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

Shared Decision-Making in Patients with an Abdominal Aortic Aneurysm or Peripheral Artery Disease: A Scoping Review

BACKGROUND

This review provides an overview of the literature on shared decision-making (SDM) in patients with abdominal aortic aneurysm (AAA) or peripheral artery disease (PAD) and identifies barriers and facilitators.

METHODS

A systematic scoping review was conducted, in which 4 databases were systematically searched for the period January 2007 to November 2024. All articles were reviewed by 2 independent authors and asses for quality using the mixed-methods appraisal tool (MMAT).

RESULTS

The literature search yielded 15,738 articles, of which 50 met the inclusion criteria. Quality assessment via MMAT showed good quality in 70% of the studies. Various influencing factors were revealed on SDM in patients, physicians, consult content, and the system or organization of care.

CONCLUSIONS

Despite increased attention, implementing SDM in AAA and PAD patients remains challenging due to healthcare professionals' limited understanding of SDM. Patients seek active involvement but often feel inadequately engaged. There is a notable lack of research focusing on health care professionals and systemic influences on SDM.

Peripheral Arterial Disease in Nova Scotia: Increased Prevalence, Low Public Awareness, and Poor Edinburgh Claudication Questionnaire Sensitivity

Background

This study had the following 3 goals: (i) to assess the prevalence of peripheral arterial disease (PAD) in a Nova Scotian population; (ii) to evaluate the validity of the Edinburgh Claudication Questionnaire (ECQ) in a Nova Scotian context; and (iii) to evaluate Nova Scotian public knowledge about PAD.

Methods

Participants were recruited from 8 sites across Nova Scotia. In 2022, they were recruited at Heartland Tour (HLT) sites-a provincial health-promotion campaign. In 2023, they were recruited in communities coinciding with HLT sites (public [PUB]). Participants completed a demographics questionnaire, ECQ, and had an ankle-brachial index (ABI) measurement. An ABI of < 0.9 was considered positive for presence of PAD.

Results

A total of 417 participants were recruited, 263 from HLT, and 154 from PUB. A total of 398 participants had ABI scores resulting in a PAD prevalence of 2.81% (249 participants) in the HLT group, and 5.37% (149 participants) in the PUB group. A total of 394 participants had both ABI and ECQ scores, with a found sensitivity of 6.67% (confidence interval 0.17%-31.95%) and specificity of 97.63% (confidence interval 95.54%-98.91%). A total of 75% of participants (311 of 417) did not have prior knowledge of PAD.

Conclusions

The PAD prevalences in both cohorts were higher than anticipated, with the PUB cohort being more than double the national average. This finding raises the following question: should specific PAD primary and/or secondary prevention strategies be targeted within the province? Our study demonstrated that a public-awareness campaign would be highly impactful, owing to a low level of awareness of PAD within both cohorts, and that the ECQ was not an effective screening tool when used on the Nova Scotian population.

Disease acceptance and social support in patients with peripheral vascular diseases treated in the surgical ward

Aim

The purpose of this study is a comparative analysis of the degree of disease acceptance and social support in patients with peripheral vascular diseases and other medical conditions treated in surgery ward.

Design

A cross‐sectional study.

Methods

This cross‐sectional study compares disease acceptance and social support in a group of 212 patients with peripheral vascular diseases and other conditions treated in surgery ward. A standardized Acceptance of Illness Scale (AIS) and Social Support Scale were used to collect the research data.

Results

Overall, on the AIS, 14% of patients with surgical diseases and 34% of patients with vascular diseases had a low disease acceptance rate. A high level of support was demonstrated in 41% of study participants with surgically treated diseases and in 17% of participants with vascular diseases.

Living a burdensome and demanding life: A qualitative systematic review of the patients experiences of peripheral arterial disease

Background

Peripheral arterial disease (PAD) has a significant negative impact on the quality of life of individuals. Understanding the experiences of people living with PAD will be useful in developing comprehensive patient-centred secondary prevention therapies for this population.

Aim

The aim of this study is to identify first-hand accounts of patients’ experiences of living with PAD.

Methods

Six databases (CINALH, PsyclNFO, MEDLINE, AMED, EMBASE, Social citation index/Science citation index via Web of Science (WOS)) and reference lists of identified studies were searched until September 2017 (updated February 2018). Qualitative studies reporting patients’ account of living with PAD were eligible for inclusion. A framework thematic synthesis was implemented.

Results

Fourteen studies with 360 participants were included. Pain and walking limitation were recurrent among the varied symptom descriptions. Patients’ ignorance and trivialisation of symptoms contributed to delays in diagnosis. Inadequate engagement in disease understanding and treatment decisions meant patients had poor attitudes towards walking treatments and unrealistic expectations about surgery. Depending on symptom progression, patients battle with walking impairment, powerlessness, and loss of independence which were a source of burden to them. Lack of disease understanding is central through patients’ journey with PAD and, although they subsequently began adaptation to long term living with PAD, many worried about their future.

Conclusions

Disease understanding is vital across the illness trajectory in patients with PAD. Although certain experiences are common throughout patient journey, some might be unique to a particular stage (e.g. unrealistic expectation about surgery, or rationale of walking in spite of pain in a supervised exercise program). Given that PAD is an overarching construct ranging from the mildest form of intermittent claudication to severe critical limb ischemia with ulceration and gangrene, consideration of important patient constructs specific to each stage of the disease may enhance treatment success. Systematic review registration CRD42017070417.

Plasma metabolomic profiles predict near-term death among individuals with lower extremity peripheral arterial disease

BACKGROUND

Individuals with peripheral arterial disease (PAD) have a nearly two-fold increased risk of all-cause and cardiovascular disease mortality compared to those without PAD. This pilot study determined whether metabolomic profiling can accurately identify patients with PAD who are at increased risk of near-term mortality.

METHODS

We completed a case-control study using (1)H NMR metabolomic profiling of plasma from 20 decedents with PAD, without critical limb ischemia, who had blood drawn within 8 months prior to death (index blood draw) and within 10 to 28 months prior to death (preindex blood draw). Twenty-one PAD participants who survived more than 30 months after their index blood draw served as a control population.

RESULTS

Results showed distinct metabolomic patterns between preindex decedent, index decedent, and survivor samples. The major chemical signals contributing to the differential pattern (between survivors and decedents) arose from the fatty acyl chain protons of lipoproteins and the choline head group protons of phospholipids. Using the top 40 chemical signals for which the intensity was most distinct between survivor and preindex decedent samples, classification models predicted near-term all-cause death with overall accuracy of 78% (32/41), a sensitivity of 85% (17/20), and a specificity of 71% (15/21). When comparing survivor with index decedent samples, the overall classification accuracy was optimal at 83% (34/41) with a sensitivity of 80% (16/20) and a specificity of 86% (18/21), using as few as the top 10 to 20 chemical signals.

CONCLUSIONS

Our results suggest that metabolomic profiling of plasma may be useful for identifying PAD patients at increased risk for near-term death. Larger studies using more sensitive metabolomic techniques are needed to identify specific metabolic pathways associated with increased risk of near-term all-cause mortality among PAD patients.

Demanding attention: reconsidering the role of attention control groups in behavioral intervention research

Attention control groups play an important but controversial role in randomized controlled trials of behavioral interventions. The study by Pagoto et al. in this issue of Psychosomatic Medicine provides an informative example of some of the problems that attention control conditions can create in psychosomatic and behavioral medicine trials. This article discusses the reasons why these problems occur and provides some practical solutions. It also explains why controlling for attention is unnecessary and counterproductive in some behavioral trials.

Can attention control conditions have detrimental effects on behavioral medicine randomized trials?

OBJECTIVE

Attention control (AC) conditions are used to balance nonspecific attention in randomized trials of behavioral interventions. Very little guidance about which behavioral interventions and outcomes merit AC is available in the literature. The primary aim of the present study is to demonstrate a scenario in which use of AC in a behavioral randomized trial was unnecessary and possibly detrimental.

METHODS

Exploratory analyses were performed in a randomized controlled trial that tested whether a patient-centered counseling intervention reduced low-density lipoprotein cholesterol levels in 355 participants with peripheral arterial disease, compared with AC and usual care (UC) conditions. The patient-centered counseling intervention was designed to activate participants to ask their physician for lipid-lowering medication and/or increase dose intensity, increase medication adherence, and reduce fat intake. The AC condition involved attention-matched telephone-delivered health education, and the UC condition consisted of an educational pamphlet.

RESULTS

At 12-month follow-up, the mean low-density lipoprotein cholesterol changes were -11.1 and -6.8 mg/dL in the UC and AC conditions, respectively (p=.17). The proportion of participants who increased the use or dose intensity of medication was significantly lower in AC than in UC: 17.5% versus 30.5% (p=.03). No significant difference in other outcomes was observed between AC and UC.

CONCLUSIONS

AC has significantly worse medication outcomes, and there is no indication of a therapeutic effect on other end points. Implications for the use of AC in behavioral randomized trials are discussed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00217919.

Gender differences in cholesterol-lowering medication prescribing in peripheral artery disease

Among 320 patients with lower extremity peripheral artery disease (PAD) and low-density lipoprotein-cholesterol (LDL-C) levels > 70 mg/dl, we determined whether male sex, higher education, and greater self-efficacy for willingness to request therapy from one’s physician were associated with increases in LDL-C-lowering medication and achievement of an LDL-C level < 70 mg/dl at 1-year follow-up. Participants were enrolled in a randomized controlled clinical trial to determine whether a telephone counseling intervention can help PAD patients achieve an LDL-C level < 70 mg/dl, compared to usual care and attention control conditions, respectively. Adjusting for age, race, comorbidities, PAD severity, and other covariates, male sex (odds ratio = 3.33, 95% confidence interval = 1.64 to 6.77, p = 0.001) was associated with a higher likelihood of adding cholesterol-lowering medication during follow-up, but was not associated with achieving an LDL-C < 70 mg/dl (odds ratio = 1.09, 95% confidence interval = 0.55 to 2.18). No associations of education level or self-efficacy with study outcomes were identified. In conclusion, male PAD patients with baseline LDL-C levels ≥ 70 mg/dl were more likely to intensify LDL-C-lowering medication during 1-year follow-up than female PAD patients. Despite greater increases in LDL-C-lowering medication among female PAD patients, there was no difference in the degree of LDL-C lowering during the study between men and women with PAD. Clinical Trial Registration – URL: http://www.clinicaltrials.gov/ct2/show/NCT00217919

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.