Statin, antiplatelet prescriptions lag for PAD patients at risk of stroke

Heart patients with symptoms of peripheral artery disease (PAD) continue to see low rates of prescriptions for antiplatelets, statins and ACE inhibitors, despite those drugs’ potential to prevent against major events like stroke, according to research published Nov. 15 in Stroke.

First author Domenico R. Nastasi, of the Queensland Research Centre for Peripheral Arterial Disease in Australia, and colleagues wrote that global guidelines presently encourage the use of antiplatelet therapies, statins, and antihypertensives to mitigate PAD patients’ three- to five-times increased risk for adverse cardiovascular events. Though PAD care tends to revolve around lower limb ischemia, intermittent claudication or critical limb ischemia, Nastasti et al. said it’s important to also consider the impact PAD can have on future strokes.

“Previous cohort studies report that the incidence of stroke in PAD patients ranges from 0.8 to 4.7 events per 100 patient-years, and it is possible that this variation may be because of differences in the prescription of antihypertensive drugs, antiplatelet medication and statins,” the authors wrote.

They said antiplatelet monotherapy is currently the intervention with the strongest base of evidence for preventing stroke in PAD sufferers. Meta-analyses have suggested aspirin and clopidogrel could reduce relative risk of stroke by up to 36 percent, but Nastasi and coauthors argued most data available today provide limited evidence, and current guidelines are based on trials that included PAD patients only as subgroups of larger populations.

“The aim of this study was to systematically review the incidence of stroke in patients with symptoms of PAD and investigate the reported prescription of preventative medications and the association of this and other cardiovascular disease risk factors with stroke incidence,” the researchers wrote.

They achieved that with a large-scale database search that yielded 12 studies involving 67,915 symptomatic PAD patients. A meta-analysis of data from seven studies found an incidence of stroke of 1.31 per 100 patient-years, and Nastasi et al. found patients with critical limb ischemia, which often presents as gangrene, experienced stroke 2.3 times more frequently than patients with intermittent claudication.

According to the study, reported prescriptions of antihypertensive agents varied between 10 percent and 71 percent in different trials. Prescription of antiplatelet drugs fell between 49 percent and 90 percent, and statin prescriptions varied between 11 percent and 79 percent. Meta-regression suggested a link between the prescription of antiplatelets and statins and a lower risk of stroke, but no such correlation was found for antihypertensive medications.

“This review suggests that a low prescription of cardiovascular medications, particularly antiplatelet agents and statins, contributes to the high reported incidence of stroke in PAD patients,” Nastasi and co-authors said. “Effective, evidence-based methods are needed to achieve better implementation of medical management among PAD patients. This may include encouraging patients to take a more active role in their self-management and further encouraging physicians to implement guideline-recommended medical management.”