Medical management of patients with peripheral arterial disease (original) (raw)
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Pharmacological prevention of atherothrombotic events in patients with peripheral arterial disease
European Journal of Clinical Investigation, 2007
Peripheral arterial disease (PAD) is strongly associated with atherosclerosis in the coronary and carotid arteries, leading to a highly increased incidence of myocardial infarction, ischaemic stroke and cardiovascular death. Fortunately, pharmacological interventions in large clinical trials have been as effective in subgroups of patients with PAD as in subjects with other atherosclerotic disease. Antiplatelet treatment is indicated in virtually all patients with PAD. Aspirin 75-325 mg day − 1 is considered as first-line treatment, and clopidogrel 75 mg day − 1 is an effective alternative. Statin therapy is indicated to achieve a target lowdensity lipoprotein cholesterol level of ≤ 2·5 mmol L − 1 in patients with PAD and there is emerging evidence that even lower levels are beneficial. Lowering of plasma homocysteine by supplementing folic acid, vitamin B 12 and vitamin B 6 is not recommended in patients with mild to moderate hyperhomocysteinaemia in the 12-25 µ mol L − 1 range, since it does not reduce the incidence of cardiovascular events. Antihypertensive treatment is indicated to achieve a goal blood pressure of ≤ 140/90 mmHg or ≤ 130/80 mmHg in the presence of diabetes or chronic kidney disease. All classes of antihypertensive drugs are acceptable for treatment of hypertension in patients with PAD, but angiotensin-converting enzyme inhibitors ramipril or perindopril are especially appropriate because they reduce the incidence of cardiovascular events beyond their blood pressure-lowering effects. Beta-blockers should not be used as first-line antihypertensive treatment. Diabetic patients with PAD should reduce their glycosylated haemoglobin to ≤ 7%. In conclusion, pharmacological secondary prevention of cardiovascular morbidity and mortality in patients with PAD should be as comprehensive as that in patients with established coronary or cerebrovascular disease.
Current Management of Peripheral Artery Disease: Focus on Pharmacotherapy
Peripheral artery disease (PAD) is the occlusion or narrowing of the arteries supplying the lower extremities. Peripheral artery disease has been estimated to affect approximately 240 million people worldwide, approximately 70% of whom are within low-or middle-income countries. Due to the ageing population and diabetes epidemic, the prevalence of PAD is rapidly rising. The symptoms of PAD are heterogeneous and thus a high index of suspicion is needed to prevent delays in diagnosis and treatment. Measurement of ankle brachial pressure index or arterial duplex ultrasound are traditionally used to diagnose PAD. Patients with PAD have a high risk of major adverse cardiovascular events. Early diagnosis and implementation of secondary cardiovascular prevention is therefore critical. This includes therapies to reduce low-density lipoprotein cholesterol, such as statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, blood-pressure reducing medications and anti-thrombotic drugs. Treatments to facilitate smoking cessation and control blood sugar if relevant and an exercise programme are also critical in reducing cardiovascular risk. Currently, these treatments are not well implemented. This review summarises the clinical presentation, risk factors and medical management of PAD. Global efforts are needed to reduce the burden from the growing PAD epidemic by implementing best practices and improving outcomes through further research.
Comparative effectiveness review of antiplatelet agents in peripheral artery disease
Journal of the American Heart Association, 2014
Institute of Medicine as one of the top 100 priorities for comparative effectiveness research because of the large population of patients affected with significant morbidity and mortality, the multiple potential treatment options, and the high costs of care to the health care system. 1 The goal of medical therapy in patients with PAD is to reduce the risk of future cardiovascular (CV) morbidity and mortality, improve walking distance and functional status in patients with intermittent claudication (IC), and reduce amputation in patients with critical limb ischemia (CLI). Secondary prevention includes the use of antiplatelet agents and the management of other risk factors, such as tobacco use, diabetes mellitus, hyperlipidemia, and hypertension. It is not clear which antiplatelet strategy (aspirin versus clopidogrel or monotherapy versus dual antiplatelet therapy [DAPT]) is of most benefit. Furthermore, the role of these agents in patients with asymptomatic PAD is also unclear. We conducted a systematic review evaluating various treatment modalities for PAD. 2 This article, which is derived from that review, focuses on the comparative effectiveness and safety of (1) aspirin versus placebo or no antiplatelet, (2) clopidogrel versus aspirin, (3) clopidogrel plus aspirin versus aspirin alone, and (4) other antiplatelet comparisons. Methods Data Sources and Searches Searches were limited to articles published from January 1995 to August 2012. Exact search strings are listed in the full Agency for Healthcare Research and Quality (AHRQ) report. 2 We supplemented electronic searches with a manual search of references from systematic reviews and pivotal articles in the field. We also searched the gray literature of study registries and conference abstracts for relevant articles from completed studies that have not been published in a peer-reviewed journal, including ClinicalTrials.gov, the World Health Organization's International Clinical Trials Registry Platform Search Portal, and the ProQuest COS Conference Papers Index. Scientific information packets were requested from manufacturers of medications and devices and reviewed for relevant articles. Study Selection Studies were limited to adult populations aged 18 years or older with lower-extremity PAD. English-language randomized or observational studies were included. Detailed inclusion and exclusion criteria are in the full report. 2 Data Extraction and Quality Assessment Abstracted data included study design, patient characteristics overall and by study group (age, sex, and race), vascular disease risk factors (diabetes, tobacco use, chronic kidney disease, hyperlipidemia, or other comorbid diseases), and interventionspecific factors (antiplatelet therapy, and, if applicable, type of endovascular or surgical revascularization). Outcomes captured included overall morality, CV mortality, nonfatal myocardial infarction (MI), nonfatal stroke, repeat revascularization, vessel patency, and composite CV events (CVEs; CV mortality, nonfatal MI, and nonfatal stroke). Safety outcomes included adverse drug reactions and bleeding. Disagreements were resolved by consensus. We evaluated the quality of individual studies as described in the AHRQ's "Methods Guide for Effectiveness and Comparative Effectiveness Reviews," 3 assigning summary ratings of good, fair, or poor.
The Influence of Risk Factors on the Choice of Therapeutic Method in Peripheral Arterial Disease
Acta Medica Transilvanica, 2020
Peripheral arterial disease (PAD) is characterized by obstruction in the lower limbs, mainly due to atherosclerosis. The prevalence of the pathology in people under 40 years of age is 6% and 15-20% in the population over 65 years old.(1,2) Approximately 50% of the affected persons are, at the time of examination, asymptomatic.(3) The most important risk factors associated with this condition are smoking, diabetes mellitus (DM), high cholesterol and high blood pressure (HBP). The current study shows that, regardless of the association of risk factors or pre-hospital treatment, these patients do not benefit from a certain type of treatment (drug or interventional), which corresponds to the existing data in the literature, which do not document the choice of type of treatment depending on the patient’s age or comorbidities.
2010
We sought to investigate the effect of cardiac medication on long-term mortality in patients with peripheral arterial disease (PAD). BACKGROUND Peripheral arterial disease is associated with increased cardiovascular morbidity and mortality. Treatment guidelines recommend aggressive management of risk factors and lifestyle modifications. However, the potential benefit of cardiac medication in patients with PAD remains ill defined. METHODS In this prospective observational cohort study, 2,420 consecutive patients (age, 64 Ϯ 11 years, 72% men) with PAD (ankle-brachial index Յ0.90) were screened for clinical risk factors and cardiac medication. Follow-up end point was death from any cause. Propensity scores for statins, beta-blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, diuretics, nitrates, coumarins, and digoxin were calculated. Cox regression models were used to analyze the relation between cardiac medication and long-term mortality. RESULTS Medical history included diabetes mellitus in 436 patients (18%), hypercholesterolemia in 581 (24%), smoking in 837 (35%), hypertension in 1,162 (48%), coronary artery disease in 1,065 (44%), and a history of heart failure in 214 (9%). Mean ankle-brachial index was 0.58 (Ϯ0.18). During a median follow-up of eight years, 1,067 patients (44%) died. After adjustment for risk factors and propensity scores, statins (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.36 to 0.58), beta-blockers (HR 0.68, 95% CI 0.58 to 0.80), aspirins (HR 0.72, 95% CI 0.61 to 0.84), and ACE inhibitors (HR 0.80, 95% CI 0.69 to 0.94) were significantly associated with a reduced risk of long-term mortality. CONCLUSIONS On the basis of this observational longitudinal study, statins, beta-blockers, aspirins, and ACE inhibitors are associated with a reduction in long-term mortality in patients with PAD.
Journal of Vascular Surgery
Objective: Long-term progression of peripheral arterial disease (PAD) as initial manifestation of atherosclerotic arterial disease is not well described. Cardiovascular (CV) risk was examined in different PAD populations diagnosed in a hospital setting in Sweden. Methods: Data for this retrospective cohort study were retrieved by linking data on morbidity, medication use, and mortality from Swedish national registries. Primary CV outcome was a composite of myocardial infarction, ischemic stroke (IS), and CV death. Kaplan-Meier analysis and Cox proportional hazards modeling was used for describing risk and relative risk. Results: Of 66,189 patients with an incident PAD diagnosis (2006-2013), 40,136 had primary PAD, 16,786 had PAD þ coronary heart disease (CHD), 5803 had PAD þ IS, and 3464 had PAD þ IS þ CHD. One-year cumulative incidence rates of major CV events for the groups were 12%, 21%, 29%, and 34%, respectively. Corresponding numbers for 1-year all-cause death were 16%, 22%, 33%, and 35%. Compared with the primary PAD population, the relative risk increase for CV events was highest in patients with PAD þ IS þ CHD (hazard ratio [HR], 2.01), followed by PAD þ IS (HR, 1.87) and PAD þ CHD (HR, 1.42). Despite being younger, the primary PAD population was less intensively treated with secondary preventive drug therapy. Conclusions: PAD as initial manifestation of atherosclerotic disease diagnosed in a hospital-based setting conferred a high risk: one in eight patients experienced a major CV event and one in six patients died within 1 year. Despite younger age and substantial risk of future major CV events, patients with primary PAD received less intensive secondary preventive drug therapy.