Variability and Outcomes of Medical and Lifestyle Management of Peripheral Arterial Disease at the Time of Lower Extremity Bypass
Ryan Howard1, Jeremy Albright1, Matthew Corriere1, Nicholas Osborne1, Eugene Laveroni2, Peter Henke1
1Michigan Medicine, Ann Arbor, MI;2Beaumont Health, Farmington Hills, MI
INTRODUCTION: First-line treatment of peripheral arterial disease (PAD) involves medical therapy and lifestyle modification. Specifically, the 2016 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for the management of PAD make Class I recommendations for antiplatelet therapy, statin therapy, antihypertensive therapy, and cilostazol therapy, as well as exercise therapy and smoking cessation. Although evidence supports medical and lifestyle management of PAD prior to surgical intervention, it is currently unclear whether clinical practice reflects this. Moreover, it is also unknown whether variability in medical and lifestyle optimization prior to revascularization affects short- and long-term outcomes. This study was conducted to determine the proportion of patients actively receiving evidence-based medical and lifestyle therapy at the time of surgery in a regional hospital network and whether receipt of therapy affected outcomes.
METHODS: We conducted a retrospective study of adult patients undergoing elective open lower extremity bypass for claudication, rest pain, or tissue loss from 2012-2021 within a large, statewide, 35 hospital quality registry. The primary exposures were preoperative medical therapy (specifically antiplatelet agents, statins, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), and cilostazol) and lifestyle management including supervised exercise therapy and participation in smoking cessation counseling. The primary outcomes were 30-day and 1-year mortality, hospital readmission, amputation, wound complication, myocardial infarction, non-patent bypass, and non-ambulatory functional status. Multivariable logistic regression was performed to estimate the association of receiving some or all recommended therapy on outcomes.
RESULTS: 10,278 patients underwent bypass surgery during the study period, with a mean age of 65.8 (10.4) years and 7,036 (68.5%) males. The prevalence of medical and lifestyle management at the time of surgery was variable (Figure 1). Of the original cohort, 30-day follow-up data were available for 9,664 patients (94.0% follow-up rate) and 1-year follow-up data were available for 7,341 patients (71.4% 1-year follow-up rate). Among patients on relevant medications at discharge, at 30 days, 96.8% were still taking antiplatelet agents, 96.7% were still taking statins, 86.5% were still taking ACEI/ARBs, and 24.7% of patients who received smoking cessation therapy had quit smoking. Compared to patients on no therapy, patients on some therapy had significantly lower odds of amputation at 30 days (aOR 0.61 [95% CI 0.38-1.00]). At one year, there was no significant association between being on some or all therapy and any outcomes, however similar trends were observed for amputation (some therapy aOR 0.64 [95% CI 0.39-1.04]; all therapy aOR 0.48 [95% CI 0.22-1.04]).
CONCLUSIONS: Although medical and lifestyle management is recommended as first-line treatment for patients with PAD, preoperative adherence to these recommendations was highly variable. Patients actively receiving preoperative treatment appear to have a lower risk of subsequent amputation after surgery. This suggests that not only are there significant opportunities to improve adherence to evidence-based treatment of PAD, but that doing so may benefit patients postoperatively.
Prevalence of medical therapy and lifestyle modification at the time of surgery.
Prevalence of smoking cessation therapy calculated among 4,916 current smokers.
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