Missed Opportunities with Patients with Peripheral Vascular Disease

Little is known about how good are our counseling efforts on medication use and lifestyle as regards patients with peripheral vascular disease. More often than not, we use our time with these patients to discuss the technical feasibility of rechanneling, or to analyze the risk of eventual amputation. However, how often do we seize the opportunity to counsel these patients on the importance of exercise, smoking cessation, or control of the blood pressure and cholesterol levels? And, also important, how many times do we think about whether a patient with intermittent claudication may also present concomitant coronary disease or carotid artery disease?

Some may always do this while others may never think about it. Certain professionals may see vascular disease as a systemic disease, while others may focus on the target surface femoral artery causing the symptoms. However, beyond our point of view or mere speculation, as of now there were no formal studies answering the aforementioned questions.

This study evaluated trends in both medical therapy and lifestyle counseling for patients diagnosed with peripheral vascular disease from 2005 through 2012.

Data from outpatient visits among patients with peripheral vascular disease were obtained from national outpatient registries in the United States.

Trends in the proportion of visits of patients under medical treatment (antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and cilostazol) and lifestyle counseling (exercise or diet counseling and smoking cessation) were evaluated.

Over an 8-year follow-up, in 1982 patients (mean age: 69.2 years old; 51.8% were female), concomitant coronary disease was present in 24.3%.

Medication use for cardiovascular prevention and treatment of symptoms of claudication was low: any antiplatelet therapy in 35.7%, statin in 33.1%, angiotensin-converting enzyme inhibitors (or angiotensin receptor blockers) in 28.4%, and cilostazol (the only drug clearly aimed at treating symptoms of claudication) in only 4.7% of visits.

Diet counseling or smoking cessation counseling was used in 35.8% of visits.

There was no significant change in medication use or lifestyle counseling over time.

Compared with patients with peripheral vascular disease alone, patients with concomitant coronary disease were more likely to be prescribed antiplatelet therapy (odds ratio [OR]: 2.6), statins (OR: 2.6), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (OR: 2.6), and smoking cessation counseling (OR: 4.4).

These last figures evidence an underestimation of peripheral vascular disease, with a focus only on the lower limbs and a lack of understanding of its status as a systemic disease.

Conclusion

The use of guideline-recommended therapies in patients with peripheral vascular disease is much lower than expected, which means that we are missing a great opportunity to improve the quality of care in this high-risk population.

Original title: Underuse of Prevention and Lifestyle Counseling in Patients with Peripheral Artery Disease.

Reference: Jeffrey S. Berger et al. Am Coll Cardiol 2017;69:2293–300.

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