PVD: Risk Factor Reduction

Patient with peripheral vascular disease or atherosclerotic coronary artery disease have essentially identical risk factors profiles. These risk factors are modifiable, producing very demonstrable long term reductions in both morbidity and mortality.  Unfortunately, there is a considerable underutilization of evidence based therapies or lifestyle modifications in these patient populations. If such risk factor modifications were aggressively followed, the longterm survival and prevention of disease recurrence would be significantly improved.

One of the goals of our practice is to apply incorporate a rigorous approach in recommending risk factor modification strategies for all of out vascular and cardiac patients (including those who do not undergo interventions). We aim to institute the following secondary prevention measures at either the initial evaluation or at subsequent assessments (unless specific contradictions are identified):

Anti-platelet therapy: aspirin or clopidogrel (plavix) for all patients have been shown to provide a distinct mortality benefit (CAPRIE study).
Lipid Lowering Therapy: statins should be considered for all patients with vascular or coronary disease to prevent coronary events and reduce cardiovascular and general mortality. There is a demonstrated benefit of statins even for those with normal lipid profiles. The recommended target goal is an LDL-C of less than 100mg/dl.
Beta-Blocker Therapy: shown to have a significant survival benefit in patients with ischemic heart disease and particularly those with myocardial injury.  
ACE Inhibitor Therapy: The HOPE trial shows a favorable effect for all patients with vascular disease. Benefits include modification of endothelial dysfunction and left ventricular remodeling.
Smoking Cessation: complete abstinence from all tobacco products is of unquestioned importance. Long-term support and reinforcement of abstinent behavior is imperative.
Weight loss/ Diet/Exercise: AHA guidelines for ideal body weight should be adhered to. Additionally, regular and vigorous exercise intervals five or more days each week should be the goal. Comprehensive cardiac rehabilitation programs are very useful in tailoring exercise programs and reinforcing lifestyle modification interventions.
Diabetes Management: Careful attention to strict glucose control has well recognized long term cardiovascular implications.
    
We attempt to institute or reinforce these interventions in all our patients with peripheral vascular disease and coronary artery disease. Clearly the primary physician has the greater opportunity to provide continued reinforcement of lifestyle modifications and effect changes in the long term outlook for this segment of the patient population. However, our goal is to impact these patients for the long term through our usually short (but often significant) encounters with them.

Risk factor modification is a life-long endeavor and fraught with many obstacles to success. However, we hope out interactions with these patients will positively affect their long-term outcomes.