How Do We Optimize the Medical Therapy of Patients with Critical Limb Ischemia? Ehrin J. Armstrong, MD MSc MAS Director, Interventional Cardiology Director, Vascular Laboratory VA Eastern Colorado Healthcare System Associate Professor Of Medicine University of Colorado
DISCLOSURES Ehrin Armstrong, MD, MSc Consultant/Advisory Board: Abbott Vascular, Boston Scientific, Medtronic, Cardiovascular Systems, Spectranetics
Patients with PAD and CLI Die from Cardiovascular Causes ABI < 0.90 is associated with 2-3 fold increased risk of mortality. Criqui N Engl J Med 1992;326:381-386.
Norgren, J Vasc Surg 2007
Guideline-Recommended Treatment Patients with PAD are consistently undertreated with guidelinerecommended therapies. Statins (Class I) Smoking cessation (Class I) Antiplatelet therapy (Class I) ACE Inhibitors (Class IIa) Glycemic Reduction in Patients with Diabetes (Class IIa) Khumbani Eur Heart J 2014;35:2864-2872. Westin J Am Coll Cardiol 2014;63:682-690. Armstrong J Vasc Surg 2014
380 patients with CLI. 246 (65%) patients prescribed statins. Propensity weighting used to adjust for baseline differences.
Decreased Stroke/MI/Death With Statins HR 0.53 (95% CI 0.28-0.99) Westin, J Am Coll Cardiol 2014
Improved Amputation-Free Survival With Statins HR 0.53 (95% CI 0.35-0.98) Westin, J Am Coll Cardiol 2014
Improved Limb Salvage With Statins Aiello, J Vasc Surg 2012;55:371-380
739 patients with claudication or CLI. Assessed relationship between smoking cessation within one year and outcomes. Armstrong, J Vasc Surg 2014
Smoking Cessation after Angiography 204 (28%) were active smokers at time of angiography. 61/204 patients (30%) successfully quit in the next year. Only 13% of patients utilized any pharmacologic aids. Armstrong, J Vasc Surg 2014
Reduced Mortality in Patients with CLI Who Quit Smoking 5 Year Mortality 19% vs. 43% (p=0.01) Armstrong, J Vasc Surg 2014
Improved Amputation-Free Survival in Patients with CLI Who Quit Smoking Rate of amputation or death 28% vs. 53% (p=0.01) Armstrong, J Vasc Surg 2014
Antiplatelet Therapy in CLI Antiplatelet therapy with aspirin or clopidogrel is a Class I recommendation for all patients with PAD. Clopidogrel may have a slight benefit over ASA when used as monotherapy in patients with PAD (CAPRIE study). Dual antiplatelet therapy (DAPT) may have additional benefits relative to ASA monotherapy in patients with PAD (CHARISMA study).
57,041 patients undergoing LE revasc (28% bypass) 39% DAPT usage after bypass, 69% DAPT usage after endovascular intervention. 5 year outcomes stratified by CLI vs. claudication. Soden et al, J Vasc Surg 2016;64:1633-1644
Survival Benefit in CLI Soden et al, J Vasc Surg 2016;64:1633-1644
Angiotensin Converting Enzyme Inhibitors In Patients with CLI ACE Inhibitors are a Class IIa recommendation among patients with PAD. Majority of data derived from HOPE study. Benefit is in improvement of HTN and reduction of cardiovascular events.
ACEI/ARB in Critical Limb Ischemia 464 patients with critical limb ischemia. 269 (58%) prescribed ACEI or ARB 206 ACEI 65 ARB Baseline differences included higher prevalence of diabetes, hypertension, and established CAD in ACEI/ARB group. Armstrong, Vasc Med 2015
Decreased MI/Death/Stroke in Patients with CLI Prescribed ACEI HR 0.76 (95% CI 0.58-0.99) Armstrong, Vasc Med 2015
Decreased Mortality in Patients with CLI Prescribed ACEI HR 0.71 (95% CI 0.53-0.95) Armstrong, Vasc Med 2015
No Effect of ACEI on Limb Events HR 0.97 (95% CI 0.69-1.35) Armstrong, Vasc Med 2015
Glycemic Control 50-75% of patients with CLI have diabetes. Intensive glycemic control has marginal effect on cardiovascular outcomes. Tight glycemic control may promote wound healing.
Fasting Glucose and Limb Events After Infrapopliteal Balloon Angioplasty 309 infrapopliteal lesions in 149 patients with DM. Fasting blood glucose was obtained on the day of the procedure. Median fasting blood glucose was 144 mg/dl. Singh et al, Vasc Med 2014;19:307-314.
Primary Patency Patency 16% vs. 45% Singh et al, Vasc Med 2014;19:307-314.
Patency by Quartile of Glucose Singh et al, Vasc Med 2014;19:307-314.
Major Adverse Limb Events MALE 24% vs. 15% Singh et al, Vasc Med 2014;19:307-314.
How Can We Further Optimize Medical Therapy? Further research into intensive antiplatelet and antithrombotic therapy. Vorapaxar Direct thrombin inhibitors Xa inhibitors Increased quality of care performance measures for appropriate medical therapy.
Thank You Ehrin J. Armstrong, MD MSc MAS Director, Interventional Cardiology Director, Vascular Laboratory VA Eastern Colorado Healthcare System Associate Professor Of Medicine University of Colorado