Guideline-directed statin intensification in patients with new or worsening symptoms of peripheral artery disease

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

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.

Preoperative Statin Use is Associated With Lower Incidence of Limb Loss After Lower Extremity Endovascular Interventions

BACKGROUND

Statin therapy is the primary lipid-lowering agent used in peripheral artery disease (PAD) patients. Although the benefits of statins have been described in the literature, most studies have focused on postoperative statin use and outcomes in major upper body vasculature. Our study aimed to assess the impact of statin therapy on postoperative outcomes of lower extremity endovascular interventions including mortality and amputation rates.

METHODS

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2012 to 2019 was utilized for this study. Patients were divided into 2 groups: those on preoperative statins (Group I) and those not on statins (Group II). Univariate and multivariate analyses were performed to assess statin's effect on postoperative outcomes.

RESULTS

A total of 12,217 patients (72.7%) were in Group I and 4599 patients (27.3%) were in Group II. The distribution of primary outcomes was as follows: Amputation (Group I: 3% vs Group II: 3.9%, P <.05) and Mortality (Group I: 1.6% vs Group II: 1.9%, P = .086). Statin use was associated with decreased amputation rates. Patients with tissue loss were 5 times more likely to undergo amputations (AOR: 5.58 [CI 2.29-13.63] P < .01) within 30-days postoperatively as compared to those whose presenting symptoms were claudication.

CONCLUSION

Statin therapy was associated with a decreased limb loss within 30-days after intervention at the time of lower extremity endovascular intervention. Patients presenting with rest pain and tissue loss had a higher incidence of limb loss than claudicants.

Statins and Peripheral Arterial Disease: A Narrative Review

Peripheral arterial disease (PAD) is a highly prevalent atherosclerotic condition. In patients with PAD, the presence of intermittent claudication leads to a deterioration in quality of life. In addition, even in asymptomatic cases, patients with PAD are at high risk of cardiac or cerebrovascular events. Treatment of PAD is based on lifestyle modifications; regular exercise; smoking cessation; and control of cardiovascular risk factors, including hypercholesterolemia. A growing number of studies have shown that statins reduce cardiovascular risk and improve symptoms associated with PAD. Current guidelines recommend the use of statins in all patients with PAD in order to decrease cardiovascular events and mortality. However, the prescribing of statins in patients with PAD is lower than in those with coronary heart disease. This review provides relevant information from the literature that supports the use of statins in patients with PAD and shows their potential benefit in decreasing lower limb complications as well as cardiovascular morbidity and mortality.

Quality assessment and comparative analysis on the recommendations of current guidelines on the management of peripheral arterial disease: a systematic review protocol

INTRODUCTION

Peripheral arterial disease (PAD) is the third leading atherosclerotic arterial disease. There is evidence that there is a high variation in the quality and recommendations of clinical practice guidelines for PAD, leading to the possibility of confusion among clinicians and patients. This study aims to conduct a quality assessment and comparative analysis of the clinical practice guidelines on PAD written between 2010 and 2020.

METHOD AND ANALYSIS

We aim to perform a systematic review of clinical practice guidelines written between 2010 and 2020. A search for guidelines will be conducted through medical databases Scope, Pubmed, TRIP, Guideline Clearinghouses and specialist international organisations' specific websites. Guidelines that meet the inclusion criteria will be extracted from the search result. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II instrument) will assess the quality of the selected guidelines. The recommendations, level of evidence and other relevant information will be extracted in a datasheet for qualitative analysis. The score for each guideline's quality will be represented using charts and central tendency measures for comparison. The summary of recommendations will also be represented in tables for easy comparison for similarities and variations across sections. Finally, the level of evidence on which the recommendations are based will also be noted along with other significant characteristics such as the authors' financial relationship to the biomedical community. We aim to point out deficiencies present in current guidelines and elucidate areas where recommendations are made with low-level evidence. The results will enable the scientific community to design future research to fill in PAD management knowledge gaps.

ETHICS AND DISSEMINATION

No ethical approval was sought. Dissemination will be via journal articles and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020219176.

Trends in statin utilization among adults with severe peripheral artery disease including critical limb ischemia in an integrated healthcare delivery system

Evidence suggests that statin therapy in patients with peripheral artery disease (PAD) is beneficial yet use remains suboptimal. We examined trends in statin use, intensity, and discontinuation among adults aged ⩾ 40 years with incident severe PAD and a subset with critical limb ischemia (CLI) between 2002 and 2015 within an integrated healthcare delivery system. Discontinuation of statin therapy was defined as the first 90-day gap in treatment within 1 year following PAD diagnosis. We identified 11,059 patients with incident severe PAD: 31.1% (n = 3442) with CLI and 68.9% (n = 7617) without CLI. Mean (SD) age was 68.6 (11.3) years, 60.5% were male, 54.2% white, 23.2% Hispanic, and 16.2% black. Statin use in the year before diagnosis increased from 50.4% in 2002 to 66.0% in 2015 (CLI: 43.7% to 68.0%; without CLI: 53.1% to 64.2%, respectively). The proportion of patients on high-intensity statins increased from 7.3% in 2002 to 41.9% in 2015 (CLI: 7.2% to 39.4%; without CLI: 7.4% to 44.2%, respectively). Of the 40.5% (n = 4481) who were not on a statin in the year before diagnosis, 13.5% (n = 607) newly initiated therapy within 1 month (CLI: 10.1% (n = 150); without CLI: 15.3% (n = 457)). Following diagnosis, 12.5% (n = 660) discontinued statin therapy within 1 year (CLI: 15.5% (n = 202); without CLI: 11.5% (n = 458)). Although use of statins increased from 2002 to 2015, a substantial proportion of the overall PAD and CLI subpopulation remained untreated with statins, representing a significant treatment gap in a population at high risk for cardiovascular events and adverse limb outcomes.

Guideline-directed statin intensification in patients with new or worsening symptoms of peripheral artery disease

BACKGROUND

The ACC/AHA cholesterol guidelines recommend patients with peripheral artery disease (PAD) be treated with a moderate to high-intensity statin. The extent to which patients with new or worsening PAD symptoms are offered guideline therapy is unknown.

HYPOTHESIS

There is significant variability in rate of guideline-directed statin intensification across clinical practices.

METHODS

In the PORTRAIT registry, patterns of statin therapy were assessed in 1144 patients at 16 PAD specialty clinics between June 2011 and December 2015 before and after an evaluation for new or worsening claudication symptoms. We documented whether patients were treated with a guideline statin as well as the incidence of statin intensification. Statin intensification was defined as transitioning from no statin or low-intensity statin to moderate or high-intensity statin treatment. Patient factors associated with intensification were examined. Site and provider-level variation in intensification was summarized using an adjusted median odds ratio (aMOR).

RESULTS

Among 1144 patients, 810 (70.8%) were initially on guideline therapy compared to 334 (29.2%) that were not. In the latter, 103 (30.8%) received intensification following evaluation. Patients with typical symptoms displayed greater odds of intensification (OR 3.74; 95% CI: 1.23-11.41) while older patients had lower odds of intensification (OR 0.60/decade; 95% CI: 0.41-0.88). Site variability for statin intensification was observed across sites (aMOR = 3.15; 95% CI 1.22-9.60, [P = 0.02]) but not providers (aMOR = 1.89; 95% CI 1.00-3.90, [P = 0.14]).

CONCLUSIONS

Most patients evaluated at a PAD specialty clinic for new or worsening claudication symptoms arrived on guideline statin therapy. Only 31% not receiving appropriate therapy underwent statin intensification. These findings highlight an important opportunity to optimize medical therapy for patients with PAD.