Statin therapy less common in PAD than CHD, cerebrovascular disease
Patients with peripheral artery disease were less likely to be treated with statin therapy compared with those with cerebrovascular disease or CHD despite having a high risk for atherosclerotic CVD events, researchers found.
“In our study, we found that patients with peripheral artery disease have high risk for future cardiovascular events similar to patients with heart disease or those with a prior stroke,” Lisandro D. Colantonio, MD, PhD, scientist II in the department of epidemiology at the University of Alabama at Birmingham, told Healio. “Overall, the use of statins, a first-line therapy to reduce the risk for cardiovascular events, was low in our study population. Notably, statin use was even lower in patients with peripheral artery disease vs. those with heart disease or a prior stroke.”
Statin therapy in several conditions
In this retrospective cohort study published in the Journal of the American College of Cardiology, researchers analyzed data from 943,232 patients aged at least 19 years with a history of PAD, cerebrovascular disease or CHD. All patients had commercial or Medicare health insurance. Researchers also identified patients with pharmacy fills for statins.
The primary outcome was ASCVD events, defined as a composite of cerebrovascular disease, CHD and PAD events. Cerebrovascular disease events included hospitalizations for carotid revascularization or stroke. CHD events were defined as inpatient or outpatient coronary revascularization and hospitalizations for acute MI. PAD events included hospitalizations for peripheral artery revascularization or thrombolysis, acute limb ischemia or nontraumatic lower-extremity amputation above the ankle.
During a median follow-up of 3 years, there were 83,736 ASCVD events. The age-standardized rate of ASCVD events per 1,000 person-years increased as patients had a history of one or more conditions of interest (PAD, cerebrovascular disease and CHD). The event rate per 1,000 person-years for patients with a history of one condition was 40.8 (95% CI, 40.3-41.3), 68.9 for those with a history of two conditions (95% CI, 67.9-70) and 119.5 for patients with a history of three conditions (95% CI, 117-122).
The event rate for ASCVD events was 34.7 for patients with PAD only (95% CI, 33.2-36.2), 42.2 for patients with CHD only (95% CI, 41.5-42.8) and 38.9 for patients with cerebrovascular disease only (95% CI, 37.6-40.1).
When assessing patients with two conditions, the ASCVD event rate was 72.8 for patients with PAD and CHD (95% CI, 71-74.7), 63.9 for patients with PAD and cerebrovascular disease (95% CI, 60.6-67.4) and 67.9 for patients with CHD and cerebrovascular disease (95% CI, 66.4-69.3).
Statin use was lowest in patients with PAD only (33.9%) compared with those with CHD only (51.7%) or cerebrovascular disease only (43%).
“Given their high risk for cardiovascular events, patients with peripheral artery disease should be intensively treated similar to patients with heart disease or those who have had a stroke,” Colantonio said in an interview. “Treatment should include high-intensity statin therapy, lifestyle modification interventions, antiplatelet therapy and adequate control of risk factors like hypertension or diabetes. Ezetimibe and a PCSK9 inhibitor may also be beneficial for some patients. Clinicians should also investigate the presence of peripheral artery disease in all of their patients with heart disease or stroke, as we found that having widespread disease in multiple arteries (or parts of the body) is associated with even higher risk for cardiovascular events. “
Underutilization of lipid-lowering therapy
In a related editorial, Marc P. Bonaca, MD, MPH, associate professor and director of vascular research at University of Colorado School of Medicine in Aurora, and Connie N. Hess, MD, MHS, associate professor of medicine at University of Colorado School of Medicine, wrote: “Taken together, these observations confirm the risk profile of patients with symptomatic atherosclerotic vascular disease and the important association of polyvascular disease with outcomes. These finding also underscore overall underutilization of lipid-lowering therapy and highlight disparities in utilization based on vascular territory, with lower statin use and statin intensity in those with PAD. The authors’ observations are an important call to action to improve the provision of care in patients with atherosclerotic vascular disease overall and to better understand drivers behind disparities in treatment of these populations.”
For more information:
Lisandro D. Colantonio, MD, PhD, can be reached at email@example.com; Twitter: @lcolantonio