Sigvant Birgitta, Kragsterman Björn, Falkenberg Mårten, Hasvold Pål, Johansson Saga, Thuresson Marcus, Nordanstig Joakim
Department of Vascular Surgery, Karlstad Central Hospital, Karlstad, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden.
Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.
J Vasc Surg. 2016 Oct;64(4):1009-1017.e3. doi: 10.1016/j.jvs.2016.03.429. Epub 2016 May 18.
Peripheral artery disease (PAD) is common worldwide, and PAD patients are increasingly offered lower limb revascularization procedures. The aim of this population-based study was to describe the current risk for cardiovascular (CV) events and mortality and also to elucidate the current pharmacologic treatment patterns in revascularized lower limb PAD patients.
This observational, retrospective cohort study analyzed prospectively collected linked data retrieved from mandatory Swedish national health care registries. The Swedish National Registry for Vascular Surgery database was used to identify revascularized PAD patients. Current risk for CV events and death was analyzed, as were prescribed drugs aimed for secondary prevention. A Cox proportional hazard regression model was used to explore risk factors for suffering a CV event.
Between May 2008 and December 2013, there were 18,742 revascularized PAD patients identified. Mean age was 70.0 years among patients with intermittent claudication (IC; n = 6959) and 76.8 years among patients with critical limb ischemia (CLI; n = 11,783). Antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and beta-blockers were used by 73%, 60%, 57%, and 49% at admission for revascularization. CV event rate (a composite of myocardial infarction, ischemic stroke, or CV death) at 12, 24, and 36 months was 5.1% (95% confidence interval [CI], 4.5-5.6), 9.5% (95% CI, 8.7-10.3), and 13.8% (95% CI, 12.8-14.8) in patients with IC and 16.8% (95% CI, 16.1-17.6), 25.9% (95% CI, 25.0-26.8), and 34.3% (95% CI, 33.2-35.4) in patients with CLI. Best medical treatment, defined as any antiplatelet or anticoagulant therapy along with statin treatment, was offered to 65% of IC patients and 45% of CLI patients with little change during the study period. Statin therapy was associated with reduced CV events (hazard ratio, 0.76; 95% CI, 0.71-0.81; P < .001), whereas treatment with low-dose aspirin was not.
Revascularized PAD patients are still at a high risk for CV events without a declining time trend. A large proportion of both IC and CLI patients were not offered best medical treatment. The most commonly used agent was aspirin, which was not associated with CV event reduction. This study calls for improved medical management and highlights an important and partly unmet medical need among revascularized PAD patients.
外周动脉疾病（PAD）在全球范围内都很常见，越来越多的PAD患者接受了下肢血运重建手术。这项基于人群的研究旨在描述当前心血管（CV）事件和死亡的风险，并阐明接受血运重建的下肢PAD患者目前的药物治疗模式。
这项观察性、回顾性队列研究分析了从瑞典强制性国家医疗保健登记处前瞻性收集的关联数据。瑞典国家血管外科登记数据库用于识别接受血运重建的PAD患者。分析了当前CV事件和死亡的风险，以及用于二级预防的处方药。采用Cox比例风险回归模型探索发生CV事件的风险因素。
2008年5月至2013年12月期间，共识别出18742例接受血运重建的PAD患者。间歇性跛行（IC；n = 6959）患者的平均年龄为70.0岁，严重肢体缺血（CLI；n = 11783）患者的平均年龄为76.8岁。在血运重建入院时，73%、60%、57%和49%的患者使用了抗血小板治疗、他汀类药物、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂和β受体阻滞剂。IC患者在12、24和36个月时的CV事件发生率（心肌梗死、缺血性中风或CV死亡的综合发生率）分别为5.1%（95%置信区间[CI]，4.5 - 5.6）、9.5%（95%CI，8.7 - 10.3）和13.8%（95%CI，12.8 - 14.8），CLI患者分别为16.8%（95%CI，16.1 - 17.6）、25.9%（95%CI，25.0 - 26.8）和34.3%（95%CI，33.2 - 35.4）。最佳药物治疗定义为任何抗血小板或抗凝治疗以及他汀类治疗，在研究期间，65%的IC患者和45%的CLI患者接受了最佳药物治疗，且变化不大。他汀类治疗与CV事件减少相关（风险比，0.76；95%CI，0.71 - 0.81；P <.001），而低剂量阿司匹林治疗则不然。
接受血运重建的PAD患者仍然面临较高的CV事件风险，且无下降的时间趋势。很大一部分IC和CLI患者未接受最佳药物治疗。最常用的药物是阿司匹林，它与CV事件减少无关。这项研究呼吁改善医疗管理，并凸显了接受血运重建的PAD患者中一个重要且部分未满足的医疗需求。
