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Statins cut limb events in PAD patients 他汀可减少外周动脉疾病患者肢体事件  

2013-09-24 16:29:00|  分类: 他汀类 |  标签: |举报 |字号 订阅

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By: By MITCHEL L. ZOLER, Cardiology News Digital Network


AMSTERDAM – Treatment with a statin cut the relative rate of worsening peripheral artery disease by roughly 20% in a registry with nearly 6,000 peripheral artery disease patients.


But the registry data also showed that more than a third of patients with peripheral artery disease (PAD) failed to receive statin treatment, Dr. Dharam Kumbhani said at the annual Congress of the European Society of Cardiology.


"This is one of the first, and largest, studies to demonstrate an impact [of statin treatment] on adverse limb outcomes in patients with PAD, including worsening claudication, new critical limb ischemia, need for revascularization, and notably need for ischemic amputations. But despite having a class I recommendation for use in patients with PAD, data from this large, international registry suggest that statin use remains suboptimal," said Dr. Kumbhani, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas.


"Future research should focus on improving patient and physician compliance with statin use across the entire spectrum of PAD patients," he said.


Concomitant coronary artery disease, as well as the specialty of the treating physician, seemed to link with statin use in these patients, Dr. Kumbhani added. "In PAD patients with CAD, statin use occurred in about 75%; in PAD patients without CAD, it was less than 50%."


Statins were most reliably prescribed to PAD patients by cardiologists, who administered the drugs to about 80% of all their PAD patients, regardless of concomitant CAD. In contrast, vascular surgeons prescribed statins to fewer than half their PAD patients, and in those who did not have concomitant CAD, statin use fell to less than a third. About 70% of all patients enrolled in the registry received their treatment from a primary care physician.


The data came from the Reduction of Atherothrombosis for Continued Health (REACH) registry, which followed more than 45,000 enrolled patients for at least 4 years at more than 3,600 centers in 29 countries; more than a quarter were U.S. patients (JAMA 2010;304:1350-7). Enrolled patients were at least 45 years old and had at least three atherosclerosis risk factors or established vascular disease in the coronary, cerebral, or peripheral domains. The enrolled patients included 5,861 with established, symptomatic PAD, of whom 3,643 (62%) were on statin treatment at the time they entered the registry.


During 4-year follow-up the rate of the primary systemic outcome – a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke – decreased by a statistically significant, relative 15% among patients on a statin compared with those not on a statin at baseline, in a propensity-score adjusted analysis.


Statin use linked with a statistically significant, 21% relative drop in worsening PAD events, compared with nonuse, in the propensity-score adjusted model. Adjusted analyses also showed statistically significant reductions for most of the individual outcomes that formed the composites, including a 27% relative reduction in nonfatal strokes and a 43% relative drop in limb amputations.


The systemic benefits seen in the registry from statin use in patients with PAD are consistent with results from randomized, controlled trials, but finding statin use also linked with decreased adverse limb outcomes is new, Dr. Kumbhani said.


The REACH registry is funded by Sanofi and Bristol-Myers Squibb. Dr. Kumbhani reported having no relevant financial disclosures.




阿姆斯特丹——欧洲心脏病学会(ESC)年会上报告的一项纳入近6,000例外周动脉疾病(PAD)患者的注册研究数据显示,他汀类药物治疗可使患者PAD恶化率相对降低约20%。但数据也显示,1/3以上PAD患者并未接受他汀类治疗。


德州大学西南医学中心介入心脏病专家Dharam Kumbhani医生报告称,减少动脉粥样硬化血栓形成的持续健康(REACH)注册研究是迄今最大规模地评估他汀类治疗对PAD患者不良肢体结局影响的研究之一。不良结局包括跛行恶化、新发严重肢体缺血、需要血运重建、尤其是需要缺血性截肢。尽管他汀类被列为PAD患者Ⅰ级推荐治疗用药,但注册数据显示,他汀类应用情况并不理想。“未来研究应关注如何改善患者和医生对他汀类药物应用推荐指南的依从性。”


DharamKumbhani医生
 
研究者还报告称,患者的他汀类用药情况似乎与是否伴有冠状动脉疾病(CAD)以及主治医生的专业有关。伴有CAD的PAD患者的他汀类用药比例约为75%,而无CAD的PAD患者的用药比例低于50%。无论PAD患者是否伴有CAD,心脏病医生的他汀类处方率约为80%。相反,血管外科医生仅对不足50%的PAD患者开具他汀类,而对于不伴有CAD的患者,他汀类应用比例小于1/3。约70%注册患者的治疗药物处方来自初级保健医生。


REACH登记研究对29个国家3,600余家医学中心的45,000余例患者进行了至少4年的随访,其中1/4以上患者为美国人(JAMA 2010;304:1350-7 )。入组患者年龄≥45岁,至少具有3项动脉粥样硬化危险因素或确诊为冠脉、脑动脉或外周动脉血管疾病。入组患者包括5,861例症状性PAD确诊患者,其中3,643 例(62%)在入组时接受了他汀类治疗。


倾向评分校正分析结果显示,与基线未服用他汀类的患者相比,服用患者4年随访期间主要全身性复合结局(包括心血管死亡、非致命性心梗和非致命性卒中)发生率相对下降15%,具有统计学显著意义。PAD事件恶化发生率相对下降21%,也具有统计学显著意义。此外,复合结局中的大多数指标也呈显著性下降,包括非致命性卒中和肢体截肢率分别相对下降27%和43%。


研究者指出,上述PAD患者他汀类治疗全身受益结果与随机对照试验结果相一致,但他汀类应用与不良肢体结局下降相关则属首次发现。


REACH注册研究由塞诺菲和百时美施贵宝公司资助。Kumbhani医生报告无相关利益冲突。


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