Medical Therapy and Guideline Updates for Peripheral Arterial Disease

Multiple approaches can be taken to optimize medical therapy in patients with PAD.

A session presented at the American College of Cardiology Scientific Sessions 2022 on treatments for peripheral arterial disease (PAD) highlights the promising future of therapy for cardiovascular health.

Connie Ng Hess, MD, MHS, provided updates on PCSK9 inhibitors (PCKS9i) and anticoagulation treatments as well as the risk of major cardiovascular events (MACE) and how to optimize the common risk factors in PAD: lifestyle modification, diabetes risk, lipid risk, and thrombotic risk.

For example, Hess discussed exciting updates surrounding thrombotic risk solutions from the phase 3 VOYAGER PAD clinical trial. The trial found that rivaroxaban (Xarelto; Janssen Pharmaceutical Companies) at a vascular dose of 2.5 mg twice daily plus aspirin 100 mg once daily lowers severe vascular events in patients with peripheral arterial disease (PAD) following lower-extremity revascularization.

These findings, highlight the impact of the rivaroxaban vascular dose in patients with PAD both with and without chronic kidney disease and among those with and without a history of statin therapy, according to the study investigators. The treatment regimen with rivaroxaban was able to reduce major adverse limb events, with a specific consistent benefit.

PAD affects an estimated 20 million adults in the United States and is the leading cause of amputations, with these rates continuing to rise. However, it frequently remains untreated, with only approximately 8.5 million individuals diagnosed with the condition. PAD causes blood vessels to narrow and decreases blood flow to the limbs, which most frequently affects the legs.

In terms of glycemic control, 2016 guidelines highlight that coordination between members of health care teams is crucial and beneficial for patients to reduce adverse limb-related outcomes. After a study found a consistent benefit from using dapagliflozin, the treatment was shown to be a candidate to improve limb outcomes in patients with PAD.

“In summary, there are multiple factors that can be taken to optimize medical therapy in PAD,” Hess said. “In terms of lipid management, we know now that the lower the better and there is more outcome data for things such as statins, ezetimibe, and PCKS9i.”

Sahil A. Parikh, MD, FACC, FSCAI discussed paclitaxel safety updates in PAD, noting that paclitaxel is still the easiest and most beneficial therapeutic option for patients with PAD. In trials such as SAFE-PAD and SWEDEPAD, there was not found to be a greater mortality risk or issues in the diverse subgroups that used drug-eluding devices with paclitaxel.

For example, the SAFE-PAD trial found that drug-coated devices were noninferior to non-drug-coated devices for all-cause mortality in Medicare beneficiaries with femoropopliteal revascularization, according to an initial report from the SAFE-PAD study presented during last year’s ACC sessions.

The SWEDEPAD trial, published in December 2020, found no difference in the incidence of death among patients with PAD administered treatment with paclitaxel-coated or uncoated endovascular devices during 1 to 4 years of follow-up.

Even in the VA population, which is the highest risk population for cardiovascular issues, there was no disadvantage in using paclitaxel, according to Parikh.

Parikh said there was no mortality hazard in the continuation of using pacilatexel in PAD with the ever-growing studies and evidence to support its benefits.

“The avalanche of data has been relevant now more than ever, especially considering the discussion of this topic and the new analyses of patient level data that is out today,” Parikh said.

REFERENCE

Trends and Updates in PAD. ACC 2022. April 3, 2022. Accessed April 3, 2022.