Underuse of Prevention and Lifestyle Counseling in Patients With Peripheral Artery Disease

Abstract

Background Little is known about patterns of medication use and lifestyle counseling in patients with peripheral artery disease (PAD) in the United States. Objective We sought to evaluate trends in both medical therapy and lifestyle counseling for PAD patients in the United States from 2005 through 2012. Methods Data from 1,982 outpatient visits among patients with PAD were obtained from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, a nationally representative assessment of office-based and hospital outpatient department practice. We evaluated trends in the proportion of visits with medication use (antiplatelet therapy, statins, ACE-inhibitors [ACE-I] or angiotensin receptor blockers [ARB], and cilostazol) and lifestyle counseling (exercise or diet counseling and smoking cessation). Results Over the 8-year period, the average annual number of ambulatory visits in the U.S. for PAD was 3,883,665. Across all visits, mean age was 69.2 years, 51.8% were female and 56.6% were Non-Hispanic white. Comorbid coronary artery disease (CAD) was present in 24.3% of visits. Medication use for cardiovascular prevention and symptoms of claudication was low: any antiplatelet therapy in 35.7% (standard error [SE] 2.7), statin 33.1% (SE, 2.4), ACE-I/ARB 28.4% (SE, 2.0), and cilostazol in 4.7% (SE, 1.0) of visits. Exercise or diet counseling was used in 22% (SE, 2.3) of visits. Among current smokers with PAD, smoking cessation counseling or medication was used in 35.8% (SE, 4.6) of visits. There was no significant change in medication use or lifestyle counseling over time. Compared to visits for patients with PAD alone, comorbid PAD and CAD were more likely to be prescribed antiplatelet therapy (OR 2.6 [1.8–3.9]), statins (OR 2.6 [1.8–3.9]), ACE-I/ARB (OR 2.6 [1.8–3.9]), and smoking cessation counseling (OR 4.4 [2.0–9.6]). Conclusions The use of guideline-recommended therapies in patients with PAD was much lower than expected, which highlights an opportunity to improve the quality of care in these high-risk patients.

Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial

“…This finding emphasises the importance of optimising treatment in the general peripheral artery disease population. 4,25,26 Consistent benefits in the reduction of major adverse cardiovascular events and major adverse limb events occurred with combination of rivaroxaban 2·5 mg plus aspirin compared with aspirin alone but did not occur to the same extent with the rivaroxaban 5 mg twice a day regimen. These results are also consistent with the results of the overall trial, which have been reported separately.…”

Peripheral vascular disease risk in diabetic individuals without coronary heart disease

“…According to national surveys of ambulatory care practices, adherence to guideline-directed medical therapy in patients with PAD lags behind that of CHD, whereas a co-diagnosis of CHD increases the odds of proper PAD treatment [3]. Adherence to CHD risk factor modification has also been found to be suboptimal in patients with diabetes [5].…”

“…Diabetes severity was stratified by [1] no use of medications (e.g. diet controlled) [2], use of oral glucose-lowering agents only, or [3] use of insulin with or without the use of oral glucose-lowering agents. Coronary heart disease (CHD) was defined as prior myocardial infarction or prior coronary revascularization (coronary artery bypass, angioplasty, or percutaneous coronary intervention).…”

“…Peripheral vascular disease, which includes disease of the carotid, aorta, and lower extremity arterial beds, is primarily caused by atherosclerosis and is therefore influenced by the presence of diabetes [2]. Peripheral vascular disease and diabetes are both increasingly prevalent conditions, affecting an estimated 200 and 360 million people worldwide, respectively [3,4]. Despite the high prevalence and well established morbidity of both of these conditions, use of guideline-directed medical therapy remains suboptimal in patients diagnosed with peripheral vascular disease and diabetes, especially in individuals without a history of coronary heart disease [3,5].…”

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

“…Several studies have reported underutilization of established risk‐reduction therapies such as statins for peripheral artery disease relative to coronary artery disease,6, 7, 8 which may lead to poor cardiovascular and limb outcomes 9. Nevertheless, few data exist on the utilization of statin therapy among patients with carotid artery disease.…”