Optimizing Anticoagulation in Vascular Disease Patients: Reimagining the Standard of Care - Episode 10

Improving Outcomes in PAD

April 8, 2022

The panel concludes with final thoughts on how to improve outcome for patients with PAD.

Manesh Patel, MD:This has been fun. We’ve discussed a broad range of topics. If you’ve been watching this and thinking about your patients with PAD [peripheral artery disease], we’ve heard important messages how underrepresented they are in trials; how their comorbidities are not identified frequently. Chris, any final thoughts on how you would think about a quality system for these patients? What should we do to better understand how we can improve the gaps you highlighted?

Christopher Granger, MD:It’s an extraordinarily high-risk population that has loss of limb as a major complication. We must focus on systematic approaches, ensuring that patients are getting the best prevention therapy for vascular disease. That includes lifestyle and best approaches to help people stop smoking. It also includes high-intensity statins, which are grossly underused in this population, and the use of the low-dose anticoagulation. The rivaroxaban-aspirin combination is the single approach that’s proven to prevent these vascular events and that combination of things. Larry is the smartest person I know in the cardiovascular disease sphere, but we must measure what we’re doing. We must know in each of our health systems who has PAD, who they’re seeing, and how they’re being managed. We need systems in place to ensure that we have tools to work with the patient, their family, their network of providers, and the systems so they’re getting these treatments to improve their outcome.

Manesh Patel, MD:That’s a health system level. Amr, what about our catheterization or our endovascular labs where we’re doing a variety of things? Are there other things people are putting in place to make sure our patients with PAD do better?

Amr Abbas, MD:We have a ways to go, including choosing patients who will benefit from the procedure. We’ve come full circle with percutaneous coronary interventions, where stents are good…but hold on, don’t go too fast. Are we really benefiting our patients? The second part is, what treatments can we do so we won’t end up in the catheterization lab again? We talked a little about some of the therapies that can prevent major adverse limb events. To carry on what Chris said, I’m reviewing a paper talking about these measures, and 1 of the big measures that will be important in PAD is patient-reported outcomes. Patient-reported outcome measure how we will see from point A to point B if we have improved our patients’ symptoms and expectancy.

Manesh Patel, MD:That’s a great way to think about it. Almost all our procedures we can think about, before the procedure, what data should we know about our patient to ensure they need it? We could say the right patient, the right time-appropriate idea. This is a field in which we don’t agree on the anatomy classification. I’m putting that out there for people to remember where we are. Different groups will classify the anatomy in different ways, and we need standardization on that risk. Measuring those outcomes is a great idea. Larry, I’ll give you the final word on what we’re doing to engage our patients.

Larry Allen, MD:The good news is that there’s a lot that we can do for PAD these days. We’ve gone through a variety of approaches. Short of a procedure, most of those involve patients changing their behavior—taking a drug, stopping smoking, increasing their exercise. All these things are on a day-to-day basis with the patient, so we’ve got to stop talking about compliance. We should move on from adherence and talk about engagement and activation. The way to do that is to bring our patients into the conversation about the medical decisions we’re making. We can’t do everything at once, so let’s talk about what seems to fit with patients, what’s high value, give them data, allow them to ask questions, encourage them to bring ideas to you, and then have real shared decision-making. You’ve conveyed information to them that you think is important, and they’ve brought to you what’s important in their own lives and what fits with them. Then you have a deliberate conversation about what you’re going to do and follow that up. These are high-risk patients with a lot to do. There’s a great place for shared decision-making to where the art of medicine plays out. The fun of being a clinician is helping people live better lives. It’s a great place to do that.

Manesh Patel, MD:That’s a great way to think about it and to explain shared decision-making. We’re learning outside medicine the idea of engagement and activation—people who follow you, want to do what you tell them to do. Changing patient behavior is hard, but changing a physician’s behavior is even harder. Hopefully people have been watching and thinking, “How do I take care of my patients? Are there things we could make a meaningful difference?” I’ll make 1 last shout-out to a patient advocacy group called Vascular Cures, which does a lot of patient voice work as a nonprofit looking at ways in which to improve vascular health. Thank you all for watching. Thanks to my panel and the audience. This has been great.

This transcript has been edited for clarity.

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