Transcript Long-Term Comparative Outcomes of Patients With Peripheral

Long-Term Comparative Outcomes of Patients With Peripheral Artery Disease
With and Without Concomitant Coronary Artery Disease
Debbie C. Chen1, Gagan D. Singh MD1, Ehrin J. Armstrong MD MSc MAS2, Stephen W. Waldo MD2, John R. Laird MD1, Ezra A. Amsterdam MD1
1
University of California, Davis Vascular Center ; 2 University of Colorado, Division of Cardiology and VA Eastern Colorado Healthcare System, Denver, CO
BACKGROUND
RESULTS
 Patients with PAD have the same or higher risk of
major adverse cardiovascular events (MACE) and
mortality as patients with coronary artery disease
(CAD).1,2
Total 879 patients
 Patients with PAD are less likely than patients with
CAD to receive optimal guideline-directed medical
therapy (GDMT), including aspirin, angiotensinconverting enzyme inhibitors (ACEI), and statins.3
 There are little contemporary data describing longterm outcomes among high-risk, symptomatic PAD
patients with or without concomitant CAD.4
PAD
only
48%
Retrospective cohort study utilizing the University of
California, Davis, PAD Registry, which comprises all
patients with a clinical diagnosis of who underwent
diagnostic and/or therapeutic endovascular intervention
at UCDMC between 2006 and 2013.
EMR chart review: 330 data elements/patient were
obtained, including:
 Baseline demographics
 Pre-procedure and 2-year GDMT use
 Laboratory and procedural data
 Clinical outcomes
Study Population
All 879 patients in the registry had PAD defined by:
 Critical limb ischemia (CLI)
 Intermittent Claudication (IC)
Specific Aims
1.
2.
Determine how the presence of CAD affects 5-year
mortality and MACE.
Determine how the presence of CAD affects the use
of GDMT among patients with symptomatic PAD.
CLI
57%
CAD
+PAD
52%
43%
Outcomes
METHODS
Study Design and Data Sources
Table 1: Baseline
Characteristics
Type of PAD
Claudiation
Outcome Rates
CONCLUSIONS
Unadjusted
HR
(95% CI)
P
Value
Adjusted
HR
(95% CI)
P
Value
MACE
Death
CAD + PAD
N=456
55%
55%
PAD only
N=423
41%
40%
1.72 (1.31-2.13)
1.86 (1.40-2.42)
0.0001
0.0001
1.24 (0.96-1.60)
1.35 (1.02-1.80)
0.10
0.04
MACE
Death
CAD + CLI
N=251
71%
70%
CLI only
N=246
52%
51%
1.91 (1.42-2.54)
2.04 (1.52-2.81)
0.0001
0.0001
1.52 (1.14-2.03)
1.64 (1.12-2.20)
0.01
0.006
MACE
Death
CAD + IC
N=205
35%
35%
IC only
N=177
26%
24%
Age, years
Male (%)
BMI, kg/m2
CHF (%)
EF (%)
DM (%)
HbA1c (%)
ESRD (%)
GFR, ml/min
Creatinine, mg/dL
Smoking
Active
Prior
Never
HTN (%)
Stroke (%)
LDL, mg/dl
Medications
Aspirin
DAPT
Beta Blocker
ACEI/ARB
Statin
CAD+PAD
(N=456)
PAD Only
(N=423)
68 ± 11
291 (64)
27 ± 5
155 (34)
52 ±17
240 (53)
7.6 ± 2.0
83 (18)
57 ± 29
1.9 ± 1.9
66 ± 13
220 (52)
27 ± 6
51 (12)
60 ± 13
204 (48)
7.9 ± 2.1
35 (8)
65 ± 28
1.5 ± 1.7
103 (23)
243 (53)
110 (24)
401 (88)
77 (17)
79 ± 33
139 (33)
174 (41)
110 (26)
337 (80)
64 (15)
98 ± 38
354 (78)
143 (31)
316 (69)
295 (65)
388 (85)
228 (54)
51 (12)
145 (34)
231 (55)
282 (67)
P Value
0.008
0.0001
0.6
0.0001
0.0002
0.2
0.2
0.0001
0.0007
0.001
0.0001
0.001
0.5
0.00001
0.0001
0.0001
0.0001
0.002
0.0001
 Compared to patients with PAD only, patients with
CAD + PAD had:
 More baseline comorbidities
 Higher rates of GDMT use
 Despite receiving more optimal GDMT, PAD patients
with concomitant CAD had significantly higher rates
of 5-year all-cause mortality.
 The subgroup of CLI patients with concomitant
CAD was at particularly high risk for both MACE and
all-cause mortality.
LIMITATIONS



REFERENCES
Characteristics of CAD Patients (N=456)
1.38 (0.83-2.32)
1.79 (0.97-3.28)
0.21
0.06
1.40 (0.61-1.79)
1.32 (0.68-2.55)
0.89
0.41
History of MI (%)
206 (45)
History of PCI (%)
157 (34)
History of CABG (%)
204 (45)
History of coronary revascularization (%)
361 (80)
Single center, retrospective study
Unable to fully assess reasons for not prescribing GDMT
Causes of mortality unknown
1. Pande RL, Perlstein TS, Beckman JA, Creager MA. Secondary prevention and
mortality in peripheral artery disease: National Health and Nutrition Examination
Study, 1999 to 2004. Circulation. 2011; 124:17–23.
2. Welten GMJM, Schouten O, Hoeks SE, et al. Long-term prognosis of patients
with peripheral arterial disease: a comparison in patients with coronary artery
disease. J Am Coll Cardiol. 2008;51:1588–1596.
3. Subherwal S, Patel MR, Kober L, et al. Missed opportunities: Despite
improvement in use of cardioprotective medications among patients with lowerextremity peripheral artery disease, underuse remains. Circulation. 2012;126:13451354
4. Suarez C, Zeymer U, Limbourg T, et al. Influence of polyvascular disease on
cardiovascular event rates. Insights from the REACH Registry. Vasc Med. 2010;
15(4) 259-265.
ACKNOWLEDGEMENTS AND DISCLOSURES
 We thank the UC Davis School of Medicine Medical Student
Research Program for their support of this senior Scholarly
Project Option (SPO)

John Laird reports being a consultant for Boston Scientific, Covidien, Abbott,
Bard, and Medtronic. Ehrin Armstrong reports being a consultant for Abbott
Vascular, Medtronic, Merck, and Spectranetics. Ezra A. Amsterdam is on the
Advisory Board of Astra Zeneca. All other authors report no conflicts of interest
related to this study.