Falling Short on Cardiovascular Disease Prevention at the Time of Limb Revascularization

A United States national cardiovascular disease registry-based study found that nearly two thirds of patients with peripheral artery disease (PAD) who were not already on a statin were not newly prescribed a statin at the time of limb revascularization.¹ This is a missed opportunity.

The case for statins in patients with PAD is loud and clear. Firstly, low-density lipoprotein (LDL) has a causal role in atherogenesis and as such, statins reduce morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Importantly, risk reduction from statin use is proportional to estimated future risk. Secondly, PAD is a key manifestation of ASCVD and so its presence predicts a tremendous future risk of ASCVD events (i.e., heart attack, stroke, limb loss, and cardiovascular mortality). And finally, statins meaningfully reduce future ASCVD risk in patients with PAD. Indeed, in patients with PAD, statin use has been shown to reduce mortality by 25% and amputation by 33%.² Ergo, we must capitalize on any encounter with a patient who has PAD by counseling regarding a heart-healthy lifestyle and prescribing a statin.

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The 2018 American and 2019 European cholesterol guidelines both give a class I recommendation for prescribing high-intensity statins for secondary prevention of ASCVD including in patients with PAD.^3,4 And yet, practice consistently falls short of recommendations. Remarkably, of all patients with ASCVD enrolled in the PINNACLE national outpatient registry during 2017-2018 (n = >2.5 million patients), 52.7% had no history of lipid lowering therapy use.⁵ Adherence to guideline-recommended preventive therapies is even lower for patients with PAD. A study of more than 14,000 US adults enrolled in the 2006-2015 Medical Expenditure Panel Survey found that, compared to patients with coronary artery disease, those with PAD were twice more likely to report no statin use.⁶ Consistent with other cardiovascular diseases, women also suffer from gender-based disparities when it comes to PAD. A study of the VA healthcare system spanning 2013-2014 showed that women with PAD were 32% less likely to have been prescribed a statin than men with PAD.

And now, Singh et al. showed that of 125,791 patients presenting for peripheral revascularization within the Vascular Quality Initiative registry, only 30% of patients not on a statin were discharged with a new statin prescription. These results are disappointing but also present us with an opportunity to tangibly improve upon systems of care and the lives of our patients with PAD. As an interventional cardiology fellow, I have come to value the procedural encounter as an invaluable moment to counsel our patients, optimize medical therapy, and reinvigorate the patients’ engagement with healthcare and their commitment to their own health. It is time to seize this opportunity.

References

1. Singh N, Ding L, Devera J, Magee GA, Garg PK. Prescribing of Statins After Lower Extremity Revascularization Procedures in the US. JAMA Netw Open. 2021;4(12):e2136014-e2136014. doi:10.1001/JAMANETWORKOPEN.2021.36014
2. Arya S, Khakharia A, Binney ZO, et al. Association of statin dose with amputation and survival in patients with peripheral artery disease. Circulation. 2018;137(14):1435-1446. doi:10.1161/CIRCULATIONAHA.117.032361
3. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):3168-3209. doi:10.1016/j.jacc.2018.11.002
4. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular riskThe Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Eur Heart J. 2020;41(1):111-188. doi:10.1093/EURHEARTJ/EHZ455
5. Abstract 12904: Assessing Low-Density Lipoprotein Cholesterol Risk in Secondary Prevention Patients Within The PINNACLE National Outpatient Registry. Circulation. Accessed December 20, 2021. https://www.ahajournals.org/doi/10.1161/circ.140.suppl_1.12904
6. Tibuakuu M, Okunrintemi V, Shahu A, et al. Abstract 25: Patient-reported Outcomes, Resource Utilization, and Healthcare Expenditures Across the 3 Major Atherosclerotic Diseases: The Medical Expenditure Panel Survey (meps). Circ Cardiovasc Qual Outcomes. 2020;13(Suppl_1). doi:10.1161/HCQ.13.SUPPL_1.25