Advances in the Management of Peripheral Arterial Disease - Episode 13
Transcript:Deepak L. Bhatt, MD, MPH: From a surgical perspective, specifically vascular surgery, how do you see vascular surgeons—I don’t mean yourself; I know you’re on top of the literature and provide excellent care because I’ve seen it firsthand—out there feeling responsible for managing the medical therapy of patients with PAD [peripheral artery disease]? I don’t think there’s a right or wrong answer, but how many are actually managing things like the antithrombotic therapy or the lipid-lowering therapy versus deferring it back to the primary care physician, cardiologist, or vascular medicine specialists if there is 1 involved in the patient’s care beyond the vascular surgeon?
Matthew T. Menard, MD: Your average vascular surgeon is very comfortable with the use of antiplatelet therapy, aspirin, Plavix [clopidogrel]. The curve falls off when you get to the alternatives to Plavix. Most vascular surgeons are not so familiar with a couple of good alternatives and not particularly savvy with platelet sensitivity. That might be coming around the corner. The test case was with statins, and that was where we were charged with stepping up and ensuring that our patients were on good statin therapy and lipid-lowering therapy. Many did adopt that and even wrote the prescriptions themselves or made clear contact with the primary care physician or the overarching vascular medicine doctor to make sure that part of the regimen was intact.
The current challenge is that there are so many outstanding drugs that you have been talking about that are now out there: vorapaxar, evolocumab, rivaroxaban, and ticagrelor. It’s a challenge for anyone to figure out what the best regimen is in a given patient, and it becomes pretty complicated in a heartbeat. Getting back to 1 of your earlier questions and the challenges we face, I don’t think we have done what the neurology community has done for stroke and what you all have done for heart attack. By and large, your average civilian knows that if you have a heart attack, you’ve got to get yourself to the hospital and that time matters.
It might not have translated into actual intervention times, as you mentioned, but that is the big challenge we’re facing. We have to do the same thing for critical limb ischemia for the legs. The silos, as Mike was talking about, are incredibly important. They are coming down. There’s much more interaction across the divide than there used to be, and it’s even more important—with all these different medications and how they’re best used—for that to happen.
Transcript Edited for Clarity