Atherosclerotic risk factor reduction in peripheral arterial diseasea: results of a national physician survey

Evaluating Receipt of Optimal Medical Therapy Among Structurally Disadvantaged Groups Undergoing Amputation

BACKGROUND

Optimal medical therapy (OMT) for peripheral artery disease (PAD) is associated with decreased major amputation and mortality. OMT has several components, including antiplatelet and high-intensity statin therapy, blood pressure control, etc. While there are disparities in receipt of OMT among PAD patients, it is unknown if patients from disadvantaged neighborhoods, measured by the area deprivation index (ADI), are less likely to be on OMT.

METHODS

We performed a retrospective review of patients that underwent major lower extremity amputation between 2015 and 2019 at 2 large academic healthcare systems. Primary exposure was high ADI, defined as ADI ≥60th percentile, and secondary exposure was non-Hispanic Black (NHB) race. For each analysis, the primary outcome of interest was receipt of OMT, defined here as at least one antiplatelet agent and a high-intensity statin. The exposure outcome relationship was assessed using multivariable logistic regression.

RESULTS

Among 354 patients with median age of 66 (interquartile range [IQR] 58-74), 267 (75.4%) were male, 219 (61.9%) identified as NHB and 116 (32.8%) as non-Hispanic White (NHW). Overall, 91 (25.7%) patients were on OMT at time of amputation despite 57.3% of the cohort being established with a vascular surgeon. Compared to those with low ADI, the category high ADI had a higher proportion of NHB patients (48.1% vs 70.3%, P = 0.001) and patients were more often hospitalized at the University-affiliated facilities (47.4% vs 63.0%, P = 0.004). High ADI was not associated with receipt of OMT prior to major amputation (adjusted odds ratio [aOR] 0.72, 95% confidence interval [CI] 0.42-1.24). In secondary analysis, NHB race was not associated with receipt of OMT. Stratification by facility type (Veterans Affairs and University-affiliated facilities) also showed no association between high ADI or race and receipt of OMT.

CONCLUSIONS

Neighborhood economic well-being is not associated with receipt of OMT prior to major amputation. While the absence of socioeconomic disparities is notable, the proportion of patients on OMT is suboptimal. Care processes should be critically evaluated and quality measures potentially created to improve the rate of receipt of OMT among patients at risk for amputation.

Adherence and Persistence to Antiplatelet Therapy in Lower Extremity Peripheral Arterial Disease: A Danish Population Based Cohort Study

OBJECTIVE

Adherence to antiplatelet therapy is recommended but unexplored in patients with symptomatic lower extremity peripheral arterial disease (PAD). Therefore, this study aimed to determine adherence and persistence to antiplatelet therapy in patients with PAD, defined as intermittent claudication and chronic limb threatening ischaemia.

DESIGN

Population based nationwide cohort study.

METHODS

This study included all Danish citizens aged ≥ 40 years with a first inpatient or outpatient diagnosis of symptomatic PAD between 2010 - 2017, and who had at least one prescription claim for aspirin and/or clopidogrel within 90 days after diagnosis. Adherence was determined by the proportion of days covered (PDC) during the first year after diagnosis. Persistence was defined as no treatment gap ≥ 30 days between prescription renewals over three year follow up.

RESULTS

A total of 39 687 patients were eligible for inclusion, of whom 23 279 (58.7%) claimed a prescription for aspirin and/or clopidogrel within 90 days of diagnosis. Among these, 12 898 (55.4%) were prevalent users, while the remainder comprised new users who initiated the therapy after the index PAD diagnosis. The mean PDC was 74.5% (SD 35.0%) for prevalent users and 60.5% (SD 30.5%) for new users. Adherence increased with age and number of concomitant drugs. The overall one year cumulative incidence treatment discontinuation was 13.0% (95% CI 12.5 - 13.4%) overall, 17.2% (CI 16.6 - 17.9%) for prevalent users, and 7.9% (CI 7.4 - 8.4%) for new users. At three year follow up, the cumulative incidence of discontinuation was 31.5% (CI 30.9 - 32.2%) overall, 44.6% (CI 43.7 - 45.4%) for prevalent users, and 14.6% (CI 13.9 - 15.3) for new users.

CONCLUSION

Less than 60% of patients with newly diagnosed symptomatic PAD claimed a prescription for antiplatelet therapy within 90 days of diagnosis, and both adherence and persistence were moderate during the first year after diagnosis. These findings underscore the importance of efforts to improve the initiation and continuation of antiplatelet therapy in patients with PAD.

Disparities in Diagnosis, Treatment, and Outcomes of Peripheral Artery Disease: JACC Scientific Statement

Disparities by sex, race, socioeconomic status, and geography exist in diagnosis, treatment, and outcomes for people with lower extremity peripheral artery disease (PAD). PAD prevalence is similar in men and women, but women have more atypical symptoms and undergo lower extremity revascularization at older ages compared to men. People who are Black have an approximately 2-fold higher prevalence of PAD, compared to people who are White and have more atypical symptoms, greater mobility loss, less optimal medical care, and higher amputation rates. Although fewer data are available for other races, people with PAD who are Hispanic have higher amputation rates than White people. Rates of amputation also vary by geography in the United States, with the highest rates of amputation in the southeastern United States. To improve PAD outcomes, intentional actions to eliminate disparities are necessary, including clinician education, patient education with culturally appropriate messaging, improved access to high-quality health care, science focused on disparity elimination, and health policy changes.

Peripheral Artery Disease: Overview of Diagnosis and Medical Therapy

Peripheral artery disease (PAD) affects approximately 230 million people worldwide and is associated with an increased risk of major adverse cardiovascular and limb events. Even though this condition is considered a cardiovascular equivalent, it remains an underrecognized and undertreated entity. Antiplatelet and statin therapy, along with smoking cessation, are the foundations of therapy to reduce adverse events but are challenging to fully implement in this patient population. Race and socioeconomic status also have profound impacts on PAD outcomes.

Aspirin nonsensitivity in patients with vascular disease: Assessment by light transmission aggregometry (aspirin nonsensitivity in vascular patients)

BACKGROUND

Aspirin is a key antiplatelet therapy for the prevention of thrombotic events in patients with cardiovascular disease. Studies suggest that ≈20% of patients with cardiac disease suffer from aspirin nonsensitivity, a phenomenon characterized by the inability of 81 mg aspirin to inhibit platelet aggregation and/or prevent adverse cardiovascular events.

OBJECTIVES

To investigate aspirin nonsensitivity in patients with vascular disease and assess the consequences of aspirin nonsensitivity.

METHODS

One hundred fifty patients presenting to St. Michael's Hospital's outpatient clinics with evidence of vascular disease (peripheral arterial disease or carotid artery stenosis) and a previous prescription of 81 mg of aspirin were recruited in this study. Light transmission aggregometry with arachidonic acid induction was used to determine sensitivity to aspirin. Patients with a maximum aggregation ≥20% in response to arachidonic acid were considered aspirin nonsensitive, as per previous studies.

RESULTS

Of the 150 patients recruited, 36 patients (24%) were nonsensitive to 81 mg of aspirin. Of these 36 nonsensitive patients, 30 patients provided a urine sample for urine salicyluric acid analysis (a major metabolite of aspirin). Urine analysis demonstrated that 14 patients were compliant and 16 were noncompliant with their aspirin therapy. Major adverse cardiovascular events and major adverse limb events were significantly higher in the nonsensitive patients compared to sensitive patients (hazard ratio, 3.68; P < 0.001).

CONCLUSION

These data highlight the high prevalence of aspirin nonsensitivity and noncompliance in patients with vascular disease and emphasizes the urgent need for improved medical management options for this patient population.

Elevated plasma levels of NT-proBNP in ambulatory patients with peripheral arterial disease

N-terminal pro B-type natriuretic peptide (NT-proBNP), a cardiac disease biomarker, has been demonstrated to be a strong independent predictor of cardiovascular events in patients without heart failure. Patients with peripheral arterial disease (PAD) are at high risk of cardiovascular events and death. In this study, we investigated levels of NT-proBNP in patients with PAD compared to non-PAD controls. A total of 355 patients were recruited from outpatient clinics at a tertiary care hospital network. Plasma NT-proBNP levels were quantified using protein multiplex. There were 279 patients with both clinical and diagnostic features of PAD and 76 control patients without PAD (non-PAD cohort). Compared with non-PAD patients, median (IQR) NT-proBNP levels in PAD patients were significantly higher (225 ng/L (120-363) vs 285 ng/L (188-425), p- value = 0.001, respectively). Regression analysis demonstrated that NT-proBNP remained significantly higher in patients with PAD relative to non-PAD despite adjusting for age, sex, hypercholesterolemia, smoking and hypertension [odds ratio = 1.28 (1.07-1.54), p-value <0.05]. Subgroup analysis showed elevated NT-proBNP levels in patients with PAD regardless of prior history of CHF, CAD, diabetes and hypercholesteremia (p-value <0.05). Finally, spearmen's correlation analysis demonstrated a negative correlation between NT-proBNP and ABI (ρ = -0.242; p-value < 0.001). In conclusion, our data shows that patients with PAD in an ambulatory care setting have elevated levels of NT-proBNP compared to non-PAD patients in the absence of cardiac symptoms.

Transradial endovascular intervention: Results from the Radial accEss for nAvigation to your CHosen lesion for Peripheral Vascular Intervention (REACH PVI) study

BACKGROUND/PURPOSE

The transradial approach has been proposed as an alternative to traditional transfemoral access for diagnostic and therapeutic purposes in several catheterization procedures. Historically, extended length devices for lower limb endovascular interventions have been limited. The aim of this study was to investigate the acute clinical outcomes of orbital atherectomy (OA) via transradial access (TRA) for the treatment of lower extremity peripheral artery disease (PAD).

METHODS/MATERIALS

REACH PVI was a multicenter, prospective, observational study (NCT03943160) including subjects with PAD and target lesion morphology appropriate for OA. All patients were followed post-procedure through the first standard of care follow-up visit.

RESULTS

A total of 50 patients were enrolled. In most cases the indication for intervention was disabling claudication (74.0%). Overall, 50 target lesions were treated, 92.0% of lesions were femoropopliteal and 8.0% were infrapopliteal. The average lesion length was 98.3 ± 87.5 mm and 78.0% of the lesions were severely calcified. Balloon angioplasty was performed in 98.0% of target lesions, while a stent was deployed in 16.0%. Treatment success was 98.0%; in only one case the result was sub-optimal (>30% stenosis with stent placement) and a significant dissection was reported. No serious distal embolization, serious thrombus formation or serious acute vessel closure were observed intra- or post-procedurally.

CONCLUSIONS

Transradial OA followed by percutaneous transluminal angioplasty for lower extremity PAD is feasible and demonstrates a favorable safety profile. Extended length devices such as the Extended Length Orbital Atherectomy System could further facilitate transradial endovascular procedures by increasing its spectrum of application.

Clinical considerations after endovascular therapy of peripheral artery disease

Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.

Three-Year Outcomes of Orbital Atherectomy for the Endovascular Treatment of Infrainguinal Claudication or Chronic Limb-Threatening Ischemia

Purpose: To investigate the outcomes of orbital atherectomy (OA) for the treatment of patients with peripheral artery disease (PAD) manifesting as claudication or chronic limb-threatening ischemia (CLTI). Materials and Methods: The database from the LIBERTY study (ClinicalTrials.gov identifier NCT01855412) was interrogated to identify 503 PAD patients treated with any commercially available endovascular devices and adjunctive OA for 617 femoropopliteal and/or infrapopliteal lesions. Cox regression analyses were employed to examine the association between baseline Rutherford category (RC) stratified as RC 2-3 (n=214), RC 4-5 (n=233), or RC 6 (n=56) and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE), and major amputation/death at up to 3 years of follow-up. The mean lesion lengths were 78.7±73.7, 131.4±119.0, and 95.2±83.9 mm, respectively, for the 3 groups. Results: After OA, balloon angioplasty was used in >98% of cases, with bailout stenting necessary in 2.0%, 2.8%, and 0% of the RC groups, respectively. A small proportion (10.8%) of patients developed angiographic complications, without differences based on presentation. During the 3-year follow-up, claudicants were at lower risk for MAE, death, and major amputation/death than patients with CLTI. The 3-year Kaplan-Meier survival estimates were 84.6% for the RC 2-3 group, 76.2% for the RC 4-5 group, and 63.7% for the RC 6 group. The 3-year freedom from major amputation was estimated as 100%, 95.3%, and 88.6%, respectively. Among CLTI patients only, the RC at baseline was correlated with the combined outcome of major amputation/death, whereas RC classification did not affect TVR, MAE, major amputation, or death rates. Conclusion: Peripheral artery angioplasty with adjunctive OA in patients with CLTI or claudication is safe and associated with low major amputation rates after 3 years of follow-up. These results demonstrate the utility of OA for patients across the spectrum of PAD.

Sex-Related Differences in the Outcomes of Endovascular Interventions for Chronic Limb-Threatening Ischemia: Results from the LIBERTY 360 Study

INTRODUCTION

Previous studies have suggested that women with chroniclimb-threatening ischemia (CLTI) may have worse outcomes than men. The aim of this study was to determine whether there are sex-related differences in outcomes of patients with CLTI undergoing endovascular treatment with current endovascular technologies.

PATIENTS AND METHODS

Data were derived from the LIBERTY 360 study (NCT01855412). Hazard ratios and the respective 95% confidence intervals were synthesized to examine the association between sex and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE) and major amputation/death up to 3 years of follow-up.

RESULTS

A total of 689 patients with CLTI (female: N=252 vs male: N=437) treated with any FDA approved or cleared device were included. The mean lesion length was 126.9±117.3mm and 127.4±113.3mm for the female and male patients, respectively. Although a slightly higher incidence of in-hospital mortality was observed in the female group (1.2% vs 0.0%, p=0.049), there was no difference in female vs male survival rates during follow-up. However, the risk of major amputation at 18 months was higher for the male group (male vs female: HR: 2.36; 95% CI: 1.09-5.12; p=0.030). No difference between the two groups was detected in terms of TVR or MAE during follow-up.

DISCUSSION

Data regarding sex-related disparity in outcomes after endovascular therapy of patients with CLTI are conflicting. Gender-related characteristics rather than biological sex characteristics might be the cause of these conflicting findings. Further studies are needed to evaluate the role of sex in revascularization outcomes among this high-risk population.

Polyvascular Disease: Reappraisal of the Current Clinical Landscape

Atherosclerosis within 2 or more arterial beds has been termed polyvascular disease. Although polyvascular disease has long been associated with heightened cardiovascular risk, much is still unknown regarding its pathophysiology and management. In this past decade, the field of cardiovascular disease has experienced exponential growth in terms of antithrombotic and lipid-lowering therapies aimed at mitigating ischemic events. This review describes the inherent risk associated with polyvascular disease in contemporary observational and clinical trial populations and summarizes novel therapies in this high-risk population.

Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Peripheral Arterial and Ischemic Cerebrovascular Disease Compared to Veterans With Coronary Heart Disease

Cardiovascular disease (CVD) is a systemic process involving multiple vascular beds and includes coronary heart disease (CHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). All these manifestations are associated with an increased risk of subsequent myocardial infarction, stroke, and death. Guideline-directed medical therapy is recommended for all patients with CVD. In a cohort of US veterans, we identified 1,242,015 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013 to September 30, 2014. CVD included diagnoses of CHD, PAD, or ICVD. We assessed the frequency of risk factor optimization and the use of guideline-directed medical therapy in patients with CHD, PAD alone, ICVD alone, and PAD + ICVD groups. A composite of 4 measures (blood pressure <140/90 mm Hg, A1c <7% in diabetics, statin use, and antiplatelet use in eligible patients), termed optimal medical therapy (OMT) was compared among groups. Multivariate logistic regression was performed with CHD as the referent category. CHD comprised 989,380 (79.7%), PAD alone 70,404 (5.7%), ICVD alone 163,730 (13.2%), and PAD + ICVD 18,501 (1.5%) of the cohort. Overall, only 36% received OMT with adjusted odds ratios of 0.54 (95% CI 0.53 to 0.55), 0.77 (0.76 to 0.78), and 0.97 (0.94 to 1.00) for patients with PAD alone, ICVD alone, and PAD + ICVD, respectively, compared with patients with CHD. In conclusion, OMT was low in all groups. Patients with PAD alone and ICVD alone were less likely to receive OMT than those with CHD and PAD + ICVD.

Poor knowledge of peripheral arterial disease among the Saudi population: A cross-sectional study

Peripheral arterial disease is a marker of severe atherosclerosis with a significantly higher risk of cardiovascular morbidity and mortality. It is often underdiagnosed and undertreated. Public and patients' perception of peripheral arterial disease is influenced by their knowledge of the condition. In this study, we aimed to evaluate the Saudi public's knowledge of peripheral arterial disease and its specific characteristics. We conducted an interview-based cross-sectional survey, and collected data on basic demographics, self-reported peripheral arterial disease awareness, and knowledge of clinical features, risk factors, preventative measures, management strategies, and potential complications of peripheral arterial disease. A total of 866 participants completed the survey (response rate, 94%); two-thirds were females. Only 295 (34%) of the surveyed participants indicated awareness of peripheral arterial disease. Overall peripheral arterial disease knowledge was low among the "peripheral arterial disease aware" group, particularly in the clinical features domain. Age > 40 years, female gender, and higher education were predictors of self-reported awareness of peripheral arterial disease. In conclusion, the Saudi public is largely unaware of peripheral arterial disease. Educational programs are important to address this critical knowledge gap.

Vascular Disease and Risk Stratification for Ischemic Stroke and All-Cause Death in Heart Failure Patients without Diagnosed Atrial Fibrillation: A Nationwide Cohort Study

Background

Stroke and mortality risk among heart failure patients previously diagnosed with different manifestations of vascular disease is poorly described. We conducted an observational study to evaluate the stroke and mortality risk among heart failure patients without diagnosed atrial fibrillation and with peripheral artery disease (PAD) or prior myocardial infarction (MI).

Methods

Population-based cohort study of patients diagnosed with incident heart failure during 2000–2012 and without atrial fibrillation, identified by record linkage between nationwide registries in Denmark. Hazard rate ratios of ischemic stroke and all-cause death after 1 year of follow-up were used to compare patients with either: a PAD diagnosis; a prior MI diagnosis; or no vascular disease.

Results

39,357 heart failure patients were included. When compared to heart failure patients with no vascular disease, PAD was associated with a higher 1-year rate of ischemic stroke (adjusted hazard rate ratio [HR]: 1.34, 95% confidence interval [CI]: 1.08–1.65) and all-cause death (adjusted HR: 1.47, 95% CI: 1.35–1.59), whereas prior MI was not (adjusted HR: 1.00, 95% CI: 0.86–1.15 and 0.94, 95% CI: 0.89–1.00, for ischemic stroke and all-cause death, respectively). When comparing patients with PAD to patients with prior MI, PAD was associated with a higher rate of both outcomes.

Conclusions

Among incident heart failure patients without diagnosed atrial fibrillation, a previous diagnosis of PAD was associated with a significantly higher rate of the ischemic stroke and all-cause death compared to patients with no vascular disease or prior MI. Prevention strategies may be particularly relevant among HF patients with PAD.

Coronary revascularization induces a shift from cardiac toward noncardiac mortality without improving survival in vascular surgery patients

OBJECTIVE

Although evidence has shown that ischemic heart disease (IHD) in vascular surgery patients has a negative impact on the prognosis after surgery, it is unclear whether directed treatment of IHD may influence cause-specific and overall mortality. The objective of this study was to determine the prognostic implication of coronary revascularization (CR) on overall and cause-specific mortality in vascular surgery patients.

METHODS

Patients undergoing surgery for abdominal aortic aneurysm, carotid artery stenosis, or peripheral artery disease in a university hospital in The Netherlands between January 2003 and December 2011 were retrospectively included. Survival estimates were obtained by Kaplan-Meier and Cox regression analysis.

RESULTS

A total of 1104 patients were included. Adjusted survival analyses showed that IHD significantly increased the risk of overall mortality (hazard ratio [HR], 1.50; 95% confidence interval, 1.21-1.87) and cardiovascular death (HR, 1.93; 95% confidence interval, 1.35-2.76). Compared with those without CR, patients previously undergoing CR had similar overall mortality (HR, 1.38 vs 1.62; P = .274) and cardiovascular mortality (HR, 1.83 vs 2.02; P = .656). Nonrevascularized IHD patients were more likely to die of IHD (6.9% vs 35.7%), whereas revascularized IHD patients more frequently died of cardiovascular causes unrelated to IHD (39.1% vs 64.3%; P = .018).

CONCLUSIONS

This study confirms the significance of IHD for postoperative survival of vascular surgery patients. CR was associated with lower IHD-related death rates. However, it failed to provide an overall survival benefit because of an increased rate of cardiovascular mortality unrelated to IHD. Intensification of secondary prevention regimens may be required to prevent this shift toward non-IHD-related death and thereby improve life expectancy.

Multicenter cross-sectional study of asymptomatic peripheral arterial disease among patients with a single previous coronary or cerebrovascular event in the Arabian Gulf

OBJECTIVE

To evaluate the epidemiology and predictors of asymptomatic peripheral artery disease (PAD) in patients with a single previous coronary or cerebrovascular event in the Arabian Gulf.

METHODS

This was a cross-sectional, multicenter, observational survey in consecutive patients (≥18 years) with documented previous coronary and/or cerebrovascular atherothrombotic event in the United Arab Emirates (UAE), Kuwait and Qatar (64 centers), from October 2008 to December 2010. PAD was defined as an ankle brachial index <0.9 in at least one leg.

RESULTS

The overall mean age of the cohort (n = 2110) was 54 ± 11 years with only 14% being female (n = 303). The prevalence of asymptomatic PAD was 13.7%, with the highest prevalence seen in Kuwait (16.3%) and the UAE (14.7%) and the lowest in Qatar (5.3%). There were significant differences in the prevalence of asymptomatic PAD among the ethnic groups (p < 0.001): it was highest among the local Arabs and Caucasians at 19% and lowest among South East Asians (6%). The multivariate logistic model demonstrated that the most significant predictors of PAD were old age (adjusted odds ratio [OR], 1.04; 95% CI: 1.02-1.05; p < 0.001), female gender (OR, 1.56; 95% CI: 1.06-2.29; p = 0.024), ethnicity (OR, 0.39; 95% CI: 0.19-0.79; p = 0.009), smoking (OR, 1.70; 95% CI: 1.22-2.37: p = 0.002) and diabetes mellitus (OR, 1.49; 95% CI: 1.14-1.94; p = 0.004).

CONCLUSIONS

PAD is prevalent in the Arabian Gulf and is more likely to be associated with old age, females, ethnicity, smokers and those with diabetes mellitus.

Adherence to guideline-recommended therapy is associated with decreased major adverse cardiovascular events and major adverse limb events among patients with peripheral arterial disease

BACKGROUND

Current guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin-converting enzyme (ACE) inhibitors. The combined effects of multiple guideline-recommended therapies in patients with symptomatic PAD have not been well characterized.

METHODS AND RESULTS

We analyzed a comprehensive database of all patients with claudication or critical limb ischemia (CLI) who underwent diagnostic or interventional lower-extremity angiography between June 1, 2006 and May 1, 2013 at a multidisciplinary vascular center. Baseline demographics, clinical data, and long-term outcomes were obtained. Inverse probability of treatment propensity weighting was used to determine the 3-year risk of major adverse cardiovascular or cerebrovascular events (MACE; myocardial infarction, stroke, or death) and major adverse limb events (MALE; major amputation, thrombolysis, or surgical bypass). Among 739 patients with PAD, 325 (44%) had claudication and 414 (56%) had CLI. Guideline-recommended therapies at baseline included use of aspirin in 651 (88%), statin medications in 496 (67%), ACE inhibitors in 445 (60%), and smoking abstention in 528 (71%) patients. A total of 237 (32%) patients met all four guideline-recommended therapies. After adjustment for baseline covariates, patients adhering to all four guideline-recommended therapies had decreased MACE (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.89; P=0.009), MALE (HR, 0.55; 95% CI, 0.37 to 0.83; P=0.005), and mortality (HR, 0.56; 95% CI, 0.38 to 0.82; P=0.003), compared to patients receiving less than four of the recommended therapies.

CONCLUSIONS

In patients with claudication or CLI, combination treatment with four guideline-recommended therapies is associated with significant reductions in MACE, MALE, and mortality.

Home-based walking exercise intervention in peripheral artery disease: a randomized clinical trial

IMPORTANCE

Clinical practice guidelines state there is insufficient evidence to support advising patients with peripheral artery disease (PAD) to participate in a home-based walking exercise program.

OBJECTIVE

To determine whether a home-based walking exercise program that uses a group-mediated cognitive behavioral intervention, incorporating both group support and self-regulatory skills, can improve functional performance compared with a health education control group in patients with PAD with and without intermittent claudication.

DESIGN, SETTING, AND PATIENTS

Randomized controlled clinical trial of 194 patients with PAD, including 72.2% without classic symptoms of intermittent claudication, performed in Chicago, Illinois between July 22, 2008, and December 14, 2012.

INTERVENTIONS

Participants were randomized to 1 of 2 parallel groups: a home-based group-mediated cognitive behavioral walking intervention or an attention control condition.

MAIN OUTCOMES AND MEASURES

The primary outcome was 6-month change in 6-minute walk performance. Secondary outcomes included 6-month change in treadmill walking, physical activity, the Walking Impairment Questionnaire (WIQ), and Physical and Mental Health Composite Scores from the 12-item Short-Form Health Survey.

RESULTS

Participants randomized to the intervention group significantly increased their 6-minute walk distance ([reported in meters] 357.4 to 399.8 vs 353.3 to 342.2 for those in the control group; mean difference, 53.5 [95% CI, 33.2 to 73.8]; P < .001), maximal treadmill walking time (intervention, 7.91 to 9.44 minutes vs control, 7.56 to 8.09; mean difference, 1.01 minutes [95% CI, 0.07 to 1.95]; P = .04), accelerometer-measured physical activity over 7 days (intervention, 778.0 to 866.1 vs control, 671.6 to 645.0; mean difference, 114.7 activity units [95% CI, 12.82 to 216.5]; P = .03), WIQ distance score (intervention, 35.3 to 47.4 vs control, 33.3 to 34.4; mean difference, 11.1 [95% CI, 3.9 to 18.1]; P = .003), and WIQ speed score (intervention, 36.1 to 47.7 vs control, 35.3-36.6; mean difference, 10.4 [95% CI, 3.4 to 17.4]; P = .004).

CONCLUSION AND RELEVANCE

A home-based walking exercise program significantly improved walking endurance, physical activity, and patient-perceived walking endurance and speed in PAD participants with and without classic claudication symptoms. These findings have implications for the large number of patients with PAD who are unable or unwilling to participate in supervised exercise programs.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00693940.

Impact of critical limb ischemia on long-term cardiac mortality in diabetic patients undergoing percutaneous coronary revascularization

OBJECTIVE

Development of critical limb ischemia (CLI) has been reported as an independent predictor of cardiac mortality in diabetic patients. We aimed to determine whether CLI, managed in a structured setting of close collaboration between different vascular specialists and treated with early endovascular intervention, has any impact on long-term cardiac mortality of diabetic patients initially presenting with symptomatic coronary artery disease (CAD).

RESEARCH DESIGN AND METHODS

We designed a prospective observational study of 764 consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in whom development of CLI was assessed by a dedicated diabetic foot clinic. Cardiac mortality at 4-year follow-up was the primary end point of the study.

RESULTS

Among the 764 patients, 111 (14%) developed CLI (PCI-CLI group) and underwent revascularization of 145 limbs, with procedural success in 140 (96%). PCI-CLI patients at baseline had lower left ventricular ejection fraction (51 ± 11% vs. 53 ± 10%, P = 0.008), higher prevalence of dialysis (7% vs. 0.3%, P < 0.0001), and longer diabetes duration (13 ± 8 vs. 11 ± 7 years, P = 0.02) compared with PCI-only patients. At 4-year follow-up, cardiac mortality occurred in 10 (9%) PCI-CLI patients vs. 42 (6%) PCI-only patients (P = 0.2). Time-dependent Cox regression model for cardiac death revealed that CLI was not associated with an increased risk of cardiac mortality (hazard ratio 1.08 [95% CI 0.89-3.85]; P = 0.1).

CONCLUSIONS

The development of promptly assessed and aggressively treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially presenting with symptomatic CAD.

Missed Opportunities

Background—

Patients with peripheral artery disease (PAD) are at high risk of cardiovascular events and benefit from aggressive secondary prevention; however, changes in the use of cardioprotective medications after incident diagnosis of PAD have not been well described.

Methods and Results—

We used Danish nationwide administrative registries (2000–2007) to identify 2 groups with incident PAD: PAD alone (n=34 160) and PAD with history of coronary artery disease (CAD) (n=9570). With the use of a comparator with incident CAD alone (n=154 183), we assessed temporal trends and comparative use of cardioprotective medications. Relative differences in medication use were examined by using multivariable logistic regression. Use of medications improved temporally among both groups: for PAD alone, any antiplatelet use increased from 29% to 59% from 2000 to 2007 ( P <0.0001), whereas statin use increased 6-fold (9%–56%; P <0.0001). However, use of these therapies by 18 months after incident diagnosis for both PAD groups remained modest and lower in comparison with CAD alone (any antiplatelet, 53% versus 66%; statins, 40% versus 52%; angiotensin-converting enzyme inhibitors, 20% versus 29%). Relative to CAD alone, patients with PAD alone were less likely to use any antiplatelet (adjusted odds ratio, 0.50; 95% confidence interval, 0.49–0.52), statins (adjusted odds ratio, 0.50; 95% confidence interval, 0.48–0.52), or angiotensin-converting enzyme inhibitors (adjusted odds ratio, 0.51; 95% confidence interval, 0.49–0.53) by 18 months.

Conclusions—

Despite improvement in the use of cardioprotective medications over time, patients with PAD alone remain less likely than those with CAD alone to use these agents.

The Group Oriented Arterial Leg Study (GOALS) to improve walking performance in patients with peripheral arterial disease

People with lower extremity peripheral artery disease (PAD) have greater functional impairment and faster functional decline than those without PAD. We describe methods for the Group Oriented Arterial Leg Study (GOALS), an ongoing randomized controlled clinical trial designed to determine whether a Group-Mediated Cognitive Behavioral (GMCB) intervention improves functional performance in PAD participants, compared to a health education control condition. In GOALS, PAD participants were randomized to either an intervention or a health education control condition in a parallel design. Both conditions consist of weekly group sessions with other PAD participants. In the intervention, cognitive behavioral techniques are used to assist participants in setting and adhering to home-based walking exercise goals. Participants are encouraged to walk for exercise at home at least 5 days/week. In the control condition, participants receive lectures on health-related topics. After 6 months of on-site weekly sessions, participants are transitioned to telephone follow-up for another 6 months. Participants in the intervention are asked to continue home walking exercise. The primary outcome is change in six-minute walk performance between baseline and six-month follow-up. Secondary outcomes include change in six-minute walk performance at 12-month follow-up, and change in treadmill walking performance, the Walking Impairment Questionnaire, quality of life, and physical activity at six and 12-month follow-up. In conclusion, if our group-mediated cognitive behavioral intervention is associated with improved walking performance in individuals with PAD, results will have major public health implications for the large and growing number of people with PAD.

Atherosclerotic disease and risk factor modification in Saudi Arabia: a call to action

PURPOSE

Atherosclerotic disease (AD) is the leading cause of death worldwide and in Saudi Arabia. Intensive risk reduction therapy plays a major role in reducing adverse cardiovascular outcomes in patients with AD. The level of awareness of this important fact amongst physicians (family physicians, general internists, cardiologists and vascular surgeons) in managing these patients in Saudi Arabia is not currently known. This study was conducted to examine the perceptions and knowledge of risk reduction therapy in patients with AD amongst physicians in Saudi Arabia in two clinical presentations; coronary artery disease (CAD) and peripheral artery disease (PAD).

MATERIALS AND METHODS

We conducted a cross-sectional self-administered survey of 897 physicians at different hospitals in four provinces in Saudi Arabia.

RESULTS

The recommended targets of low density lipoprotein-cholesterol (LDL-C), blood glucose, and blood pressure in patients with CAD and PAD were known as 40% and 36%; 70% and 66%; and 32% and 28% of physicians, respectively. The initiation of antiplatelet medications, angiotensin converting enzyme (ACE) inhibitors, statins, and nicotine replacement therapy for smokers in patients with CAD and PAD were recommended by 98% and 97%; 52% and 34%; 61% and 56%; and 50% and 43% of physicians, respectively. Compared to other specialties, cardiologists had the lowest threshold for initiating risk reduction therapy, whereas vascular surgeons had the highest threshold.

CONCLUSION

The level of physician awareness of atherosclerosis risk reduction therapy across Saudi Arabia has revealed knowledge and action gaps. A call to action to implement effective strategies to encourage health professionals to use risk reduction therapy and increase public awareness is needed.

Internal Medicine Interns Have a Poor Knowledge of Peripheral Artery Disease

Peripheral arterial disease (PAD) is common and carries an increased risk of morbidity and mortality. The level of knowledge among incoming medical trainees about PAD is unknown. During orientation to a single internal medicine residency program, incoming medical interns were given a 19-question multiple-choice questionnaire. The questions fell into 1 of 4 categories about PAD: (1) prevalence, (2) screening, (3) treatment, and (4) outcome. Sixty-two incoming interns were queried. The percentage of questions answered correctly overall was 41.7% (10.5%-73.7%). The percentage of questions answered correctly in the prevalence, screening, treatment, and outcome groups were 48.9% (0 to 100%), 33.8% (0 to 80%), 45.0% (0 to 87.5%), and 42.5% (0 to 100%), respectively. Internal medicine interns have poor knowledge about PAD including its prevalence, screening, treatment, and outcomes. Increased education during medical school is encouraged.

Efficacy of optimal long-term management of multiple cardiovascular risk factors (CVD) on walking and quality of life in patients with peripheral artery disease (PAD): protocol for randomized controlled trial

Peripheral artery disease (PAD) is an understudied chronic illness most prevalent in elderly individuals. PAD patients experience substantial walking impairment due to symptoms of limb ischemia that significantly diminishes quality of life (QOL). Cardiovascular disease (CVD) morbidity and mortality is increased in this population because of aggressive atherosclerosis resulting from untreated CVD risk factors. Despite current national guidelines recommending intensive CVD risk factor management for PAD patients, untreated CVD risk factors are common. Interventions that bridge this gap are imperative. The Vascular Insufficiency - Goals for Optimal Risk Reduction (VIGOR(2)) study is a randomized controlled trial (RCT) that examines the effectiveness of a long-term multifactor CVD risk reduction program on walking and quality of life in patients with PAD. The purpose of this article is to provide a detailed description of the design and methods of VIGOR(2). Clinical Trial Registration - URL: http://clinicaltrials.gov/ct2/show/NCT00537225.

Outcomes and Risk Prediction Model for Peripheral Arterial Disease in Patients with Stable Coronary Artery Disease

We used the National Heart, Lung, and Blood Institute Limited Access Dataset of Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE) Trial (n = 8290) which included patients with stable coronary artery disease (CAD) and preserved ejection fraction (>40%). We identified risk factors for the development of critical peripheral arterial disease (PAD; those needing angioplasty, bypass grafting, or aneurysm repair) and formulated a risk score by multivariate analyses. A total of 220 patients (2.8%) developed critical PAD over a mean follow-up of 4.7 years. Significant predictors of critical PAD were history of intermittent claudication, smoking, hypertension (HTN), coronary-artery bypass grafting (CABG), diabetes, age, serum cholesterol, and body mass index (BMI). Incident critical PAD was associated with increased composite outcome of cardiovascular death, myocardial infarction, percutaneous transluminal coronary angioplasty, or CABG (hazard ratio 1.82, 95% CI 1.50-2.22, P < .001). Risk assessment using our score may identify CAD patients at risk for critical PAD events.

Secondary Pharmacotherapeutic Prevention among German Primary Care Patients with Peripheral Arterial Disease

Background. The aim of the study was to determine the secondary preventive medical supply of patients with peripheral arterial disease (PAD) in German primary care. Methods and Results. A population-based case control study was conducted using electronic medical records of patients extracted from the CONTENT primary care database of Heidelberg, Germany, between April 2007 and March 2010. The prescription rates of cardiovascular medication among symptomatic PAD patients were analysed by means of the ATC classification and compared with those of patients with cardiovascular disease (CVD). 479 cases with PAD and 958 sex- and age-matched control CVD patients were identified. PAD patients showed significantly lower prescription rates for cardiac agents (21.7% versus 37%), β-blockers (50.1% versus. 66.2%), and lipid-lowering agents (50.3% versus 55.9%) compared to CVD patients. In contrast, significantly more prescriptions of antidiabetic agents (28.2% versus 20.3%), particularly insulin and analogues (12.5% versus 8%), and calcium channel blockers (29.2% versus 24.3%) were found in PAD patients. Low-dose aspirin use among both PAD and CVD patients was underestimated, as it is available without a prescription. Conclusions. Optimal pharmacotherapeutical care of patients with PAD requires more intensive cardioprotective medication in primary care settings.

Suboptimal use of risk reduction therapy in peripheral arterial disease patients at a major teaching hospital

BACKGROUND AND OBJECTIVES

Current evidence suggests that modification of atherosclerosis risk factors plays an important role in reducing adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD). This study was undertaken to determine whether patients in this high-risk group were adequately using risk factor modification therapy.

DESIGN AND SETTING

Prospective study of consecutive patients with PAD from a teaching hospital.

PATIENTS AND METHODS

The collected data included information about atherosclerotic risk factors and utilization of risk factor modification therapy

RESULTS

The 391 patients had a mean (standard deviation of 3 (1) atherosclerotic risk factors. Hypertension was identified in 56.8% of patients (222/391), of whom only 37.4% (83/222) had adequate blood pressure control (BP <140/90 mm Hg). The prevalence of diabetes mellitus (DM) was 35 % (137/391). Among patients with DM, only 49% (67/137) had adequate blood glucose control (glycosylated hemoglobin, HbA1c <7%). Statins were currently prescribed in 61% of patients (238/391), 38.7% (92/238) of whom continued to have low-density lipoprotein (LDL) >2.5 mmol/L, compared to a rate of 76.5% (117/153) among non-statin users (P<.001). The majority of patients of patients ( 72.4%; 283/391) were overweight/obese. Many patients (67.3%; 263/391) were nonsmokers; however, most (73.4%; 193/263) had a history of smoking. Antiplatelets were prescribed for 78.3% of patients (306/391), of whom 70.6% (216/306) were taking aspirin. Angiotensin converting enzyme (ACE) inhibitors were prescribed for 44.8% of patients (175/391). Among rampril users, only 36.8% of patients (53/144) were on an optimal dose.

CONCLUSION

Although atherosclerotic risk factors were prevalent in patients with PAD, we found that patients received sub-optimal use of risk reduction treatments. Effective strategies to encourage health professionals to use these adjunctive therapies need to be developed.

Activating peripheral arterial disease patients to reduce cholesterol: a randomized trial

BACKGROUND

Peripheral arterial disease patients are less likely than other high-risk patients to achieve ideal low-density lipoprotein (LDL) cholesterol levels. This randomized controlled trial assessed whether a telephone counseling intervention, designed to help peripheral arterial disease patients request more intensive cholesterol-lowering therapy from their physician, achieved lower LDL cholesterol levels than 2 control conditions.

METHODS

There were 355 peripheral arterial disease participants with baseline LDL cholesterol ≥70 mg/dL enrolled. The primary outcome was change in LDL cholesterol level at 12-month follow-up. There were 3 parallel arms: telephone counseling intervention, attention control condition, and usual care. The intervention consisted of patient-centered counseling, delivered every 6 weeks, encouraging participants to request increases in cholesterol-lowering therapy from their physician. The attention control condition consisted of telephone calls every 6 weeks providing information only. The usual care condition participated in baseline and follow-up testing.

RESULTS

At 12-month follow-up, participants in the intervention improved their LDL cholesterol level, compared with those in attention control (-18.4 mg/dL vs -6.8 mg/dL, P=.010) but not compared with those in usual care (-18.4 mg/dL vs -11.1 mg/dL, P=.208). Intervention participants were more likely to start a cholesterol-lowering medication or increase their cholesterol-lowering medication dose than those in the attention control (54% vs 18%, P=.001) and usual care (54% vs 31%, P <.001) conditions.

CONCLUSION

Telephone counseling that helped peripheral arterial disease patients request more intensive cholesterol-lowering therapy from their physician achieved greater LDL cholesterol decreases than an attention control arm that provided health information alone.

Quality assurance in perioperative care

Nowadays more and more clinical guidelines are developed. Clinical guidelines aim to assist practitioner and patient decision making about appropriate care for specific clinical conditions. Furthermore, guidelines can play a crucial role in the quality cycle form guidelines to clinical practice. However, this does not necessarily mean that these guidelines are actually implemented and the ultimately goal, improved patient outcome, is achieved. Care gaps exist between guidelines and daily clinical practice in perioperative care. Research should be focused on identification of barriers to adherence and subsequent effect implementation strategies to achieve higher standards of quality of care. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment of patients with peripheral arterial disease.

Protective vascular treatment of patients with peripheral arterial disease: guideline adherence according to year, age and gender

OBJECTIVES

To evaluate vasoprotective pharmacological treatment of patients with peripheral arterial disease (PAD) according to: 1) year, 2) age and 3) gender.

METHODS

An observational retrospective study was conducted to evaluate the systemic vascular treatment of a population-based cohort of patients with PAD > or = 50 years old, discharged from a tertiary-care teaching hospital between January 1, 1997 and December 11, 2006. Data were obtained from the Régie de l'assurance maladie du Québec. Drugs evaluated included antiplatelet agents (APs), statins (STs) and angiotensin converting enzyme inhibitors (ACEIs), and a combination of all three. Proportions of patients treated were compared according to year, age and gender using Chi-square.

RESULTS

The mean age of the study population (5962 individuals) was 73.2 +/- 9.1 years; 43.8% were women. After hospital discharge, 71.6%, 47.6%, 42.2% and 20.6% were taking respectively, an AP, statin, ACEI or all three. Protective treatment improved significantly from 1997 to 2006. Significantly more subjects 50-64 years used a statin or all three agents, compared to subjects > or = 65 years (statins: 56.6% vs. 45.8%, all three: 26.2% vs. 19.5%; p < 0.001). Significantly more men than women used statins (49.1% vs. 45.6%; p < 0.001) and ACEIs (44.5% vs. 39.3%; p < 0.001). Similarily, use of all three agents was 22.4% for men and 18.2% for women (p < 0.001).

CONCLUSIONS

Although systemic vascular treatment received by patients with PAD has increased in the past years, it remains suboptimal, particularly for older patients and women. Strategies to improve adherence to treatment guidelines should be developed for these high-risk populations.

The development of a theory-based instrument to evaluate the effectiveness of continuing medical education

PURPOSE

To determine the psychometric properties of a theoretically based continuing medical education (CME) evaluation instrument examining attitudinal determinants of physicians' changes in medical practices after a CME intervention. The instrument's scales represented constructs from the theory of planned behavior.

METHOD

The authors based the template instrument on educational objectives of the CME intervention and adapted it to the clinical domain of preoperative breast cancer therapy. Development of the initial survey involved cognitive testing, pilot tests, and expert reviews. The authors asked 269 clinicians to complete the 35-item instrument before the CME intervention. Factor analysis and item analysis guided the development of the final six subscales: positive behavioral beliefs, negative behavioral beliefs, attitude toward the behavior, perceived behavior control (self-efficacy), subjective norms, and behavioral intention.

RESULTS

Cognitive testing and pilot tests ensured the accuracy and clarity of the language and a reasonable survey length. Of the 269 clinicians, 168 (134 physicians) responded. Scales clustered according to the theoretical constructs. Items not loading in any subscales were eliminated. The final 25 items loaded on six subscales with loadings >0.54. Reliability for the subscales ranged from 0.73 to 0.93 (good for the scale development stage). The authors revised the instrument template and protocol after this initial study to increase the possibility of use in future CME evaluations.

CONCLUSIONS

The levels of content and construct validity and reliability of the CME evaluation instrument are acceptable for evaluation of CME activities targeting physicians. Instruments adapted from this template could potentially evaluate future CME activities.

Peripheral artery disease: current insight into the disease and its diagnosis and management

Peripheral artery disease (PAD), which comprises atherosclerosis of the abdominal aorta, iliac, and lower-extremity arteries, is underdiagnosed, undertreated, and poorly understood by the medical community. Patients with PAD may experience a multitude of problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. This may lead to a poor quality of life and a high rate of depression. From the standpoint of the limb, the prognosis of patients with PAD is favorable in that the claudication remains stable in 70% to 80% of patients over a 10-year period. However, the rate of myocardial infarction, stroke, and cardiovascular death in patients with both symptomatic and asymptomatic PAD is markedly increased. The ankle brachial index is an excellent screening test for the presence of PAD. Imaging studies (duplex ultrasonography, computed tomographic angiography, magnetic resonance angiography, catheter-based angiography) may provide additional anatomic information if revascularization is planned. The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death). The former is accomplished by establishing a supervised exercise program and administering cilostazol or performing a revascularization procedure if medical therapy is ineffective. A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter.

Identification of patients at risk of ischemic events for long-term secondary prevention

PURPOSE

To review the identification of patients at risk of secondary ischemic events, discuss the therapies available for their medical management, and identify the role of the nurse practitioner (NP) in their primary and long-term care.

DATA SOURCES

ACC/AHA 2007 guidelines for the management of patients with unstable angina and non-ST-elevation myocardial infarction, ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease, AHA/ASA 2006 guidelines for patients with ischemic stroke, AHA/ACC 2006 guidelines update for patients with coronary and other atherosclerotic vascular disease, and selected clinical articles identified through PubMed.

CONCLUSIONS

Preventive therapy in patients with atherothrombotic vascular disease is critical for reducing the risk of recurrent events. Almost all patients with atherosclerotic disease will benefit from general lifestyle modifications, and most will also benefit from appropriate pharmacotherapies targeting dyslipidemia, diabetes, hypertension, and platelet function. However, evidence suggests that secondary prevention strategies may not be utilized effectively.

IMPLICATIONS FOR PRACTICE

Increased awareness and implementation of clinical practice guidelines can reduce the risk of recurrent atherothrombotic events. NPs in primary care settings or in long-term care facilities are well placed to determine whether patients are receiving appropriate preventive care and to implement improvements in their management.

Atherosclerotic disease location and disparities in the control and treatment of cardiovascular risk factors in patients with Type 2 diabetes

AIMS

To assess whether differences exist in the control and intensity of medication treatment of cardiovascular risk factors in secondary prevention patients with Type 2 diabetes, depending on their atherosclerotic disease territory [coronary artery disease (CAD), cerebrovascular disease (CBVD) or peripheral arterial disease (PAD)].

METHODS

Cross-sectional analysis of 17 571 patients with Type 2 diabetes with prevalent atherosclerotic disease. Endpoints included uncontrolled cardiovascular disease (CVD) risk factors [systolic blood pressure (SBP) > or = 140 mmHg, low-density lipoprotein cholesterol > or = 3.4 mmol/l and glycated haemoglobin > or = 8.0%] and high intensity of medication treatment (defined as > or = 2 classes of anti-hypertensive agents, > or = 1 lipid-lowering agent or either insulin or > or = 2 oral glucose-lowering agents) in patients with uncontrolled CVD risk factors. Multiple-adjusted odds ratios were calculated for CAD, CBVD and PAD after adjusting for sex, age, body mass index, current smoking and diabetes duration.

RESULTS

Proportions of patients with uncontrolled risk factors were significantly different among disease territories. Decreased odds of having lipids not controlled were observed in patients with CAD, while decreased odds of having systolic blood pressure not controlled were observed in patients with PAD. PAD was associated with the highest odds of hyperglycaemia not being controlled. High-intensity treatment was observed in lipid and blood glucose management but not in hypertension management, independent of disease location.

CONCLUSIONS

In subjects with Type 2 diabetes and atherosclerotic disease, control of modifiable CVD risk factors but not intensity of medication treatment is modified by atherosclerotic disease territory. Intensity of medication treatment is different between risk factors.

A review of simple, non-invasive means of assessing peripheral arterial disease and implications for medical management

Abstract Atherosclerotic peripheral arterial disease (PAD) is highly prevalent in the elderly and subjects with atherosclerotic risk factors such as smoking, diabetes mellitus, hypertension, and hyperlipidemia. Importantly, PAD is rarely an isolated condition, but rather a manifestation of systemic atherosclerosis. Hence, there is often coexisting disease in the coronary and cerebral arteries and, consequently, an increased risk of myocardial infarction and stroke. Intermittent claudication is the classic symptom of PAD, yet up to 50% of patients are asymptomatic. Despite the availability of reliable, non-invasive screening tests, PAD is largely underdiagnosed and undertreated, mostly due to the paucity of symptoms and underutilization of screening tools. The ankle-brachial index (ABI), a simple, rapid, and inexpensive diagnostic tool, holds much prognostic value for PAD diagnosis and is ideal for implementation in the primary care physician's office. The early detection of PAD with ABI screening and subsequent medical management represents a critical opportunity to prevent considerable vascular morbidity and mortality. The management of PAD must address claudication symptoms (with cilostazol or pentoxifylline, or in severe cases endovascular or surgical revascularization) and modifiable atherosclerotic risk factors (with an aggressive global risk-reduction regimen involving lifestyle modifications, exercise, smoking cessation, and antiplatelet, lipid-lowering, and antihypertensive therapy).

Attitudes and behavior of peripheral arterial disease patients toward influencing their physician's prescription of cholesterol-lowering medication

Among 355 peripheral arterial disease (PAD) patients with low density lipoprotein cholesterol (LDL-C) levels > or = 70 mg/dl, we assessed knowledge regarding optimal LDL levels and the importance of LDL-C-lowering therapy. We also assessed PAD participants' behaviors and attitudes regarding their engagement with their physician in treatment decisions for LDL-C lowering. The average baseline LDL-C level of participants was 103.4 mg/dl +/- 30.7 mg/dl. Seventy-six percent of participants were taking at least one cholesterol-lowering medication. Sixty-six percent were unable to define their optimal LDL-C. Only 47% strongly agreed that their own actions and decisions could reduce their LDL-C. Just 29.8% were aware that patients who request specific medications from their physician were more likely to receive them, and 16% had asked their physician whether they should be taking more cholesterol-lowering medication. These findings suggest that further study is needed to identify effective interventions to educate PAD patients and their physicians about the importance of cholesterol-lowering therapy and to encourage PAD patients to participate with their physician in decisions regarding cholesterol-lowering treatment. Clinical Trial Registration - URL: http://www.clinicaltrials.gov. Unique identifier: NCT00217919.