Medical therapy

Medical Therapy and Guideline Updates for Peripheral Arterial Disease

Several approaches can be taken to optimize medical treatment in patients with PAD.

A session presented at the American College of Cardiology’s 2022 Scientific Sessions on Treatments for Peripheral Arterial Disease (PAD) highlights the therapy’s promising future for cardiovascular health.

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

For example, Hess discussed exciting updates regarding 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 reduced serious vascular events in patients with Peripheral arterial disease (PAD) after lower extremity revascularization.

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

PAD affects approximately 20 million adults in the United States and is the leading cause of amputation, with these rates continuing to rise. However, it frequently remains untreated, with only around 8.5 million people diagnosed with the disease. PAD causes blood vessels to narrow and decrease blood flow to the limbs, most commonly affecting the legs.

In terms of glycemic control, the 2016 guidelines stress that coordination between members of healthcare teams is crucial and beneficial for patients to reduce limb-related adverse events. After a study found consistent benefit from the use of dapagliflozin, the treatment emerged as a candidate for improving limb outcomes in patients with PAD.

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

Sahil A. Parikh, MD, FACC, FSCAI discussed safety updates for paclitaxel in PAD, noting that paclitaxel is still the easiest and most beneficial treatment option for patients with PAD. In trials such as SAFE-PAD and SWEDEPAD, there was no evidence of higher risk or mortality issues in the various subgroups that used anti-drug devices with paclitaxel.

For example, the SAFE-PAD trial found that drug-coated devices were non-inferior 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 last year CCA Sessions.

The SWEDEPAD trial, published in December 2020, found no difference in the incidence of death in patients with PAD who received treatment with endovascular devices coated or not with paclitaxel for 1 to 4 years of follow-up.

Even in the VA population, which is the population most at risk for cardiovascular problems, there was no downside to using paclitaxel, according to Parikh.

Parikh said there is no mortality risk in the continued use of pacilatexel in PAD with the ever-growing studies and evidence supporting its benefits.

“The avalanche of data is more relevant than ever, especially given the discussion on this topic and the new analyzes of patient-level data released today,” Parikh said.

REFERENCE

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