Markers of Optimal Medical Therapy are Associated with Improved Limb Outcomes After Elective Revascularization for Intermittent Claudication.

ABSTRACT

INTRODUCTION: Optimal medical therapy (OMT) is a modifiable factor that reduces mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates following elective endovascular revascularization for intermittent claudication (IC). METHODS: Using the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and non-smoking status defined OMT components and created three groups complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR). RESULTS: 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2,127 [5.4%] no OMT) met criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (p<0.0001). Patients without OMT were more likely to be Black or with Medicare/Medicaid (p<0.05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; p<0.001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; p<0.001) were decreased by partial or complete OMT compared to no OMT. Complete OMT significantly reduced the adjusted odds of re-intervention and MALE by 28% (aOR=0.72, 95% confidence interval [95%CI] 0.59-0.88) and 30% (aOR=0.70, 95%CI 0.58-0.85), respectively, compared to no OMT. Partial OMT reduced the adjusted odds of re-intervention and MALE by 24% (aOR=0.76, 95%CI 0.63-0.92) and 26% (aOR=0.74, 95%CI 0.62-0.89), respectively. CONCLUSIONS: Preintervention OMT is an underutilized, modifiable risk factor associated with improved one-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC prior to revascularization to optimize patient outcomes.