Meltzer Andrew J, Sedrakyan Art, Connolly Peter H, Ellozy Sharif, Schneider Darren B
Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY.
Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY.
Ann Vasc Surg. 2018 Jan;46:234-240. doi: 10.1016/j.avsg.2017.05.030. Epub 2017 Jun 8.
The objective of this study was to identify risk factors for suboptimal medical therapy (defined as reported antiplatelet and statin use) among patients undergoing lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) for symptomatic peripheral arterial disease (PAD).
The Vascular Study Group of Greater New York (VSGGNY) database was used to identify all patients undergoing PVI or LEB for PAD (2011-2013). Bivariate analyses were performed to identify characteristics of patients who were not prescribed statins and/or antiplatelet agents before revascularization. Multivariate relative risk regression models were developed to identify patients at risk for suboptimal therapy, with regards to antiplatelet and statin therapy.
About 1,030 patients underwent endovascular therapy (n = 822; 80%) or surgical bypass (n = 208; 20%) for symptomatic PAD (57.2% claudication; 15% rest pain and 27.8% tissue loss). Overall, preoperative statin use was observed in 59%. Preoperative antiplatelet therapy was observed in 79% of patients. Bivariate analysis revealed comparatively reduced statin use among patients without other cardiovascular risk factors including hypertension (63% vs. 39.3%; P < 0.0001) and coronary artery disease (CAD) with or without prior cardiac revascularization (coronary artery bypass grafting [CABG]/percutaneous coronary intervention [PCI]; 75.2% vs. 47.4%; P < 0.0001). Multivariate relative risk regression confirmed higher rates of statin use among patients with other cardiovascular risk factors including hypertension (1.14 [1.02-1.27]; P = 0.02) and CAD with prior CABG/PCI (1.22 [1.13-1.31]; P < 0.0001). Reduced statin use was observed in patients over 80 years old. (0.92 [0.84-0.1.0]; P = 0.059). By multivariate regression, antiplatelet therapy use was associated with CAD and/or prior CABG/PCI (1.11 [1.04-1.17]; P = 0.0015) and prior peripheral revascularization (1.07 [1.01-1.13]; P = 0.03).
Patients with symptomatic PAD, but without an antecedent cardiovascular history, are less likely to be optimally managed with statins and antiplatelet therapy preoperatively. Given the established role of these medications in the optimal medical management of patients with PAD, this presents an opportunity for improvement in the overall vascular care of patients undergoing intervention for symptomatic PAD at VSGGNY centers.
本研究的目的是确定在因有症状的外周动脉疾病（PAD）而接受下肢搭桥术（LEB）和外周血管介入治疗（PVI）的患者中，次优药物治疗（定义为报告使用抗血小板药物和他汀类药物）的风险因素。
使用大纽约血管研究组（VSGGNY）数据库确定所有因PAD接受PVI或LEB的患者（2011 - 2013年）。进行双变量分析以确定在血运重建前未开具他汀类药物和/或抗血小板药物的患者特征。建立多变量相对风险回归模型以确定在抗血小板和他汀类药物治疗方面存在次优治疗风险的患者。
约1030例患者因有症状的PAD接受了血管内治疗（n = 822；80%）或外科搭桥术（n = 208；20%）（57.2%为间歇性跛行；15%为静息痛，27.8%为组织缺失）。总体而言，59%的患者术前使用他汀类药物。79%的患者术前接受抗血小板治疗。双变量分析显示，在没有其他心血管危险因素的患者中，他汀类药物的使用相对减少，这些危险因素包括高血压（63%对39.3%；P < 0.0001）以及有或无既往心脏血运重建的冠状动脉疾病（CAD）（冠状动脉搭桥术[CABG]/经皮冠状动脉介入治疗[PCI]；75.2%对47.4%；P < 0.0001）。多变量相对风险回归证实，在有其他心血管危险因素的患者中，他汀类药物的使用率更高，这些危险因素包括高血压（1.14[1.02 - 1.27]；P = 0.02）以及有既往CABG/PCI的CAD（1.22[1.13 - 1.31]；P < 0.0001）。80岁以上的患者他汀类药物使用减少（0.92[0.84 - 1.0]；P = 0.059）。通过多变量回归分析，抗血小板治疗的使用与CAD和/或既往CABG/PCI（1.11[1.04 - 1.17]；P = 0.0015）以及既往外周血运重建（1.07[1.01 - 1.13]；P = 0.03）相关。
有症状的PAD患者，但无前心血管病史，术前接受他汀类药物和抗血小板治疗的可能性较小。鉴于这些药物在PAD患者最佳药物治疗中的既定作用，这为改善VSGGNY中心有症状PAD患者介入治疗的整体血管护理提供了机会。
