Risk Factors for Suboptimal Utilization of Statins and Antiplatelet Therapy in Patients Undergoing Revascularization for Symptomatic Peripheral Arterial Disease

Demographic and regional trends of peripheral artery disease-related mortality in the United States, 2000 to 2019

INTRODUCTION

Peripheral artery disease (PAD) is a common progressive atherosclerotic disease associated with significant morbidity and mortality in the US; however, data regarding PAD-related mortality trends are limited. This study aims to characterize contemporary trends in mortality across sociodemographic and regional groups.

METHODS

The Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) was queried for data regarding PAD-related deaths from 2000 to 2019 in the overall sample and different demographic (age, sex, race/ethnicity) and regional (state, urban-rural) subgroups. Crude and age-adjusted mortality rates (CMR and AAMR, respectively) per 100,000 people were calculated. Associated annual percentage changes (APC) were computed using Joinpoint Regression Program Version 4.9.0.0 trend analysis software.

RESULTS

Between 2000 and 2019, a total of 1,959,050 PAD-related deaths occurred in the study population. Overall, AAMR decreased from 72.8 per 100,000 in 2000 to 32.35 per 100,000 in 2019 with initially decreasing APCs followed by no significant decline from 2016 to 2019. Most demographic and regional subgroups showed initial declines in AAMRs during the study period, with many groups exhibiting no change in mortality in recent years. However, men, non-Hispanic (NH) Black or African American individuals, people aged ⩾ 85 years, and rural counties were associated with the highest AAMRs of their respective subgroups. Notably, there was an increase in crude mortality rate among individuals 25-39 years of age from 2009 to 2019.

CONCLUSION

Despite initial improvement, PAD-related mortality has remained stagnant in recent years. Disparities have persisted across several demographic and regional groups, requiring further investigation.

Prognostic Role of Polyvascular Involvement in Patients with Symptomatic Peripheral Artery Disease

Background: Statin therapy is recommended for patients with peripheral artery disease (PAD). However, PAD patients with polyvascular (PV) extent remain threatened by an increased residual cardiovascular (CV) risk. Purpose: To investigate the association of prescribed statin therapy and mortality in PAD patients with or without PV extent. Methods: A single-center retrospective longitudinal observational study originating from a consecutive registry with 1380 symptomatic PAD patients over a mean observational time of 60 ± 32 months. The association of atherosclerotic extent and statin use (PAD, plus one additional region (CAD or CeVD, [+1 V]), +2 vascular regions (+CAD and CeVD [+2 V]) with the risk of all-cause mortality was evaluated using Cox proportional hazard models adjusted for potential confounding factors. Results: The mean age of the study's participants was 72.0 ± 11.7 years, with 36% being female. PAD patients with PV extent [+1 V] and [+2 V] were older and suffered from diabetes, hypertension, or dyslipidemia more often; they, too, had more severely impaired kidney function (all p < 0.0001) compared to patients with PAD only. PAD patients with PV [+1 V] and [+2 V] received better statin medication and reached the recommended LDL-C target compared to PAD-only patients (p < 0.001). Despite better statin treatment, the rate of all-cause mortality was higher in PV patients than in PAD-only patients (PAD only: 13%; [+1 V]: 22%; [+2 V]: 35%; p < 0.0001). Conclusion: PV patients receive better statin therapy than PAD-only patients but nevertheless still have higher mortality rates. Future studies are needed to explore whether more aggressive LDL-lowering treatment for PAD patients may be translated into better prognosis.

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.

Prescribing of Statins After Lower Extremity Revascularization Procedures in the US

IMPORTANCE

The use of statins in patients with symptomatic peripheral artery disease remains suboptimal despite strong clinical practice guideline recommendations; however, it is unknown whether rates are associated with substantial improvements after lower extremity revascularization.

OBJECTIVE

To report longitudinal trends of statin use in patients with peripheral artery disease undergoing lower extremity revascularization and to identify the clinical and procedural characteristics associated with prescriptions for new statin therapy at discharge.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cross-sectional study using data from the Vascular Quality Initiative registry of patients who underwent lower extremity peripheral artery disease revascularization from January 1, 2014, through December 31, 2019. The Vascular Quality Initiative is a multicenter registry database including academic and community-based hospitals throughout the US. Patients aged 18 years or older undergoing lower extremity revascularization with available statin data (preprocedure and postprocedure) were included. Those not receiving statin therapy for medical reasons were excluded from final analyses.

EXPOSURES

Patients undergoing lower extremity revascularization for whom statin therapy is indicated.

MAIN OUTCOMES AND MEASURES

Multivariate logistic regression was used to determine the clinical and procedural characteristics associated with new statin prescription for patients not already taking a statin preprocedure. The overall rates of statin prescription as well as rates of new statin prescription at discharge were determined. In addition, the clinical, demographic, and procedural characteristics associated with new statin prescription were analyzed.

RESULTS

There were 172 025 procedures corresponding to 125 791 patients (mean [SD] age, 67.7 [11.0] years; 107 800 men [62.7%]; and 135 405 White [78.7%]) included in the analysis. Overall rates of statin prescription at discharge improved from 17 299 of 23 093 (75%) in 2014 to 29 804 of 34 231 (87%) in 2019. However, only 12 790 of 42 020 patients (30%) not already taking a statin at the time of revascularization during the study period were newly discharged with a statin medication. New statin prescription rates were substantially lower after endovascular intervention (7745 of 29 581 [26%]) than after lower extremity bypass (5045 of 12 439 [41%]). Body mass index of 30 or greater (odds ratio [OR], 1.13; 95% CI, 1.04-1.24; P < .001), diabetes (diet-controlled vs no diabetes, OR, 1.22; 95% CI, 1.05-1.41; P = .01), smoking (current vs never, OR, 1.32; 95% CI, 1.21-1.45; P < .001), hypertension (OR, 1.19; 95% CI, 1.09-1.29; P < .001), and coronary heart disease (OR, 1.26; 95% CI, 1.17-1.35; P < .001) were associated with an increased likelihood of new statin prescription after endovascular intervention, whereas female sex, older age, antiplatelet use, and prior peripheral revascularization were associated with a decreased likelihood.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, although statin use was associated with a substantial improvement after lower extremity revascularization, more than two-thirds of patients not already taking a statin preprocedure remained not taking a statin at discharge. Further investigations to understand the clinical implications of these findings and develop clinician- and system-based interventions are needed.

Evidence-based medical treatment of peripheral arterial disease: A rapid review

ABSTRACT Introduction: Peripheral arterial disease (PAD) treatment guidelines recommend the use of statins and antiplatelets in all PAD patients to reduce adverse cardiovascular and limb-related outcomes. In addition, hypertension and diabetes should be treated to reach recommended targets. The aim of this rapid review was to evaluate the level of adherence to evidence-based medical therapy (EBMT) recommended by PAD treatment guidelines in the real-world setting. Methods: We searched PubMed and Embase using keywords, MeSH and Emtree terms related to the population, exposure and outcomes from their inception to 22 September 2020. We included randomised controlled trials, non-randomised studies, and observational studies reporting adherence to at least 1 of these 4 drug classes: (1) statins, (2) antiplatelets, (3) antihypertensives and (4) antidiabetic drugs. Non-English articles, abstracts, dissertations, animal studies and case reports or series were excluded. A narrative summary of the results was performed. Results: A total of 42 articles were included in the review. The adherence to lipid-lowering drugs/statins ranged from 23.5 to 92.0% and antiplatelets from 27.5 to 96.3%. Only 7 and 5 studies reported use of “any anti-hypertensive” and “any anti-diabetic” medications, respectively, and the proportion of the cohort treated were generally close to the proportion with hypertension and/or diabetes. Adherence in studies published in 2016–2020 ranged from 52.4–89.6% for lipid-lowering drugs and 66.2–96.3% for antiplatelets. Conclusion: EBMT adherence in PAD patients was highly variable and a substantial proportion in many settings were undertreated. There was also a notable lack of studies in Asian populations. Keywords: Evidence-practice gap, medication adherence, pharmacoepidemiology

Underuse of statins for secondary prevention of atherosclerotic cardiovascular disease events among ambulatory surgical patients

Although statins are highly effective for reducing cardiovascular disease events, prior studies demonstrate their significant underuse in the US population, including among those with known atherosclerotic disease. It is unknown whether this finding applies to the subset of patients who present for outpatient surgery, as such patients would be expected to have recent exposures to healthcare providers during the preoperative referral period. The primary aim of this manuscript was to ascertain the prevalence of statin underuse and associated risk-factors for such underuse among ambulatory surgical patients with documented atherosclerotic cardiovascular disease. This was a retrospective observational study of a random sample of 600 patients ages 40-75 years presenting for ambulatory surgery within a 6-month period in 2016, at one of three ambulatory surgical centers affiliated with a large, tertiary care hospital. Compilation and analysis of data occurred in 2018-2019. Of the 600 subjects, 117 (19.5%) had documented atherosclerotic cardiovascular disease. Within this high-risk group, only 71 (60.7%) carried a prescription for any statin, and only 30 (25.6%) were prescribed a recommended high intensity statin dose for secondary prevention. In a multivariable logistic regression analysis, older age, male sex, and treatment for hypertension were positively associated with statin use. In conclusion, statin underuse among ambulatory surgical patients is common and mirrors what has been observed in non-surgical populations. Future trials are needed to investigate the possible role of surgical teams to promote guideline-based statin therapy, including the role of preoperative screening interventions to impact long term cardiovascular morbidity and mortality.

Comparative Study of the Results of a Three-year Observation of Cardiologists and Surgeons in Patients with Peripheral Atherosclerosis

Aim. To compare the results of 3-year follow-up of patients with peripheral atherosclerosis (PA) in two patient cohorts: during outpatient monitoring by cardiologists and when observed by surgeons.

Material and methods. The first group included 131 patients with PA who sought medical attention in outpatient clinic in 2013-2014 and then were observed by a surgeon. The second group is represented by 454 patients with PA who sought medical attention in outpatient clinic in 2010- 2012 and then underwent observation by a cardiologist as a part of a pilot project. The average follow-up duration in the studied groups was three years. The groups were compared according to the main demographic, anthropometric indicators, the presence of risk factors for atherosclerosis, comorbidity, the prevalence of atherothrombotic events in history, laboratory and instrumental examination data. Additionally, after 3 years of observation the incidence of deaths and amputations was assessed in groups.

Results. Patients of the second group were older than these in the first group (p<0.001). Patients of the group 1 compared to the group 2 were more often overweight (p=0.005), suffered from diabetes mellitus (p<0.001), had a disability (p<0.001). Among patients of the group 2 compared with the group 1, the clinical picture of angina pectoris (p=0.001), rhythm disorders (p=0.058) were more often observed, they had a greater number of myocardial infarctions (p<0.001) and myocardial revascularization operations in the history: coronary bypass surgery (p=0.029), percutaneous coronary interventions (p<0.001), and underwent coronary angiography (p<0.001). Patients in group 2 were more likely to receive statins (p<0.001), β-blockers (p<0.001), angiotensin-converting enzyme inhibitors, and calcium channel blockers, angiotensin II receptor blockers, and antiarrhythmics (p<0.001). Pentoxifylline was prescribed more often in the first group (p<0.001). With a three-year observation of PA patients a fatal outcome occurred in 8.2% of cases, amputation – in 1.4%. In the first group, compared with the second one, there were more often observed deaths in general (p=0.023), death from cardiac causes, stroke, disability (p=0.005) and amputations (p=0.003). The risk of adverse outcomes (death and amputations) was increased in the presence of signs of chronic lower limb ischemia of stage III, a history of amputation, more than 70% stenosis and occlusions of lower limb arteries, chronic lung disease, and angina symptoms. The risk of adverse outcomes was decreased in outpatient observation by cardiologist, taking statins, aspirin, and performing exercise therapy.

Conclusion. Observation of PA patients by a cardiologist results in more frequent optimal drug therapy (due to the better adherence of cardiologists to clinical recommendations for the treatment of such patients) and improves the prognosis of these patients. 

The compelling arguments for the need of medical vascular physicians in Europe

Summary. The burden of vascular diseases is growing worldwide, as the population ages, prompting a call to action not only in terms of awareness but also and most urgently in recognizing the need for vascular physicians, also called angiologists. Vascular medicine views the vascular system (arteries, veins, and lymphatics) as a whole, unique, and independent entity requiring specialized competencies. Vascular physicians offer a holistic and comprehensive approach to vascular patients including provision of interventional procedures, management of a heterogeneous group of multi-morbid and frail patients affected by multi-vessel diseases, and connecting different specialists in a multidisciplinary effort. Vascular medicine practise varies across European countries. While it is a firmly accepted medical speciality in many European countries it is not formally recognized by the European Union limiting adoption in the other countries. The lack of vascular physicians likely accounts for inequality of care of vascular patients as compared for example to patients with heart disease and might contribute to adverse outcomes and healthcare costs associated with vascular diseases. To move forward in the struggle to provide efficient care for multimorbid poly-vascular patients, it is essential to establish vascular medicine programs in Europe and worldwide. Important steps to achieve this goal include improving public awareness of vascular diseases, attain formal recognition by the EU of angiology/vascular medicine as a medical specialty, creating specialized treatment guidelines, and to harmonize vascular care in Europe.

Statin loading in cardiovascular surgery: never too early to treat

PURPOSE OF REVIEW

The effects of statin loading before, during or after vascular interventions on cardiovascular and renal outcomes are discussed. Furthermore, the selection of optimal statin type and dose, according to current evidence or guidelines, is considered. The importance of treating statin intolerance and avoiding statin discontinuation is also discussed.

RECENT FINDINGS

Statin loading has been shown to beneficially affect cardiovascular outcomes, total mortality and/or contrast-induced acute kidney injury, in patients undergoing vascular procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), carotid artery stenting, endovascular aneurysm repair, open abdominal aortic aneurysms (AAA) repair and lower extremities vascular interventions. High-dose statin pretreatment is recommended for PCI and CABG according to current guidelines. Statin discontinuation should be avoided during acute cardiovascular events and vascular interventions; adequate measures should be implemented to overcome statin intolerance.

SUMMARY

Statin loading is an important clinical issue in patients with cardiac and noncardiac vascular diseases, including carotid artery disease, peripheral artery disease and AAA, undergoing vascular interventions. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to statin loading, discontinuation and intolerance.

Advances in the Management of Peripheral Artery Disease

PURPOSE OF REVIEW

This paper provides a concise update on the management of peripheral artery disease (PAD).

RECENT FINDINGS

PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group. Structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs will improve. Finally, ensuring more patients with PAD receive aspirin therapy and statins may improve long-term survival, while further research will help determine if adding newer antiplatelet or anticoagulant medications may reduce leg amputations in selected patients. Clinicians should have a low threshold to obtain an angiogram and to pursue revascularization in patients with foot ulcers, gangrene, or foot infections. In patients with claudication, clinicians should maximize the benefits derived from exercise therapy and medical management before offering percutaneous or surgical revascularization.