Improving outcomes in patients with peripheral arterial disease

Endothelial SHP-1 regulates diabetes-induced abnormal collateral vessel formation and endothelial cell senescence

BACKGROUND

Critical limb ischemia is a major cause of peripheral arterial disease and morbidity affecting patients with diabetes. Diabetes-induced premature senescence of endothelial cells (EC) has been proposed as a mechanism leading to impaired ischemia-driven angiogenesis. We showed that hyperglycemia induced expression of the protein tyrosine phosphatase SHP-1, which reduced angiogenic factor activity in ischemic muscle of diabetic mice. Here, we evaluate the impact of SHP-1 deletion on EC function and senescence.

METHODS

Ligation of the femoral artery was performed in nondiabetic (NDM) and 3 months diabetic (DM) mice with EC-specific deletion of SHP-1. Cell migration, proliferation and protein expression were evaluated in EC exposed to normal (NG) or high glucose (HG) concentrations. Gastrocnemius and tibial artery of patients with diabetes were collected and analyzed.

RESULTS

Blood flow reperfusion and limb function were reduced by 43 % and 82 %, respectively in DM mice as compared to NDM mice. EC-specific deletion of SHP-1 in DM mice restored blood flow reperfusion by 60 %, and limb function by 86 %, while capillary density was similar to NDM mice. Moreover, ablation of SHP-1 in EC prevented diabetes-induced expression of the senescence markers p53 and p21 and counteracted Nrf2 downregulation. In EC, elevated expression of beta-galactosidase, p21 and p53, and suppression of Nrf2 and VEGF actions were observed in EC exposed to HG levels and human muscle and artery of patients with diabetes, effects that were reversed by overexpression of dominant negative SHP-1.

CONCLUSION

SHP-1 in EC is a central effector of diabetes-induced senescence and induces aberrant collateral vessel formation and blood flow reperfusion. Reduced SHP-1 expression counteracts these pathologic features.

Multicomponent interventions designed to support adherence to guideline-recommended therapy in patients with peripheral artery disease: A scoping review

Adherence to guideline-recommended therapies for peripheral artery disease (PAD), including pharmacotherapy (antiplatelet, lipid-lowering, and antihypertensive agents) and lifestyle modifications (smoking cessation, diet, weight management, and physical activity) remains low. Though single-component interventions targeting smoking cessation, exercise, or medication adherence show some efficacy, comprehensive multicomponent interventions are vital for addressing the complexity of PAD management. This review systematically synthesized multicomponent interventions for patients with PAD. A systematic search was conducted in Embase, MEDLINE, Cochrane Library, APA PsycINFO, CINAHL, Web of Science Core Collection, ProQuest, and Google Scholar to identify primary research describing multicomponent interventions supporting PAD treatment adherence, published between 2007 and 2024. A narrative synthesis was reported using the Template for Intervention Description and Replication (TIDieR) checklist and the behavioral change techniques (BCT) taxonomy. Out of 15 studies (2462 patients, 60.4% men) included in this review, only two addressed all guideline-recommended treatment aspects. Key intervention components included structured exercise (12/15) and education programs (10/15). Most interventions were delivered by multidisciplinary teams in hospital settings over 3 months. Only one study employed behavioral theory in its development, and most interventions (13/15) focused on the BCT 'instructions on how to perform a behavior' rather than diverse BCTs. No interventions significantly increased adherence to all PAD therapies. Few studies measured the intervention's impact on adherence, making it difficult to determine effective intervention characteristics. Most interventions lacked behavioral science approaches and were not designed to address specific adherence determinants. Future interventions should incorporate these elements to effectively address patients' needs. Open Science Framework Registry ID: osf.io/7xqzj.

Evaluation of provider support for a supervised exercise therapy protocol in patients with symptomatic PAD: A quality improvement project

BACKGROUND

Peripheral artery disease (PAD) affects more than 8 million individuals in the United States and many patients diagnosed with PAD are not receiving supervised exercise therapy which considered first line therapy in a program of comprehensive evidence-based care. This lack of evidence-based therapy can lead to reduced functional status, limited mobility, poor quality of life, and contribute to escalating healthcare costs in the population of patients with symptomatic peripheral artery disease.

PROBLEM

An analysis conducted on the current treatment practices for patients with symptomatic PAD by practitioners at a private cardiology group practice in Eastern North Carolina revealed that supervised exercise therapy (SET) was not prescribed for their population of patients with PAD. The absence of an evidence-based guideline-directed SET protocol partnered with no operating vascular wellness program created variations in the treatment of patients diagnosed with symptomatic PAD. These variations can impact the quality of care delivery and outcomes of individuals diagnosed with PAD. The main purpose of this quality improvement project was to evaluate provider support in adopting an evidence-based SET protocol into current treatment practices of individuals with symptomatic PAD. This quality improvement initiative is relevant to other clinical venues as it may further define the role of gaining provider support through formal evaluative instruments of patient protocols such as SET to increase availability, access, and referrals of patients needing healthcare services.

METHODS

A quality improvement initiative was implemented to determine if the practitioners in a private cardiology group practice in Eastern North Carolina would support the adoption of an evidence-based SET protocol into their current treatment practices for individuals with symptomatic PAD. Through the utilization of the best empirical evidence, a protocol for SET was developed. The SET protocol was then appraised by the private cardiology group practitioners using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

The utilization of the AGREE II tool by the cardiology practitioners demonstrated that the evidence-based SET protocol quality rating scores in all six domains were greater than seventy percent. All providers supported the recommended SET protocol using the AGREE II instrument (n = 5, 100%).

CONCLUSION

Success in provider support for the adoption of a SET protocol was the result of cardiology practitioners' appraisal of the evidence and vision to reduce the variation in current treatment practices of patients with symptomatic PAD. More investigation is needed across various healthcare systems to further evaluate provider support of SET protocols to further reduce variation in the treatment of patients with symptomatic PAD.

Risk factors associated with amputation-free survival for patients with peripheral arterial disease: a systematic review

AIMS

Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes.

METHODS AND RESULTS

A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included 'peripheral arterial disease', 'risk factors', and 'amputation-free survival'. The quality of the studies was evaluated using the Joanna Briggs Institute's Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure).

CONCLUSION

We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.

Ideal Cardiovascular Health Metrics on the New Occurrence of Peripheral Artery Disease: A Prospective Cohort Study in Northern China

Peripheral artery disease (PAD) is a common atherosclerotic disease which could lead to severe cardiovascular and cerebrovascular events. Previous studies have indicated the ideal cardiovascular health (ICVH) was associated with many atherosclerotic diseases and cardiovascular events. This study aimed to find out the relationship between ICVH metrics and the new occurrence of PAD. We collected information of baseline from 2010 on the seven ICVH metrics (including smoking, body mass index, dietary intake, physical activity, blood pressure, total cholesterol and fasting blood glucose); and assessed PAD by ankle brachial index among the enrolled participants. The relationship between the ICVH metrics and new occurrence of PAD was analyzed using the multivariate logistic regression in 2018. There were 214 participants were diagnosed with the new occurrence of PAD during the follow-up visit. Participants with PAD tend to be older, with a lower level of education and a higher morbidity of hypertension. Among the seven ICVH metrics, BMI seems to be the most sensitive metric to the occurrence of PAD after adjusting the other risk factors (HR (95% CI) = 0.704 (0.529-0.937), P = 0.0163). We further found out as the number of ICVH metric increased, the morbidity of PAD decreased gradually (HR (95% CI) = 0.888 (0.801-0.984), P for trend= 0.0240). There is no difference between different age and gender groups. The ICVH metrics affect the new occurrence of PAD in a Chinese population. It enhances the importance of ideal health behaviors and factors in the prevention of PAD.

Telemedicine in patients with peripheral arterial disease: is it worth the effort?

Introduction: For patients with peripheral arterial disease (PAD), the various components of telemedicine, such as telemonitoring, telecoaching, and teleconsultation, could be valuable in daily management. The objective of this review was to give an overview of the current use of telemedicine interventions in PAD. Areas covered: A literature search was performed for studies that evaluated patients with PAD of the aorto-pedal trajectory, who were monitored by telemedicine and acted upon accordingly. The primary outcome was health-related outcomes. The studies that were found focused mainly on wearable activity monitoring and telecoaching in PAD (n = 4) or wound monitoring after vascular surgery (n = 2). Main results indicate that telemedicine interventions are able to detect (post-operative) complications early, improve functional capacity and claudication onset time, and improve PAD patients' quality of life. Expert opinion: The use of telemedicine in PAD patients is still an under-explored area. Studies investigating the use of telemedicine in PAD are very limited and show varying results. Owing to its high potential in improving physical ability, lifestyle coaching, and timely detection of deterioration, future research should focus on proper implementation of telemedicine in PAD patients, including clinical and feasibility outcomes, effect on workload of nurses, and cost-efficiency.