Vascular Medicine最新文献

Background: Healthcare utilization for patients with peripheral artery disease (PAD) is high, but stratifying patients' risk of hospitalization at initial evaluation is challenging. We examined the association between health status at PAD presentation and risk of (1) combined all-cause hospital admissions and emergency department (ED) visits and (2) all-cause hospital admissions.

Methods: Patients with claudication enrolled at US sites in the PORTRAIT registry were included. Health status was assessed using the Peripheral Artery Questionnaire (PAQ), a PAD-specific patient-reported outcome measure. Crude overall and cause-specific hospital admissions and ED visits were reported by PAQ overall summary score (PAQ-OS) ranges (0-24, 25-49, 50-74, and 75-100). Kaplan-Meier survival and unadjusted and adjusted Cox proportional hazards models examined the association between baseline PAQ scores and (1) combined all-cause hospital admissions or ED visits and (2) all-cause hospital admissions over 12 months.

Results: Of 796 patients, 349 (44%) had a hospital admission or ED visit over 12 months. Patients in the lowest (PAQ-OS = 0-24) versus the highest range (PAQ-OS = 75-100) had higher rates of 12-month (53.3% vs 22.4%) hospital admission and ED visits. In the adjusted model, each 10-point decrease in PAQ-OS was associated with a higher risk of all-cause hospital admission and ED visits (HR = 1.1, 95% CI 1.1-1.2, p < 0.0010) and all-cause hospital admission (HR = 1.1, 95% CI 1.1-1.2, p < 0.0010) at 12 months.

Conclusion: PAD-specific health status is associated with an increased risk of healthcare utilization. Baseline health status may help stratify risk in patients with PAD, although replication and further validation of results are necessary.

Background: In 2019, the US Food and Drug Administration issued a warning that symptomatic relief from claudication using paclitaxel-coated devices might be associated with an increase in mortality over 5 years. We designed a discrete-choice experiment (DCE) to quantify tradeoffs that patients would accept between a decreased risk of clinically driven target-vessel revascularization (CDTVR) and increased mortality risk.

Methods: Patients with claudication symptoms were recruited from seven medical centers to complete a web-based survey including eight DCE questions that presented pairs of hypothetical device profiles defined by varying risks of CDTVR and overall mortality at 2 and 5 years. Random-parameters logit models were used to estimate relative preference weights, from which the maximum-acceptable increase in 5-year mortality risk was derived.

Results: A total of 272 patients completed the survey. On average, patients would accept a device offering reductions in CDTVR risks from 30% to 10% at 2 years and from 40% to 30% at 5 years if the 5-year mortality risk was less than 12.6% (95% CI: 11.8-13.4%), representing a cut-point of 4.6 percentage points above a baseline risk of 8%. However, approximately 40% chose the device alternative with the lower 5-year mortality risk in seven (20.6%) or eight (18.0%) of the eight DCE questions regardless of the benefit offered.

Conclusions: Most patients in the study would accept some incremental increase in 5-year mortality risk to reduce the 2-year and 5-year risks of CDTVR by 20 and 10 percentage points, respectively. However, significant patient-level variability in risk tolerance underscores the need for systematic approaches to support benefit-risk decision making.

Introduction: Direct oral anticoagulants (DOACs) have overtaken warfarin in the treatment of nonvalvular atrial fibrillation (AF) and venous thromboembolism (VTE). Limited data explore the safety of DOACs in obesity.

Methods: This multicenter retrospective study between June 2015 and September 2019 uses the Michigan Anticoagulation Quality Improvement Initiative (MAQI²) registry to compare DOACs and warfarin across weight classes (not obese: body mass index (BMI) ⩾ 18.5 and < 30; obese: BMI ⩾ 30 and < 40; severely obese: BMI ⩾ 40). Primary outcomes include major, clinically relevant nonmajor (CRNM), and minor bleeding events per 100 patient-years. Secondary outcomes include stroke, recurrent VTE, and all-cause mortality.

Results: DOACs were prescribed to 49% of the 4089 patients with AF and 46% of the 3162 patients with VTE. Compared to patients treated with warfarin, those treated with DOACs had a higher estimated glomerular filtration rate across BMI categories regardless of indication. In the AF population, severely obese patients treated with DOACs had more major (3.4 vs 1.8, p = 0.004), CRNM (8.6 vs 5.9, p = 0.019), and minor bleeding (11.4 vs 9.9, p = 0.001). There was no difference in stroke or all-cause mortality. In the VTE population, both CRNM (7.5 vs 6.7, p = 0.042) and minor bleeding (19.3 vs 10.5, p < 0.001) events occurred at higher rates in patients treated with DOACs. There was no difference in recurrent pulmonary embolism, stroke, or all-cause mortality.

Conclusion: There is a higher rate of bleeding in severely obese patients with VTE and AF treated with DOACs compared to warfarin, without a difference in secondary outcomes. Further studies to compare the anticoagulant classes and understand bleeding drivers in this population are needed.