While medical care of patients with peripheral arterial disease (PAD) who undergo percutaneous coronary intervention (PCI) has improved in the past decade and the need for repeat revascularization has dropped, rates of death and myocardial infarction (MI) remain unchanged. The findings, from a retrospective analysis spanning 10 years of practice patterns, were published online January 28, 2011, ahead of print in the American Journal of Cardiology.

Evaluating Progress Through the Eras

Researchers led by Elizabeth M. Holper, MD, from the University of Texas Southwestern (Dallas, TX), used data from the National Heart, Lung, and Blood Institute Dynamic Registry to evaluate trends in treatment practices and outcomes among PCI patients who had concomitant PAD. The analysis included 866 subjects treated between 1997 and 2006 who were enrolled in 5 waves that captured different eras of PCI development:

• Early BMS Era
  • Wave 1: July 1997 to February 1998
• BMS Era
  • Wave 2: February to June 1999
  • Wave 3: October 2001 to March 2002
• DES Era
  • Wave 4: February to May 2004
  • Wave 5: February to August 2006

Over the course of the study period, patients were progressively less likely to have previous MI and, conversely, were more apt to have hypertension, hypercholesterolemia, or renal disease. The percentages of patients discharged on medications including aspirin, beta-blockers, ACE-inhibitors, thienopyridines, and statins significantly increased across the 3 treatment eras. In addition, the mean length of stay decreased from 3.3 days in the early BMS era to 2.8 days in the BMS era and 2.2 days in the DES era (P for trend = 0.004).

In conjunction with these changes, in-hospital CABG diminished significantly, as did the 1-year rates for repeat revascularizations. Cumulative 1-year mortality and MI rates remained stubbornly consistent over time, however (table 1).

Table 1. Changing Outcomes in PAD Patients

Similarly, 1-year adjusted hazard ratios for both death and MI remained stable across the eras, although the risk of repeat revascularization was curbed by the advent of DES use (table 2).

Table 2. Adjusted 1-Year HR (95% CI) vs. Early BMS Era

 
“In conclusion, despite significant improvements in medical therapy and a decrease in repeat revascularization over time, patients with PAD who undergo PCI have a persistent high rate of death and MI,” the investigators write.

More Expected from Medical Therapy

Dr. Holper told TCTMD in a telephone interview that the study provides an encouraging message. “Our PAD patients are those we think of as very high risk, so it’s important to note that we’re seeing a profound reduction over time in their revascularization rates,” she said, although she expressed surprise at the lack of change in death and MI.

“It could be that we need to get data on the adherence rates of these medications,” Dr. Holper speculated. “Are all of their parameters maximized? Are they at the lowest risk possible on these medications?”

But in a telephone interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said the results made sense. “Patients with PAD are some of the highest risk patients we treat because they have extensive coronary artery disease and cerebrovascular disease,” he commented. “They also have a lot of comorbidities and tend to be older. . . . In these eras, rates of death and MI related to coronary disease are predominantly due to access to care, and this study is already looking at patients who were referred for PCI, so it can’t pick that up.”

Treat PAD Aggressively

Despite its limitations, Dr. Holper said, “medical therapy for these patients currently is the best we have, and the best ways we can effect a difference [in outcomes] is to carefully manage their cardiovascular risk factors with close clinical follow-up and to have both patients and physicians involved in making sure those parameters are as optimized as they can be.”

In particular, she added, “[t]he optimization of medical therapy is probably what we need to focus on, in conjunction with effective revascularization.”

Dr. Kirtane agreed that patient management is key. “The main thing is recognizing that their cardiovascular risk is substantial and then implementing proven therapies—smoking cessation, cholesterol modification, exercise programs, revascularization when appropriate, and that sort of thing. PAD is an under-recognized disease entity,” he said, pointing out that physicians often do not treat these patients as aggressively as they should. “In fact, you could argue from a public health perspective that if we were really to focus on disease modifications in patients with PAD, that could reduce a lot of potential expenditures and suffering because these are such high-risk patients.”

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