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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] [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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Cucato G, Longano PP, Perren D, Ritti-Dias RM, Saxton JM. Effects of additional exercise therapy after a successful vascular intervention for people with symptomatic peripheral arterial disease. Cochrane Database Syst Rev 2024; 5:CD014736. [PMID: 38695785 PMCID: PMC11064885 DOI: 10.1002/14651858.cd014736.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is characterised by obstruction or narrowing of the large arteries of the lower limbs, usually caused by atheromatous plaques. Most people with PAD who experience intermittent leg pain (intermittent claudication) are typically treated with secondary prevention strategies, including medical management and exercise therapy. Lower limb revascularisation may be suitable for people with significant disability and those who do not show satisfactory improvement after conservative treatment. Some studies have suggested that lower limb revascularisation for PAD may not confer significantly more benefits than supervised exercise alone for improved physical function and quality of life. It is proposed that supervised exercise therapy as adjunctive treatment after successful lower limb revascularisation may confer additional benefits, surpassing the effects conferred by either treatment alone. OBJECTIVES To assess the effects of a supervised exercise programme versus standard care following successful lower limb revascularisation in people with PAD. SEARCH METHODS We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registers, most recently on 14 March 2023. SELECTION CRITERIA We included randomised controlled trials which compared supervised exercise training following lower limb revascularisation with standard care following lower limb revascularisation in adults (18 years and older) with PAD. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were maximum walking distance or time (MWD/T) on the treadmill, six-minute walk test (6MWT) total distance, and pain-free walking distance or time (PFWD/T) on the treadmill. Our secondary outcomes were changes in the ankle-branchial index, all-cause mortality, changes in health-related quality-of-life scores, reintervention rates, and changes in subjective measures of physical function. We analysed continuous data by determining the mean difference (MD) and 95% confidence interval (CI), and dichotomous data by determining the odds ratio (OR) with corresponding 95% CI. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified seven studies involving 376 participants. All studies involved participants who received either additional supervised exercise or standard care after lower limb revascularisation. The studies' exercise programmes varied, and included supervised treadmill walking, combined exercise, and circuit training. The duration of exercise therapy ranged from six weeks to six months; follow-up time ranged from six weeks to five years. Standard care also varied between studies, including no treatment or advice to stop smoking, lifestyle modifications, or best medical treatment. We classified all studies as having some risk of bias concerns. The certainty of the evidence was very low due to the risk of bias, inconsistency, and imprecision. The meta-analysis included only a subset of studies due to concerns regarding data reporting, heterogeneity, and bias in most published research. The evidence was of very low certainty for all the review outcomes. Meta-analysis comparing changes in maximum walking distance from baseline to end of follow-up showed no improvement (MD 159.47 m, 95% CI -36.43 to 355.38; I2 = 0 %; 2 studies, 89 participants). In contrast, exercise may improve the absolute maximum walking distance at the end of follow-up compared to standard care (MD 301.89 m, 95% CI 138.13 to 465.65; I2 = 0 %; 2 studies, 108 participants). Moreover, we are very uncertain if there are differences in the changes in the six-minute walk test total distance from baseline to treatment end between exercise and standard care (MD 32.6 m, 95% CI -17.7 to 82.3; 1 study, 49 participants), and in the absolute values at the end of follow-up (MD 55.6 m, 95% CI -2.6 to 113.8; 1 study, 49 participants). Regarding pain-free walking distance, we are also very uncertain if there are differences in the mean changes in PFWD from baseline to treatment end between exercise and standard care (MD 167.41 m, 95% CI -11 to 345.83; I2 = 0%; 2 studies, 87 participants). We are very uncertain if there are differences in the absolute values of ankle-brachial index at the end of follow-up between the intervention and standard care (MD 0.01, 95% CI -0.11 to 0.12; I2 = 62%; 2 studies, 110 participants), in mortality rates at the end of follow-up (OR 0.92, 95% CI 0.42 to 2.00; I2 = 0%; 6 studies, 346 participants), health-related quality of life at the end of follow-up for the physical (MD 0.73, 95% CI -5.87 to 7.33; I2 = 64%; 2 studies, 105 participants) and mental component (MD 1.04, 95% CI -6.88 to 8.95; I2 = 70%; 2 studies, 105 participants) of the 36-item Short Form Health Survey. Finally, there may be little to no difference in reintervention rates at the end of follow-up between the intervention and standard care (OR 0.91, 95% CI 0.23 to 3.65; I2 = 65%; 5 studies, 252 participants). AUTHORS' CONCLUSIONS There is very uncertain evidence that additional exercise therapy after successful lower limb revascularisation may improve absolute maximal walking distance at the end of follow-up compared to standard care. Evidence is also very uncertain about the effects of exercise on pain-free walking distance, six-minute walk test distance, quality of life, ankle-brachial index, mortality, and reintervention rates. Although it is not possible to confirm the effectiveness of supervised exercise compared to standard care for all outcomes, studies did not report any harm to participants from this intervention after lower limb revascularisation. Overall, the evidence incorporated into this review was very uncertain, and additional evidence is needed from large, well-designed, randomised controlled studies to more conclusively demonstrate the role additional exercise therapy has after lower limb revascularisation in people with PAD.
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Affiliation(s)
- Gabriel Cucato
- Department of Sport, Exercise, and Rehabilitation, Northumbria University, Newcastle-upon-Tyne, UK
| | - Paulo Pl Longano
- Ciências da Reabilitação, Universidade Nove de Julho, São Paulo, Brazil
| | - Daniel Perren
- Department of Vascular Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | | | - John M Saxton
- Department of Sport, Health & Exercise Science, University of Hull, Hull, UK
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Hallak AO, Hallak FZ, Hallak YO, Hallak OO, Hayson AW, Tanami SA, Bennett WL, Lavie CJ. Exercise Therapy in the Management of Peripheral Arterial Disease. Mayo Clin Proc Innov Qual Outcomes 2023; 7:476-489. [PMID: 37823000 PMCID: PMC10562863 DOI: 10.1016/j.mayocpiqo.2023.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Abstract
The incidence and prevalence of peripheral artery disease (PAD) are increasing globally and have a marked economic burden in the United States. The American Heart Association/American College of Cardiology guidelines recommend exercise therapy as a Class 1A, but its utilization remains suboptimal. This state-of-the-art review aims to provide a comprehensive review of the most updated information available on PAD, along with its risk factors, management options, outcomes, economic burden, and the role of exercise therapy in managing PAD.
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Affiliation(s)
- Ahmad O. Hallak
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA
| | | | - Yusuf O. Hallak
- School of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | | | - Aaron W. Hayson
- Department of Vascular Surgery, Ochsner Medical Center, New Orleans, LA
| | - Sadia A. Tanami
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo
| | | | - Carl J. Lavie
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA
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Shin WY, Lee HJ, Kim JH. Real-World Safety and Effectiveness of Controlled-Release Cilostazol in Patients with Symptomatic Peripheral Artery Disease. Clin Drug Investig 2023; 43:729-738. [PMID: 37653223 DOI: 10.1007/s40261-023-01302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Cilostazol is the only first-line medication for treating intermittent claudication, and the controlled-release (CR) formulation is associated with a lower prevalence of adverse events (AEs). OBJECTIVE The objective of the study was to assess the safety and effectiveness of cilostazol CR in patients with symptomatic peripheral artery disease (PAD). METHODS In this multicentre (113 sites), open-label, prospective observational study, we evaluated the real-world safety and effectiveness of cilostazol CR 200 mg once daily in patients with symptomatic PAD treated in routine clinical settings. The primary endpoint was the incidence and severity of AEs, and their causal relationship with cilostazol CR. The secondary endpoint was the effectiveness of the drug, as assessed by each patient's physician, for improving intermittent claudication. RESULTS Among 2063 participants who received cilostazol CR for a mean duration of 88.6 days, 99 (4.80 %) experienced adverse drug reactions (ADRs), although no unexpected adverse reactions were observed. There was no significant difference in the incidence of ADRs according to patient demographics and comorbidities (all p > 0.05). The treatment was 'effective' in 1600 patients (78.93 %), although effectiveness significantly differed according to the patients' sex and the presence of comorbidities, including diabetes mellitus, hypertension, and coronary artery disease (all p < 0.01). CONCLUSIONS This study demonstrated the tolerability and effectiveness of cilostazol CR treatment in patients with symptomatic PAD.
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Affiliation(s)
- Woo-Young Shin
- Department of Family Medicine, Chung-Ang University College of Medicine, Heukseok-ro 102, Dongjak-gu, Seoul, 06973, Republic of Korea
| | - Hye Jun Lee
- Department of Family Medicine, Chung-Ang University College of Medicine, Heukseok-ro 102, Dongjak-gu, Seoul, 06973, Republic of Korea
| | - Jung-Ha Kim
- Department of Family Medicine, Chung-Ang University College of Medicine, Heukseok-ro 102, Dongjak-gu, Seoul, 06973, Republic of Korea.
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Wu CK, Lin CH, Yar N, Kao ZK, Yang YB, Chen YY. Long-Term Effectiveness of Cilostazol in Patients with Hemodialysis with Peripheral Artery Disease. J Atheroscler Thromb 2023; 30:943-955. [PMID: 36216573 PMCID: PMC10406651 DOI: 10.5551/jat.63404] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 08/25/2022] [Indexed: 08/04/2023] Open
Abstract
AIM The aim of this study was to investigate the effects of continuous cilostazol use on emergency department (ED) visits, hospitalizations, and vascular outcomes in patients with hemodialysis (HD) with peripheral artery disease (PAD). METHODS This retrospective cohort study recruited 558 adult patients, who had received chronic HD for at least 90 days between January 1, 2008 and December 31, 2012, from the National Health Insurance Research Database. Eligible patients were divided into two groups based on continuing or discontinuing cilostazol treatment. Outcome measures were ED visits, hospitalizations, mortality, and vascular outcomes such as percutaneous transluminal angioplasty, surgical bypass, lower leg amputation, ischemic stroke, hemorrhagic stroke, and cardiovascular events. RESULTS Patients with continuous cilostazol use had significantly higher prevalence of stroke, cancer, vintage, and the use of angiotensin receptor blocker and β-blocker, but significantly lower incidence of ischemic stroke and cardiovascular events, as well as lower mortality, than those without continuous cilostazol use (all p<.05). Continuous cilostazol use was independently associated with lower risk of ED visits, hemorrhagic stroke, and cardiovascular events (adjusted hazard ratios: 0.79, 0.29, and 0.67; 95% confidence intervals: 0.62-0.98, 0.10-0.84, and 0.48-0.96, respectively; all p<.05). Continuous cilostazol use was significantly associated with higher ED visit-free and cardiovascular event-free rates (log-rank test; p<.05). CONCLUSION Continuous treatment of cilostazol in patients with HD with PAD significantly decreases the risk of ED visits, hemorrhagic stroke, and cardiovascular events and improves ED visit-free and cardiovascular event-free rates during long-term follow-up.
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Affiliation(s)
- Chung-Kuan Wu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Chia-Hsun Lin
- School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Noi Yar
- College of Management, School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Zih-Kai Kao
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Bei Yang
- Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yun-Yi Chen
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Research, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Taipei, Taiwan
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Liu H, Shao T, Yang T, Li D, Wang H, Cheng Y, Zhang T, Zhang J. Comparison of Cilostazol versus Clopidogrel in Addition to Aspirin in Patients with Ischemic Stroke who Underwent Intracranial or Extracranial Artery Stent Implantation. J Atheroscler Thromb 2023; 30:1010-1021. [PMID: 36328566 PMCID: PMC10406684 DOI: 10.5551/jat.63632] [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: 04/18/2022] [Accepted: 09/19/2022] [Indexed: 08/04/2023] Open
Abstract
AIMS The role of cilostazol after intracranial or extracranial artery stent implantation is still unclear. Therefore, we designed this trial to explore the efficacy and safety of cilostazol in this particular population. METHODS In this retrospective study, patients were divided into the cilostazol or clopidogrel group by the antiplatelet therapy received after artery stent implantation. The primary efficacy endpoint was ischemic stroke. Bleeding events and other antiplatelet drug-related adverse reactions (ADRs) were also recorded. Neurological function prognosis was evaluated by the modified Rankin Scale (mRS) after discharge. RESULTS A total of 156 patients were enrolled; 56 underwent intracranial artery stenting, 95 underwent extracranial artery stenting, and 5 underwent intracranial combined with extracranial artery stenting. Any stroke and bleeding events in the hospital of the two groups were comparable (P=0.38, P=0.34, respectively). The incidence of stroke recurrence tended to be lower in the cilostazol group, although not significant (cilostazol vs. clopidogrel, 1.35% vs. 4.88%, P=0.25). There was a significant difference of any bleeding events between the two groups (cilostazol vs. clopidogrel, 5.41% vs. 20.73%, P=0.02). During follow-up, we did not observe an apparent increase of ADRs in the cilostazol group (cilostazol vs. clopidogrel, palpitation 4.05% vs. 2.44%, P=0.58; gastrointestinal discomfort events 8.11% vs. 12.20%, P=0.80). There were no differences between the two groups of neurological function prognosis (P=0.29). CONCLUSIONS Cilostazol-based dual antiplatelet therapy could be recommended as an effective and safe therapy regimen among patients undergoing intracranial or extracranial artery stent implantation.
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Affiliation(s)
- Hui Liu
- China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tengfei Shao
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tao Yang
- Biomedical Informatics Research Lab, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Di Li
- Department of Pharmacy, Wuhan No.1 Hospital, Wuhan, Hubei, China
| | - Huan Wang
- Department of Pharmacy, Wuhan Fourth Hospital,Wuhan,Hubei, China
| | - Yue Cheng
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tingzheng Zhang
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jinping Zhang
- China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
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Sarpe AK, Flumignan CD, Nakano LC, Trevisani VF, Lopes RD, Guedes Neto HJ, Flumignan RL. Duplex ultrasound for surveillance of lower limb revascularisation. Cochrane Database Syst Rev 2023; 7:CD013852. [PMID: 37470266 PMCID: PMC10357487 DOI: 10.1002/14651858.cd013852.pub2] [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: 07/21/2023]
Abstract
BACKGROUND Lower extremity atherosclerotic disease (LEAD) - also known as peripheral arterial disease - refers to the obstruction or narrowing of the large arteries of the lower limbs, most commonly caused by atheromatous plaque. Although in many cases of less severe disease patients can be asymptomatic, the major clinical manifestations of LEAD are intermittent claudication (IC) and critical limb ischaemia, also known as chronic limb-threatening ischaemia (CLTI). Revascularisation procedures including angioplasty, stenting, and bypass grafting may be required for those in whom the disease is severe or does not improve with non-surgical interventions. Maintaining vessel patency after revascularisation remains a challenge for vascular surgeons, since approximately 30% of vein grafts may present with restenosis in the first year due to myointimal hyperplasia. Restenosis can also occur after angioplasty and stenting. Restenosis and occlusions that occur more than two years after the procedure are generally related to progression of the atherosclerosis. Surveillance programmes with duplex ultrasound (DUS) scanning as part of postoperative care may facilitate early diagnosis of restenosis and help avoid amputation in people who have undergone revascularisation. OBJECTIVES To assess the effects of DUS versus pulse palpation, arterial pressure index, angiography, or any combination of these, for surveillance of lower limb revascularisation in people with LEAD. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 February 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared DUS surveillance after lower limb revascularisation versus clinical surveillance characterised by medical examination with pulse palpation, with or without any other objective test, such as arterial pressure index measures (e.g. ankle-brachial index (ABI) or toe brachial index (TBI)). Our primary outcomes were limb salvage rate, vessel or graft secondary patency, and adverse events resulting from DUS surveillance. Secondary outcomes were all-cause mortality, functional walking ability assessed by walking distance, clinical severity scales, quality of life (QoL), re-intervention rates, and functional walking ability assessed by any validated walking impairment questionnaire. We presented the outcomes at two time points: two years or less after the original revascularisation (short term) and more than two years after the original revascularisation (long term). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis when appropriate. MAIN RESULTS We included three studies (1092 participants) that compared DUS plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation and arterial pressure index (ABI or TBI) for surveillance of lower limb revascularisation with bypass. One study each was conducted in Sweden and Finland, and the third study was conducted in the UK and Europe. The studies did not report adverse events resulting from DUS surveillance, functional walking ability, or clinical severity scales. No study assessed surveillance with DUS scanning after angioplasty or stenting, or both. We downgraded the certainty of evidence for risk of bias and imprecision. Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (short-term time point) In the short term, DUS surveillance may lead to little or no difference in limb salvage rate (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.49 to 1.45; I² = 93%; 2 studies, 936 participants; low-certainty evidence) and vein graft secondary patency (RR 0.92, 95% CI 0.67 to 1.26; I² = 57%; 3 studies, 1092 participants; low-certainty evidence). DUS may lead to little or no difference in all-cause mortality (RR 1.11, 95% CI 0.70 to 1.74; 1 study, 594 participants; low-certainty evidence). There was no clear difference in QoL as assessed by the 36-item Short Form Health Survey (SF-36) physical score (mean difference (MD) 2 higher, 95% CI 2.59 lower to 6.59 higher; 1 study, 594 participants; low-certainty evidence); the SF-36 mental score (MD 3 higher, 95% CI 0.38 lower to 6.38 higher; 1 study, 594 participants; low-certainty evidence); or the EQ-5D utility score (MD 0.02 higher, 95% CI 0.03 lower to 0.07 higher; 1 study, 594 participants; low-certainty evidence). DUS may increase re-intervention rates when considered any therapeutic intervention (RR 1.38, 95% CI 1.05 to 1.81; 3 studies, 1092 participants; low-certainty evidence) or angiogram procedures (RR 1.53, 95% CI 1.12 to 2.08; 3 studies, 1092 participants; low-certainty evidence). Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (long-term time point) One study reported data after two years, but provided only vessel or graft secondary patency data. DUS may lead to little or no difference in vessel or graft secondary patency (RR 0.83, 95% CI 0.19 to 3.51; 1 study, 156 participants; low-certainty evidence). Other outcomes of interest were not reported at the long-term time point. AUTHORS' CONCLUSIONS Based on low certainty evidence, we found no clear difference between DUS and standard surveillance in preventing limb amputation, morbidity, and mortality after lower limb revascularisation. We found no studies on DUS surveillance after angioplasty or stenting (or both), only studies on bypass grafting. High-quality RCTs should be performed to better inform the best medical surveillance of lower limb revascularisation that may reduce the burden of peripheral arterial disease.
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Affiliation(s)
- Anna Kp Sarpe
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Disciplines of Emergency Medicine and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Durham, USA
| | - Henrique J Guedes Neto
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Can Depboylu B, Yazman S, Harmandar B, Funda Tetik M, Istar H, Arslan K, Ilhan G. Do Patients With Arterial Occlusive Disease of Different Etiologies Benefit Equally From Cilostazol? Tex Heart Inst J 2023; 50:490714. [PMID: 36763036 PMCID: PMC9969766 DOI: 10.14503/thij-21-7747] [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: 02/11/2023]
Abstract
BACKGROUND Cilostazol is a guideline-recommended drug that improves intermittent claudication and quality of life in patients with chronic atherosclerotic peripheral arterial disease. The drug is used for most etiologies of arterial occlusive diseases in clinical practice. This study aimed to evaluate whether patients benefit equally from cilostazol regardless of etiology. METHODS Patients on cilostazol were divided into 4 groups according to arterial occlusive disease etiology: (1) atherosclerosis, (2) diabetic angiopathy, (3) embolism/thrombosis, and (4) Buerger disease. Patients' maximum walking distance, ankle-brachial index score and distal tissue oxygen saturation (Sto2), clinical improvement onset time, ability to reach maximum benefit time, vascular surgeries, and wounds were compared before they started cilostazol and after 12 months. Results were evaluated at a statistical significance of P < .05. RESULTS In 194 patients, 307 target extremities were evaluated in the 4 disease groups. After cilostazol use, maximum walking distance, ankle-brachial index score, and distal Sto2 increased significantly in all groups (P < .001), but distal Sto2 in the diabetic angiopathy and Buerger disease groups was significantly lower than in the atherosclerosis group (P < .001). Ankle-brachial index and distal Sto2 differences in the Buerger disease group were significantly lower (both P < .001). The vascular surgery counts decreased significantly in the atherosclerosis and embolism/thrombosis groups (P = .019 and P = .004, respectively). CONCLUSION Patients with nonatherosclerotic arterial occlusive disease also benefit from cilostazol, but patients with Buerger disease or diabetic angiopathy seem to benefit less. Combining cilostazol with anticoagulant or antiaggregant agents and closer monitoring of these patients may produce better results.
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Affiliation(s)
- Burak Can Depboylu
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
| | - Serkan Yazman
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
| | - Bugra Harmandar
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
| | - Muruvvet Funda Tetik
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
| | - Hande Istar
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
| | - Kadir Arslan
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
| | - Gokhan Ilhan
- Department of Cardiovascular Surgery, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey
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Reitz KM, Althouse AD, Forman DE, Zuckerbraun BS, Vodovotz Y, Zamora R, Raffai RL, Hall DE, Tzeng E. MetfOrmin BenefIts Lower Extremities with Intermittent Claudication (MOBILE IC): randomized clinical trial protocol. BMC Cardiovasc Disord 2023; 23:38. [PMID: 36681798 PMCID: PMC9862509 DOI: 10.1186/s12872-023-03047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC. METHODS 200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol. DISCUSSION MOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC. TRIAL REGISTRATION The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | | | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Wolff Center, UPMC, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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10
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Lee JK, Hsieh IC, Su CH, Huang HL, Lei MH, Chiu KM, Huang CL, Chen CC, Hsu PC, Hsu CH, Huang CY, Lee CH, Chang WC, Lee HF, Liu JC, Yeh HI. Referral, Diagnosis, and Pharmacological Management of Peripheral Artery Disease: Perspectives from Taiwan. ACTA CARDIOLOGICA SINICA 2023; 39:97-108. [PMID: 36685160 PMCID: PMC9829835 DOI: 10.6515/acs.202301_39(1).20220815a] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/15/2022] [Indexed: 01/24/2023]
Abstract
Peripheral artery disease (PAD) imposes a heavy burden of major adverse cardiovascular events that are associated with considerable mortality and morbidity, and major adverse limb events (e.g., thrombectomy, revascularization, amputation) that can substantially impact patients' daily functioning and quality of life. Global registry data have indicated that PAD is an underdiagnosed disease in Taiwan, and its associated risk factors remain inadequately controlled. This review discusses the burden of PAD in Taiwan, major guidelines on PAD management, and the latest clinical trial outcomes. Practical experience, opinions, and the latest trial data were integrated to derive a series of clinical algorithms - patient referral, PAD diagnosis, and the antithrombotic management of PAD. These algorithms can be adapted not only by physicians in Taiwan involved in the clinical management of patients with PAD but also by general practitioners in local clinics and regional hospital settings, with the ultimate aim of improving the totality of PAD patient care in Taiwan.
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Affiliation(s)
- Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chuang Gung University College of Medicine, Taoyuan
| | - Chun-Hung Su
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung
| | - Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei
| | - Meng-Huan Lei
- Division of Cardiology, Department of Internal Medicine, Lotung Poh-Ai Hospital, Yilan
| | - Kuan-Ming Chiu
- Division of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City
| | - Chien-Lung Huang
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chuang Gung University College of Medicine, Taoyuan
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital & College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Chung-Ho Hsu
- Division of Cardiology, China Medical University Hospital, Taichung
| | - Chun-Yao Huang
- Division of Cardiology, Taipei Medical University Hospital, Taipei
| | - Cheng-Han Lee
- Department of Cardiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Wei-Chun Chang
- Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Hsin-Fu Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chuang Gung University College of Medicine, Taoyuan
| | - Ju-Chi Liu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University
| | - Hung-I Yeh
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, MacKay Medical College, New Taipei City, Taiwan
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11
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Katsiki N, Tentolouris N, Marakomichelakis G, Richter D, Giannoukas A, Koufaki P, Papanas N. Real world data from a multi-centre study on the effects of cilostazol on pain symptoms and walking distance in patients with peripheral arterial disease. BMC Res Notes 2022; 15:373. [PMID: 36536424 PMCID: PMC9764459 DOI: 10.1186/s13104-022-06264-0] [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: 06/29/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE to assess the effects of cilostazol on pain-free walking distance in PAD patients with IC at 3 and 6 months in a real world, prospective, observational study. We included 1015 PAD patients presenting with IC (71.3% men, 93.5% white, mean age 69.2 ± 8.7 years). Patients were followed up for 6 months by their physicians. RESULTS Cilostazol significantly increased pain-free walking distance by a median of 285 and 387 m at 3 and 6 months, respectively (p < 0.01 for all comparisons). This effect was significant for patients 50-74 years (but not for those aged ≥ 75 years) and independent of smoking status, changes in physical activity, comorbidities and concomitant medication for PAD (i.e., acetylsalicylic acid and clopidogrel). Furthermore, significant reductions were observed in systolic (from 139 ± 16 to 133 ± 14 mmHg; p < 0.001) and diastolic blood pressure (from 84 ± 9 mmHg to 80 ± 10 mmHg; p < 0.001). Smoking cessation and increased physical activity were reported by the majority of participants. In conclusion, cilostazol was shown to safely decrease pain symptoms and improve pain-free walking in PAD patients with IC in a real world setting. Benefits also occurred in terms of BP and lifestyle changes.
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Affiliation(s)
- Niki Katsiki
- grid.449057.b0000 0004 0416 1485Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece ,grid.440838.30000 0001 0642 7601School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Nikolaos Tentolouris
- grid.5216.00000 0001 2155 0800First Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Marakomichelakis
- grid.414655.70000 0004 4670 4329Fourth Department of Internal Medicine and Angiology Unit, Evangelismos General Hospital, Athens, Greece
| | - Dimitrios Richter
- grid.459474.fCardiac Department, Euroclinic Hospital, Athens, Greece
| | - Athanasios Giannoukas
- grid.410558.d0000 0001 0035 6670Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - Nikolaos Papanas
- grid.12284.3d0000 0001 2170 8022Diabetic Foot Clinic, Diabetes Centre, Second Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
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12
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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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13
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Rimamskep SG, Favour M, Demilade SA, Charles AC, Olaseni BM, Bob-Manuel T. Peripheral Artery Disease: A comprehensive updated review. Curr Probl Cardiol 2021; 47:101082. [PMID: 34906615 DOI: 10.1016/j.cpcardiol.2021.101082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/03/2022]
Abstract
Peripheral arterial disease is estimated to affect more than 200 million people worldwide. Although more than 50% of those affected are asymptomatic, it accounts for 3-4% of amputations and a crude five-year death rate of 82.4 deaths per 1000 patient-years when adjusted for duration of follow-up. Additionally, peripheral artery disease is often an indicator of obstructive atherosclerotic disease involvement of cerebral and coronary vessels, consequently increasing the risk of stroke, cardiovascular death, and myocardial infarction in these patient populations. The management of peripheral arterial disease includes conservative therapies, pharmacological treatments, interventional and surgical revascularization of blood vessels. Percutaneous transluminal angioplasty with balloons and stents has improved clinical outcomes compared to medical treatment alone. Despite these advances, the prevalence of peripheral arterial disease remains high. This review article aims to provide focused, up-to-date information on the clinical course, diagnosis, medical and interventional approach of the management of peripheral artery disease.
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Affiliation(s)
| | - Markson Favour
- Department of Internal Medicine, Lincoln Medical Centre NY, USA
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14
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de Havenon A, Sheth KN, Madsen TE, Johnston KC, Turan T, Toyoda K, Elm JJ, Wardlaw JM, Johnston SC, Williams OA, Shoamanesh A, Lansberg MG. Cilostazol for Secondary Stroke Prevention: History, Evidence, Limitations, and Possibilities. Stroke 2021; 52:e635-e645. [PMID: 34517768 PMCID: PMC8478840 DOI: 10.1161/strokeaha.121.035002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol's pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Kevin N. Sheth
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Tracy E. Madsen
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Karen C. Johnston
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Tanya Turan
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Kazunori Toyoda
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Jordan J. Elm
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Joanna M. Wardlaw
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - S. Claiborne Johnston
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Olajide A. Williams
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Ashkan Shoamanesh
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
| | - Maarten G. Lansberg
- Department of Neurology, University of Utah (A.D.); Department of Neurology, Yale University (K.N.S.); Department of Emergency Medicine, Brown University (T.M.); Department of Neurology, University of Virginia (K.J.); Department of Neurology, Medical University of South Carolina (T.T., J.E.); Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan (K.T.); Center for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh (J.M.W.); Dell Medical School (S.C.J.); Department of Neurology, Columbia University (O.W.); Department of Medicine (Neurology), McMaster University/Population Heath Research Institute (A.S.); Department of Neurology, Stanford University (M.L.)
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15
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Cucato G, Perren D, Ritti-Dias RM, Saxton JM. Effects of additional exercise therapy after a successful vascular intervention for patients with symptomatic peripheral arterial disease. Hippokratia 2021. [DOI: 10.1002/14651858.cd014736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Gabriel Cucato
- Department of Sport, Exercise, and Rehabilitation; Northumbria University; Newcastle-upon-Tyne UK
| | - Daniel Perren
- Health Education England North East; Newcastle upon Tyne UK
| | | | - John M Saxton
- Department of Sport, Exercise, and Rehabilitation; Northumbria University; Newcastle-upon-Tyne UK
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16
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Rababa'h AM, Hussein SA, Khabour OF, Alzoubi KH. The Protective Effect of Cilostazol in Genotoxicity Induced by Methotrexate in Human Cultured Lymphocytes. Curr Mol Pharmacol 2021; 13:137-143. [PMID: 31702497 DOI: 10.2174/1874467212666191023120118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/13/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Methotrexate is an antagonist of folic acid that has been shown to be genotoxic to healthy body cells via induction of oxidative stress. Cilostazol is a phosphodiesterase III inhibitor and a potent antioxidant drug. OBJECTIVE To evaluate the potential protective effect of cilostazol on methotrexate genotoxicity. METHODS The genotoxic effect of methotrexate by measuring the frequency of chromosomal aberrations (CAs) and sister chromatid exchanges (SCEs) in human cultured lymphocytes was studied. RESULTS Methotrexate significantly increased the frequency of CAs and SCEs (p < 0.0001) as compared to control cultures. This chromosomal damage induced by methotrexate was considerably decreased by pretreatment of the cells with cilostazol (P < 0.01). Moreover, the results showed that methotrexate resulted in a notable reduction (P < 0.01) in cells kinetic parameters, the mitotic index (MI) and the proliferative index (PI). Similarly, cilostazol significantly reduced the mitotic index, which could be related to the anti-proliferative effect (P < 0.01). CONCLUSION Methotrexate is genotoxic, and cilostazol could prevent the methotrexate-induced chromosomal damage with no modulation of methotrexate-induced cytotoxicity.
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Affiliation(s)
- Abeer M Rababa'h
- Department of Clinical Pharmacy, College of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Samah A Hussein
- Department of Clinical Pharmacy, College of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Omar F Khabour
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, College of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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17
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El-Hachem N, Fardoun MM, Slika H, Baydoun E, Eid AH. Repurposing Cilostazol for Raynaud's Phenomenon. Curr Med Chem 2021; 28:2409-2417. [PMID: 32881655 DOI: 10.2174/0929867327666200903114154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/22/2022]
Abstract
Raynaud 's Phenomenon (RP) results from exaggerated cold-induced vasoconstriction. RP patients suffer from vasospastic attacks and compromised digital blood perfusion leading to a triple color change at the level the fingers. Severe RP may cause ulcers and threaten tissue viability. Many drugs have been used to alleviate the symptoms of RP. These include calcium-channel blockers, cGMP-specific phosphodiesterase type 5 inhibitors, prostacyclin analogs, and angiotensin receptor blockers. Despite their variety, these drugs do not treat RP but rather alleviate its symptoms. To date, no drug for RP has been yet approved by the U.S Food and Drugs Administration. Cilostazol is a selective inhibitor of phosphodiesterase-III, originally prescribed to treat intermittent claudication. Owing to its antiplatelet and vasodilating properties, cilostazol is being repurposed as a potential drug for RP. This review focuses on the different lines of action of cilostazol serving to enhance blood perfusion in RP patients.
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Affiliation(s)
- Nehme El-Hachem
- Laboratory of Medical Genetics, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Beirut, Lebanon
| | - Manal M Fardoun
- Department of Biology, American University of Beirut, Beirut, Lebanon
| | - Hasan Slika
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Elias Baydoun
- Department of Biology, American University of Beirut, Beirut, Lebanon
| | - Ali H Eid
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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18
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Keohane CR, Twyford M, Hannon E, Tawfick W, Walsh SR. Medical management of PAD: Expand or consolidate? ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:376-378. [PMID: 34100514 DOI: 10.47102/annals-acadmedsg.2021163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Colum R Keohane
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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19
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Thanigaimani S, Phie J, Sharma C, Wong S, Ibrahim M, Huynh P, Moxon J, Jones R, Golledge J. Network Meta-Analysis Comparing the Outcomes of Treatments for Intermittent Claudication Tested in Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e019672. [PMID: 33890475 PMCID: PMC8200724 DOI: 10.1161/jaha.120.019672] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background No network meta-analysis has considered the relative efficacy of cilostazol, home exercise therapy, supervised exercise therapy (SET), endovascular revascularization (ER), and ER plus SET (ER+SET) in improving maximum walking distance (MWD) over short- (<1 year), moderate- (1 to <2 years), and long-term (≥2 years) follow-up in people with intermittent claudication. Methods and Results A systematic literature search was performed to identify randomized controlled trials testing 1 or more of these 5 treatments according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The primary outcome was improvement in MWD assessed by a standardized treadmill test. Secondary outcomes were adverse events and health-related quality of life. Network meta-analysis was performed using the gemtc R statistical package. The Cochrane collaborative tool was used to assess risk of bias. Forty-six trials involving 4256 patients were included. At short-term follow-up, home exercise therapy (mean difference [MD], 89.4 m; 95% credible interval [CrI], 20.9-157.7), SET (MD, 186.8 m; 95% CrI, 136.4-237.6), and ER+SET (MD, 326.3 m; 95% CrI, 222.6-430.6), but not ER (MD, 82.5 m; 95% CrI, -2.4 to 168.2) and cilostazol (MD, 71.1 m; 95% CrI, -24.6 to 167.9), significantly improved MWD (in meters) compared with controls. At moderate-term follow-up, SET (MD, 201.1; 95% CrI, 89.8-318.3) and ER+SET (MD, 368.5; 95% CrI, 195.3-546.9), but not home exercise therapy (MD, 99.4; 95% CrI, -174.0 to 374.9) or ER (MD, 84.2; 95% CrI, -35.3 to 206.4), significantly improved MWD (in meters) compared to controls. At long-term follow-up, none of the tested treatments significantly improved MWD compared to controls. Adverse events and quality of life were reported inconsistently and could not be meta-analyzed. Risk of bias was low, moderate, and high in 4, 24, and 18 trials respectively. Conclusions This network meta-analysis suggested that SET and ER+SET are effective at improving MWD over the moderate term (<2 year) but not beyond this. Durable treatments for intermittent claudication are needed.
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Affiliation(s)
- Shivshankar Thanigaimani
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - James Phie
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Chinmay Sharma
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Shannon Wong
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Muhammad Ibrahim
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Pacific Huynh
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Joseph Moxon
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Rhondda Jones
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Jonathan Golledge
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia.,The Department of Vascular and Endovascular Surgery Townsville University Hospital Townsville Queensland Australia
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20
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Harwood AE, Pymer S, Ibeggazene S, Parmenter B, Chetter IC. Non-pharmaceutical alternatives or adjuncts to exercise programmes for people with intermittent claudication. Hippokratia 2021. [DOI: 10.1002/14651858.cd014677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Amy Elizabeth Harwood
- Centre for Sport, Exercise and Life Sciences, Faculty of Health and Life Sciences; Coventry University; Coventry UK
- Academic Vascular Surgical Unit, Hull York Medical School; Hull University Teaching Hospitals NHS Trust; Hull UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, Hull York Medical School; Hull University Teaching Hospitals NHS Trust; Hull UK
| | - Saïd Ibeggazene
- College of Health, Wellbeing and Life Sciences; Sheffield Hallam University; Sheffield UK
| | - Belinda Parmenter
- Department of Exercise Physiology, Faculty of Medicine; UNSW; Sydney Australia
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull York Medical School; Hull University Teaching Hospitals NHS Trust; Hull UK
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21
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Sarpe AKP, Flumignan CDQ, Nakano LCU, Trevisani VFM, Lopes RD, Guedes Neto HJ, Flumignan RLG. Duplex ultrasound for surveillance of lower limb revascularisation. Hippokratia 2021. [DOI: 10.1002/14651858.cd013852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anna KP Sarpe
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Carolina DQ Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Luis CU Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Virginia FM Trevisani
- Disciplines of Emergency Medicine and Rheumatology; Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro; São Paulo Brazil
| | - Renato D Lopes
- Division of Cardiology; Duke University Medical Center; Durham USA
| | - Henrique J Guedes Neto
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Ronald LG Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
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22
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Cilostazol Solubilization and Stabilization Using a Polymer-Free Solid Dispersion System. J Pharm Innov 2021. [DOI: 10.1007/s12247-021-09533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Kalantzi K, Tentolouris N, Melidonis AJ, Papadaki S, Peroulis M, Amantos KA, Andreopoulos G, Bellos GI, Boutel D, Bristianou M, Chrisis D, Dimitsikoglou NA, Doupis J, Georgopoulou C, Gkintikas SA, Iraklianou S, Kanellas Κ, Kotsa K, Koufakis T, Kouroglou M, Koutsovasilis AG, Lanaras L, Liouri E, Lixouriotis C, Lykoudi A, Mandalaki E, Papageorgiou E, Papanas N, Rigas S, Stamatelatou MI, Triantafyllidis I, Trikkalinou A, Tsouka AN, Zacharopoulou O, Zoupas C, Tsolakis I, Tselepis AD. Efficacy and Safety of Adjunctive Cilostazol to Clopidogrel-Treated Diabetic Patients With Symptomatic Lower Extremity Artery Disease in the Prevention of Ischemic Vascular Events. J Am Heart Assoc 2020; 10:e018184. [PMID: 33327737 PMCID: PMC7955466 DOI: 10.1161/jaha.120.018184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Type 2 diabetes mellitus is a risk factor for lower extremity arterial disease. Cilostazol expresses antiplatelet, anti‐inflammatory, and vasodilator actions and improves the claudication intermittent symptoms. We investigated the efficacy and safety of adjunctive cilostazol to clopidogrel‐treated patients with type 2 diabetes mellitus exhibiting symptomatic lower extremity arterial disease, in the prevention of ischemic vascular events and improvement of the claudication intermittent symptoms. Methods and Results In a prospective 2‐arm, multicenter, open‐label, phase 4 trial, patients with type 2 diabetes mellitus with intermittent claudication receiving clopidogrel (75 mg/d) for at least 6 months, were randomly assigned in a 1:1 ratio, either to continue to clopidogrel monotherapy, without receiving placebo cilostazol (391 patients), or to additionally receive cilostazol, 100 mg twice/day (403 patients). The median duration of follow‐up was 27 months. The primary efficacy end point, the composite of acute ischemic stroke/transient ischemic attack, acute myocardial infarction, and death from vascular causes, was significantly reduced in patients receiving adjunctive cilostazol compared with the clopidogrel monotherapy group (sex‐adjusted hazard ratio [HR], 0.468; 95% CI, 0.252–0.870; P=0.016). Adjunctive cilostazol also significantly reduced the stroke/transient ischemic attack events (sex‐adjusted HR, 0.38; 95% CI, 0.15–0.98; P=0.046) and improved the ankle‐brachial index and pain‐free walking distance values (P=0.001 for both comparisons). No significant difference in the bleeding events, as defined by Bleeding Academic Research Consortium criteria, was found between the 2 groups (sex‐adjusted HR, 1.080; 95% CI, 0.579–2.015; P=0.809). Conclusions Adjunctive cilostazol to clopidogrel‐treated patients with type 2 diabetes mellitus with symptomatic lower extremity arterial disease may lower the risk of ischemic events and improve intermittent claudication symptoms, without increasing the bleeding risk, compared with clopidogrel monotherapy. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02983214.
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Affiliation(s)
- Kallirroi Kalantzi
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | - Nikolaos Tentolouris
- 1st Department of Propaedeutic Internal Medicine Medical School National and Kapodistrian University of Athens Greece
| | | | - Styliani Papadaki
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | - Michail Peroulis
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | | | | | | | | | | | - Dimitrios Chrisis
- 3rd Internal Medicine Department and Diabetes Center General Hospital of Nikaia Athens Greece
| | - Nikolaos A Dimitsikoglou
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | - John Doupis
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | | | - Stergios A Gkintikas
- Division of Endocrinology and Metabolism and Diabetes Center First Department of Internal Medicine Medical School Aristotle University of ThessalonikiAHEPA University Hospital Thessaloniki Greece
| | - Styliani Iraklianou
- 3rd Department of Internal Medicine Center General Hospital "Tzaneio," Piraeus Greece
| | - Κonstantinos Kanellas
- 3rd Department of Internal Medicine Center General Hospital "Tzaneio," Piraeus Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Center First Department of Internal Medicine Medical School Aristotle University of ThessalonikiAHEPA University Hospital Thessaloniki Greece
| | - Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Center First Department of Internal Medicine Medical School Aristotle University of ThessalonikiAHEPA University Hospital Thessaloniki Greece
| | | | | | - Leonidas Lanaras
- Department of Internal Medicine General Hospital of Lamia Greece
| | - Eirini Liouri
- 3rd Internal Medicine Department and Diabetes Center General Hospital of Nikaia Athens Greece
| | | | - Akrivi Lykoudi
- 3rd Internal Medicine Department and Diabetes Center General Hospital of Nikaia Athens Greece
| | - Efthymia Mandalaki
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | - Evanthia Papageorgiou
- 3rd Internal Medicine Department and Diabetes Center General Hospital of Nikaia Athens Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine Democritus University of Thrace Alexandroupolis Greece
| | - Spyridon Rigas
- 3rd Internal Medicine Department and Diabetes Center General Hospital of Nikaia Athens Greece
| | | | - Ioannis Triantafyllidis
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | | | - Aikaterini N Tsouka
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
| | | | | | | | - Alexandros D Tselepis
- Atherothrombosis Research Center Laboratory of Biochemistry Department of Chemistry University of Ioannina Greece
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Burleva EP, Korelin SV. [Prospects of clinical application of cilostazol for peripheral artery disease]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:28-36. [PMID: 33063749 DOI: 10.33529/angiq2020304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This article presents a review of the literature on studying Cilostazol, a type 3 phosphodiesterase inhibitor, also providing the Russian and foreign statistics on the prevalence of peripheral artery disease. It is underlined that the majority of patients with peripheral artery disease have atherosclerotic lesions in the coronary and cerebral vascular basins. Cilostazol deservedly occupies the first lines in the sections of pharmacotherapy for intermittent claudication in international and Russian consensus documents on peripheral artery disease. The drug has an extensive evidence base for the following pharmacological effects: vasodilating, antiplatelet, endothelial protective, and vasculogenic. Clinical efficacy of Cilostazol was confirmed in 15 randomized clinical trials (3 718 patients with intermittent claudication) studying the use of Cilostazol taken twice daily at doses of 50 mg, 100 mg, and 150 mg as compared with placebo or versus pentoxifylline given in a dose of 400 mg three times daily, with a demonstrable increase in the pain-free walking distance and the maximal walking distance on the background of taking Cilostazol. The drug significantly improves the outcomes of endovascular interventions on arteries of lower extremities, decreasing the incidence of restenosis, prolonging limb survival, and reducing the frequency of major amputations. Many studies addressing the use of Cilostazol in patients with coronary and cerebral atherosclerosis have investigated the effect of the drug as a component of dual antiplatelet therapy (aspirin + Cilostazol) and triple antiplatelet therapy (aspirin + clopidogrel + Cilostazol) after endovascular interventions. The addition of Cilostazol to treatment resulted in a significant decrease in the occurrence of re-stenosis, with no increase in the incidence of haemorrhage. Cilostazol may be recommended for patients with multifocal atherosclerosis and resistance to aspirin and clopidogrel. Also presented in the article are the results of a Russian clinical trial studying comparative efficacy of Cilostazol and pentoxifylline in patients with intermittent claudication.
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Affiliation(s)
- E P Burleva
- Chair of Surgery, Endoscopy and Coloproctology, Ural State Medical University of the RF Ministry of Public Health, Yekaterinburg, Russia
| | - S V Korelin
- Clinical Hospital 'Russian Railways-Medicine', Yekaterinburg, Russia
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Abstract
BACKGROUND Intermittent claudication (IC) is a symptom of peripheral arterial disease (PAD) and is associated with high morbidity and mortality. Pentoxifylline, one of many drugs used to treat IC, acts by decreasing blood viscosity, improving erythrocyte flexibility, and promoting microcirculatory flow and tissue oxygen concentration. Many studies have evaluated the efficacy of pentoxifylline in treating people with PAD, but results of these studies are variable. This is the second update of a review first published in 2012. OBJECTIVES To determine the efficacy of pentoxifylline in improving the walking capacity (i.e. pain-free walking distance and total (absolute, maximum) walking distance) of people with stable intermittent claudication, Fontaine stage II. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 28 January 2020. There were no language restrictions. SELECTION CRITERIA We included all double-blind, randomised controlled trials (RCTs) comparing pentoxifylline versus placebo or any other pharmacological intervention in people with IC Fontaine stage II. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed the included studies, matched data and resolved disagreements by discussion. Review authors assessed the methodological quality of studies using the Cochrane 'Risk of bias' tool and collected results related to the outcomes of interest, pain-free walking distance (PFWD), total walking distance (TWD), ankle-brachial pressure index (ABI), quality of life (QoL) and side effects. Comparison of studies was based on duration and dose of pentoxifylline. We used GRADE criteria to assess the certainty of the evidence. MAIN RESULTS We identified no new eligible studies for this update. This review includes 24 studies with 3377 participants. Seventeen studies compared pentoxifylline versus placebo. The seven remaining studies compared pentoxifylline with flunarizine (one study), aspirin (one study), Gingko biloba extract (one study), nylidrin hydrochloride (one study), prostaglandin E1 (two studies), and buflomedil and nifedipine (one study). Risk of bias for the individual studies was generally unclear because there was a lack of methodological reporting for many of the included studies, especially regarding randomisation and allocation methods. Most included studies did not provide adequate information to allow selective reporting to be judged and did not report blinding of assessors. Heterogeneity between included studies was considerable with regards to multiple variables, including duration of treatment, dose of pentoxifylline, baseline walking distance and participant characteristics; therefore, pooled analysis for comparisons which included more than one study, was not possible. Pentoxifylline compared to placebo Of 17 studies comparing pentoxifylline with placebo, 11 reported PFWD and 14 reported TWD; the difference in percentage improvement in PFWD for pentoxifylline over placebo ranged from -33.8% to 73.9% and in TWD ranged from 1.2% to 155.9%. It was not possible to pool the data of the studies because data were insufficient and findings from individual trials were unclear. Most included studies suggested a possible improvement in PFWD and TWD for pentoxifylline over placebo (both low-certainty evidence). The five studies which evaluated pre-exercise ABI comparing pentoxifylline and placebo found no evidence of a difference (moderate-certainty evidence). Two of the three studies that evaluated QoL between people who received pentoxifylline and placebo were larger studies that used validated QoL tools and generally found no evidence of a difference between groups. One small, short-term study, which did not specify which QoL tool was used, reported improved QoL in the pentoxifylline group (moderate-certainty evidence). Pentoxifylline generally was well tolerated; the most commonly reported side effects consisted of gastrointestinal symptoms such as nausea (low-certainty evidence). Certainty of the evidence from this review was low or moderate, with downgrading due to risk of bias concerns, inconsistencies between studies and the inability to evaluate imprecision because meta-analysis could not be undertaken. The seven remaining studies compared pentoxifylline with either flunarizine, aspirin, Gingko biloba extract, nylidrin hydrochloride, prostaglandin E1, or buflomedil and nifedipine; data were too limited to allow any meaningful conclusions to be made. AUTHORS' CONCLUSIONS There is a lack of high-certainty evidence for the effects of pentoxifylline compared to placebo, or other treatments, for IC. There is low-certainty evidence that pentoxifylline may improve PFWD and TWD compared to placebo, but no evidence of a benefit to ABI or QoL (moderate-certainty evidence). Pentoxifylline was reported to be generally well tolerated (low-certainty evidence). Given the large degree of heterogeneity between the studies, the role of pentoxifylline for people with IC Fontaine class II remains uncertain.
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Affiliation(s)
| | | | - Mohammed Abdel-Hadi
- Department of Cardiology and Vascular Diseases, Herz-Kreislauf-Zentrum Rotenburg, Rotenburg, Germany
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Desai K, Han B, Kuziez L, Yan Y, Zayed MA. Literature review and meta-analysis of the efficacy of cilostazol on limb salvage rates after infrainguinal endovascular and open revascularization. J Vasc Surg 2020; 73:711-721.e3. [PMID: 32891809 DOI: 10.1016/j.jvs.2020.08.125] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 08/11/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Current clinical guidelines recommend the use of cilostazol in the treatment of patients with infrainguinal peripheral artery disease (PAD) who experience intermittent claudication. However, the role of cilostazol therapy in patients with advanced PAD and critical limb ischemia (CLI) remains unclear. To conduct a meta-analysis of randomized controlled trials and cohort studies that evaluated the effect of cilostazol vs standard antiplatelet therapy on limb-related and arterial patency-related outcomes. We also reviewed literature pertinent to the effect of cilostazol on wound healing in patients with advanced PAD. METHODS We performed a MEDLINE, EMBASE, COCHRANE (CENTRAL), SCOPUS, and US Clinical Trials database search for all trials and studies since 1999 that compared cilostazol with standard antiplatelet therapy in the setting of infrainguinal PAD revascularization procedures (endovascular or open). Aggregate data was collected from four randomized control trials and six retrospective cohort studies. The end point incidence ratios and treatment effects were generated from each study and reported as hazard ratios (HR) using a random-effect model. We also reviewed 10 studies that evaluated the effect of cilostazol on wound healing in patients with advanced PAD. RESULTS From more than 25,000 total patients, 3136 patients met our inclusion criteria. All patients had at least lifestyle-impacting intermittent claudication, and more than 50% met the definition of CLI (Rutherford class ≥4). Patient age range was 53 to 83 years, and the majority were male (66%). The mean follow-up time averaged 2 years across all studies. Meta-analysis revealed that cilostazol treatment favored amputation-free survival (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.69-0.91), limb salvage rate (HR, 0.42; 95% CI, 0.27-0.66), decreased repeat revascularization (risk ratio [RR], 0.44; 95% CI, 0.37-0.52), and decreased restenosis (RR, 0.68; 95% CI, 0.61-0.76). Cilostazol treatment also increased freedom from target lesion revascularization (RR, 1.35; 95% CI, 1.21-1.53) with no difference in all-cause mortality. Effective wound healing was found to be an inconsistent outcome measure in patients receiving cilostazol therapy. CONCLUSIONS We observed that cilostazol therapy has a beneficial impact on all limb-related and arterial patency-related outcomes, but no effect on all-cause mortality in patients with advanced PAD and CLI undergoing revascularization procedures. Additional studies are needed to evaluate the effect of cilostazol therapy on wound healing in patients with advanced PAD.
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Affiliation(s)
- Kshitij Desai
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Britta Han
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | | | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Mohamed A Zayed
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo; Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, Mo; McKelvey School of Engineering, Department of Biomedical Engineering, Washington University, St. Louis, Mo; St. Louis Veterans Affairs Medical Center, St. Louis, Mo.
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Trani A, Benedetto P, Di Leo F, Baiano A, Esposito A, Menna D, Allegretti A, Cappiello PA, Dell'Edera D. Long term efficacy and safety of rivaroxaban plus cilostazol in the treatment of critical ischemia of the lower limbs in a frail, elderly patient with non valvular atrial fibrillation. J Pharm Health Care Sci 2020; 6:17. [PMID: 32774874 PMCID: PMC7398073 DOI: 10.1186/s40780-020-00173-9] [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: 04/03/2020] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Many patients with critical lower limb ischemia are not eligible for revascularization procedures. Still, given the emerging role of both platelet and coagulation activation in the formation of arterial thrombi, they may benefit from the novel anticoagulant and antiplatelet drugs. Case presentation We describe the case of a male with critical lower limb ischemia complicated by older age, frailty, polymorbidity and non valvular atrial fibrillation, who was deemed as non eligible for surgery. The patient was successfully treated with the combination of rivaroxaban and cilostazol, and the clinical benefit was maintained throughout 32 months, with no occurrence of major or minor hemorrhagic or thrombotic events. Conclusions To our knowledge, this is the first report on the efficacy and safety of such a combination therapy in critical lower limb ischemia. In a clinical setting in which alternative pharmacological approaches are urgently needed, the association of rivaroxaban and cilostazol warrants further investigations.
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Affiliation(s)
- Antonio Trani
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Pietro Benedetto
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Ferdinando Di Leo
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Angela Baiano
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Andrea Esposito
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Danilo Menna
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Arianna Allegretti
- Cytogenetic and Molecular Genetics Unit, "Madonna delle Grazie" Hospital, 75100 Matera, Italy
| | - Pierluigi Antonino Cappiello
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Domenico Dell'Edera
- Cytogenetic and Molecular Genetics Unit, "Madonna delle Grazie" Hospital, 75100 Matera, Italy
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Abola MTB, Golledge J, Miyata T, Rha SW, Yan BP, Dy TC, Ganzon MSV, Handa PK, Harris S, Zhisheng J, Pinjala R, Robless PA, Yokoi H, Alajar EB, Bermudez-delos Santos AA, Llanes EJB, Obrado-Nabablit GM, Pestaño NS, Punzalan FE, Tumanan-Mendoza B. Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee. J Atheroscler Thromb 2020; 27:809-907. [PMID: 32624554 PMCID: PMC7458790 DOI: 10.5551/jat.53660] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD. OBJECTIVES The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD. METHODOLOGY A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique. RESULTS A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.
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Affiliation(s)
- Maria Teresa B Abola
- Department of Clinical Research, Philippine Heart Center and University of the Philippines College of Medicine, Metro Manila, Philippines
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, and Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Seung-Woon Rha
- Dept of Cardiology, Internal Medicine, College of Medicine, Korea University; Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Timothy C Dy
- The Heart Institute, Chinese General Hospital and Medical Center, Manila, Philippines
| | | | | | - Salim Harris
- Neurovascular and Neurosonology Division, Neurology Department, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital; International University of Health and Welfare, Fukuoka, Japan
| | - Elaine B Alajar
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital; University of the Philippines College of Medicine, Manila, Philippines
| | | | - Elmer Jasper B Llanes
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines Philippine General Hospital, Manila, Philippines
| | | | - Noemi S Pestaño
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital, Manila, Philippines
| | - Felix Eduardo Punzalan
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines; Philippine General Hospital, Manila, Philippines
| | - Bernadette Tumanan-Mendoza
- Department of Clinical Epidemiology, University of the Philippines College of Medicine, Manila, Philippines
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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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Patel RA, Sakhuja R, White CJ. The Medical and Endovascular Treatment of PAD: A Review of the Guidelines and Pivotal Clinical Trials. Curr Probl Cardiol 2020; 45:100402. [DOI: 10.1016/j.cpcardiol.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/23/2022]
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Cacione DG, Macedo CR, do Carmo Novaes F, Baptista-Silva JC. Pharmacological treatment for Buerger's disease. Cochrane Database Syst Rev 2020; 5:CD011033. [PMID: 32364620 PMCID: PMC7197514 DOI: 10.1002/14651858.cd011033.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Buerger's disease (thromboangiitis obliterans) is a non-atherosclerotic, segmental inflammatory pathology that most commonly affects the small and medium sized arteries, veins, and nerves in the upper and lower extremities. The aetiology is unknown, but involves hereditary susceptibility, tobacco exposure, immune and coagulation responses. In many cases, there is no possibility of revascularisation to improve the condition. Pharmacological treatment is an option for patients with severe complications, such as ischaemic ulcers or rest pain.This is an update of the review first published in 2016. OBJECTIVES To assess the effectiveness of any pharmacological agent (intravenous or oral) compared with placebo or any other pharmacological agent in patients with Buerger's disease. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 15 October 2019. The review authors searched LILACS, ISRCTN, Australian New Zealand Clinical Trials Registry, EU Clinical Trials Register, clincialtrials.gov and the OpenGrey Database to 5 January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving pharmacological agents used in the treatment of Buerger's disease. DATA COLLECTION AND ANALYSIS Two review authors, independently assessed the studies, extracted data and performed data analysis. MAIN RESULTS No new studies were identified for this update. Five randomised controlled trials (total 602 participants) compared prostacyclin analogue with placebo, aspirin, or a prostaglandin analogue, and folic acid with placebo. No studies assessed other pharmacological agents such as cilostazol, clopidogrel and pentoxifylline or compared oral versus intravenous prostanoid. Compared with aspirin, intravenous prostacyclin analogue iloprost improved ulcer healing (risk ratio (RR) 2.65; 95% confidence interval (CI) 1.15 to 6.11; 98 participants; 1 study; moderate-certainty evidence), and helped to eradicate rest pain after 28 days (RR 2.28; 95% CI 1.48 to 3.52; 133 participants; 1 study; moderate-certainty evidence), although amputation rates were similar six months after treatment (RR 0.32; 95% CI 0.09 to 1.15; 95 participants; 1 study; moderate-certainty evidence). When comparing prostacyclin (iloprost and clinprost) with prostaglandin (alprostadil) analogues, ulcer healing was similar (RR 1.13; 95% CI 0.76 to 1.69; 89 participants; 2 studies; I² = 0%; very low-certainty evidence), as was the eradication of rest pain after 28 days (RR 1.57; 95% CI 0.72 to 3.44; 38 participants; 1 study; low-certainty evidence), while amputation rates were not measured. Compared with placebo, the effects of oral prostacyclin analogue iloprost were similar for: healing ischaemic ulcers (iloprost 200 mcg: RR 1.11; 95% CI 0.54 to 2.29; 133 participants; 1 study; moderate-certainty evidence, and iloprost 400 mcg: RR 0.90; 95% CI 0.42 to 1.93; 135 participants; 1 study; moderate-certainty evidence), eradication of rest pain after eight weeks (iloprost 200 mcg: RR 1.14; 95% CI 0.79 to 1.63; 207 participants; 1 study; moderate-certainty evidence, and iloprost 400 mcg: RR 1.11; 95% CI 0.77 to 1.59; 201 participants; 1 study; moderate-certainty evidence), and amputation rates after six months (iloprost 200 mcg: RR 0.54; 95% CI 0.19 to 1.56; 209 participants; 1 study, and iloprost 400 mcg: RR 0.42; 95% CI 0.13 to 1.31; 213 participants; 1 study). When comparing folic acid with placebo in patients with Buerger's disease and hyperhomocysteinaemia, pain scores were similar, there were no new cases of amputation in either group, and ulcer healing was not assessed (very low-certainty evidence). Treatment side effects such as headaches, flushing or nausea were not associated with treatment interruptions or more serious consequences. Outcomes such as amputation-free survival, walking distance or pain-free walking distance, and ankle brachial index were not assessed by any study. Overall, the certainty of the evidence was very low to moderate, with few studies, small numbers of participants, variation in severity of disease of participants between studies and missing information (for example regarding baseline tobacco exposure). AUTHORS' CONCLUSIONS Moderate-certainty evidence suggests that intravenous iloprost (prostacyclin analogue) is more effective than aspirin for eradicating rest pain and healing ischaemic ulcers in Buerger's disease, but oral iloprost is not more effective than placebo. Very low and low-certainty evidence suggests there is no clear difference between prostacyclin (iloprost and clinprost) and the prostaglandin analogue alprostadil for healing ulcers and relieving pain respectively in severe Buerger's disease. Very low-certainty evidence suggests there is no clear difference in pain scores and amputation rates between folic acid and placebo, in people with Buerger's disease and hyperhomocysteinaemia. Further well designed RCTs assessing the effectiveness of pharmacological agents (intravenous or oral) in people with Buerger's disease are needed.
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Affiliation(s)
- Daniel G Cacione
- Division of Vascular and Endovascular Surgery, Department of Surgery, UNIFESP - Escola Paulista de Medicina, São Paulo, Brazil
| | - Cristiane R Macedo
- Brazilian Cochrane Centre, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | | | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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Jéhannin P, Craughwell M, Omarjee L, Donnelly A, Jaquinandi V, Mahé G, Le Faucheur A. A systematic review of lower extremity electrical stimulation for treatment of walking impairment in peripheral artery disease. Vasc Med 2020; 25:354-363. [PMID: 32303155 DOI: 10.1177/1358863x20902272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Lower extremity peripheral artery disease (PAD) induces an ischemic pain in the lower limbs and leads to walking impairment. Electrical stimulation has been used in patients with PAD, but no systematic review has been proposed to address the efficacy of the technique as a treatment for walking impairment in PAD. A systematic search was performed to identify trials focused on electrical stimulation for the treatment of walking impairment in patients with PAD in the Cochrane Central Register, PubMed, Embase, and the Web of Science. Studies were included where the primary outcomes were pain-free walking distance and/or maximal walking distance. When appropriate, eligible studies were independently assessed for quality using the Cochrane Collaboration's tool for assessing risk of bias. Five studies eligible for inclusion were identified, of which only two were randomized controlled studies. Trial heterogeneity prevented the use of the GRADE system and the implementation of a meta-analysis. Three types of electrical stimulation have been used: neuromuscular electrical stimulation (NMES, n = 3), transcutaneous electrical stimulation (n = 1), and functional electrical stimulation (n = 1). The two available randomized controlled studies reported a significant improvement in maximal walking distance (+40 m/+34% and +39 m/+35%, respectively) following a program of NMES. Owing to the low number of eligible studies, small sample size, and the risk of bias, no clear clinical indication can be drawn regarding the efficacy of electrical stimulation for the management of impaired walking function in patients with PAD. Future high-quality studies are required to define objectively the effect of electrical stimulation on walking capacity.
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Affiliation(s)
- Pierre Jéhannin
- Clinical Investigation Centre, INSERM, Rennes, France.,University of Rennes 1, Rennes, France
| | - Meghan Craughwell
- Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
| | - Loukman Omarjee
- Clinical Investigation Centre, INSERM, Rennes, France.,University Hospital of Rennes, Rennes, France
| | - Alan Donnelly
- Department of Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
| | - Vincent Jaquinandi
- Clinical Investigation Centre, INSERM, Rennes, France.,University of Rennes 1, Rennes, France.,University Hospital of Rennes, Rennes, France
| | - Guillaume Mahé
- Clinical Investigation Centre, INSERM, Rennes, France.,University of Rennes 1, Rennes, France.,University Hospital of Rennes, Rennes, France
| | - Alexis Le Faucheur
- Clinical Investigation Centre, INSERM, Rennes, France.,University of Rennes, M2S-EA 7470, Rennes, France
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Mehta A, Mavromatis K, Ko YA, Rogers SC, Dhindsa DS, Goodwin C, Patel R, Martini MA, Prasad M, Mokhtari A, Hesaroieh IG, Frohwein SC, Kutner MH, Harzand A, Wells BJ, Duwayri Y, Alabi O, Rajani RR, Brewster LP, Waller EK, Quyyumi AA. Rationale and design of the granulocyte-macrophage colony stimulating factor in peripheral arterial disease (GPAD-3) study. Contemp Clin Trials 2020; 91:105975. [PMID: 32145440 PMCID: PMC7263983 DOI: 10.1016/j.cct.2020.105975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lower extremity peripheral arterial disease (PAD) is a public health problem and many patients with PAD experience claudication despite adequate medical and/or surgical management. Mobilization of endogenous progenitor cells using Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF) is a novel therapeutic option that has shown promising results in experimental models and phase I/IIA clinical trials. The GPAD-3 trial will study the effect of two successive administrations of GM-CSF at 3-month interval for improving claudication among patients with lower extremity PAD. METHODS We plan to recruit 176 patients in this ongoing randomized, double-blind, placebo-controlled Phase IIB trial. After screening for inclusion and exclusion criteria, eligible subjects undergo a 4-week screening phase where they perform subcutaneous placebo injections thrice weekly and walk at least three times a day until they develop claudication. After the screening phase, eligible subjects undergo baseline testing and are randomized 2:1 to receive 500 μg/day of GM-CSF subcutaneously thrice weekly for three weeks or placebo injections. After 3 months, follow-up endpoint testing is performed and subjects in the GM-CSF group receive the second administration of the drug for three weeks while subjects in placebo group receive matching placebo injections. All participants undergo endpoint testing at six-month and nine-month follow-up. The primary endpoint is change in 6-min walk distance between baseline and 6-month follow-up. CONCLUSION GPAD-3 explores a novel approach to address the need for alternative therapies that can alleviate symptoms among patients with lower extremity PAD. If successful, this study will pave the way for a pivotal Phase III trial.
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Affiliation(s)
- Anurag Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kreton Mavromatis
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Atlanta VA Medical Center, Decatur, Georgia
| | - Yi-An Ko
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Steven C Rogers
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Devinder S Dhindsa
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Cydney Goodwin
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Mohammad A Martini
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mahadev Prasad
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ali Mokhtari
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Iraj G Hesaroieh
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen C Frohwein
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael H Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arash Harzand
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Atlanta VA Medical Center, Decatur, Georgia
| | - Bryan J Wells
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Yazan Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Olamide Alabi
- Atlanta VA Medical Center, Decatur, Georgia; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ravi R Rajani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Luke P Brewster
- Atlanta VA Medical Center, Decatur, Georgia; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Edmund K Waller
- Winship Cancer Institute, Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
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Gaddi AV, Capello F, Gheorghe-Fronea OF, Fadda S, Darabont RO. Sulodexide improves pain-free walking distance in patients with lower extremity peripheral arterial disease: A systematic review and meta-analysis. JRSM Cardiovasc Dis 2020; 9:2048004020907002. [PMID: 32110390 PMCID: PMC7025427 DOI: 10.1177/2048004020907002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 01/22/2023] Open
Abstract
Peripheral arterial disease is associated with very high cardiovascular risk. The main symptom is intermittent claudication, which strongly affects the quality of life. Therefore, treatment goals in peripheral arterial disease consist of the reduction of cardiovascular events and the relief of symptoms. An increase in pain-free walking distance, evaluated based on the Initial Claudication Distance, was also a strong positive prognostic factor in patients with peripheral arterial disease. Our objective was to reassess whether sulodexide is effective in improving Initial Claudication Distance. For this, we searched the literature according to the PRISMA checklist for double blind clinical trials assessing the improvement in the Initial Claudication Distance after 90 days of standard therapeutic regimen with sulodexide in adult patients with peripheral arterial disease. We found and assessed for bias in 11 studies eligible for review and meta-analysis. Data extracted from those studies favoured the sulodexide group, showing an overall difference in Initial Claudication Distance of +68.9 (CI 95%; ± 11.9 m) at the end of treatment (p < 0.001). According to this review, sulodexide is effective in improving Initial Claudication Distance and consequently the quality of life in patients with peripheral arterial disease. Further studies are needed to assess the effects of this drug on disease progression in asymptomatic patients with peripheral arterial disease.
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Affiliation(s)
| | - Fabio Capello
- Department of Paediatrics, AUSL della Romagna, Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Oana Florentina Gheorghe-Fronea
- Discipline of Cardiology, Clinical Emergency Hospital Bucharest, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | | | - Roxana Oana Darabont
- Discipline of Internal Medicine and Cardiology, University Emergency Hospital Bucharest, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
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Krishna SM, Omer SM, Li J, Morton SK, Jose RJ, Golledge J. Development of a two-stage limb ischemia model to better simulate human peripheral artery disease. Sci Rep 2020; 10:3449. [PMID: 32103073 PMCID: PMC7044206 DOI: 10.1038/s41598-020-60352-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 01/29/2020] [Indexed: 12/24/2022] Open
Abstract
Peripheral arterial disease (PAD) develops due to the narrowing or blockage of arteries supplying blood to the lower limbs. Surgical and endovascular interventions are the main treatments for advanced PAD but alternative and adjunctive medical therapies are needed. Currently the main preclinical experimental model employed in PAD research is based on induction of acute hind limb ischemia (HLI) by a 1-stage procedure. Since there are concerns regarding the ability to translate findings from this animal model to patients, we aimed to develop a novel clinically relevant animal model of PAD. HLI was induced in male Apolipoprotein E (ApoE-/-) deficient mice by a 2-stage procedure of initial gradual femoral artery occlusion by ameroid constrictors for 14 days and subsequent excision of the femoral artery. This 2-stage HLI model was compared to the classical 1-stage HLI model and sham controls. Ischemia severity was assessed using Laser Doppler Perfusion Imaging (LDPI). Ambulatory ability was assessed using an open field test, a treadmill test and using established scoring scales. Molecular markers of angiogenesis and shear stress were assessed within gastrocnemius muscle tissue samples using quantitative polymerase chain reaction. HLI was more severe in mice receiving the 2-stage compared to the 1-stage ischemia induction procedure as assessed by LDPI (p = 0.014), and reflected in a higher ischemic score (p = 0.004) and lower average distance travelled on a treadmill test (p = 0.045). Mice undergoing the 2-stage HLI also had lower expression of angiogenesis markers (vascular endothelial growth factor, p = 0.004; vascular endothelial growth factor- receptor 2, p = 0.008) and shear stress response mechano-transducer transient receptor potential vanilloid 4 (p = 0.041) within gastrocnemius muscle samples, compared to animals having the 1-stage HLI procedure. Mice subjected to the 2-stage HLI receiving an exercise program showed significantly greater improvement in their ambulatory ability on a treadmill test than a sedentary control group. This study describes a novel model of HLI which leads to more severe and sustained ischemia than the conventionally used model. Exercise therapy, which has established efficacy in PAD patients, was also effective in this new model. This new model maybe useful in the evaluation of potential novel PAD therapies.
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Affiliation(s)
- Smriti M Krishna
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Safraz Mohamed Omer
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Jiaze Li
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Susan K Morton
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Roby J Jose
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia
| | - Jonathan Golledge
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, 4811, Australia.
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, 4811, Australia.
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Bauersachs R, Debus S, Nehler M, Huelsebeck M, Balradj J, Bowrin K, Briere JB. A Targeted Literature Review of the Disease Burden in Patients With Symptomatic Peripheral Artery Disease. Angiology 2019; 71:303-314. [DOI: 10.1177/0003319719896477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients with peripheral artery disease (PAD) have an increased risk of cardiovascular (CV) and limb events, but the disease is frequently underdiagnosed and treatment options are limited. This review examines the disease burden of symptomatic PAD as well as key guideline recommendations. Publications were identified using the ProQuest portal to access the Medline, Medline In-Process, and Embase databases. Search terms for symptomatic PAD were combined with terms relevant to epidemiology, burden, treatment practice, and physiopathology. Articles in English published between January 2001 and September 2016 were screened according to the population, interventions, comparator, outcomes, and study design criteria. Relevant publications (n = 200) were identified. The reported incidence and prevalence of PAD varied depending on the definitions used and the study populations. Patients generally had a poor prognosis, with an increased risk of mortality, CV, and limb events and decreased quality of life. Guideline recommendations included ankle–brachial index measurements, exercise testing, and angiography for diagnosis and risk factor modification, antiplatelets, cilostazol, exercise therapy, or surgical interventions for treatment, depending on the patient profile. The clinical, humanistic, and economic burden of disease in patients with symptomatic PAD is substantial and needs to be reduced through improved PAD management.
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Affiliation(s)
- Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmBH, Darmstadt, Germany
| | - Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery, Angiology, Endovascular Interventions, University of Hamburg-Eppendorf, Hamburg Germany
| | - Mark Nehler
- Vascular Surgery and Endovascular Therapy Faculty, University of Colorado and CPC Research, Denver, CO, USA
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Ambler GK, Waldron CA, Contractor UB, Hinchliffe RJ, Twine CP. Umbrella review and meta-analysis of antiplatelet therapy for peripheral artery disease. Br J Surg 2019; 107:20-32. [DOI: 10.1002/bjs.11384] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/31/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
Abstract
Background
The literature on antiplatelet therapy for peripheral artery disease has historically been summarized inconsistently, leading to conflict between international guidelines. An umbrella review and meta-analysis was performed to summarize the literature, allow assessment of competing safety risks and clinical benefits, and identify weak areas for future research.
Methods
MEDLINE, Embase, DARE, PROSPERO and Cochrane databases were searched from inception until January 2019. All meta-analyses of antiplatelet therapy in peripheral artery disease were included. Quality was assessed using AMSTAR scores, and GRADE analysis was used to quantify the strength of evidence. Data were pooled using random-effects models.
Results
Twenty-eight meta-analyses were included. Thirty-three clinical outcomes and 41 antiplatelet comparisons in 72 181 patients were analysed. High-quality evidence showed that antiplatelet monotherapy reduced non-fatal strokes (3 (95 per cent c.i. 0 to 6) fewer per 1000 patients), In symptomatic patients, it reduced cardiovascular deaths (8 (0 to 16) fewer per 1000 patients), but increased the risk of major bleeding (7 (3 to 14) more events per 1000). In asymptomatic patients, monotherapy reduced non-fatal strokes (5 (0 to 8) fewer per 1000), but had no other clinical benefit. Dual antiplatelet therapy caused more major bleeding after intervention than monotherapy (37 (8 to 102) more events per 1000), with very low-quality evidence of improved endovascular patency (risk ratio 4·00, 95 per cent c.i. 0·91 to 17·68).
Conclusion
Antiplatelet monotherapy has minimal clinical benefit for asymptomatic peripheral artery disease, and limited benefit for symptomatic disease, with a clear risk of major bleeding. There is a lack of evidence to guide antiplatelet prescribing after peripheral endovascular intervention.
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Affiliation(s)
- G K Ambler
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - C-A Waldron
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - U B Contractor
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - R J Hinchliffe
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - C P Twine
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
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Saati A, AlHajri N, Ya'qoub L, Ahmed W, Alasnag M. Peripheral Vascular Disease in Women: Therapeutic Options in 2019. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:68. [PMID: 31728774 DOI: 10.1007/s11936-019-0769-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW In recent years, there have been advances in the prevention, management, and control of peripheral vascular disease (PVD). There is a trend towards aggressive risk factor modification, noninvasive screening, and endovascular revascularization with surgical approaches reserved only for select cases. This article reviews the different management strategies ranging from pharmacotherapy, revascularization, and rehabilitation with an emphasis on the response of women to these therapies. RECENT FINDINGS Overall, the representation of women in the majority of the published data in this arena remains poor. Studies examining medical therapy and endovascular and surgical revascularization were not designed to address sex disparities. Nevertheless, we dissect these therapies and their relevant randomized trials. The paucity of data investigating the response of women to the different management options makes it difficult to make any evidence-based recommendations. This not only applies to the type of intervention, but also the appropriate timing and risks entailed.
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Affiliation(s)
| | - Noora AlHajri
- Division of Cardiovascular Science, National Institute of Health/National Institute of Aging (NIH/NIA), Baltimore, MD, USA
| | | | - Waqar Ahmed
- Cardiac Center, King Fahd Armed Forces Hospital, PO Box 9862, Jeddah, 21159, Saudi Arabia
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, PO Box 9862, Jeddah, 21159, Saudi Arabia.
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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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Current Therapeutic Strategies in Diabetic Foot Ulcers. Medicina (B Aires) 2019; 55:medicina55110714. [PMID: 31731539 PMCID: PMC6915664 DOI: 10.3390/medicina55110714] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/16/2019] [Accepted: 10/21/2019] [Indexed: 01/07/2023] Open
Abstract
Diabetic foot ulcers (DFUs) are the fastest growing chronic complication of diabetes mellitus, with more than 400 million people diagnosed globally, and the condition is responsible for lower extremity amputation in 85% of people affected, leading to high-cost hospital care and increased mortality risk. Neuropathy and peripheral arterial disease trigger deformities or trauma, and aggravating factors such as infection and edema are the etiological factors for the development of DFUs. DFUs require identifying the etiology and assessing the co-morbidities to provide the correct therapeutic approach, essential to reducing lower-extremity amputation risk. This review focuses on the current treatment strategies for DFUs with a special emphasis on tissue engineering techniques and regenerative medicine that collectively target all components of chronic wound pathology.
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Su SC, Hung YJ, Huang CL, Shieh YS, Chien CY, Chiang CF, Liu JS, Lu CH, Hsieh CH, Lin CM, Lee CH. Cilostazol inhibits hyperglucose-induced vascular smooth muscle cell dysfunction by modulating the RAGE/ERK/NF-κB signaling pathways. J Biomed Sci 2019; 26:68. [PMID: 31492153 PMCID: PMC6731603 DOI: 10.1186/s12929-019-0550-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/25/2019] [Indexed: 02/08/2023] Open
Abstract
Background Increasing evidence suggests that high glucose (HG) causes abnormalities in endothelial and vascular smooth muscle cell function (VSMC) and contributes to atherosclerosis. Receptor for advanced glycation end-products (RAGE) has been linked to the pathogenesis of both the macrovascular and microvascular complications of diabetes. Cilostazol is used to treat diabetic vasculopathy by ameliorating HG-induced vascular dysfunction. Objectives In this study, we investigated whether the cilostazol suppression of HG-induced VSMC dysfunction is through RAGE signaling and its possible regulation mechanism. Method We investigated the effect of HG and cilostazol on RAGE signaling in A7r5 rat VSMCs. Aortic tissues of streptozotocin (STZ) diabetic mice were also collected. Results Aortic tissue samples from the diabetic mice exhibited a significantly decreased RAGE expression after cilostazol treatment. HG increased RAGE, focal adhesion kinase (FAK), matrix metalloproteinase-2 (MMP-2), intercellular cell adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) expressions, and was accompanied with increased reactive oxygen species (ROS), cell proliferation, adhesion and migration. Cilostazol significantly reversed HG-induced RAGE, ROS, downstream gene expressions and cell functions. RAGE knockdown significantly reversed the expressions of HG-induced vasculopathy related gene expressions and cell functions. Cilostazol with RAGE knockdown had additive effects on downstream ERK/NF-κB signaling pathways, gene expressions and cell functions of A7r5 rat VSMCs in HG culture. Conclusions Both in vitro and in vivo experimental diabetes models showed novel signal transduction of cilostazol-mediated protection against HG-related VSMC dysfunction, and highlighted the involvement of RAGE signaling and downstream pathways.
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Affiliation(s)
- Sheng-Chiang Su
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Jen Hung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. .,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan. .,Division of Biochemistry, National Defense Medical Center, Taipei, Taiwan.
| | - Chia-Luen Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Shing Shieh
- School of Dentistry, National Defense Medical Center, Taipei, Taiwan.,Department of Oral Diagnosis and Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,Division of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Chu-Yen Chien
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Fu Chiang
- School of Dentistry, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Jhih-Syuan Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chieh-Hua Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chang-Hsun Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Ming Lin
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Hsing Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. .,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan. .,Division of Biochemistry, National Defense Medical Center, Taipei, Taiwan.
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Aoki J, Iguchi Y, Urabe T, Yamagami H, Todo K, Fujimoto S, Idomari K, Kaneko N, Iwanaga T, Terasaki T, Tanaka R, Yamamoto N, Tsujino A, Nomura K, Abe K, Uno M, Okada Y, Matsuoka H, Yamagata S, Yamamoto Y, Yonehara T, Inoue T, Yagita Y, Kimura K. Acute Aspirin Plus Cilostazol Dual Therapy for Noncardioembolic Stroke Patients Within 48 Hours of Symptom Onset. J Am Heart Assoc 2019; 8:e012652. [PMID: 31347430 PMCID: PMC6761671 DOI: 10.1161/jaha.119.012652] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background The aim of the present study was to investigate the efficacy and safety of antiplatelet (aspirin plus cilostazol) dual therapy for patients with noncardioembolic stroke within 48 hours of symptom onset. Methods and Results The ADS (Acute Aspirin Plus Cilostazol Dual Therapy for Non‐Cardiogenic Stroke Patients Within 48 Hours of Symptom Onset ) study is an investigator‐initiated, prospective, multicenter (34 hospitals in Japan), randomized, open‐label, and aspirin‐controlled trial. Acute stroke patients with noncardioembolic stroke within 48 hours of onset were studied. The subjects were randomly allocated to combination therapy with aspirin 81 to 200 mg plus cilostazol 200 mg (dual group) and single therapy with aspirin 81 to 200 mg (aspirin group) for 14 days. After the 14 days, all patients took the cilostazol 200 mg for 3 months. A primary efficacy outcome was defined as any one of the following occurring (neurological deterioration, symptomatic stroke recurrence, or transient ischemic attack) within 14 days. A primary safety outcome included intracerebral hemorrhage and subarachnoid hemorrhage. Between May 2011 and June 2017, 1201 patients (796 [66%] men; median age, 69 [61–77] years) randomized 1:1 to either the dual group or the aspirin group were analyzed. Initial National Institutes of Health Stroke Scale score was 2 (1–4) in both groups (P=0.830). A primary efficacy outcome was observed in 11% in the dual group and 11% in the aspirin group (P=0.853). A primary safety outcome occurred in 2 (0.3%) in the dual group and in 1 (0.2%) in the aspirin group (P=0.624). Conclusions Dual antiplatelet therapy using cilostazol and aspirin was safe but did not reduce the rate of short‐term neurological worsening. Clinical Trial Registration URL: umin.ac.jp/ctr/index/htm. Unique identifier: UMIN000004950.
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Affiliation(s)
- Junya Aoki
- Department of Neurological Science Graduate School of Medicine Nippon Medical School Tokyo Japan.,Department of Stroke Medicine Kawasaki Medical School Okayama Japan
| | - Yasuyuki Iguchi
- Department of Neurology Jikei University School of Medicine Tokyo Japan
| | - Takao Urabe
- Department of Neurology Juntendo University Urayasu Hospital Chiba Japan
| | - Hiroshi Yamagami
- Department of Neurology, Stroke Center Kobe City Medical Center General Hospital Hyogo Japan
| | - Kenichi Todo
- Department of Neurology, Stroke Center Kobe City Medical Center General Hospital Hyogo Japan
| | - Shigeru Fujimoto
- Department of Cerebrovascular Medicine, Stroke Center Steel Memorial Yawata Hospital Fukuoka Japan
| | - Koji Idomari
- Department of Stroke Medicine Okinawa Kyodo Hospital Okinawa Japan
| | - Nobuyuki Kaneko
- Department of Stroke Medicine Okinawa Kyodo Hospital Okinawa Japan
| | - Takeshi Iwanaga
- Department of Stroke Medicine Okayama Red Cross Hospital Okayama Japan
| | - Tadashi Terasaki
- Department of Neurology Japanese Red Cross Kumamoto Hospital Kumamoto Japan
| | - Ryota Tanaka
- Department of Neurology Faculty of Medicine Juntendo University Tokyo Japan
| | - Nobuaki Yamamoto
- Department of Clinical Neurosciences Institute of Biomedical Sciences Tokushima University Tokushima Japan
| | - Akira Tsujino
- Department of Neurology and Strokology Nagasaki University Hospital Nagasaki Japan
| | | | - Koji Abe
- Department of Neurology Okayama University Medical School Okayama Japan
| | - Masaaki Uno
- Department of Neurosurgery Kawasaki Medical School Okayama Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology Clinical Research Institute National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Hideki Matsuoka
- Department of Cerebrovascular Medicine NHO Kagoshima Medical Center Kagoshima Japan
| | - Sen Yamagata
- Department of Neurosurgery Kurashiki Central Hospital Okayama Japan
| | | | - Toshiro Yonehara
- Department of Neurology Stroke Center Saiseikai Kumamoto Hospital Kumamoto Japan
| | - Takeshi Inoue
- Department of Stroke Medicine Kawasaki Medical School General Medical Center Kawasaki Medical School Okayama Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine Kawasaki Medical School Okayama Japan
| | - Kazumi Kimura
- Department of Neurological Science Graduate School of Medicine Nippon Medical School Tokyo Japan.,Department of Stroke Medicine Kawasaki Medical School Okayama Japan
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43
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Yeong XL, Chan ESY, Samuel M, Choong AMTL. Venous arterialization for the salvage of critically ischemic lower limbs. Hippokratia 2019. [DOI: 10.1002/14651858.cd013269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Xue Lun Yeong
- University of New South Wales; Level 5, Wallace Wurth Building 18 High Street Sydney NSW Australia 2052
| | - Edwin SY Chan
- Singapore Clinical Research Institute; Cochrane Singapore; Nanos Building #02-01 31 Biopolis Way Singapore Singapore 138669
| | - Miny Samuel
- NUS Yong Loo Lin School of Medicine; Dean's Office; NUHS Tower Block, Level 11 1E Kent Ridge Road Singapore Singapore 119228
| | - Andrew MTL Choong
- SingVaSC, Singapore Vascular Surgical Collaborative; Singapore Singapore
- National University of Singapore; Cardiovascular Research Institute; Singapore Singapore
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Surgery; Singapore Singapore
- National University Heart Centre; Division of Vascular Surgery; Singapore Singapore
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44
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Tummala S, Scherbel D. Clinical Assessment of Peripheral Arterial Disease in the Office: What Do the Guidelines Say? Semin Intervent Radiol 2019; 35:365-377. [PMID: 30728652 DOI: 10.1055/s-0038-1676453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lower extremity peripheral arterial disease (PAD) is the manifestation of atherosclerotic disease within the lower extremities. The presentation of PAD is diverse ranging from asymptomatic disease to claudication or to debilitating rest pain, nonhealing ulcers, and gangrene. PAD is associated with significant morbidity, mortality, and healthcare costs. Proper diagnosis and management of PAD is important so as to maintain quality of life and reduce the risk of cardiovascular disease and adverse limb events such as amputation. This document provides a comprehensive outpatient approach to the clinical assessment of PAD that includes risk factors, diagnosis, treatment, and follow-up options.
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Affiliation(s)
- Srini Tummala
- Limb Preservation Program, Department of Interventional Radiology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Derek Scherbel
- University of Miami, Miller School of Medicine, Miami, Florida
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45
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Gurney ME. Genetic Association of Phosphodiesterases With Human Cognitive Performance. Front Mol Neurosci 2019; 12:22. [PMID: 30800055 PMCID: PMC6376954 DOI: 10.3389/fnmol.2019.00022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/21/2019] [Indexed: 01/03/2023] Open
Abstract
Recent, large-scale, genome-wide association studies (GWAS) provide a first view of the genetic fine structure of cognitive performance in healthy individuals. These studies have pooled data from up to 1.1 million subjects based on simple measures of cognitive performance including educational attainment, self-reported math ability, highest math class taken, and pooled, normalized scores from cognitive tests. These studies now allow the genome-wide interrogation of genes and pathways for their potential impact on human cognitive performance. The phosphodiesterase (PDE) enzymes regulate key cyclic nucleotide signaling pathways. Many are expressed in the brain and have been the targets of CNS drug discovery. Genetic variation in PDE1C, PDE4B and PDE4D associates with multiple measures of human cognitive function. The large size of the human PDE4B and PDE4D genes allows genetic fine structure mapping to transcripts encoding dimeric (long) forms of the enzymes. Upstream and downstream effectors of the cAMP pathway modulated by PDE4D [adenylate cyclase 1 (ADCY1), ADCY8, PRKAR1A, CREB1, or CREBBP] did not show genetic association with cognitive performance, however, genetic association was seen with brain derived neurotrophic factor (BDNF), a gene whose expression is modulated by cAMP. Notably absent was genetic association in healthy subjects to targets of CNS drug discovery designed to improve cognition in disease states by the modulation of cholinergic [acetylcholinesterase (ACHE), choline acetyltransferase (CHAT), nicotinic alpha 7 acetylcholine receptor (CHRNA7)], serotonergic (HTR6), histaminergic (HRH3), or glutamatergic (GRM5) pathways. These new data provide a rationale for exploring the therapeutic benefit of selective inhibitors of PDE1C, PDE4B and PDE4D in CNS disorders affecting cognition.
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Affiliation(s)
- Mark E Gurney
- Tetra Discovery Partners, Grand Rapids, MI, United States
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46
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Abstract
Peripheral arterial disease (PAD) is a prevalent, morbid, and mortal disease. Claudication represents an early, yet common manifestation of PAD. A clinical history and physical examination combined with an ankle-brachial index can help make a diagnosis of claudication. Due to the polyvascular nature of the underlying atherosclerosis, PAD is often associated with heart disease and stroke. Although health implications of PAD derive from both its limb and cardiovascular manifestations, claudication is life-threatening, less limb-threatening. Medical modification of cardiovascular risk factors and exercise are the cornerstone in the treatment of claudication. Revascularization in claudication is focused at improvement in claudication symptoms and functional status, rather than aggressive attempts at limb salvage. The aim of this article is to summarize the strategies in the treatment of claudication, to serve as a concise and informative reference for physicians who are managing these patients. A framework of the decision-making process in the management of patients with claudication is shown, which can be applied in clinical practice.
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Affiliation(s)
- Keith Pereira
- Division of Vascular and Interventional Radiology, Saint Louis University, St. Louis, Missouri
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47
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Asano W, Takahashi Y, Kawano M, Hantani Y. Identification of an Arginase II Inhibitor via RapidFire Mass Spectrometry Combined with Hydrophilic Interaction Chromatography. SLAS DISCOVERY 2018; 24:457-465. [PMID: 30523711 DOI: 10.1177/2472555218812663] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Peripheral arterial disease (PAD) is an occlusive disease that can lead to atherosclerosis. The involvement of arginase II (Arg II) in PAD progression has been proposed. However, no promising drugs targeting Arg II have been developed to date for the treatment of PAD. In this study, we established a method for detecting the activity of Arg II via high-throughput label-free RapidFire mass spectrometry using hydrophilic interaction chromatography, which enables the direct measurement of l-ornithine produced by Arg II. This approach facilitated a robust high-concentration screening of fragment compounds and the identification of a fragment that inhibits the activity of Arg II. We further confirmed binding of the fragment to the potential allosteric site of Arg II using a surface plasmon resonance assay. We concluded that the identified fragment is a promising compound that may lead to novel drugs to treat PAD, and our method for detecting the activity of Arg II can be applied to large-scale high-throughput screening to identify other structural types of Arg II inhibitors.
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Affiliation(s)
- Wataru Asano
- 1 Biological/Pharmacological Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., Takatsuki, Osaka, Japan
| | - Yu Takahashi
- 1 Biological/Pharmacological Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., Takatsuki, Osaka, Japan.,2 Current address: Department of Applied Biological Chemistry, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Motoaki Kawano
- 1 Biological/Pharmacological Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., Takatsuki, Osaka, Japan
| | - Yoshiji Hantani
- 1 Biological/Pharmacological Research Laboratories, Central Pharmaceutical Research Institute, Japan Tobacco Inc., Takatsuki, Osaka, Japan
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48
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Nativel M, Potier L, Alexandre L, Baillet-Blanco L, Ducasse E, Velho G, Marre M, Roussel R, Rigalleau V, Mohammedi K. Lower extremity arterial disease in patients with diabetes: a contemporary narrative review. Cardiovasc Diabetol 2018; 17:138. [PMID: 30352589 PMCID: PMC6198374 DOI: 10.1186/s12933-018-0781-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/17/2018] [Indexed: 12/24/2022] Open
Abstract
Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.
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Affiliation(s)
- Mathilde Nativel
- Département d'Endocrinologie, Diabétologie, Nutrition, Hôpital Haut-Lévêque, Avenue de Magellan, 33604, Pessac Cedex, France
| | - Louis Potier
- Département d'Endocrinologie, Diabétologie, Nutrition, Assistance Publique - Hôpitaux de Paris, Hospital Bichat, DHU FIRE, Paris, France.,UFR de Médecine, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Laure Alexandre
- Département d'Endocrinologie, Diabétologie, Nutrition, Hôpital Haut-Lévêque, Avenue de Magellan, 33604, Pessac Cedex, France.,Faculté de Médecine, Université de Bordeaux, Bordeaux, France
| | - Laurence Baillet-Blanco
- Département d'Endocrinologie, Diabétologie, Nutrition, Hôpital Haut-Lévêque, Avenue de Magellan, 33604, Pessac Cedex, France
| | - Eric Ducasse
- Faculté de Médecine, Université de Bordeaux, Bordeaux, France.,Département de Chirurgie Vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Gilberto Velho
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Michel Marre
- Département d'Endocrinologie, Diabétologie, Nutrition, Assistance Publique - Hôpitaux de Paris, Hospital Bichat, DHU FIRE, Paris, France.,UFR de Médecine, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France.,Fondation Adolphe de Rothschild Hospital, Paris, France
| | - Ronan Roussel
- Département d'Endocrinologie, Diabétologie, Nutrition, Assistance Publique - Hôpitaux de Paris, Hospital Bichat, DHU FIRE, Paris, France.,UFR de Médecine, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Vincent Rigalleau
- Département d'Endocrinologie, Diabétologie, Nutrition, Hôpital Haut-Lévêque, Avenue de Magellan, 33604, Pessac Cedex, France.,Faculté de Médecine, Université de Bordeaux, Bordeaux, France
| | - Kamel Mohammedi
- Département d'Endocrinologie, Diabétologie, Nutrition, Hôpital Haut-Lévêque, Avenue de Magellan, 33604, Pessac Cedex, France. .,Faculté de Médecine, Université de Bordeaux, Bordeaux, France.
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49
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Klarin D, Damrauer SM, Cho K, Sun YV, Teslovich TM, Honerlaw J, Gagnon DR, DuVall SL, Li J, Peloso GM, Chaffin M, Small AM, Huang J, Tang H, Lynch JA, Ho YL, Liu DJ, Emdin CA, Li AH, Huffman JE, Lee JS, Natarajan P, Chowdhury R, Saleheen D, Vujkovic M, Baras A, Pyarajan S, Di Angelantonio E, Neale BM, Naheed A, Khera AV, Danesh J, Chang KM, Abecasis G, Willer C, Dewey FE, Carey DJ, Concato J, Gaziano JM, O'Donnell CJ, Tsao PS, Kathiresan S, Rader DJ, Wilson PWF, Assimes TL. Genetics of blood lipids among ~300,000 multi-ethnic participants of the Million Veteran Program. Nat Genet 2018; 50:1514-1523. [PMID: 30275531 PMCID: PMC6521726 DOI: 10.1038/s41588-018-0222-9] [Citation(s) in RCA: 385] [Impact Index Per Article: 64.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/03/2018] [Indexed: 01/17/2023]
Abstract
The Million Veteran Program (MVP) was established in 2011 as a national
research initiative to determine how genetic variation influences the health of
U.S. military veterans. We genotyped 312,571 MVP participants using a custom
biobank array and linked the genetic data to laboratory and clinical phenotypes
extracted from electronic health records covering a median of 10.0 years of
follow-up. Among 297,626 veterans with at least 1 blood lipid measurement
including 57,332 blacks and 24,743 Hispanics, we tested up to ~32 million
variants for association with lipid levels and identified 118 novel genome-wide
significant loci after meta-analysis with data from the Global Lipids Genetics
Consortium (total N > 600,000). Through a focus on mutations predicted to
result in a loss of gene function and a phenome-wide association study, we
propose novel indications for pharmaceutical inhibitors targeting PCSK9
(abdominal aortic aneurysm), ANGPTL4 (type 2 diabetes), and PDE3B (triglycerides
and coronary disease).
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Affiliation(s)
- Derek Klarin
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Boston VA Healthcare System, Boston, MA, USA
| | - Scott M Damrauer
- Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Jacqueline Honerlaw
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - David R Gagnon
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Scott L DuVall
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jin Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Gina M Peloso
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Mark Chaffin
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Aeron M Small
- Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jie Huang
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Hua Tang
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Julie A Lynch
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Massachusetts College of Nursing and Health Sciences, Boston, MA, USA
| | - Yuk-Lam Ho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Dajiang J Liu
- Department of Public Health Sciences, Institute of Personalized Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Connor A Emdin
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Jennifer E Huffman
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA
| | - Jennifer S Lee
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Pradeep Natarajan
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rajiv Chowdhury
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Danish Saleheen
- Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marijana Vujkovic
- Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aris Baras
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Saiju Pyarajan
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emanuele Di Angelantonio
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Benjamin M Neale
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Aliya Naheed
- Initiative for Noncommunicable Diseases, Health Systems and Population Studies Division, International Centre for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Amit V Khera
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - John Danesh
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kyong-Mi Chang
- Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gonçalo Abecasis
- Center for Statistical Genetics, Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Cristen Willer
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA.,Department of Human Genetics, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | | | | | - John Concato
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.,Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - J Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Christopher J O'Donnell
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Philip S Tsao
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sekar Kathiresan
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Daniel J Rader
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter W F Wilson
- Atlanta VA Medical Center, Decatur, GA, USA.,Emory Clinical Cardiovascular Research Institute, Atlanta, GA, USA
| | - Themistocles L Assimes
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,VA Palo Alto Health Care System, Palo Alto, CA, USA.
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50
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME, Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis J, Joglar J, Pressler SJ, Wijeysundera DN. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary. Vasc Med 2018; 22:NP1-NP43. [PMID: 28494710 DOI: 10.1177/1358863x17701592] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
-
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | | | - Heather L Gornik
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | | | | | | | - Douglas E Drachman
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,5 Society for Cardiovascular Angiography and Interventions Representative
| | - Lee A Fleisher
- 6 ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Francis Gerry R Fowkes
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,7 Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative
| | | | - Scott Kinlay
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,8 Society for Vascular Medicine Representative
| | - Robert Lookstein
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Sanjay Misra
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,9 Society of Interventional Radiology Representative
| | - Leila Mureebe
- 10 Society for Clinical Vascular Surgery Representative
| | - Jeffrey W Olin
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Rajan A G Patel
- 7 Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative
| | | | - Andres Schanzer
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,11 Society for Vascular Surgery Representative
| | - Mehdi H Shishehbor
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Kerry J Stewart
- 3 ACC/AHA Representative.,12 American Association of Cardiovascular and Pulmonary Rehabilitation Representative
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