Adherence to lipid management guidelines is associated with lower mortality and major adverse limb events in patients undergoing revascularization for chronic limb-threatening ischemia

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Abstract

Objective:

The 2013 American College of Cardiology/American Heart Association lipid management guidelines recommend high-intensity statins for all patients ≤75 years old with chronic limb-threatening ischemia (CLTI) and moderate-intensity statins for CLTI patients >75 years old without contraindications or on dialysis, but these recommendations are based primarily on coronary and stroke data. We aimed to validate these guidelines in patients with CLTI and to assess current adherence to these recommendations.

Methods:

We identified all patients with CLTI who underwent first-time revascularization (endovascular or surgical) at Beth Israel Deaconess Medical Center from 2005 to 2014. Patients were classified as taking high-intensity, moderate-intensity, low-intensity, or no statin postoperatively. Outcomes included death and major adverse limb event (MALE). Propensity scores were calculated for the probability of receiving guideline-recommended intensity of statin therapy to account for nonrandom assignment of treatments. Cox regression models were constructed and adjusted for the propensity scores and further adjusted for strong potential confounders.

Results:

After excluding patients on hemodialysis (n = 252), we identified 1019 limbs from 931 patients with a median follow-up of 380 days. Patients discharged on the recommended statin intensity had higher rates of preoperative statin use, coronary artery disease, chronic kidney disease, stroke, atrial fibrillation, congestive heart failure, and coronary artery bypass grafting; they had lower smoking rates and were less likely to be ambulatory preoperatively. Overall, only 35% were taking the recommended statin dosage: 55% of those >75 years old and 20% of those ≤75 years old. In multivariable analysis including propensity scores where appropriate, discharge on any statin was associated with lower mortality (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.60-0.90; P < .01). Discharge on the recommended intensity of statin therapy was associated with lower mortality (HR, 0.73; 95% CI, 0.60-0.99; P < .05) and lower MALE rate (HR, 0.71; 95% CI, 0.51-0.97; P < .05). Patients >75 years old and ≤75 years old accrued similar benefit. In patients >75 years old, moderate-intensity statin therapy was associated with lower rates of death and MALE compared with high-intensity therapy but did not reach statistical significance.

Conclusions:

Use of the recommended intensity of statin therapy in compliance with 2013 American College of Cardiology/American Heart Association lipid management guidelines is associated with significantly improved survival and lower MALE rate in patients undergoing revascularization for CLTI. Adherence to current guidelines is an appealing target for quality improvement.

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