Chen Debbie C, Singh Gagan D, Armstrong Ehrin J, Waldo Stephen W, Laird John R, Amsterdam Ezra A
Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Division of Cardiovascular Medicine, Department of Internal Medicine, University of California Davis Vascular Center, Sacramento, California.
Am J Cardiol. 2017 Apr 15;119(8):1146-1152. doi: 10.1016/j.amjcard.2016.12.023. Epub 2017 Jan 25.
There are limited contemporary data on guideline-directed medical therapy (GDMT) utilization and long-term clinical outcomes in patients with peripheral artery disease (PAD) with and without concomitant coronary artery disease (CAD). From 2006 to 2013, 879 patients with claudication or critical limb ischemia (CLI) underwent diagnostic angiography or therapeutic endovascular intervention at our multidisciplinary vascular center. GDMT use was assessed at the time of angiography, and major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause mortality were determined during 5 years of follow-up. Cox proportional hazard modeling was used to adjust for baseline differences between patients with and without concomitant CAD. Despite a higher adherence to GDMT (all p ≤0.002) for the use of aspirin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statins, patients with PAD and concomitant CAD had higher unadjusted 5-year rates of MACCE (hazard ratio [HR] 1.7, 95% CI 1.3 to 2.1, p = 0.0001) and all-cause mortality (HR 1.86, 95% CI 1.4 to 2.4, p = 0.0001). After adjustment for baseline co-morbidities, the presence of CAD remained an independent risk factor for mortality (adjusted HR 1.35, 95% CI 1.02 to 1.80, p = 0.04) but not for MACCE (adjusted HR 1.24, 95% CI 0.96 to 1.60, p = 0.10) in patients with PAD. A sensitivity analysis limited to patients with CLI demonstrated that concomitant CAD was associated with significantly higher adjusted rates of both MACCE (adjusted HR 1.52, 95% CI 1.14 to 2.03, p = 0.01) and mortality (adjusted HR 1.64, 95% CI 1.12 to 2.20, p = 0.006). In conclusion, despite higher rates of GDMT use, PAD patients with concomitant CAD had significantly increased risk of all-cause mortality during a 5-year postprocedural follow-up. The subgroup of CLI patients with concomitant CAD was at particularly high risk for both MACCE and all-cause mortality.
关于外周动脉疾病（PAD）伴或不伴冠状动脉疾病（CAD）患者的指南指导药物治疗（GDMT）应用情况及长期临床结局，目前当代数据有限。2006年至2013年期间，879例有间歇性跛行或严重肢体缺血（CLI）的患者在我们的多学科血管中心接受了诊断性血管造影或治疗性血管内介入治疗。在血管造影时评估GDMT的使用情况，并在5年随访期间确定主要不良心血管和脑血管事件（MACCE）及全因死亡率。采用Cox比例风险模型对伴或不伴CAD患者的基线差异进行校正。尽管在使用阿司匹林、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂和他汀类药物方面，PAD伴CAD患者对GDMT的依从性更高（所有p≤0.002），但PAD伴CAD患者未经校正的5年MACCE发生率（风险比[HR]1.7，95%CI 1.3至2.1，p = 0.0001）和全因死亡率（HR 1.86，95%CI 1.4至2.4，p = 0.0001）更高。在对基线合并症进行校正后，CAD的存在仍然是PAD患者死亡率的独立危险因素（校正后HR 1.35，95%CI 1.02至1.80，p = 0.04），但不是MACCE的独立危险因素（校正后HR 1.24，95%CI 0.96至1.60，p = 0.10）。一项仅限于CLI患者的敏感性分析表明，合并CAD与MACCE（校正后HR 1.52，95%CI 1.14至2.03，p = 0.01）和死亡率（校正后HR 1.64，95%CI 1.12至2.20，p = 0.006）的校正后发生率显著升高相关。总之，尽管GDMT使用率较高，但PAD伴CAD患者在术后5年随访期间全因死亡风险显著增加。合并CAD的CLI患者亚组在MACCE和全因死亡率方面风险尤其高。
