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Predictors of Medical Therapy in Lower Extremity Peripheral Artery Disease
Quick Takes
- Overall use of guideline-directed medical therapy in patients undergoing PAD revascularization is low.
- Use of Class I medical therapy (antiplatelet and statin) is more common than Class II therapies (ACE inhibitor or angiotensin receptor blocker) following PAD revascularization.
Study Questions:
What is the use of guideline-directed medical therapy (GDMT) for patients with lower extremity peripheral artery disease (PAD) following peripheral vascular intervention?
Methods:
The authors used the 2014-2018 Vascular Study Group of New England Vascular Quality Initiative database to explore predictors of GDMT following peripheral vascular intervention for lower extremity PAD. GDMT was defined as use of antiplatelet agents, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers. Key predictors explored include sex, age, and comorbid conditions using multivariable logistic regression.
Results:
Among 12,316 patients undergoing lower extremity PAD revascularization, only 47.4% were discharged on GDMT. Most patients received antiplatelet therapy (95.2%) and statin therapy (83.5%). However, use of ACE inhibitors or angiotensin-receptor antagonists was less common (55.8%). Predictors of lower GDMT use included female sex, older age, end-stage renal disease, chronic limb-threatening ischemia, and congestive heart failure. Predictors of higher GDMT use were hypertension, diabetes, coronary artery disease, and prior lower extremity revascularization.
Conclusions:
The authors concluded that fewer than one-half of all patients undergoing lower extremity PAD revascularization received appropriate GDMT.
Perspective:
While the authors highlight the need for better use of GDMTs for patients with PAD, they also provide some reassuring news. Namely, the use of Class I recommendations (antiplatelet therapy and statins) were broadly adopted. The use of Class IIa therapies (ACE inhibitor or angiotensin-receptor antagonist) was less common. As long as hypertension was well controlled in the population, it is not clear that all patients need to receive ACE inhibitors or angiotensin-receptor antagonists. In light of the recent VOYAGER PAD study (DOI: 10.1056/NEJMoa2000052), further work should be done to assess when a dual pathway inhibition approach of rivaroxaban 2.5 mg twice daily plus low-dose aspirin should be used in this population.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Hypertension
Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Coronary Artery Disease, Diabetes Mellitus, Endovascular Procedures, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Ischemia, Kidney Failure, Chronic, Myocardial Revascularization, Peripheral Arterial Disease, Platelet Aggregation Inhibitors, Primary Prevention, Vascular Diseases
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