Khariton Yevgeniy, Patel Krishna K, Chan Paul S, Pokharel Yashashwi, Wang Jingyan, Spertus John A, Safley David M, Hiatt William R, Smolderen Kim G
Department of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
University of Missouri-Kansas City, Kansas City, Missouri.
Clin Cardiol. 2018 Nov;41(11):1414-1422. doi: 10.1002/clc.23087. Epub 2018 Oct 19.
The ACC/AHA cholesterol guidelines recommend patients with peripheral artery disease (PAD) be treated with a moderate to high-intensity statin. The extent to which patients with new or worsening PAD symptoms are offered guideline therapy is unknown.
There is significant variability in rate of guideline-directed statin intensification across clinical practices.
In the PORTRAIT registry, patterns of statin therapy were assessed in 1144 patients at 16 PAD specialty clinics between June 2011 and December 2015 before and after an evaluation for new or worsening claudication symptoms. We documented whether patients were treated with a guideline statin as well as the incidence of statin intensification. Statin intensification was defined as transitioning from no statin or low-intensity statin to moderate or high-intensity statin treatment. Patient factors associated with intensification were examined. Site and provider-level variation in intensification was summarized using an adjusted median odds ratio (aMOR).
Among 1144 patients, 810 (70.8%) were initially on guideline therapy compared to 334 (29.2%) that were not. In the latter, 103 (30.8%) received intensification following evaluation. Patients with typical symptoms displayed greater odds of intensification (OR 3.74; 95% CI: 1.23-11.41) while older patients had lower odds of intensification (OR 0.60/decade; 95% CI: 0.41-0.88). Site variability for statin intensification was observed across sites (aMOR = 3.15; 95% CI 1.22-9.60, [P = 0.02]) but not providers (aMOR = 1.89; 95% CI 1.00-3.90, [P = 0.14]).
Most patients evaluated at a PAD specialty clinic for new or worsening claudication symptoms arrived on guideline statin therapy. Only 31% not receiving appropriate therapy underwent statin intensification. These findings highlight an important opportunity to optimize medical therapy for patients with PAD.
美国心脏病学会/美国心脏协会（ACC/AHA）胆固醇指南建议外周动脉疾病（PAD）患者接受中等强度至高强度他汀类药物治疗。对于出现新的或恶化的PAD症状的患者，接受指南推荐治疗的程度尚不清楚。
不同临床实践中，遵循指南进行他汀类药物强化治疗的比例存在显著差异。
在PORTRAIT注册研究中，于2011年6月至2015年12月期间，对16家PAD专科诊所的1144例患者在评估新的或恶化的间歇性跛行症状前后的他汀类药物治疗模式进行了评估。我们记录了患者是否接受了指南推荐的他汀类药物治疗以及他汀类药物强化治疗的发生率。他汀类药物强化治疗定义为从不使用他汀类药物或低强度他汀类药物治疗转变为中等强度或高强度他汀类药物治疗。研究了与强化治疗相关的患者因素。使用调整后的中位数优势比（aMOR）总结了强化治疗在不同地点和医疗服务提供者层面的差异。
在1144例患者中，810例（70.8%）最初接受了指南推荐的治疗，而334例（29.2%）未接受。在后者中，103例（30.8%）在评估后接受了强化治疗。有典型症状的患者强化治疗的几率更高（比值比[OR] 3.74；95%置信区间[CI]：1.23 - 11.41），而老年患者强化治疗的几率较低（OR 0.60/每十年；95% CI：0.41 - 0.88）。在不同地点观察到他汀类药物强化治疗存在差异（aMOR = 3.15；95% CI 1.22 - 9.60，[P = 0.02]），但在不同医疗服务提供者之间未观察到差异（aMOR = 1.89；95% CI 1.00 - 3.90，[P = 0.14]）。
在PAD专科诊所接受新的或恶化的间歇性跛行症状评估的大多数患者已接受指南推荐的他汀类药物治疗。只有31%未接受适当治疗的患者接受了他汀类药物强化治疗。这些发现凸显了优化PAD患者药物治疗的重要机会。
