Prescriber implementation of guideline-directed medical therapy remains poor in the peripheral artery disease population

Abstract

Objective

Peripheral artery disease (PAD) is one of the most prevalent forms of cardiovascular (CV) disease, with many progressing to CV morbidity/death. Adherence to guideline-directed optimal medical therapy (OMT) in PAD is vital. This study evaluated provider adherence to OMT patients with PAD.

Methods

This is a retrospective cohort study of 3471 patients with PAD who underwent vascular laboratory imaging between 2017 and 2022 at a single large, academic, tertiary referral center. OMT was defined by 2016 American Heart Association guidelines. Adherence to guidelines was denoted by active prescriptions for antiplatelet and statin. The presence of high-intensity OMT (HIOMT) was defined as prescriptions for an antiplatelet and high-intensity statin. Prevalence and incidence (change to OMT/HIOMT within 60 days of index ankle-brachial index [ABI]) were evaluated. Multivariable models were created evaluating predictors of OMT and HIOMT prevalence and incidence.

Results

The OMT prevalence was 45.3%, whereas the HIOMT prevalence was 23.6% at the time of index vascular laboratory. Incident OMT was 24.3%, whereas incident HIOMT was 11.2% within 60 days. Age, minimum/maximum ABI, insurance status, smoking status, and comorbidities were associated with prevalent OMT/HIOMT. Age, gender, minimum/maximum ABI, smoking status, and hemoglobin A1C were associated with incident HIOMT. In multivariable models, incident HIOMT was less common for female patients (odds ratio: 0.7; 95% confidence interval: 0.52-0.91), whereas lower ABIs were predictive of HIOMT (odds ratio: 0.6; 95% confidence interval: 0.51-0.72).

Conclusions

Despite clear guidelines regarding OMT for patients with atherosclerotic CV disease, in this real-world study of guideline-directed management of PAD, adherence to OMT remains low, especially for HIOMT. Predictors of appropriate HIOMT prescription include lower ABI and non-female sex. Given the high prevalence of PAD, the heterogeneity of caregivers, and the widespread availability of screening, this population should be targeted for better adherence to HIOMT to prevent CV morbidity and death.