Division of Cardiology, Duke University Health System, Durham, NC.
Department of Population Health Sciences, Duke University, Durham, NC.
Am Heart J. 2021 Sep;239:135-146. doi: 10.1016/j.ahj.2021.05.014. Epub 2021 May 27.
PAD increases the risk of cardiovascular mortality and limb loss, and disparities in treatment and outcomes have been described. However, the association of patient-specific characteristics with variation in outcomes is less well known.
Patients with PAD from Duke University Health System (DUHS) between January 1, 2015 and March 31, 2016 were identified. PAD status was confirmed through ground truth adjudication and predictive modeling using diagnosis codes, procedure codes, and other administrative data. Symptom severity, lower extremity imaging, and ankle-brachial index (ABI) were manually abstracted from the electronic health record (EHR). Data was linked to Centers for Medicare and Medicaid Services data to provide longitudinal follow up. Primary outcome was major adverse vascular events (MAVE), a composite of all-cause mortality, myocardial infarction (MI), stroke, lower extremity revascularization and amputation.
Of 1,768 patients with PAD, 31.6% were asymptomatic, 41.2% had intermittent claudication (IC), and 27.3% had chronic limb-threatening ischemia (CLTI). At 1 year, patients with CLTI had higher rates of MAVE compared with asymptomatic or IC patients. CLTI and Medicaid dual eligibility were independent predictors of mortality. CLTI and Black race were associated with amputation.
Rates of MAVE were highest in patients with CLTI, but patients with IC or asymptomatic disease also had high rates of adverse events. Black and Medicaid dual-eligible patients were disproportionately present in the CLTI subgroup and were at higher risk of amputation and mortality, respectively. Future studies must focus on early identification of high-risk patient groups to improve outcomes in patients with PAD.
PAD 增加了心血管死亡率和肢体丧失的风险，并且已经描述了治疗和结果的差异。然而，患者特定特征与结果变化的关联知之甚少。
从杜克大学健康系统（DUHS）确定了 2015 年 1 月 1 日至 2016 年 3 月 31 日期间患有 PAD 的患者。通过使用诊断代码、程序代码和其他行政数据进行地面真实裁决和预测建模来确认 PAD 状态。症状严重程度、下肢影像和踝肱指数（ABI）从电子健康记录（EHR）中手动提取。数据与医疗保险和医疗补助服务中心（CMS）数据链接，以提供纵向随访。主要结果是主要血管不良事件（MAVE），这是全因死亡率、心肌梗死（MI）、中风、下肢血运重建和截肢的综合指标。
在 1768 名患有 PAD 的患者中，31.6%的患者无症状，41.2%的患者间歇性跛行（IC），27.3%的患者患有慢性肢体威胁性缺血（CLTI）。在 1 年时，CLTI 患者的 MAVE 发生率高于无症状或 IC 患者。CLTI 和医疗补助双重资格是死亡率的独立预测因素。CLTI 和黑人种族与截肢有关。
CLTI 患者的 MAVE 发生率最高，但患有 IC 或无症状疾病的患者也有很高的不良事件发生率。黑人患者和同时符合医疗补助条件的患者不成比例地出现在 CLTI 亚组中，分别面临更高的截肢和死亡率风险。未来的研究必须集中于早期识别高危患者群体，以改善 PAD 患者的预后。
