Advances in the Management of Peripheral Arterial Disease - Episode 6
Transcript: Deepak L. Bhatt, MD, MPH: Matt, you get a lot of patients with PAD [peripheral artery disease] referred to you. What’s your first line of attack before taking them to the catheterization suite or to the operating room?
Matthew T. Menard, MD: I think Marc ticked off the list of very appropriate and necessary interventions in terms of risk factor reduction. Certainly, be aware of what their diabetic status is, what their hemoglobin A1c is, and whether they have a good endocrinologist or diabetologist in their corner. How are their hypertension and hyperlipidemia faring? Almost all of our patients would best benefit from a high-dose statin, Lipitor [atorvastatin] 80 mg or Crestor [rosuvastatin] 40 mg. Is that part of the regimen that they receive? Smoking cessation is important. Education is certainly a big part of intervention, just as Marc and you were discussing. Letting them know that they’re not going to hurt themselves if they keep walking is incredibly important. A walking regimen is really a big part of the treatment program and should be the first step for all of us in terms of claudicants. Fortunately, a lot of effort went into trying to get that to be a reimbursable intervention and that effort paid off. That is now something that physicians can get reimbursed for.
Unfortunately, we don’t have great walking programs, and it’s one of the many things that we look to the cardiology world and cardiovascular world for. You have been doing this for decades, and you’ve been doing it well. Many of the walking programs are glorified post-CABG [coronary artery bypass surgery] or post—cardiac intervention rehabilitation programs. We really need to do better in that regard because that’s such a mainstay of treatment. There’s a sizable number of patients who will do just fine with that. They are able to achieve benefit. Often, you can double the distance that you walk with a good walking program. That’s paramount.
It’s a different tact for critical inpatients, as they have a real risk of amputation if left untreated. The stark difference is for claudicants, with a 2% to 3%—some series say 5% to 10%—risk of amputation over time if untreated. With critical ischemia, it’s as high as 35% risk at one year.
We’re certainly taught that those are the folks for whom we really should be thinking about intervention. Some of the trial data that we may talk about are incredibly encouraging. We now have a whole series of pharmacological weapons, but the mainstay of treatment really is intervention. In this day and age, we’ve got two different options: We’ve got a surgical bypass and endovascular therapy, and part of the challenge is sorting out which is the best first-line approach for given patients.
Deepak L. Bhatt, MD, MPH: That’s a good way of synthesizing the approach. With respect to exercise, Marc, it might be useful to inform the audience. There have been some changes in terms of cardiac rehabilitation and coverage of that in the past few years. Are there any specifics you want to share?
Marc P. Bonaca, MD, MPH: For a patient with peripheral artery disease, as Matt said, every chapter and guideline for the last 2 decades has said you need to undergo supervised exercise; but no one ever paid for it, at least in the United States, so it wasn’t available. That was just changed. Now that you can order it and it’s reimbursed, a lot of folks have struggled with how to deliver that. But most of the patients with cardiac rehabilitation or peripheral artery disease now have supervised exercise therapy. I think it’s a very different type of exercise. In cardiac rehabilitation, there’s a huge coaching element. As you said, Deepak, your brain is saying, “stop,” but you need to keep going.
There is a big coaching element and getting the right supervised exercise therapy is critical. It’s not a reality for many patients, and now in the COVID-19 [coronavirus disease 2019] era, the last thing we want is groups of patients coming together. There are some home-based mechanisms for exercise. Mary McDermott, MD’s group has been a leader in home-based therapies. It’s not as effective as supervised exercise, but it’s better than no exercise. I think remote, facilitated home-based exercise programs are probably a good method right now. Coach patients not to give up, but to persist.
Deepak L. Bhatt, MD, MPH: I think that was a really great point, particularly about home-based approaches, whether that involves using remote technology or apps. There are a few different methods out there. I think now we have no choice because of COVID-19, as we’re not going to tell people to get together in groups of more than 10.
But even post—COVID-19, the reality is some people will never show up to rehabilitation for whatever reason: it’s too far to drive or they don’t perceive that their work schedule will allow them to do it. But this might be a way of getting other folks, even if there was not an epidemic, to exercise who otherwise wouldn’t have.
Marc P. Bonaca, MD, MPH: That’s a great comment.
Transcript Edited for Clarity