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Ravangard R, Ghanbari M, Attar A, Jafari A. Polypill versus medication monotherapy in the prevention of cardiovascular diseases in Iran: An economic evaluation study. Health Sci Rep 2024; 7:e2240. [PMID: 38974330 PMCID: PMC11225077 DOI: 10.1002/hsr2.2240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 07/09/2024] Open
Abstract
Background and Aims Cardiovascular diseases (CVDs) are one of the major diseases in developing and developed countries and have high prevalence and mortality rates. Pharmacological interventions, especially the use of combination medications, can have preventive effects in patients with CVDs. Recently, in the PolyIran trial, a combination of atorvastatin, hydrochlorothiazide, aspirin, and valsartan or enalapril (Polypill) was shown to be effective in providing survival benefits as a primary prevention strategy. In the present study, we examine the cost-effectiveness of the use of polypill compared to its individual components (named as medication monotherapy) in the prevention of CVDs in Iran. Methods This was an economic evaluation study conducted to compare the cost-utility of polypill with that of medication monotherapy for 10,000 hypothetical cohorts of people over 35 years of age using the Markov model and with a lifetime horizon. The study perspective was patient perspective and direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio were estimated. To deal with uncertaintysensitivity analyses were used. Results The results showed that polypill, with the lowest costs (871 USD) and highest QALYs (14.55), had the most cost-utility than medication monotherapy. Also, the results showed that the highest sensitivities were related to the utilities of angina and stroke states. At the 21,768 USD threshold, polypill had a 92% probability of being cost-effective versus other medications. Conclusion Considering that polypill had the most cost-utility, it is suggested that health system policymakers pay special attention to polypill in designing clinical guidelines. Also, through covering this medication by health insurance organizations, it is possible to complete the country's medicine pharmacopeia in preventing CVDs.
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Affiliation(s)
- Ramin Ravangard
- Health Human Resources Research Center, School of Management and Medical Information SciencesShiraz University of Medical SciencesShirazIran
| | - Mohadese Ghanbari
- School of Management and Medical Information Sciences, Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Armin Attar
- Department of Cardiovascular Medicine, TAHA clinical trial groupShiraz University of Medical SciencesShirazIran
| | - Abdosaleh Jafari
- Health Human Resources Research Center, School of Management and Medical Information SciencesShiraz University of Medical SciencesShirazIran
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Hoitz N, Kraima A, Fioole B, Mees B, de Borst GJ, Ünlü Ç. Surveillance After Surgical and Endovascular Treatment for Peripheral Artery Disease: a Dutch Survey. Eur J Vasc Endovasc Surg 2024; 67:980-986. [PMID: 38159674 DOI: 10.1016/j.ejvs.2023.12.029] [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: 06/19/2023] [Revised: 10/18/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE At present, there is no clear, optimal approach to surveillance after invasive treatment of peripheral artery disease (PAD) in terms of modality, duration, clinical benefit, and cost effectiveness. The ongoing debate on the clinical benefit and cost effectiveness of standard surveillance creates a clear knowledge gap and may result in overtreatment or undertreatment. In this study, a survey was conducted among vascular surgeons in the Netherlands to assess the currently applied surveillance programmes. METHODS All vascular surgeons from the Dutch Society for Vascular Surgery received an online survey on follow up after open and endovascular revascularisation in patients with PAD. Surveillance was defined as at least one follow up visit after intervention with or without additional imaging or ankle brachial index (ABI) measurement. Ten types of PAD intervention were surveyed. RESULTS Surveys were returned by 97 (46.2%) of 210 vascular surgeons, and 76% reported using a routine follow up protocol after an invasive intervention. Clinical follow up only is most commonly performed after femoral endarterectomy (53%). After peripheral bypass surgery, clinical follow up only is applied rarely (4 - 8%). In six of the 10 interventions surveyed, duplex ultrasound (DUS) was the most used imaging modality for follow up. After bypass surgery, 76 - 86% of vascular surgeons perform DUS with or without ABI measurement. After endovascular interventions, 21 - 60% performed DUS surveillance. Lifelong surveillance is most often applied after aortobifemoral bypass (57%). Surveillance frequency and duration vary greatly within the same intervention. Frequencies range from every three or six months to annually. Duration ranges from one time surveillance to lifelong follow up. CONCLUSION There is significant practice variation in surveillance after surgical and endovascular treatment of patients with PAD in the Netherlands. Prospective studies to evaluate treatment outcomes and to define the clinical need and cost effectiveness of standardised surveillance programmes for patients with PAD are recommended.
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Affiliation(s)
- Nathalie Hoitz
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands.
| | - Annelot Kraima
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Barend Mees
- Department of Vascular Surgery, MUMC+, Maastricht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, the Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Omiye JA, Ghanzouri I, Lopez I, Wang F, Cabot J, Amal S, Ye J, Lopez NG, Adebayo-Tijani F, Ross EG. Clinical use of polygenic risk scores for detection of peripheral artery disease and cardiovascular events. PLoS One 2024; 19:e0303610. [PMID: 38758931 PMCID: PMC11101066 DOI: 10.1371/journal.pone.0303610] [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: 07/19/2023] [Accepted: 04/26/2024] [Indexed: 05/19/2024] Open
Abstract
We have previously shown that polygenic risk scores (PRS) can improve risk stratification of peripheral artery disease (PAD) in a large, retrospective cohort. Here, we evaluate the potential of PRS in improving the detection of PAD and prediction of major adverse cardiovascular and cerebrovascular events (MACCE) and adverse events (AE) in an institutional patient cohort. We created a cohort of 278 patients (52 cases and 226 controls) and fit a PAD-specific PRS based on the weighted sum of risk alleles. We built traditional clinical risk models and machine learning (ML) models using clinical and genetic variables to detect PAD, MACCE, and AE. The models' performances were measured using the area under the curve (AUC), net reclassification index (NRI), integrated discrimination improvement (IDI), and Brier score. We also evaluated the clinical utility of our PAD model using decision curve analysis (DCA). We found a modest, but not statistically significant improvement in the PAD detection model's performance with the inclusion of PRS from 0.902 (95% CI: 0.846-0.957) (clinical variables only) to 0.909 (95% CI: 0.856-0.961) (clinical variables with PRS). The PRS inclusion significantly improved risk re-classification of PAD with an NRI of 0.07 (95% CI: 0.002-0.137), p = 0.04. For our ML model predicting MACCE, the addition of PRS did not significantly improve the AUC, however, NRI analysis demonstrated significant improvement in risk re-classification (p = 2e-05). Decision curve analysis showed higher net benefit of our combined PRS-clinical model across all thresholds of PAD detection. Including PRS to a clinical PAD-risk model was associated with improvement in risk stratification and clinical utility, although we did not see a significant change in AUC. This result underscores the potential clinical utility of incorporating PRS data into clinical risk models for prevalent PAD and the need for use of evaluation metrics that can discern the clinical impact of using new biomarkers in smaller populations.
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Affiliation(s)
- Jesutofunmi A. Omiye
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, United States of America
| | - Ilies Ghanzouri
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Ivan Lopez
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Fudi Wang
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - John Cabot
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Saeed Amal
- Department of Bioengineering, The Roux Institute at Northeastern University, Portland, Maine, United States of America
| | - Jianqin Ye
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Nicolas Gabriel Lopez
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Faatihat Adebayo-Tijani
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Elsie Gyang Ross
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
- Division of Vascular Surgery, Department of Surgery, UC San Diego School of Medicine, La Jolla, California, United States of America
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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Oude Wolcherink MJ, Behr CM, Pouwels XGLV, Doggen CJM, Koffijberg H. Health Economic Research Assessing the Value of Early Detection of Cardiovascular Disease: A Systematic Review. PHARMACOECONOMICS 2023; 41:1183-1203. [PMID: 37328633 PMCID: PMC10492754 DOI: 10.1007/s40273-023-01287-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is the most prominent cause of death worldwide and has a major impact on healthcare budgets. While early detection strategies may reduce the overall CVD burden through earlier treatment, it is unclear which strategies are (most) efficient. AIM This systematic review reports on the cost effectiveness of recent early detection strategies for CVD in adult populations at risk. METHODS PubMed and Scopus were searched to identify scientific articles published between January 2016 and May 2022. The first reviewer screened all articles, a second reviewer independently assessed a random 10% sample of the articles for validation. Discrepancies were solved through discussion, involving a third reviewer if necessary. All costs were converted to 2021 euros. Reporting quality of all studies was assessed using the CHEERS 2022 checklist. RESULTS In total, 49 out of 5552 articles were included for data extraction and assessment of reporting quality, reporting on 48 unique early detection strategies. Early detection of atrial fibrillation in asymptomatic patients was most frequently studied (n = 15) followed by abdominal aortic aneurysm (n = 8), hypertension (n = 7) and predicted 10-year CVD risk (n = 5). Overall, 43 strategies (87.8%) were reported as cost effective and 11 (22.5%) CVD-related strategies reported cost reductions. Reporting quality ranged between 25 and 86%. CONCLUSIONS Current evidence suggests that early CVD detection strategies are predominantly cost effective and may reduce CVD-related costs compared with no early detection. However, the lack of standardisation complicates the comparison of cost-effectiveness outcomes between studies. Real-world cost effectiveness of early CVD detection strategies will depend on the target country and local context. REGISTRATION OF SYSTEMATIC REVIEW CRD42022321585 in International Prospective Registry of Ongoing Systematic Reviews (PROSPERO) submitted at 10 May 2022.
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Affiliation(s)
- Martijn J Oude Wolcherink
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carina M Behr
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Xavier G L V Pouwels
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carine J M Doggen
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Hendrik Koffijberg
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands.
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APLUS: A Python library for usefulness simulations of machine learning models in healthcare. J Biomed Inform 2023; 139:104319. [PMID: 36791900 DOI: 10.1016/j.jbi.2023.104319] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
Despite the creation of thousands of machine learning (ML) models, the promise of improving patient care with ML remains largely unrealized. Adoption into clinical practice is lagging, in large part due to disconnects between how ML practitioners evaluate models and what is required for their successful integration into care delivery. Models are just one component of care delivery workflows whose constraints determine clinicians' abilities to act on models' outputs. However, methods to evaluate the usefulness of models in the context of their corresponding workflows are currently limited. To bridge this gap we developed APLUS, a reusable framework for quantitatively assessing via simulation the utility gained from integrating a model into a clinical workflow. We describe the APLUS simulation engine and workflow specification language, and apply it to evaluate a novel ML-based screening pathway for detecting peripheral artery disease at Stanford Health Care.
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Cost-effectiveness analysis of screening for peripheral artery disease in patients with coronary artery disease in China: A Markov model. Int J Cardiol 2023; 371:420-426. [PMID: 36228765 DOI: 10.1016/j.ijcard.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/02/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The innovative pharmacological combination of low-dose rivaroxaban plus aspirin provides clinicians with an ideal opportunity to intensify the medical treatment of patients with coronary artery disease (CAD) and comorbid peripheral artery disease (PAD). We aimed to determine the cost-effectiveness of PAD screening using the ankle-brachial index (ABI) test in patients with CAD (with rivaroxaban administered if the PAD screening was positive) compared with no-screening strategy in China. METHODS A Markov decision model using a 1-month cycle was developed to simulate the 25-year effectiveness and cost of PAD screening on 75-year-old patients with CAD in China, evaluating the quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were conducted to assess the impact of variations in the key parameters for ICERs. RESULTS Our model found an incremental cost of RMB4,959 (US$740) and an incremental QALY of 0.054 after one-time ABI screening, leading to an ICER of RMB91,936 (US$13,717) per QALY gained over a 25-year period. The reduction in all-cause mortality related to rivaroxaban and its cost were the factors most affecting the ICER. The screening would become cost-effective by decreasing the monthly cost of rivaroxaban to RMB184.5 (US$27.5) or by using domestic-brand rivaroxaban according to the threshold of a willingness to pay RMB72,447 (US$10,809) per QALY gained. CONCLUSIONS Our study demonstrated that ABI screening for PAD to decide on low-dose rivaroxaban administration was not cost-effective for patients with CAD in China. Nevertheless, policy-guided cost changes for domestic-brand rivaroxaban could easily resolve this issue.
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Gao L, Moodie M. Offering a lifestyle intervention to women of premenopausal age as primary prevention for cardiovascular disease? - assessing its cost-effectiveness. Int J Behav Nutr Phys Act 2022; 19:152. [PMID: 36517831 PMCID: PMC9749355 DOI: 10.1186/s12966-022-01384-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is limited evidence of cost-effective primary prevention interventions for cardiovascular disease (CVD) in young women. This study aimed to assess the value for money of primary prevention of CVD in this population. METHODS A Markov microsimulation model consisting of both first-ever and recurrent CVD events was developed to simulate the lifetime intervention impact on cost and health outcomes in women of premenopausal age (30 to 54 years) from the Australian healthcare system perspective. The latest wave of the Australian National Health Survey defined the modelled population's characteristics. The intervention effectiveness of a lifestyle modification program involving changes in diet and physical activity demonstrated to be effective in this population was sourced from a systematic review and meta-analysis. The first-ever and recurrent CVD probabilities were derived from the CVD risk calculators accounting for socio-demographic and clinical characteristics. Costs and utility weights associated with CVD events and long-term management post-CVD were informed by national statistics/published literature. Sensitivity analyses were undertaken to examine the robustness of base case results. RESULTS The lifestyle modification program was associated with both higher costs and benefits (in terms of quality-adjusted life years, QALYs) as a primary prevention measure of CVD in premenopausal women, with an ICER of $96,377/QALY or $130,469/LY. The intervention led to fewer first-ever (N = -19) and recurrent CVD events (N = -23) per 10,000 women over the modelled life horizon. The avoided cost due to reduced hospitalisations (-$24) and management (-$164) of CVD could partially offset the cost associated with the intervention ($1560). Sensitivity analysis indicated that time horizon, starting age of the intervention, discount rate, and intervention effectiveness were the key drivers of the results. If the intervention was scaled up to the national level (N = 502,095 at-risk premenopausal women), the total intervention cost would be $794 million with $95 million in healthcare cost-savings. CONCLUSION Offering a lifestyle modification program to premenopausal women in Australia as primary prevention of CVD is not cost-effective from a healthcare system perspective. We should continue to search for new or adapt/optimise existing effective and cost-effective primary prevention measures of CVD for women.
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Affiliation(s)
- Lan Gao
- grid.1021.20000 0001 0526 7079Deakin Health Economics, Institute for Health Transformation, School of Health & Social Development, Faculty of Health, Deakin University, 221 Burwood Hwy, Burwood, Melbourne, Australia
| | - Marj Moodie
- grid.1021.20000 0001 0526 7079Deakin Health Economics, Institute for Health Transformation, School of Health & Social Development, Faculty of Health, Deakin University, 221 Burwood Hwy, Burwood, Melbourne, Australia
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Katorkin SE, Krivoshchekov EP, Elshin EB, Kushnarchuk MY. Modern possibilities and prospects of conservative treatment of patients with peripheral arterial diseases. AMBULATORNAYA KHIRURGIYA = AMBULATORY SURGERY (RUSSIA) 2022. [DOI: 10.21518/1995-1477-2022-19-2-50-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The most common clinical manifestation of peripheral arterial disease is intermittent claudication due to insufficient blood supply to the affected limb. The article summarizes and systematizes the latest achievements in the field of conservative treatment of patients with intermittent claudication. In accordance with the requirements of evidence-based medicine, an overview of modern promising trends in conservative therapy presented in the latest Russian and foreign consensus documents, is given. The basis of the complex treatment of patients with peripheral arterial diseases is: non-drug and drug treatment to relieve the symptoms of chronic ischemia, pharmacotherapy for the secondary prevention of cardiovascular complications, open or endovascular revascularization to increase the distance of painfree walking. With the development of atherosclerosis, disturbances in the peptide composition of the endothelium occur, which reduce the ability of the vascular wall to resist inflammation and the associated triggering of pathological processes. It has been experimentally proven that the use of a complex of peptides obtained from the vessels of healthy and young animals in this situation restores the endothelial function of the arteries, affecting the main links of pathogenesis. Decrease in oxidative stress, decrease in atherogenic and lipidemic action, normalization of vascular tone and blood coagulation parameters, increase in the microvascular bed – these are the mechanisms that justify the indication of peptides to patients with atherosclerosis obliterans. Angioprotector based on a complex of polypeptides isolated from blood vessels can become an important part of the treatment of patients with obliterating diseases of the arteries of the lower extremities, providing a complex pathogenetic effect. It is necessary to further study in multicenter clinical trials the duration of the therapeutic effect of a drug in a longer period after a course of treatment, its effect on long-term outcomes of the disease, the possibility of using repeated courses, in chronic obliterating diseases of the arteries of the lower extremities III-IV stages according to the Fontaine classification, as well as the use drug for the treatment of systemic atherosclerosis of various arterial basins.
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Zhang D, Li Y, Kalbaugh CA, Shi L, Divers J, Islam S, Annex BH. Machine Learning Approach to Predict In-Hospital Mortality in Patients Admitted for Peripheral Artery Disease in the United States. J Am Heart Assoc 2022; 11:e026987. [PMID: 36216437 DOI: 10.1161/jaha.122.026987] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Peripheral artery disease (PAD) affects >10 million people in the United States. PAD is associated with poor outcomes, including premature death. Machine learning (ML) has been increasingly used on big data to predict clinical outcomes. This study aims to develop ML models to predict in-hospital mortality in patients hospitalized for PAD based on a national database. Methods and Results Inpatient hospitalization data were obtained from the 2016 to 2019 National Inpatient Sample. A total of 150 921 inpatients were identified with a primary diagnosis of PAD and PAD-related procedures using codes of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). Four ML models, including logistic regression, random forest, light gradient boosting, and extreme gradient boosting models, were trained to predict the risk of in-hospital death based on a selection of variables, including patient characteristics, comorbidities, procedures, and hospital-related factors. In-hospital mortality occurred in 1.8% of patients. The performance of the 4 models was comparable, with the area under the receiver operating characteristic curve ranging from 0.83 to 0.85, sensitivity of 77% to 82%, and specificity of 72% to 75%. These results suggest adequate predictability for clinical decision-making. In all 4 models, the total number of diagnoses and procedures, age, endovascular revascularization procedure, congestive heart failure, diabetes, and diabetes with complications were critical predictors of in-hospital mortality. Conclusions This study demonstrates the feasibility of ML in predicting in-hospital mortality in patients with a primary PAD diagnosis. Findings highlight the potential of ML models in identifying high-risk patients for poor outcomes and guiding personalized intervention.
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Affiliation(s)
- Donglan Zhang
- Division of Health Services Research, Department of Foundations of Medicine New York University Long Island School of Medicine Mineola NY
| | - Yike Li
- Department of Otolaryngology-Head and Neck Surgery, Bill Wilkerson Center Vanderbilt University Medical Center Nashville TN
| | | | - Lu Shi
- Department of Public Health Sciences Clemson University Clemson SC
| | - Jasmin Divers
- Division of Health Services Research, Department of Foundations of Medicine New York University Long Island School of Medicine Mineola NY
| | - Shahidul Islam
- Division of Health Services Research, Department of Foundations of Medicine New York University Long Island School of Medicine Mineola NY
| | - Brian H Annex
- Department of Medicine and Vascular Biology Center Medical College of Georgia Augusta GA
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Kamenský V, Rogalewicz V, Gajdoš O, Donin G. Discrete Event Simulation Model for Cost-Effectiveness Evaluation of Screening for Asymptomatic Patients with Lower Extremity Arterial Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11792. [PMID: 36142065 PMCID: PMC9517120 DOI: 10.3390/ijerph191811792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/06/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
Lower limb ischemic disease (LEAD) affects a significant portion of the population, with most patients being asymptomatic. Patient screening is necessary because LEAD patients have an increased risk of occurrence of other cardiovascular events and manifestations of disease, in terms of leg symptoms such as intermittent claudication, critical limb ischemia, or amputation. The aim of this work was to evaluate the cost-effectiveness of screening using ABI diagnostics in asymptomatic patients and its impact on limb symptoms associated with LEAD. A discrete event simulation model was created to capture lifetime costs and effects. Costs were calculated from the perspective of the health care payer, and the effects were calculated as QALYs. A cost-effectiveness analysis was performed to compare ABI screening examination and the situation without such screening. A probabilistic sensitivity analysis and scenario analysis were carried out to evaluate the robustness of the results. In the basic setting, the screening intervention was a more expensive intervention, at a cost of CZK 174,010, compared to CZK 70,177 for the strategy without screening. The benefits of screening were estimated at 14.73 QALYs, with 14.46 QALYs without screening. The final ICER value of CZK 389,738 per QALY is below the willingness to pay threshold. Likewise, the results of the probabilistic sensitivity analysis and of the scenario analysis were below the threshold of willingness to pay, thus confirming the robustness of the results. In conclusion, ABI screening appears to be a cost-effective strategy for asymptomatic patients aged 50 years when compared to the no-screening option.
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Sartipy F, Garcia Pereira Filho AJ, Lundin F, Wahlberg E, Sigvant B. Presence of asymptomatic Peripheral Arterial Disease in combination with common risk factors elevates the cardiovascular risk Substantially. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2022; 13:200130. [PMID: 35493293 PMCID: PMC9043415 DOI: 10.1016/j.ijcrp.2022.200130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 12/24/2022]
Abstract
Background and aims This study evaluates the risks for adverse cardiovascular (CV) events in Asymptomatic Peripheral Arterial Disease (APAD) combined with different traditional CV risk factors. Methods A population-based observational study of 8000 subjects, identified 559 subjects as having APAD through ankle-brachial index (ABI) measurements and questionnaires regarding limb symptoms. This cohort and subgroups classified by presence of different traditional CV risk factors at baseline were assessed for 10 years on CV outcome. The recorded endpoints were all-cause mortality, CV mortality and non-fatal CV events. Results Before subdividing the APAD subjects, the CV mortality incidence was 28.5 deaths per 1000 person-years as compared to 8.7 deaths for references without APAD. For subjects with hypertension at baseline the CV mortality incidence was 35.4 when combined with APAD and 11.7 without. In women with hypertension but without other risk factors, presence of APAD increased the age-adjusted Hazard Ratio (HR) for fatal and non-fatal CV events by 1.86 [CI 1.54,2.24, p < 0.001]. Conclusions ABI measurements should be considered an important indication for aggressive multifactorial risk factor reduction in populations with any other prevalent CV risk factor. In hypertension, diabetes mellitus and a smoking history, coexisting APAD contributes significantly to the increased age-adjusted CV risk.
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Affiliation(s)
- Fredrik Sartipy
- Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Kirurgkliniken, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | | | - Fredrik Lundin
- Centre of Clinical Research, County Council of Värmland, Älvgatan 49, 652 30, Karlstad, Sweden
| | - Eric Wahlberg
- Department of Medicine and Health, Linköping University, Linkoping University Hospital, SE 581-53, Linköping, Sweden
| | - Birgitta Sigvant
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Biscetti F, Cecchini AL, Rando MM, Nardella E, Gasbarrini A, Massetti M, Flex A. Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review. ATHEROSCLEROSIS PLUS 2021; 46:1-14. [PMID: 36643723 PMCID: PMC9833249 DOI: 10.1016/j.athplu.2021.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/10/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023]
Abstract
Background and aims The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease. Methods Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors. Results In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease. Conclusion We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.
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Affiliation(s)
- Federico Biscetti
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy,Corresponding author. Internal and Cardiovascular Medicine Unit. Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, 00168, Italy.
| | | | - Maria Margherita Rando
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Elisabetta Nardella
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Flex
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
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Zupa MF, Codario RA, Smith KJ. Cost-effectiveness of empagliflozin versus weekly semaglutide as add-on therapy for Type 2 diabetes. J Comp Eff Res 2021; 10:1133-1141. [PMID: 34490786 DOI: 10.2217/cer-2021-0016] [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: 11/21/2022] Open
Abstract
Aim: Perform a cost-effectiveness analysis of addition of subcutaneous semaglutide versus empagliflozin to usual treatment for patients with Type 2 diabetes and cardiovascular disease in US setting. Materials & methods: A Markov decision model estimated the impact of each strategy using cardiovascular complication rates based on EMPA-REG and SUSTAIN-6 trials. Modeled cohorts were followed for 3 years at 1-month intervals beginning at age 66. Results: Compared with empagliflozin, semaglutide resulted in cost of US$19,964 per quality-adjusted life-year gained. In one-way sensitivity analysis, only semaglutide cost >US$36.25/day (base case US$18.04) resulted in empagliflozin being preferred at a willingness-to-pay threshold of US$50,000/quality-adjusted life-year gained. Conclusion: For patients with Type 2 diabetes and cardiovascular disease, semaglutide is likely more cost-effective than empagliflozin added to usual treatment.
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Affiliation(s)
- Margaret F Zupa
- Division of Endocrinology & Metabolism, University of Pittsburgh, PA 15213, USA
| | - Ronald A Codario
- Division of Endocrinology & Metabolism, University of Pittsburgh, PA 15213, USA.,Division of Endocrinology, Veteran's Health Administration Pittsburgh Health System, PA 15240, USA
| | - Kenneth J Smith
- University of Pittsburgh, Center for Research on Healthcare, PA 15213, USA
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15
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Cui C, Ramakrishnan G, Murphy J, Malas MB. Cost-Effectiveness of TransCarotid Artery Revascularization versus Carotid Endarterectomy. J Vasc Surg 2021; 74:1910-1918.e3. [PMID: 34182030 DOI: 10.1016/j.jvs.2021.05.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/17/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Recent studies have demonstrated that TransCarotid Artery Stenting (TCAR) has comparable outcomes to the surgical gold standard, carotid endarterectomy (CEA). However, few studies have analyzed the cost of TCAR and no study has evaluated its cost-effectiveness. The purpose of this study is to conduct a cost-effectiveness analysis comparing TCAR to CEA for carotid artery stenosis. METHODS We built a Markov microsimulation using transition probabilities and utilities from existing literature for symptomatic patients undergoing TCAR or CEA. Costs were derived from literature then converted to 2019 dollars. The model included six health states with monthly cycle lengths: surgery, death, alive after surgery, alive after myocardial infarction, alive after stroke, and alive after stroke and death. Quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a five-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. RESULTS For symptomatic patients, CEA cost $7821 for 2.85 QALYs while TCAR cost $19154 for 2. 92 QALYs, leading to an ICER of $152,229 per QALY gained in the TCAR arm Sensitivity analysis demonstrated that our model was most sensitive to probability of restenosis, costs of TCAR and costs of CEA. Probabilistic sensitivity analysis demonstrated TCAR would be considered cost effective 49% of iterations. CONCLUSIONS This study found that while five-year costs for TCAR were greater than CEA, TCAR afforded greater QALYs than CEA. TCAR became cost-effective at six-years follow-up.
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Affiliation(s)
- Christina Cui
- School of Medicine, University of California San Diego, La Jolla, Calif
| | - Ganesh Ramakrishnan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif.
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16
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Lindholt JS, Søgaard R. Clinical Benefit, Harm, and Cost Effectiveness of Screening Men for Peripheral Artery Disease: A Markov Model Based on the VIVA Trial. Eur J Vasc Endovasc Surg 2021; 61:971-979. [PMID: 33846075 DOI: 10.1016/j.ejvs.2021.02.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/10/2021] [Accepted: 02/20/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although screening for peripheral arterial disease (PAD) seems obvious due to its two to three times increased mortality, high prevalence in the elderly, ease of detection, and relatively harmless prevention, the evidence is sparse. METHODS A Markov decision model was created to model the lifetime effectiveness and cost effectiveness of general population PAD screening and relevant intervention in 65 year old men. The model was informed by original estimates from the VIVA trial data except for ankle brachial systolic blood pressure index test accuracy, quality of life, and background mortality, which were adopted from the literature. A Markov model was designed for 65 year old men, who were distributed in the starting states of no/detected/undetected PAD. The main outcomes were life years, quality adjusted life years, and costs of healthcare. RESULTS Screening for PAD reduced the rates of amputations and stroke by 10.9% and 2.4%, respectively, while it increased the rates of revascularisation, acute myocardial infarction, and major bleeding by 5.5%, 7.1%, and 4.3% respectively. The overall life expectancy was increased by 14 days per invited subject. The cost per life year/quality adjusted life year was estimated at €16 717/€20 673. On the addition of low dose rivaroxaban reduced the costs per life year gained by 40%. If the model ran for only five follow up years, screening reduced relative mortality by 1.71%, suggesting PAD screening accounts for one fourth of the reported overall 7% relative mortality risk reduction of combined abdominal aortic aneurysm, PAD, and hypertension screening. CONCLUSION Screening of men for PAD is likely to be both clinically effective and cost effective in a lifetime perspective.
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Affiliation(s)
- Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark; Department of Vascular Surgery, Viborg Hospital, Viborg, Denmark.
| | - Rikke Søgaard
- Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark; Department of Public Health, Aarhus University, Aarhus, Denmark
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Creager MA, Matsushita K, Arya S, Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel LP. Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association. Circulation 2021; 143:e875-e891. [PMID: 33761757 DOI: 10.1161/cir.0000000000000967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.
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18
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Behroozian AA, Beckman JA. Asymptomatic peripheral artery disease: Silent but deadly. Prog Cardiovasc Dis 2021; 65:2-8. [PMID: 33617896 DOI: 10.1016/j.pcad.2021.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/13/2021] [Indexed: 12/29/2022]
Abstract
Peripheral Artery Disease (PAD) is a manifestation of atherosclerosis characterized by diminished perfusion of the limb and a state of dysmetabolism. The asymptomatic PAD phenotype is a relatively recent classification. It is unknown how many people currently live with asymptomatic PAD because there are no universal screening recommendations for patients at risk for PAD. Patients with asymptomatic PAD suffer from a similar risk profile of morbidity and mortality as their counterparts with claudication. Despite this increased risk, there is a dearth of clinical investigations into therapies that specifically benefit the asymptomatic PAD population. At present, current pharmacotherapies that have been studied in PAD patient populations do not stratify by symptom status. We believe that further investigation of the impact of existing therapies in this unique population presents an opportunity to reduce morbidity and mortality due to PAD. This can only be achieved in combination with wide-spread adoption of screening for asymptomatic PAD.
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Affiliation(s)
- Adam A Behroozian
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua A Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN, USA.
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19
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Abstract
An estimated 237 million people suffer from peripheral arterial disease (PAD), which is associated with high morbidity and mortality, and prevalence is still increasing. Currently, we do not have any randomized trials that compare screening to no screening specifically for PAD in the general population. Presently, PAD screening is not generally established. This systematic review gives an overview of relevant literature and guidelines. Screening usually focuses on ankle-brachial index (ABI)-measurement, which enables detection of asymptomatic and symptomatic PAD, but has limitations in diabetics. There are no sufficient data on PAD screening. Guideline recommendations are heterogeneous. While some advocate no screening until better data are available, most recommend selective screening despite insufficient data on morbidity and mortality reduction in consequence of screening. We support the only evidence-based screening strategy for PAD: combined screening for abdominal aortic aneurysm (AAA), PAD and arterial hypertension in men aged 65-74 according to the VIVA study. We additionally suggest a new simple three-step screening strategy for symptomatic PAD in all individuals aged 40 and older, who see a general practitioner: Asking one question ("Do you have pain or cramps in the legs during normal walking?") followed by physical examination (normal lower extremity pulse status?) in those, whose answer is "yes", and ABI measurement unless all pulses are normal.
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Affiliation(s)
- Arne G Kieback
- Medical University Department, Division of Angiology, Kantonsspital Aarau, Aargau, Switzerland
| | - Roman Gähwiler
- Medical University Department, Division of Angiology, Kantonsspital Aarau, Aargau, Switzerland
| | - Christoph Thalhammer
- Medical University Department, Division of Angiology, Kantonsspital Aarau, Aargau, Switzerland
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20
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Abstract
Распространенность заболеваний периферических артерий (ЗПА) во всем мире достигает порядка 200 миллионов человек. Самым частым клиническим проявлением ЗПА является перемежающая хромота, возникающая вследствие недостаточного кровоснабжения пораженной конечности. В настоящем обзоре литературы обобщены и систематизированы последние достижения в области диагностики и лечения пациентов с перемежающей хромотой. Тщательный сбор анамнеза и физикальное обследование являются первоочередными мероприятиями для установления предварительного диагноза и направлены на дифференциацию сосудистых и нейрогенных причин перемежающей хромоты. Лодыжечно-плечевой индекс относится к наиболее часто используемым методам скрининга и диагностики ЗПА. Основу лечения составляют четыре взаимодополняющих подхода: немедикаментозное и лекарственное лечение для купирования симптомов хронической ишемии, фармакотерапия для вторичной профилактики сердечно-сосудистых осложнений, открытая или эндоваскулярная реваскуляризация для увеличения дистанции безболевой ходьбы. Недавнее исследование COMPASS продемонстрировало преимущества комбинированного применения 2,5 мг ривароксабана дважды в день и аспирина в части снижения уровня неблагоприятных сердечно-сосудистых событий, при этом отмечался более высокий риск геморрагических осложнений. На сегодняшний день цилостазол является единственным препаратом, обладающим доказанной терапевтической эффективностью в отношении перемежающей хромоты. Программы лечебной физкультуры под наблюдением врача либо в домашних условиях способствуют улучшению коллатерального кровообращения и увеличивают дистанцию ходьбы без боли. Назначение высоких доз статинов и антитромбоцитарных препаратов абсолютно обосновано всем пациентам с ЗПА. Ингибиторы ангиотензин-превращающего фермента обеспечивают дополнительное снижение кардиоваскулярных рисков, в особенности у пациентов с сахарным диабетом и артериальной гипертензией.
The prevalence of peripheral artery disease (PAD) worldwide reaches about 200 million people. The most frequent clinical manifestation of PAD is intermittent claudication, which occurs due to insufficient blood supply to the affected limb. This literature review summarizes and systematizes recent advances in the diagnosis and treatment of patients with intermittent claudication.Thorough case history collection and physical examination are the primary measures for making a preliminary diagnosis, which is aimed at differentiating the vascular and neurogenic causes of intermittent claudication. The ankle-shoulder index is one of the most commonly used methods for screening and diagnosing PAD. The basis of treatment consists of four complementary approaches: non-pharmacological and pharmacological treatment for the relief of symptoms of chronic ischemia, pharmacotherapy for the secondary prevention of cardiovascular complications, open or endovascular revascularization to increase the distance of pain-free walking. A recent COMPASS study demonstrated the benefits of combining 2.5 mg of rivaroxaban twice daily with aspirin in reducing adverse cardiovascular events, however there was a higher risk of hemorrhagic complications. Today, cilostazol is the only drug with proven therapeutic effectiveness against intermittent claudication. Physical therapy programs under the supervision of a doctor or at home help to improve collateral blood circulation and increase the walking distance without pain. The administration of high doses of statins and antiplatelet drugs is absolutely justified in all patients with PAD. Angiotensin converting enzyme inhibitors provide an additional reduction in cardiovascular risks, especially in patients with diabetes and hypertension.
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21
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Schousboe JT, Vo TN, Langsetmo L, Adabag S, Szulc P, Lewis JR, Kats AM, Taylor BC, Ensrud KE. Abdominal aortic calcification (AAC) and ankle-brachial index (ABI) predict health care costs and utilization in older men, independent of prevalent clinical cardiovascular disease and each other. Atherosclerosis 2020; 295:31-37. [PMID: 32000096 DOI: 10.1016/j.atherosclerosis.2020.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/22/2019] [Accepted: 01/15/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Abdominal aortic calcification (AAC) and low ankle-brachial index (ABI) are markers of multisite atherosclerosis. We sought to estimate their associations in older men with health care costs and utilization adjusted for each other, and after accounting for CVD risk factors and prevalent CVD diagnoses. METHODS This was an observational cohort study of 2393 community-dwelling men (mean age 73.6 years) enrolled in the Osteoporotic Fractures in Men (MrOS) study and U.S. Medicare Fee for Service (FFS). AAC was scored on baseline lateral lumbar spine X-rays using a 24-point scale. ABI was measured as the lowest ratio of arm to right or left ankle blood pressure. Health care costs, hospital stays, and SNF stays were identified from Medicare FFS claims over 36 months following the baseline visit. RESULTS Men with AAC score ≥9 (n = 519 [21.7% of analytic cohort]) had higher annualized total health care costs of $1473 (95% C.I. 293, 2654, 2017 U S. dollars) compared to those with AAC score 0-1, after multivariable adjustment. Men with ABI <0.90 (n = 154 [6.4% of analytic cohort]) had higher annualized total health care costs of $2705 (95% CI 634, 4776) compared to men with normal ABI (≥0.9 and < 1.4), after multivariable adjustment. CONCLUSIONS High levels of AAC and low ABI in older men are associated with higher subsequent health care costs, after accounting for clinical CVD risk factors, prevalent CVD diagnoses, and each other. Further investigations of whether preventing progression of peripheral vascular disease and calcification reduces subsequent health care costs are warranted.
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Affiliation(s)
- John T Schousboe
- Park Nicollet Clinic and HealthPartners Institute, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA.
| | - Tien N Vo
- University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - Joshua R Lewis
- Edith Cowan University, Perth, Australia; Medical School, University of Western Australia, Perth, Australia; Centre for Kidney Research, School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Brent C Taylor
- University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
| | - Kristine E Ensrud
- University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, MN, USA
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22
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Abstract
PURPOSE OF THE REVIEW Peripheral artery disease (PAD) affects close to 200 million people worldwide. Claudication is the most common presenting symptom for patients with PAD. This review summarizes the current diagnostic and treatment options for patients with claudication. Comprehensive history and physical examination in order to differentiate between claudication secondary to vascular disease vs. neurogenic causes is paramount for initial diagnosis. Ankle-brachial index is the most commonly used test for screening and diagnostic purposes. Treatment consists of four different approaches, which are best utilized in combination: non-pharmacological treatment for claudication improvement, pharmacological treatment for claudication improvement, pharmacological treatment for secondary risk reduction, and interventional treatment for claudication improvement. RECENT FINDINGS Cilostazol is the only Food and Drug Administration (FDA)-approved agent for symptomatic treatment of claudication. Supervised exercise programs provide the maximum benefit for claudication improvement, but home-based exercise programs are an alternative. High-intensity statins and an antiplatelet agent should be prescribed to all patients with PAD. Angiotensin-converting-enzyme inhibitors can provide additional risk reduction, especially in patients with diabetes or hypertension. Rivaroxaban of low dosage (2.5 mg twice daily) in combination with aspirin further decreases cardiovascular risk, but this reduction comes at the cost of higher bleeding risk. Peripheral artery disease (PAD) is a form of atherosclerotic disease that affects hundreds of millions of people worldwide-one of its most common manifestations is intermittent claudication (IC), which results from insufficient blood flow to meet the metabolic demands of an affected extremity. This paper reviews the current literature regarding the workup, diagnosis, diagnostic modalities, treatment options, and management of intermittent claudication.
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Affiliation(s)
- Prio Hossain
- UC Davis School of Medicine, Sacramento, CA, USA
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Division of Cardiology, Rocky Mountain VA Medical Center and University of Colorado, 1600 North Wheeling Street, Aurora, Denver, CO, 80045, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain VA Medical Center and University of Colorado, 1600 North Wheeling Street, Aurora, Denver, CO, 80045, USA.
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23
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Zomer E, Si S, Hird TR, Liew D, Owen AJ, Tonkin A, Reid CM, Ademi Z. Cost-effectiveness of low-dose rivaroxaban and aspirin versus aspirin alone in people with peripheral or carotid artery disease: An Australian healthcare perspective. Eur J Prev Cardiol 2018; 26:858-868. [DOI: 10.1177/2047487318817910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Aims Peripheral artery disease affects 1.2% of the population globally and is associated with an increased risk of atherothrombotic cardiovascular events, major adverse limb events and mortality. The Cardiovascular Outcomes for People Using Anti-coagulation Strategies (COMPASS) trial demonstrated positive results of rivaroxaban plus aspirin therapy compared to aspirin therapy alone in those with peripheral artery disease or carotid artery disease. We sought to estimate the cost-effectiveness from the Australian healthcare system perspective. Methods and results A Markov model was developed to simulate the experiences of a hypothetical population of 1000 individuals with peripheral artery disease or carotid artery disease, profiled on the COMPASS trial, treated with rivaroxaban plus aspirin therapy versus aspirin therapy alone. With each annual cycle, individuals were at risk of having non-fatal cardiovascular disease events, major adverse limb events, or dying. Individuals were also at risk of non-fatal major bleeding. The model had a lifetime time horizon. Costs and utilities were sourced from the literature and discounted at 5.0% annually. Rivaroxaban plus aspirin therapy prevented 143 non-fatal cardiovascular disease events, 118 major adverse limb events and 10 deaths compared to aspirin therapy alone. Conversely, 156 additional major non-fatal bleeds were accrued. With an additional 256 quality-adjusted life years gained, at an additional cost of AUD$6,858,103, the incremental cost-effectiveness ratio was AUD$26,769 (discounted) per quality-adjusted life year gained, which is below Australia’s arbitrary willingness to pay threshold of AUD$50,000. Conclusion In those with peripheral artery disease or carotid artery disease, rivaroxaban plus aspirin therapy is effective and cost-effective in the prevention of recurrent cardiovascular disease compared to aspirin therapy alone.
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Affiliation(s)
- Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Si Si
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Thomas R Hird
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Alice J Owen
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Andrew Tonkin
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Australia
- School of Public Health, Curtin University, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Australia
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24
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Mezdad T, Henni S, Feuilloy M, Chauvet P, Schang D, Abraham P. Identification of new factors associated to walking impairment in patients with vascular-type claudication. Vascular 2018; 27:260-269. [PMID: 30442076 DOI: 10.1177/1708538118813708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Mechanisms of walking limitation in arterial claudication are incompletely elucidated. We aimed to identify new variables associated to walking limitation in patients with claudication. METHODS We retrospectively analyzed data of 1120 patients referred for transcutaneous exercise oxygen pressure recordings (TcpO2). The outcome measurement was the absolute walking time on treadmill (3.2 km/h, 10% slope). We used both: linear regression analysis and a non-linear analysis, combining support vector machines and genetic explanatory in 800 patients with the following resting variables: age, gender, body mass index, the presence of diabetes, minimal ankle to brachial index at rest, usual walking speed over 10 m (usual-pace), number of comorbid conditions, active smoking, resting heart rate, pre-test glycaemia and hemoglobin, beta-blocker use, and exercise-derived variables: minimal value of pulse oximetry, resting chest-TcpO2, decrease in chest TcpO2 during exercise, presence of buttock ischemia defined as a decrease from rest of oxygen pressure index ≤15 mmHg. We tested the models over 320 other patients. RESULTS Independent variables associated to walking time, by decreasing importance in the models, were: age, ankle to brachial index, usual-pace; resting TcpO2, body mass index, smoking, buttock ischemia, heart rate and beta-blockers for the linear regression analysis, and were ankle to brachial index, age, body mass index, usual-pace, decrease in chest TcpO2, smoking, buttock ischemia, glycaemia, heart rate for the non-linear analysis. Testing of models over 320 new patients gave r = 0.509 for linear and 0.575 for non-linear analysis (both p < 0.05). CONCLUSION Buttock ischemia, heart rate and usual-pace are new variables associated to walking time.
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Affiliation(s)
| | - Samir Henni
- 1 Vascular Medicine, University Hospital, Angers, France
| | | | | | | | - Pierre Abraham
- 4 Exercise and Sports Medicine, University Hospital, Angers, France.,5 INSERM 1083, CNRS 6015, LUNAM Université, Angers, France
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McDermott MM, Criqui MH. Ankle-Brachial Index Screening and Improving Peripheral Artery Disease Detection and Outcomes. JAMA 2018; 320:143-145. [PMID: 29998324 DOI: 10.1001/jama.2018.8953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Mary M McDermott
- Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Senior Editor
| | - Michael H Criqui
- Department of Family Medicine and Preventive Health, University of California, San Diego, La Jolla
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Affiliation(s)
- Joshua A Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN, USA
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