Debbie C. Chen

Adherence to Guideline‐Recommended Therapy Is Associated With Decreased Major Adverse Cardiovascular Events and Major Adverse Limb Events Among Patients With Peripheral Arterial Disease

Background Current guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin‐converting enzyme (ACE) inhibitors. The combined effects of multiple guideline‐recommended therapies in patients with symptomatic PAD have not been well characterized. Methods and Results We analyzed a comprehensive database of all patients with claudication or critical limb ischemia (CLI) who underwent diagnostic or interventional lower‐extremity angiography between June 1, 2006 and May 1, 2013 at a multidisciplinary vascular center. Baseline demographics, clinical data, and long‐term outcomes were obtained. Inverse probability of treatment propensity weighting was used to determine the 3‐year risk of major adverse cardiovascular or cerebrovascular events (MACE; myocardial infarction, stroke, or death) and major adverse limb events (MALE; major amputation, thrombolysis, or surgical bypass). Among 739 patients with PAD, 325 (44%) had claudication and 414 (56%) had CLI. Guideline‐recommended therapies at baseline included use of aspirin in 651 (88%), statin medications in 496 (67%), ACE inhibitors in 445 (60%), and smoking abstention in 528 (71%) patients. A total of 237 (32%) patients met all four guideline‐recommended therapies. After adjustment for baseline covariates, patients adhering to all four guideline‐recommended therapies had decreased MACE (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.89; P=0.009), MALE (HR, 0.55; 95% CI, 0.37 to 0.83; P=0.005), and mortality (HR, 0.56; 95% CI, 0.38 to 0.82; P=0.003), compared to patients receiving less than four of the recommended therapies. Conclusions In patients with claudication or CLI, combination treatment with four guideline‐recommended therapies is associated with significant reductions in MACE, MALE, and mortality.

Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is associated with reduced major adverse cardiovascular events among patients with critical limb ischemia

Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are recommended for secondary prevention in peripheral artery disease, but their effectiveness in patients with critical limb ischemia (CLI) is uncertain. We reviewed 464 patients with CLI who underwent diagnostic angiography or endovascular intervention from 2006–2013 at a multidisciplinary vascular center. ACEI or ARB use was assessed at the time of angiography. Major adverse cardiovascular events (MACE), mortality, and major adverse limb events (MALE) were assessed during three-year follow-up. Propensity weighting was used to adjust for baseline differences between patients taking and not taking ACEIs or ARBs. ACEIs or ARBs were prescribed to 269 (58%) patients. Patients prescribed ACEIs or ARBs had more baseline comorbidities including diabetes and hypertension (p<0.05). Patients prescribed ACEIs or ARBs had lower three-year unadjusted rates of MACE (40% versus 47%) and mortality (33% versus 43%). After propensity weighting, ACEI or ARB use was associated with significantly lower rates of MACE (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.58–0.99, p=0.04) and overall mortality (HR 0.71, 95% CI 0.53–0.95, p=0.02). There was no significant association between ACEI or ARB use and MALE (HR 0.97, 95% CI 0.69–1.35, p=0.2) or major amputation (HR 0.74, 95% CI 0.47–1.18, p=0.1). ACEI/ARB use is associated with lower MACE and mortality in patients with CLI, but there was no effect on limb-related outcomes.

Adherence to guideline-recommended therapies among patients with diverse manifestations of vascular disease

Background Current guidelines recommend aspirin, statins, angiotensin-converting enzyme inhibitors (ACEIs), and smoking abstinence for all patients with vascular disease. There is little data on the variation in adherence to guideline-recommended therapies among patients with different clinical manifestations of vascular disease. Purpose To analyze the variation in adherence to guideline-recommended therapies among patients with diverse manifestations of vascular disease. Methods We analyzed a comprehensive database of all patients with critical limb ischemia, claudication, acute limb ischemia, carotid artery stenosis, subclavian artery stenosis, renal artery stenosis, or mesenteric ischemia who underwent angiography between 2006 and 2013 at a multidisciplinary vascular center. Results Among 1,114 patients with vascular disease, adherence to guideline-recommended therapy at time of angiography included use of aspirin in 936 (84%), statins in 753 (68%), ACEIs in 673 (60%), and smoking abstinence in 788 (71%). A total of 335 (30%) patients utilized all four guideline-recommended therapies. Adherence to four guideline-recommended therapies was lowest among patients with acute limb ischemia (14%) and highest among patients with renal artery stenosis (37%). Among all patients with vascular disease, the range of adherence to individual guidelines was 64%–91% for aspirin, 43%–83% for statins, 49%–66% for ACEIs, and 47%–78% for smoking abstention. Conclusion The majority of patients with diverse manifestations of vascular disease take aspirin and abstain from smoking while fewer patients are prescribed ACEIs and statins. Among the current recommendations, statins have the widest variation in adherence. Less than one-third of patients with diverse manifestations of vascular disease are prescribed all four guideline-recommended therapies.

Aspirin and clopidogrel high on-treatment platelet reactivity and genetic predictors in peripheral arterial disease

Our aims were to examine the prevalence and genetic predictors of aspirin and clopidogrel high on‐treatment platelet reactivity (HoTPR), and associated adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD).

Faces of Lyme

Patient 2. A 56-year-old male presented to the emergency department with 3 days of malaise and rash. He had spent time at a barbecue in Massachusetts 5 days earlier, but did not recall any insect or tick bites. Physical examination revealed a 10-cm oval-shaped erythematous, non-tender plaque with vesiculobullous surface in the left popliteal fossa with surrounding erythema (Fig. 1b). Both patients experienced complete resolution of symptoms and rash after receiving 21 days of doxycycline for treatment of presumed Lyme disease. While erythema migrans is present in up to 80% of patients with Lyme disease, only 9% present with classic central clearing. Given the poor sensitivity (<40%) of serological testing in patients with erythema migrans, the diagnosis and prompt treatment of Lyme disease often depend on physicians’ ability to recognize its varied cutaneous manifestations.

Long-Standing Goiter Causing Acute Airway Compromise.

A n 81-year-old Filipino woman with a 20-year history of benign goiter presented to the emergency department with acute shortness of breath and cough. Physical examination revealed an oxygen saturation of 76 % on room air, large anterior neck mass extending most prominently to the left side of her neck, and stridor. After treatment with albuterol, steroids, and continuous positive airway pressure ventilation, symptoms were alleviated and oxygen saturation improved to 98 % on room air. She was subsequently evaluated for thyroidectomy. Prior to surgery, radiograph (Fig. 1a) and computed tomography (Fig. 1b) of the chest showed massive substernal thyroid and prominent rightward deviation and severe narrowing of the trachea. After left hemithyroidectomy, chest radiograph revealed significant improvement in tracheal stenosis (Fig. 2). While onethird of patients with goiter have evidence of upper airway obstruction on flow-volume loops, tolerance can develop to long-standing goiters, and patients may remain asymptomatic while compensating for up to 70 % tracheal compression. 3 However, patients with goiter, particularly with substernal extension, may experience acute airway compromise in the setting of upper respiratory infections. 4 Surgical management is recommended for goiters causing compressive symptoms and should be considered in asymptomatic patients with substernal goiter and objective evidence of upper airway obstruction. 6 Figure 1 Prior to left hemithyroidectomy. a) Chest radiograph showing rightward deviation of the trachea with severe tracheal narrowing (arrows). b) Computed tomography of the chest demonstrating massive substernal thyroid (asterisks) and tracheal compression (arrow).