Jarosinski Marissa C, Hafeez Muhammed S, Sridharan Natalie D, Andraska Elizabeth A, Meyer Joseph M, Khamzina Yekaterina, Tzeng Edith, Reitz Katherine M
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD.
J Vasc Surg. 2025 Jan;81(1):200-209.e3. doi: 10.1016/j.jvs.2024.08.033. Epub 2024 Aug 27.
Optimal medical therapy (OMT) is a modifiable factor that decreases mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized that preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates after elective endovascular revascularization for intermittent claudication (IC).
Using the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and nonsmoking status defined OMT components and created three groups: complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR).
There were 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2127 [5.4%] no OMT) who met our criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (P < .0001). Patients without OMT were more likely to be Black or with Medicare or Medicaid (P < .05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; P < .001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; P < .001) were decreased by partial or complete OMT compared with no OMT. Complete OMT significantly decreased the adjusted odds of reintervention and MALE by 28% (aOR, 0.72, 95% confidence interval [95% CI], 0.59-0.88) and 30% (aOR, 0.70; 95% CI, 0.58-0.85), respectively, compared with no OMT. Partial OMT decrease the adjusted odds of reintervention and MALE by 24% (aOR, 0.76; 95% CI, 0.63-0.92) and 26% (aOR, 0.74; 95% CI, 0.62-0.89), respectively.
Preintervention OMT is an underused, modifiable risk factor associated with improved 1-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC before revascularization to optimize patient outcomes.
最佳药物治疗（OMT）是一个可改变的因素，可降低严重外周动脉疾病患者的死亡率和心血管事件发生率。我们假设，在因间歇性跛行（IC）而行择期血管腔内血运重建术前进行的OMT与改善1年再次干预率及主要肢体不良事件（MALE）发生率相关。
利用血管质量改进计划（2010 - 2020年），我们确定了接受择期血管腔内、杂交和开放手术干预的IC患者。术前抗血小板、他汀类药物使用情况及是否吸烟定义了OMT的组成部分，并创建了三组：完全（所有组成部分）、部分（1 - 2个组成部分）和无OMT。主要结局是1年再次干预。次要结局包括MALE以及与OMT使用相关的因素。多变量逻辑回归生成调整后的比值比（aOR）。
有39088例患者（14907例[38.1%]完全OMT，22054例[56.4%]部分OMT，2127例[5.4%]无OMT）符合我们的标准。接受任何OMT的患者年龄更大，患心血管疾病和糖尿病的频率更高（P <.0001）。未接受OMT的患者更可能是黑人或参加医疗保险或医疗补助（P <.05）。观察到的1年再次干预率（完全OMT组为5.3%，部分OMT组为6.1%，无OMT组为8.3%；P <.001）和MALE发生率（完全OMT组为5.6%，部分OMT组为6.3%，无OMT组为8.8%；P <.001）与无OMT相比，部分或完全OMT组有所降低。与无OMT相比，完全OMT显著降低再次干预和MALE的调整后比值比，分别降低28%（aOR，0.72，95%置信区间[95%CI]，0.59 - 0.88）和30%（aOR，0.70；95%CI，0.58 - 0.85）。部分OMT分别降低再次干预和MALE的调整后比值比24%（aOR，0.76；95%CI，0.63 - 0.92）和26%（aOR，0.74；95%CI，0.62 - 0.89）。
术前OMT是一种未充分利用的、可改变的危险因素，与改善1年再次干预率及MALE发生率相关。血管外科医生在血运重建术前对IC患者启动并维持OMT以优化患者结局方面具有独特的地位。
