; HR: 0.50 (0.27-0.92); P = 0.025. No significant differences in 3-year LS or AFS were noted between the prematched groups; LS: E Statin: 83.7% ± 0.8 versus N Statin: 84.0% ± 1.7%; P = 0.89; HR: 1.09 (0.88-1.35); P = 0.44; AFS-E Statin: 77.2% ± 1.1% versus 76.1% ± 2.5%; P = 0.17; HR: 0.97 (0.79-1.18); P = 0.74. or following PSM: AFS: 80.2% ± 2.8% vs. 74.7% ± 3.9%; P = 0.53, HR: 0.92 (0.72-1.19); P = 0.54; LS 85.3% ± 1.9% vs. 83.5% ± 2.6%; P = 0.51, HR: 1.08 (0.83-1.4); P = 0.57. Statins significantly improved LS among those with renal failure: 67.8% ± 2.6% vs. 59.7% ± 4.4%; P = 0.003; HR: 56 (0.40-0.79); P = 0.001. CONCLUSIONS Statins are independently associated with improved OS in patients who undergo PVI for CLTI and should be considered for all barring intolerance. Statin use was associated with improved LS in patients with end-stage renal disease. Additional research is needed in this area, particularly, the impact of statin therapy in high-risk CLTI subgroups.
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Affiliation(s)
- Matthew Chang
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY
| | - Monica O'Brien-Irr
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY
| | - Brittany Montross
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY
| | - Hasan Dosluoglu
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY; VA Western NY Healthcare System, Buffalo, NY
| | - Linda Harris
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY
| | - Maciej Dryjski
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY
| | - Mariel Rivero
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY; VA Western NY Healthcare System, Buffalo, NY
| | - Sikandar Z Khan
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo, Buffalo, NY.
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26
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Roberts JD. Surgery or Endovascular Therapy for Chronic Limb Ischemia. N Engl J Med 2023; 388:e37. [PMID: 36920767 DOI: 10.1056/nejmc2300713] [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] [Indexed: 03/16/2023]
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27
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Søgaard M, Nordanstig J, Eldrup N, Behrendt CA. A thought-provoking statement regarding the treatment of patients with peripheral arterial disease. VASA 2023; 52:77-80. [PMID: 36872885 DOI: 10.1024/0301-1526/a001055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Affiliation(s)
- Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Denmark.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Denmark
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany.,Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [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] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1269] [Impact Index Per Article: 1269.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Smolderen KG, Romain G, Provance JB, Scierka LE, Mao J, Goodney PP, Henke PK, Sedrakyan A, Mena-Hurtado C. Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions. JACC Cardiovasc Interv 2023; 16:332-343. [PMID: 36792257 PMCID: PMC10359106 DOI: 10.1016/j.jcin.2022.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Lack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk. OBJECTIVES The authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems. METHODS We performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups. RESULTS Of 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk. CONCLUSIONS Almost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.
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Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Psychology Section, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Phillip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, New Hampshire, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Art Sedrakyan
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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He JJ, Horns JJ, Kraiss LW, Smith BK, Griffin CL, DeMartino RR, Sarfati MR, Brooke BS. High-intensity statin therapy reduces risk of amputation and reintervention among patients undergoing lower extremity bypass for chronic limb-threatening ischemia. J Vasc Surg 2023; 77:497-505. [PMID: 36115522 DOI: 10.1016/j.jvs.2022.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Statins are considered standard-of-care medical therapy for patients undergoing lower extremity bypass (LEB) procedures for chronic limb-threatening ischemia (CLTI). It is unclear, however, whether up-titrating and maintaining patients on higher-intensity statin medications following LEB improves limb salvage outcomes. This study was designed to evaluate whether high-intensity statin therapy impacts the risk of amputation and reintervention following LEB for patients with CLTI. METHODS The IBM MarketScan database was used to identify adult patients (18-99 years old) who underwent a LEB for CLTI between 2008 and 2017. Patients lacking insurance covering drug reimbursement or those who already had undergone amputation before time of bypass were excluded. Using pharmacy claims and national drug codes to define statin intensity, patients were stratified into three groups: high-intensity, low-intensity, and limited statin therapy. The association between intensity of statin therapy and need for reintervention and/or major amputation after LEB was analyzed using Kaplan-Meier curves and risk-adjusted Cox proportional hazard models. RESULTS A total of 25,907 patients who underwent LEB for CLTI were identified, of which 6696 (26%) were maintained on high-dose statins, 9297 (36%) were on low-dose statins, and 9914 (38%) had inconsistent pharmacy claims for statin therapy after surgery. Patients on high-intensity statins were, on average, younger and more likely to be male with comorbid disease (diabetes, hypertension, hyperlipidemia, obesity, renal insufficiency, ischemic heart disease, cerebrovascular disease, and tobacco abuse) than patients on low-intensity statins or limited statin therapy (P < .001 for all comparisons). Following LEB, 6649 patients (25.6%) required a reintervention, and 2550 patients (9.8%) went on to have a major amputation during follow-up. Patients maintained on high-intensity statins after LEB had a significantly lower likelihood of requiring a reintervention (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.45-0.51; P < .001) or amputation (HR, 0.27; 95% CI, 0.24-0.30; P < .001) as compared with patients on limited statin therapy. Further, there was a dose-dependent effect for these outcomes relative to patients on low-intensity statins in risk-adjusted models, and it was independent of whether an autologous vein graft was used for the LEB. Finally, among patients who underwent a reintervention, high-dose statin therapy also significantly reduced the HR for subsequent amputation (HR, 0.21; 95% CI, 0.18-0.25; P < .001). CONCLUSIONS Patients with CLTI on high-intensity therapy following LEB had a significantly lower risk of requiring subsequent reintervention and amputation when compared with patients on low-intensity statins or with limited statin use. These data suggest that patients with CLTI should be up-titrated and/or maintained on high-intensity statins following revascularization whenever possible.
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Affiliation(s)
- Jane J He
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Joshua J Horns
- Department of Surgery, Surgical Population Analysis Research Core (SPARC), University of Utah School of Medicine, Salt Lake City, UT
| | - Larry W Kraiss
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Brigitte K Smith
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Claire L Griffin
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Mark R Sarfati
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT; Department of Surgery, Surgical Population Analysis Research Core (SPARC), University of Utah School of Medicine, Salt Lake City, UT; Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT.
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Laivuori M, Biancari F, Sinisalo J, Albäck A, Hakovirta H, Sund R, Venermo M. Statin use improves survival of patients with known or suspected lower extremity artery disease on all ankle brachial index levels. VASA 2023; 52:54-62. [PMID: 36458408 DOI: 10.1024/0301-1526/a001041] [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: 12/05/2022]
Abstract
Background: Statin medication improves the prognosis of patients with lower extremity artery disease (LEAD). Research has previously focused on patients with a lowered ankle brachial index (ABI) excluding patients with a normal or elevated ankle brachial index. The aim of this study was to analyze the impact of statin use on survival and cardiovascular mortality in patients with LEAD of different severity depicted by the ABI level. Patients and methods: 4128 ABI measurements by trained and experienced nurses between 2000 and 2009 were combined with medication data from the Social Insurance Institution and causes of death data from the national causes of death registry. End of follow-up was set at the end of 2014. The data of statin use included all statin medication with the Anatomical Therapeutic Chemical (ATC) classification codes between C10AA01 and C10AA08. Results: 1956 (47.4%) patients had statin medication. Statin use was associated with improved overall survival and amputation free survival (AFS) on all ABI levels. When adjusted for age, sex and diabetes the greatest overall survival benefit from statin use was for the patients with ABI>1.3 (hazard ratio, HR: 0.67, 95% CI: 0.48-0.94, p=0.020, reference group statin non-users) and ABI 0.9-1.3 (HR: 0.78, 95% CI: 0.65-0.94, p=0.008). In propensity score matched pairs statin treatment was associated with significantly lower all-cause mortality (p<0.0001), cardiovascular mortality (p=0.034), cerebrovascular mortality (p=0.003) and embolic stroke related mortality (p=0.001) in patients with ABI >1.3 or <0.9. Overall survival benefit was significant in females with ABI<0.5 and in males across several ABI levels. Conclusions: According to our study, statins seem to improve overall and amputation free survival regardless of ABI level. Statin use was associated with lower mortality from cerebrovascular disease, overall mortality and in the propensity score matched patients with ABI<0.9 or >1.3 with cardiovascular mortality.
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Affiliation(s)
- Mirjami Laivuori
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Finland
| | - Fausto Biancari
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Finland.,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Juha Sinisalo
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Finland
| | - Anders Albäck
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, University of Turku and Turku University Hospital, Turku, Finland.,Department of Surgery, Satasairaala, Pori, Finland
| | - Reijo Sund
- Institute of Clinical Medicine, Surgery, Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Finland
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Saaiq M. Epidemiology and Outcome of Nontraumatic Lower Limb Amputations. Med J Islam Repub Iran 2023; 37:18. [PMID: 37123335 PMCID: PMC10134094 DOI: 10.47176/mjiri.37.18] [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: 08/09/2021] [Indexed: 05/02/2023] Open
Abstract
Background In order to create a solid evidence base for the development of improved management methods, this study was performed to describe the epidemiology and outcome of nontraumatic lower limb amputations (LLAs). Methods This descriptive case series was conducted over a period of 4 years. It included all patients of both sexes and all ages who underwent LLAs for nontraumatic indications. Results There were a total of 217 patients with 136 (62.67%) men and 81(37.32%) women. The age range was 7 to 71 years, with a mean of 54.25 ± 11.49 years. The most common indication for amputation (41.47%) was diabetic foot gangrene. The most common level of amputation (48.29%) was below knee amputation. Conclusion Patients with diabetic foot gangrene, malignant tumors, and chronic neuropathic ulcers with osteomyelitis constituted the bulk of the amputees. Diabetes mellitus, obesity, and hypertension were the commonest comorbidities identified among them. Public awareness and education would ensure prompt and early health seeking at the appropriate time and help to prevent the need for major amputations in many instances. The amputees' improved reintegration into society and ability to become contributing members of society would be ensured by the provision of vigorous rehabilitation.
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Affiliation(s)
- Muhammad Saaiq
- National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan
- Corresponding author:Muhammad Saaiq,
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Shibahashi E, Jujo K, Mizobuchi K, Nakao M, Uchigata Y, Yamaguchi J. Prognostic Impact of Statins on Patients With Peripheral Artery Disease With Elevated C-Reactive Protein Levels. Am J Cardiol 2023; 186:142-149. [PMID: 36257842 DOI: 10.1016/j.amjcard.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/04/2022] [Accepted: 09/22/2022] [Indexed: 12/24/2022]
Abstract
This study aimed to elucidate the prognostic influence of statins in relation to the degree of inflammation at the time of endovascular therapy (EVT) for patients with peripheral artery disease (PAD). This observational study included patients with PAD who underwent EVT, including 285 statin users and 275 statin non-users. They were assigned into four groups depending on C-reactive protein (CRP) level at the time of EVT: low CRP (<0.1 mg/dL), intermediate-low CRP (0.1-0.3 mg/dL), intermediate-high CRP (0.3-1.0 mg/dL), and high CRP (>1.0 mg/dL). A composite of death and major amputation as the primary endpoint was compared between statin users and non-users in each CRP category. Overall, statin users showed a lower event rate than non-users (log-rank, p=0.02). However, the event rates did not differ significantly between statin users and non-users in the low, intermediate-low, and intermediate-high CRP categories. In the high CRP category, statin users showed a lower event rate than non-users (p=0.002). In this population, multivariate Cox regression analysis revealed that statin use was independently associated with the primary endpoint (hazard ratio: 0.28 [95% confidence interval: 0.14-0.55]). Statins may exert favorable prognostic effects in PAD patients with highly elevated CRP levels, but not in those with low-to-moderate CRP levels.
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Affiliation(s)
- Eiji Shibahashi
- Department of Cardiovascular Intervention, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan; Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan; Department of Cardiology, Saitama Medical University, Saitama Medical Center, Saitama, Japan.
| | - Keiko Mizobuchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masashi Nakao
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuko Uchigata
- Department of Cardiovascular Intervention, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Di X, Liu C, Ni L, Ye W, Rong Z, Zhang R, Niu S, Li F, Zheng Y, Han C, Liu Y. Rationale and design for the study of recombinant human hepatocyte growth factor plasmid in the treatment of patients with chronic limb-threatening ischemia (HOPE CLTI): Randomized, placebo-controlled, double-blind, phase III clinical trials. Am Heart J 2022; 254:88-101. [PMID: 36002048 DOI: 10.1016/j.ahj.2022.08.007] [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] [Received: 05/11/2022] [Revised: 07/31/2022] [Accepted: 08/13/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although patients with CLTI have benefited from the rapid development of endovascular techniques, many patients are considered unsuitable for revascularization procedures. A previous phase II clinical trial has suggested that recombinant human hepatocyte growth factor plasmid (NL003) can salvage limbs during the treatment of patients with CLTI. However, the safety and efficacy of this drug need to be evaluated in a larger cohort. STUDY DESIGN HOPE CLTI is a multicenter, randomized, double-blind, placebo-controlled phase III clinical study to evaluate the efficacy and safety of intramuscular injection of NL003 in CLTI patients. This study consisted of 22 trials: HOPE CLTI-1, which includes patients with rest pain (Rutherford stage 4), and HOPE CLTI-2, which includes patients with limb ulcers (Rutherford stage 5). In both trials, patients are randomized with a 2:1 ratio of intramuscular injection of NL003 to placebo. The primary endpoint of HOPE CLTI-1 is the complete pain relief rate. The primary endpoint of HOPE CLTI-2 is the complete ulcer healing rate. The safety endpoint was assessed based on adverse events after injection of NL003. Enrollment began in July 2019. The HOPE CLTI-1 trial aims to complete the randomization of at least 300 patients, while the HOPE CLTI-2 trial aims to enroll at least 240 patients. Both trials are organized such that patients will be followed for 6 months after the first intramuscular injection. CONCLUSIONS HITOP CLTI, which is comprised of 2 multicenter, double-blind, placebo-controlled phase III clinical trials, aims to evaluate the efficacy and safety of the intramuscular administration of NL003 in patients with CLTI.
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Affiliation(s)
- Xiao Di
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China.
| | - Leng Ni
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Wei Ye
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Zhihua Rong
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Rui Zhang
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Shuai Niu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Fengshi Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Chengquan Han
- R&D Center of Beijing Northland Biotech. Co., Ltd., Beijing, China
| | - Yue Liu
- R&D Center of Beijing Northland Biotech. Co., Ltd., Beijing, China
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King RW, Canonico ME, Bonaca MP, Hess CN. Management of Peripheral Arterial Disease: Lifestyle Modifications and Medical Therapies. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100513. [PMID: 39132343 PMCID: PMC11307706 DOI: 10.1016/j.jscai.2022.100513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 08/13/2024]
Abstract
Peripheral artery disease (PAD) commonly refers to atherosclerotic narrowing of noncoronary arteries, primarily those supplying the lower extremities. The risk factors for PAD include smoking, hyperlipidemia, hypertension, and diabetes mellitus. Patients with PAD are at a heightened risk of major adverse cardiovascular events (including myocardial infarction, stroke, and cardiovascular death) and major adverse limb events (including progressive symptoms or limb ischemia requiring peripheral revascularization, amputation, and acute limb ischemia), highlighting the need for guideline-directed therapies. Lifestyle modifications and medical therapies are utilized to improve function and outcomes in this patient population. Adherence to a healthy diet and smoking cessation are both associated with better outcomes in patients with PAD. Medical therapies targeting axes of risk, including lipid-modifying therapies, antithrombotic therapies, and targeted diabetes therapies, are available to reduce this risk in patients with PAD; however, significant residual risk remains. Unfortunately, despite guideline recommendations and efforts at education, even available medical therapies remain underutilized in patients with PAD. Continued development of novel therapies and efforts to improve the provision of care in patients with PAD are needed.
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Affiliation(s)
- R. Wilson King
- Department of Surgery, University of Colorado, Aurora, Colorado
- CPC Clinical Research, Aurora, Colorado
| | - Mario Enrico Canonico
- CPC Clinical Research, Aurora, Colorado
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marc P. Bonaca
- CPC Clinical Research, Aurora, Colorado
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado
| | - Connie N. Hess
- CPC Clinical Research, Aurora, Colorado
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado
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Aday AW, Duncan MS, Patterson OV, DuVall SL, Alba PR, Alcorn CW, Tindle HA, Creager MA, Bonaca MP, Damrauer SM, Wells QS, Behroozian A, Beckman JA, Freiberg MS. Association of Sex and Race With Incident Peripheral Artery Disease Among Veterans With Normal Ankle-Brachial Indices. JAMA Netw Open 2022; 5:e2240188. [PMID: 36326762 PMCID: PMC9634499 DOI: 10.1001/jamanetworkopen.2022.40188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE Reported risk of incident peripheral artery disease (PAD) by sex and race varies significantly and has not been reported in national cohorts among individuals free of baseline PAD. OBJECTIVE To evaluate the association of sex and race, as well as prevalent cardiovascular risk factors, with limb outcomes in a national cohort of people with normal baseline ankle-brachial indices (ABIs). DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from participants in the Veterans Affairs Birth Cohort Study (born 1945-1965), with follow-up data between January 1, 2000, and December 31, 2016. Baseline demographics were collected from 77 041 participants receiving care from the Veterans Health Administration with baseline ABIs of 0.90 to 1.40 and no history of PAD. Data were analyzed from October 2019 through September 2022. EXPOSURES Sex, race, diabetes, and smoking status. MAIN OUTCOMES AND MEASURES Incident PAD, defined as subsequent ABI less than 0.90, surgical or percutaneous revascularization, or nontraumatic amputation. RESULTS Of 77 041 participants with normal ABIs (73 822 [95.8%] men; mean [SD] age, 60.2 [5.9] years; 13 080 Black [18.2%] and 54 377 White [75.6%] among 71 911 participants with race and ethnicity data), there were 6692 incident PAD events over a median [IQR] of 3.9 [1.7-6.9] years. Incidence rates were lower for women than men (incidence rates [IRs] per 1000 person-years, 7.4 incidents [95% CI, 6.2-8.8 incidents] vs 19.2 incidents [95% CI, 18.7-19.6 incidents]), with a lower risk of incident PAD (adjusted hazard ratio [aHR], 0.49 [95% CI, 0.41-0.59]). IRs per 1000 person-years of incident PAD were similar for Black and White participants (18.9 incidents [95% CI, 17.9-20.1 incidents] vs 18.8 incidents [95% CI, 18.3-19.4]). Compared with White participants, Black participants had increased risk of total PAD (aHR, 1.09 [95% CI, 1.02-1.16]) and nontraumatic amputation (aHR, 1.20 [95% CI, 1.06-1.36]) but not surgical or percutaneous revascularization (aHR, 1.10 [95% CI, 0.98-1.23]) or subsequent ABI less than 0.90 (aHR, 1.04 [95% CI, 0.95-1.13]). Diabetes (aHR, 1.62 [95% CI, 1.53-1.72]) and smoking (eg, current vs never: aHR, 1.76 [95% CI, 1.64-1.89]) were associated with incident PAD. Incident PAD was rare among individuals without a history of smoking or diabetes (eg, among 632 women: IR per 1000 people-years, 2.1 incidents [95% CI, 1.0-4.5 incidents]) despite an otherwise-high-risk cardiovascular profile (eg, 527 women [83.4%] with hypertension). CONCLUSIONS AND RELEVANCE This study found that the risk of PAD was approximately 50% lower in women than men and less than 10% higher for Black vs White participants, while the risk of nontraumatic amputation was 20% higher among Black compared with White participants.
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Affiliation(s)
- Aaron W. Aday
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meredith S. Duncan
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington
| | - Olga V. Patterson
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Scott L. DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Patrick R. Alba
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Charles W. Alcorn
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Hilary A. Tindle
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A. Creager
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Marc P. Bonaca
- Colorado Prevention Center Clinical Research, Division of Cardiovascular Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Scott M. Damrauer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Quinn S. Wells
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam Behroozian
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington
- Now with Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California
| | - Joshua A. Beckman
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S. Freiberg
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Healthcare System, Nashville
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Espinola-Klein C, Weißer G, Schmitt V, Schwaderlapp M, Munzel T. Antithrombotic therapy in peripheral arterial disease. Front Cardiovasc Med 2022; 9:927645. [PMID: 36312276 PMCID: PMC9606411 DOI: 10.3389/fcvm.2022.927645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Patients with peripheral arterial disease (PAD) are at increased risk for major adverse cardiovascular events (MACE) such as cardiovascular death, myocardial infarction, and stroke as well as major adverse limb events (MALE) such as amputation and acute limb ischemia. Therefore, prevention of thrombotic events is crucial to improve the prognosis of PAD patients. This review article concludes current evidence and guideline recommendations about antithrombotic therapy in PAD patients.Antithrombotic therapy is highly effective to reduce MACE and MALE events in PAD patients. Recently, the concept of dual pathway inhibition (low-dose rivaroxaban plus acetylic salicylic acid (ASA) has been tested in the COMPASS and VOYAGER-PAD trial. Compared to ASA alone dual pathway inhibition was superior to prevent MACE and MALE. After peripheral revascularization, in particular the risk for acute limb ischemia was reduced. In contrast, the risk for major bleeding is increased. Therefore, current guidelines recommend the combination of low-dose rivaroxaban and ASA in PAD patients with low bleeding risk. In patients with high bleeding risk, a single antiplatelet drug (preferable clopidogrel) is indicated. In patients with atherosclerotic vascular disease and indication for oral anticoagulation, no additional antiplatelet drug is necessary, as this would increase the risk of bleeding without improving the prognosis. Conclusion Antithrombotic treatment reduces MACE and MALE and is recommended in all patients with PAD. Individual bleeding risk should always be considered based on the current data situation and an individual benefit-risk assessment must be carried out.
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Affiliation(s)
- Christine Espinola-Klein
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany,*Correspondence: Christine Espinola-Klein
| | - Gerhard Weißer
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Volker Schmitt
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany,Center for Cardiology, Cardiology I–General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Schwaderlapp
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Munzel
- Center for Cardiology, Cardiology I–General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Inflammatory and Prothrombotic Biomarkers, DNA Polymorphisms, MicroRNAs and Personalized Medicine for Patients with Peripheral Arterial Disease. Int J Mol Sci 2022; 23:ijms231912054. [PMID: 36233355 PMCID: PMC9569699 DOI: 10.3390/ijms231912054] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 12/24/2022] Open
Abstract
Classical risk factors play a major role in the initiation and development of atherosclerosis. However, the estimation of risk for cardiovascular events based only on risk factors is often insufficient. Efforts have been made to identify biomarkers that indicate ongoing atherosclerosis. Among important circulating biomarkers associated with peripheral arterial disease (PAD) are inflammatory markers which are determined by the expression of different genes and epigenetic processes. Among these proinflammatory molecules, interleukin-6, C-reactive protein, several adhesion molecules, CD40 ligand, osteoprotegerin and others are associated with the presence and progression of PAD. Additionally, several circulating prothrombotic markers have a predictive value in PAD. Genetic polymorphisms significantly, albeit moderately, affect risk factors for PAD via altered lipoprotein metabolism, diabetes, arterial hypertension, smoking, inflammation and thrombosis. However, most of the risk variants for PAD are located in noncoding regions of the genome and their influence on gene expression remains to be explored. MicroRNAs (miRNAs) are single-stranded, noncoding RNAs that modulate gene expression at the post-transcriptional level. Patterns of miRNA expression, to some extent, vary in different atherosclerotic cardiovascular diseases. miRNAs appear to be useful in the detection of PAD and the prediction of progression and revascularization outcomes. In conclusion, taking into account one’s predisposition to PAD, i.e., DNA polymorphisms and miRNAs, together with circulating inflammatory and coagulation markers, holds promise for more accurate prediction models and personalized therapeutic options.
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Chen W, Shi S, Tu J, Liao L, Liao Y, Chen K, Chen L, Huang R. Nutrition-related diseases and cardiovascular mortality in American society: national health and nutrition examination study, 1999-2006. BMC Public Health 2022; 22:1849. [PMID: 36192729 PMCID: PMC9531382 DOI: 10.1186/s12889-022-14257-8] [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: 05/06/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
Background Despite many significant advances in treatment and management, cardiovascular disease remains the main cause of the global disease burden. Nutrition-related disease is a modifiable cardiovascular risk factor. However, few studies have examined the relationship between nutrition-related diseases and cardiovascular mortality. Objective We aimed to investigate the association of nutrition-related diseases with cardiovascular mortality based on a large nationally representative community population. Design We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 1999–2006 with mortality follow-up through December 31, 2015. Finally, 12,469 participants were analyzed. Each participant was assigned to one of four groups: normal nutrition without sarcopenia, sarcopenia with normal nutrition, malnutrition without sarcopenia, and malnutrition-sarcopenia syndrome. Survival curves and Cox regressions based on the NHANES recommended weights were used to assess the association between nutrition-related diseases and cardiovascular mortality. Results Of the 12,469 patients included in the study and divided into four groups, malnutrition-sarcopenia syndrome had the highest 5- and 10-year cardiovascular mortality rates. After adjustment for related factors, sarcopenia with normal nutrition (hazard ratio [HR]: 1.62, 95% confidence interval [CI]: 1.28–2.06; P < 0.001), malnutrition without sarcopenia (HR: 1.28, 95% CI:1.03–1.58; P = 0.024), and malnutrition-sarcopenia syndrome (HR: 2.66, 95% CI:1.89 − 3.74; P < 0.001) were significantly associated with increased risk of all-cause mortality. Malnutrition-sarcopenia syndrome remained associated with an increased risk of cardiovascular mortality (HR: 3.56, 95% CI: 1.17 − 10.84; P < 0.001). Conclusions Malnutrition-sarcopenia syndrome was highly prevalent among community-dwelling adults in the United States and was a strong prognostic factor for cardiovascular mortality in the community setting. Randomized clinical trials are needed to demonstrate whether prevention or treatment of malnutrition-sarcopenia syndrome in community populations can reduce global cardiovascular mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14257-8.
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Affiliation(s)
- Weihua Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China
| | - Shanshan Shi
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China
| | - Jiabin Tu
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China
| | - Lihua Liao
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China
| | - Ying Liao
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China
| | - Kaihong Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China
| | - Liling Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, China.
| | - Rongchong Huang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100053, China.
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Balletshofer B, Böckler D, Diener H, Heckenkamp J, Ito W, Katoh M, Lawall H, Malyar N, Qui HJ, Reimer P, Rittig K, Zähringer M. Positionspapier zur Diagnostik und Therapie der peripheren arteriellen Verschlusskrankheit (pAVK) bei Menschen mit Diabetes mellitus – Gemeinsame Stellungnahme der Deutschen Diabetes Gesellschaft (DDG), der Deutschen Gesellschaft für Angiologie (DGA), der Deutschen Gesellschaft für Interventionelle Radiologie und minimal-invasive Therapie (DeGIR) sowie der Deutschen Gesellschaft für Gefäßchirurgie und Gefäßmedizin (DGG). DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1908-0612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Holger Diener
- Abteilung für Gefäß- und Endovaskularchirurgie, Krankenhaus Buchholz, Buchholz, Deutschland
| | - Jörg Heckenkamp
- Klinik für Gefäßchirurgie, Niels-Stensen-Kliniken, Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Wulf Ito
- Herz- und Gefäßzentrum Oberallgäu, Kempten, Deutschland
| | - Marcus Katoh
- Institut für Diagnostische und Interventionelle Radiologie, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - Holger Lawall
- Gemeinschaftspraxis Prof. Dr. C. Diehm/Dr. H. Lawall, Max-Grundig Klinik Bühlerhöhe, Ettlingen, Deutschland
| | - Nasser Malyar
- Klinik für Kardiologie I – Koronare Herzkrankheit, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Hui Jing Qui
- Klinik für Innere Medizin 1 für Diabetologie, Endokrinologie, Kardiologie und Angiologie, Marienhospital Stuttgart, Stuttgart, Deutschland
| | - Peter Reimer
- Institut für Diagnostische und Interventionelle Radiologie, Städtisches Klinikum Karlsruhe, Karlsruhe, Deutschland
| | - Kilian Rittig
- Klinik für Innere Medizin IV, Angiologie und Diabetologie, Klinikum Frankfurt (Oder), Frankfurt (Oder), Deutschland
| | - Markus Zähringer
- Klinik für Diagnostische und Interventionelle Radiologie, Marienhospital Stuttgart, Stuttgart, Deutschland
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Wolf S, Spirk D, Forgo G, Sebastian T, Voci D, Kucher N, Barco S. Prevalent use of high-intensity statin therapy and LDL-C target attainment among PAD patients undergoing angioplasty. VASA 2022; 51:357-364. [DOI: 10.1024/0301-1526/a001025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: The global burden of peripheral arterial disease (PAD) is substantial. Reducing the major modifiable risk factors for noncommunicable disease, including dyslipidaemia, represents a public health priority. Aim is to evaluate the prevalent adequate use of lipid-lowering therapy (LLT) and low-density lipoprotein cholesterol (LDL-C) attainment among patients with PAD of the lower extremities undergoing percutaneous transluminal angioplasty. Patients and methods: We screened PAD patients treated at the University Hospital Zurich (January 2012–December 2018). We excluded patients <18 years, without classifiable severity of PAD, or with missing LDL-C or medication data. In this cross-sectional study, we studied the prevalent LLT use and LDL-C values in target according to the most recent European guidelines. Available clinical data included demographic information, lipid profile, type and dose of LLT, characteristics of the artery obstruction and angioplasty. Results: A total of 2,148 angioplasties were performed in 956 patients: 614 (64%) were men; the mean age was 70.6 (SD 11.4) years. A total of 608 (64%) had a non-critical PAD (Fontaine stage I–IIb), whereas the remaining had a critical limb ischemia or a diabetic foot syndrome. Their median LDL-C value was 2.00 (Q1–Q3: 1.50–2.60) mmol/L. In accordance to the 2016 and 2019 European Society of Cardiology guidelines, the LDL-C target of 1.8 and 1.4 mmol/L was not reached in 63% (n=599) and in 79% (n=760) of patients, respectively. Only 41% (n=390) of patients were on high-intensity statin therapy. Conclusions: The attainment of LDL-C targets, as recommended by current European guidelines, and the use of high-intensity LLT were unsatisfactory in the majority of PAD patients.
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Affiliation(s)
- Simon Wolf
- Department of Angiology, University Hospital Zurich, Switzerland
| | - David Spirk
- Institute of Pharmacology, University of Bern, Switzerland
| | - Gabor Forgo
- Department of Angiology, University Hospital Zurich, Switzerland
| | - Tim Sebastian
- Department of Angiology, University Hospital Zurich, Switzerland
| | - Davide Voci
- Department of Angiology, University Hospital Zurich, Switzerland
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Switzerland
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Germany
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Lo HY, Lin YS, Lin DSH, Lee JK, Chen WJ. Association of Statin Therapy With Major Adverse Cardiovascular and Limb Outcomes in Patients With End-stage Kidney Disease and Peripheral Artery Disease Receiving Maintenance Dialysis. JAMA Netw Open 2022; 5:e2229706. [PMID: 36048442 PMCID: PMC9437764 DOI: 10.1001/jamanetworkopen.2022.29706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Controversy exists regarding whether statin therapy has benefits for patients with kidney failure, and the consequences of statin therapy for patients with kidney failure and concomitant peripheral artery disease (PAD) are particularly uncertain. OBJECTIVE To evaluate the association of statin therapy with cardiovascular (CV) and limb outcomes among patients with kidney failure and concomitant PAD and dyslipidemia who are receiving long-term maintenance dialysis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Taiwan National Health Insurance Research Database. A total of 20 731 patients with kidney failure receiving long-term maintenance dialysis who were diagnosed with PAD and dyslipidemia between January 1, 2001, and December 31, 2013, were identified, and 10 767 patients met study criteria. Data were analyzed from June 8, 2021, to June 2, 2022. MAIN OUTCOMES AND MEASURES Primary outcomes were all-cause death and the composite of endovascular therapy (EVT) and amputation. Other outcomes of interest included CV events (CV death, acute myocardial infarction, ischemic stroke, and hospitalization for heart failure), major adverse limb events (new-onset claudication, new-onset critical limb ischemia, EVT, and nontraumatic amputation), and all-cause readmission. All outcomes were examined at 1 year and 3 years of follow-up. To minimize selection bias, propensity score matching on a 1:1 ratio was performed among patients receiving statin therapy (statin group) and patients not receiving statin therapy (nonstatin group). A defined daily dose (DDD) approach was used to evaluate whether the association of statin therapy with the risk of primary outcomes was dose dependent. RESULTS Among 20 731 patients with kidney failure and concomitant PAD and dyslipidemia receiving long-term maintenance dialysis, 10 767 patients (5593 women [51.9%]; mean [SD] age, 68.5 [11.5] years; all of Taiwanese ethnicity) met the predetermined study criteria; of those, 3597 patients were receiving statin therapy, and 7170 were not. A total of 6470 patients (mean [SD] age, 66.4 [11.3] years; 3359 women [51.9%]) were included in the 1:1 propensity score-matched cohort, with 3235 patients in each group (statin and nonstatin). The incidence and risk of CV and all-cause death were significantly lower in the statin group vs the nonstatin group at 3 years of follow-up (CV death: 611 patients [18.9%] vs 685 patients [21.2%]; hazard ratio [HR], 0.86 [95% CI, 0.77-0.96]; P = .008; all-cause death: 1078 patients [33.3%] vs 1138 patients [35.2%]; HR, 0.92 [95% CI, 0.84-0.996]; P = .04). Statin use was also associated with a significantly lower incidence and risk of the composite adverse limb outcome of EVT and amputation at 3 years of follow-up (314 patients [9.7%] vs 361 patients [11.2%]; subdistribution HR, 0.85 [95% CI, 0.73-0.99]; P = .04). Results of subgroup analyses were consistent with those of the primary analysis across all subgroup variables. In the adjusted dose-response analysis, the risk reduction associated with statin use increased in a dose-dependent manner for both all-cause death (HR: 0.95 for DDD <0.50, 0.92 for DDD 0.50-0.99, 0.85 for DDD 1.00-1.49, and 0.79 for DDD ≥1.50; P = .002 for trend) and the composite outcome of EVT and amputation (subdistribution HR: 0.79 for DDD <0.50, 0.78 for DDD 0.50-0.99, 0.82 for DDD 1.00-1.49, and 0.58 for DDD ≥1.50; P = .002 for trend) compared with no statin therapy; however, not all findings in the DDD analysis were statistically significant. CONCLUSIONS AND RELEVANCE In this cohort study, statin therapy was associated with reductions in the risk of all-cause death, CV death, and the composite adverse limb outcome of EVT and amputation. These findings suggest that statin therapy may have protective CV and limb benefits for patients with kidney failure and concomitant PAD who are receiving long-term maintenance dialysis.
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Affiliation(s)
- Hao-Yun Lo
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
| | - Donna Shu-Han Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Hata Y, Iida O, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Higashino N, Toyoshima T, Kitano I, Tsuji Y, Takahara M, Mano T. Impact of Guideline-Directed Medical Therapy on 10-Year Mortality after Revascularization for Patients with Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2022. [PMID: 36031358 DOI: 10.5551/jat.63773] [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: 11/11/2022] Open
Abstract
AIMS This study aimed to investigate the long-term impact of guideline-directed medical therapy (GDMT) on 10-year mortality in patients with chronic limb-threatening ischaemia (CLTI) after revascularization. METHODS We performed a retrospective multicentre study enrolle 459 patients with CLTI who underwent revascularization (396 endovascular therapy [EVT] and 63 bypass surgery [BSX] cases) between January 2007 and December 2011. The primary outcome measure was all-cause mortality. We additionally explored the predictors for all-cause mortality using Cox regression hazard models; the influence of GDMT, defined as prescription of antiplatelet agents, statins, and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in aggregate, on all-cause mortality, and the association between baseline characteristics using interaction effects. RESULTS During the 10-year follow-up after revascularization, 234 patients died. In Kaplan-Meier analysis, 10-year mortality was significantly lower in patients who received statins (p<.001) and ACE inhibitors or ARBs (p=.010) than those who did not. However, there were no differences in 10-year mortality between patients who received anti-platelet agents and those who did not (p=.62). Interaction analysis revealed that GDMT had a significantly different hazard ratio in patients who were and were not on hemodialysis and in those treated with EVT or BSX (p for interaction =.002 and .044, respectively). In the multivariate analysis, age >75 years, non-ambulatory status, hemodialysis, congestive heart failure, left ventricular ejection fraction <50%, and GDMT were significantly associated with all-cause mortality. CONCLUSIONS Appropriate GDMT use was independently associated with 10-year mortality in patients with CLTI after revascularization.
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Affiliation(s)
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center
| | | | | | | | | | | | | | | | | | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine
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Role of Lipid-Lowering Therapy in Peripheral Artery Disease. J Clin Med 2022; 11:jcm11164872. [PMID: 36013107 PMCID: PMC9410277 DOI: 10.3390/jcm11164872] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/05/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Atherosclerosis is a multifactorial, lipoprotein-driven condition that leads to plaque formation within the arterial tree, leading to subsequent arterial stenosis and thrombosis that accounts for a large burden of cardiovascular morbidity and mortality globally. Atherosclerosis of the lower extremities is called peripheral artery disease and is a major cause of loss in mobility, amputation, and critical limb ischemia. Peripheral artery disease is a common condition with a gamut of clinical manifestations that affects an estimated 10 million people in the United States of America and 200 million people worldwide. The role of apolipoprotein B-containing lipoproteins, such as LDL and remnant lipoproteins in the development and progression of atherosclerosis, is well-established. The focus of this paper is to review existing data on lipid-lowering therapies in lower extremity atherosclerotic peripheral artery disease.
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Statins in High Cardiovascular Risk Patients: Do Comorbidities and Characteristics Matter? Int J Mol Sci 2022; 23:ijms23169326. [PMID: 36012589 PMCID: PMC9409457 DOI: 10.3390/ijms23169326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality are decreasing in high-income countries, but ASCVD remains the leading cause of morbidity and mortality in high-income countries. Over the past few decades, major risk factors for ASCVD, including LDL cholesterol (LDL-C), have been identified. Statins are the drug of choice for patients at increased risk of ASCVD and remain one of the most commonly used and effective drugs for reducing LDL cholesterol and the risk of mortality and coronary artery disease in high-risk groups. Unfortunately, doctors tend to under-prescribe or under-dose these drugs, mostly out of fear of side effects. The latest guidelines emphasize that treatment intensity should increase with increasing cardiovascular risk and that the decision to initiate intervention remains a matter of individual consideration and shared decision-making. The purpose of this review was to analyze the indications for initiation or continuation of statin therapy in different categories of patient with high cardiovascular risk, considering their complexity and comorbidities in order to personalize treatment.
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47
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Jia X, Al Rifai M, Saeed A, Ballantyne CM, Virani SS. PCSK9 Inhibitors in the Management of Cardiovascular Risk: A Practical Guidance. Vasc Health Risk Manag 2022; 18:555-566. [PMID: 35898405 PMCID: PMC9309324 DOI: 10.2147/vhrm.s275739] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/13/2022] [Indexed: 01/19/2023] Open
Abstract
Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are potent medications in the toolkit for treatment of atherosclerotic cardiovascular disease. These agents have been well studied in clinical trials supporting their efficacy in dramatically reducing low-density lipoprotein cholesterol (LDL-C) and impact on cardiovascular outcomes. Since the approval of commercial use for PCSK9 inhibitors in 2015, we have also gained significant experience in the use of these therapeutics in the real-world setting. In this article, we review current guideline recommendations, clinical trial evidence on efficacy and safety as well as data on cost-effectiveness, prescription and adherence. We focus primarily on the monoclonal antibody class of PCSK9 inhibitors in this review while also touching on other types of therapeutics that are under development.
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Affiliation(s)
- Xiaoming Jia
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mahmoud Al Rifai
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Anum Saeed
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Salim S Virani
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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48
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Krawisz AK, Natesan S, Wadhera RK, Chen S, Song Y, Yeh RW, Jaff MR, Giri J, Julien H, Secemsky EA. Differences in Comorbidities Explain Black-White Disparities in Outcomes After Femoropopliteal Endovascular Intervention. Circulation 2022; 146:191-200. [PMID: 35695005 DOI: 10.1161/circulationaha.122.058998] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Black adults have a higher incidence of peripheral artery disease and limb amputations than White adults in the United States. Given that peripheral endovascular intervention (PVI) is now the primary revascularization strategy for peripheral artery disease, it is important to understand whether racial differences exist in PVI incidence and outcomes. METHODS Data from fee-for-service Medicare beneficiaries ≥66 years of age from 2016 to 2018 were evaluated to determine age- and sex-standardized population-level incidences of femoropopliteal PVI among Black and White adults over the 3-year study period. Patients' first inpatient or outpatient PVIs were identified through claims codes. Age- and sex-standardized risks of the composite outcome of death and major amputation within 1 year of PVI were examined by race. RESULTS Black adults underwent 928 PVIs per 100 000 Black beneficiaries compared with 530 PVIs per 100 000 White beneficiaries (risk ratio, 1.75 [95% CI, 1.73-1.77]; P<0.01). Black adults who underwent PVI were younger (mean age, 74.5 years versus 76.4 years; P<0.01), were more likely to be female (52.8% versus 42.7%; P<0.01), and had a higher burden of diabetes (70.6% versus 56.0%; P<0.01), chronic kidney disease (67.5% versus 56.6%; P<0.01), and heart failure (47.4% versus 41.7%; P<0.01) than White adults. When analyzed by indication for revascularization, Black adults were more likely to undergo PVI for chronic limb-threatening ischemia than White adults (13 023 per 21 352 [61.0%] versus 59 956 per 120 049 [49.9%]; P<0.01). There was a strong association between Black race and the composite outcome at 1 year (odds ratio, 1.21 [95% CI, 1.16-1.25]). This association persisted after adjustment for socioeconomic status (odds ratio, 1.08 [95% CI, 1.03-1.13]) but was eliminated after adjustment for comorbidities (odds ratio, 0.96 [95% CI, 0.92-1.01]). CONCLUSIONS Among fee-for-service Medicare beneficiaries, Black adults had substantially higher population-level PVI incidence and were significantly more likely to experience adverse events after PVI than White adults. The association between Black race and adverse outcomes appears to be driven by a higher burden of comorbidities. This analysis emphasizes the critical need for early identification and aggressive management of peripheral artery disease risk factors and comorbidities to reduce Black-White disparities in the development and progression of peripheral artery disease and the risk of adverse events after PVI.
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Affiliation(s)
- Anna K Krawisz
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Medicine, Division of Cardiology (A.K.K., R.K.W., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA (A.K.K., R.K.W., R.W.Y., M.R.J., E.A.S.)
| | - Sahana Natesan
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Rishi K Wadhera
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Medicine, Division of Cardiology (A.K.K., R.K.W., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA (A.K.K., R.K.W., R.W.Y., M.R.J., E.A.S.)
| | - Siyan Chen
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Yang Song
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W Yeh
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Medicine, Division of Cardiology (A.K.K., R.K.W., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA (A.K.K., R.K.W., R.W.Y., M.R.J., E.A.S.)
| | - Michael R Jaff
- Harvard Medical School, Boston, MA (A.K.K., R.K.W., R.W.Y., M.R.J., E.A.S.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Leonard Davis Institute of Health Economics (J.G., H.J.), Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Cardiovascular Medicine Division (J.G., H.J.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Howard Julien
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Leonard Davis Institute of Health Economics (J.G., H.J.), Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Cardiovascular Medicine Division (J.G., H.J.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eric A Secemsky
- Department of Medicine, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (A.K.K., S.N., R.K.W., S.C., Y.S., R.W.Y., E.A.S.), Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA (A.K.K., R.K.W., R.W.Y., M.R.J., E.A.S.)
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Daso G, Chen AJ, Yeh S, O'Connell JB, Rigberg DA, de Virgilio C, Gelabert HA, Ulloa JG. Lower Extremity Amputations Among Veterans: Have Ambulatory Outcomes and Survival Improved? Ann Vasc Surg 2022; 87:311-320. [PMID: 35810947 DOI: 10.1016/j.avsg.2022.06.007] [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: 03/03/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We hypothesize among patients undergoing lower extremity amputation, access to pre, and post operative rehabilitation services; as well as improved medical care, have led to higher rates of postoperative ambulation, and improved survival. METHODS Retrospective single center review of all major lower extremity amputations performed at the Greater Los Angeles Veterans Affairs Healthcare System from 2000 - 2020 stratified into multiyear cohorts. We abstracted demographics, operative indication, comorbidities, preoperative medical management, perioperative complications, discharge location, and pre- and postoperative ambulatory status. Odds of ambulation after amputation were analyzed using multivariate logistic regression. Survival was analyzed using multivariate logistic regression and Kaplan-Meier survival analysis. Multivariate logistic predictors were selected based on prior literature and clinical experience. RESULTS We identified 654 operations in our study, noting less amputations performed in the latest three cohort years as compared to the initial cohort (2000 - 2004). Patients undergoing below-knee amputations (BKA) had 2.7 times (p < 0.05) greater odds of postoperative ambulation and 86% (p < 0.05) increased odds of survival compared to above-knee amputations (AKA). The odds of ambulation increased by 8.8% (p < 0.05) for each consecutive study year. Ambulation post-amputation conferred 13.2 times (p < 0.05) greater odds of survival. The odds of survival in "emergent" operations decreased by 48% (p < 0.05) compared to an "elective" operation. For each additional comorbidity, the odds of survival decreased by 18% (p < 0.05). Patients with any perioperative complication had a 48% (p < 0.05) lower odds of survival. Kaplan Meier survival estimates demonstrated significant survival difference between patients by amputation level and postoperative ambulatory status (p < 0.05). CONCLUSIONS Ambulatory status following distal amputation has improved over time and is significantly associated with increased survival post-amputation. Patients undergoing a BKA or discharged home were most likely to ambulate postoperatively. Amputation level, preoperative comorbidities, and perioperative complications remain strong predictors of survival.
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Affiliation(s)
- Gabrielle Daso
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Alina J Chen
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Savannah Yeh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jessica B O'Connell
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - David A Rigberg
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - Christian de Virgilio
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - Hugh A Gelabert
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - Jesus G Ulloa
- Division of Vascular & Endovascular Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; Division of Vascular Surgery, Surgical & Perioperative Careline, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA.
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Kim Y, Thangappan K, DeCarlo CS, Jessula S, Majumdar M, Patel SS, Zacharias N, Mohapatra A, Dua A. Outcomes of Femoropopliteal Bypass for Lifestyle-Limiting Claudication in the Endovascular Era. J Surg Res 2022; 279:323-329. [PMID: 35809357 DOI: 10.1016/j.jss.2022.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/23/2022] [Accepted: 06/09/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Outcomes after femoropopliteal bypass for intermittent claudication (IC) remain unclear in the endovascular era. METHODS A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures performed between 1995 and 2020. Demographics, operative details, and outcomes were documented. A statistical analysis included Kaplan-Meier curves and Cox proportional hazards ratios (HR). RESULTS A total of 282 patients underwent femoropopliteal bypass surgery for IC. Median age was 68 y (interquartile range, 61-73 y). Bypass conduits included great saphenous vein (GSV) (48.2%), prosthetic grafts (48.9%), and non-GSV autogenous grafts (2.8%). Distal bypass target was above-knee in 62.1% and below-knee in 37.9% of patients. The most common postoperative complications were wound infections (14.2%) followed by unplanned 30-d hospital readmissions (12.4%). Mortality rates were low at 0.4% (30 d) and 3.2% (1 y). Five-year primary patency rates trended highest for claudicants undergoing above-knee bypass with GSV conduit (log-rank P = 0.065). Five-year amputation-free survival rates were highest using GSV conduit regardless of distal bypass target (log-rank P = 0.017). On a multivariable analysis, age (HR 1.02 [1.00-1.04], P = 0.023) and active smoking (HR 1.48 [1.06-2.06], P = 0.021) were identified as risk factors for diminished primary graft patency. Risk factors for amputation-free survival included age (HR 1.03 [1.01-1.05], P < 0.001) and GSV conduit type (HR 0.65 [0.46-0.90], P = 0.011). CONCLUSIONS Femoropopliteal bypass among claudicants is associated with high rates of wound infection and hospital readmission. Active smoking portends worse outcomes in this population. These data may inform clinical decision-making regarding surgical intervention for claudication in the endovascular era.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Karthik Thangappan
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Charles S DeCarlo
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Shiv S Patel
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
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