PVD: Pharmacologic Treatment

The systemic nature of vascular disease and the commonality of risk factors affecting patients with both cardiac and peripheral vascular disease is well recognized. It is often observed that pharmacologic therapy for these diseases is frequently suboptimal leaving room for significant improvement in long term patient care.

A recently published article (Journal of Vascular Surgery 2004; 40: 691-7) revisited that observation. The  records of 313 patients with the diagnosis of AAA were examined to determine 1) the number of patients in whom a statin drug, antiplatelet agent, B-blocker, and ACE inhibitor is indicated and 2) the number of patients who are currently receiving evidence based cardiovascular risk reduction therapy.

The high prevalence of cardiovascular disease and risk factors in patients with AAA means that most have an indication for risk factor reduction using currently accepted medication regimens. However, in that review suboptimal cardiovascular risk management was clearly evident.
 
In patients with an accepted indication for treatment, only 60% were using an antiplatelet agent, 41% a statin drug, 38% a beta blocker, and 39% an ACE inhibitor.

Current evidence shows the effectiveness of these therapies. Antiplatelet therapy reduces vascular events by 25% and vascular mortality by one sixth. In patients who have had an MI, beta blocker therapy reduces mortality by as much as 40%. The HOPE study showed that Ramipril reduced the risk of MI, stroke, or cardiovascular death by 22% in patients with LV systolic dysfunction or after MI. The 2003 Heart Protection Study showed a 25% reduction in cardiovascular events in patients with arterial occlusive disease.

All patients with arterial occlusive disease benefit from the use of these drugs. Furthermore, the effect of each agent appears to be independent and additive. It has been estimated that when these drugs are used in combination, two thirds to three fourths of future vascular events can be prevented.

The cost of these drugs is quite low (ASA: $0.30/28d, propranalol $1.00/28d, captopril $2.00/28d). Statins, however, remain relatively expensive ($23.00/28d). However, the short and long term benefits of these therapies are great and warrant our routine consideration for this patient population.

Other risk factor preventions such as smoking cessation are of obvious importance to long term patient well being.

We are attempting to improve the usage of these therapies in the patients we treat. We would encourage the consideration of these four drugs in every vascular patient to maximize their longterm survival. The benefits are great while the downside is quite small.