Medical therapy beneficial in PAD, but underprescribed
There is now plentiful evidence that medical therapy benefits patients with peripheral artery disease, which is reflected in guidelines but not followed nearly enough, a speaker stated at the International Symposium on Endovascular Therapy.
“We just need to prescribe these therapies,” Cardiology Today Editorial Board Member Michael R. Jaff, DO, vice president of clinical affairs, technology and innovation at Boston Scientific, said during a presentation.
Recommendations for MACE reduction in asymptomatic patients with PAD, defined as ankle-brachial index less than 0.9, include lifestyle modifications, smoking cessation, statin therapy and BP control with ACE inhibitors or angiotensin receptor blockers, with antiplatelet therapy appropriate for some patients, Jaff said. He noted additional recommendations in symptomatic patients with PAD include aspirin or thienopyridine therapy and protease-activated receptor-1 (PAR-1) antagonist therapy.
Exercise should accompany any medical therapy for claudicants, Jaff said, noting a review of 22 randomized trials showed exercise improved maximum walking time, pain-free walking distance and maximum walking distance in this population, and that CMS now covers supervised exercise therapy for patients with PAD.
The COMPASS trial showed low-dose rivaroxaban (Xarelto, Janssen/Bayer) plus aspirin improved CV outcomes in patients with PAD and CAD, and there is also evidence that cilostazol benefits claudicants, Jaff said.
“However, many patients cannot tolerate cilostazol, and it is contraindicated in congestive heart failure patients,” he said.
Some guidelines recommend that most patients with PAD receive high-intensity statins, and an analysis of the FOURIER trial of the PCSK9 inhibitor evolocumab (Repatha, Amgen) showed it conferred an absolute risk reduction for CV events of 3.5% in patients with PAD compared with placebo, with a number needed to treat of 29, Jaff said.
In addition, among patients with diabetes and PAD, the SGLT2 inhibitor empagliflozin (Jardiance, Boehringer Ingelheim/Eli Lilly) “shows promise in reducing MACE,” he said.
However, “medical therapy is real and critical, and yet there is poor adherence to guidelines,” Jaff said, noting that according to a 2015 study, among patients with PAD, only 18.7% were taking statins, 20.8% were taking ACE inhibitors or angiotensin receptor blockers and 27.4% were taking antiplatelet therapy.
“Can medical therapy help? Yes,” Jaff said. “It absolutely improves pain-free walking distance. It absolutely reduces morbidity and mortality rates. New evidence suggests reduction in major adverse limb events and hospitalization for acute PAD-related events.” – by Erik Swain
Jaff MR. Session 1: Townhall: Innovation, Artificial Intelligence and Other Disruptors. Presented at: the International Symposium on Endovascular Therapy (ISET); Jan. 22-25, 2020; Hollywood, Fla.
Disclosure: Jaff reports he became an employee of Boston Scientific effective Jan. 1, holds equity in EFemoral, Embolitech, Gemini, PQ Bypass, Primacea, Sano V and Vascular Therapies and previously consulted for Abbott, Biotronik, Boston Scientific, Medtronic, Micell, Philips/Volcano, Sanofi, Silk Road Medical, Vactronix and Venarum.