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Medical therapy for PAD making great strides
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HOLLYWOOD, Fla. — While not expected to replace endovascular interventions in the near future, medical therapies for peripheral artery disease are making significant progress, which could mean fewer procedures in the future, a speaker said at the International Symposium on Endovascular Therapy.
The pace of breakthroughs in medical therapy has prompted the question of whether medical therapy will replace peripheral interventional procedures, according to Michael R. Jaff, DO, MSVM, FSCAI, FACP, FACC, president of Newton-Wellesley Hospital, professor of medicine at Harvard Medical School and a member of the Cardiology Today and Cardiology Today’s Intervention Editorial Boards.
Medical breakthroughs of note include “a cure for hemophilia — who would have imagined that — being able to edit your own DNA to be able to stop the expression of the disease for which you are at risk and, of course, all the incredible work that is going on with genetic engineering for treatment of leukemia. None of these are device-based,” he said.
Artificial intelligence may also shape the future of PAD diagnosis and treatment, Jaff said. He noted that while AI, which already has the ability to quickly and correctly diagnose conditions based on imaging, may not replace physicians, those who use AI may provide better treatment of patients in the future than those who do not.
Currently, he said, “there is not a chance that medical therapy is going to replace endovascular therapy” for PAD, because most current treatments have been around for a long time. “It’s not particularly exciting, it’s fairly palliative and reduces risks of heart attacks, stroke and vascular death to a degree, but certainly not enough for our patients to be happy.”
Medical and other preventive therapies employed today include aspirin, clopidogrel, smoking cessation, LDL reduction via statins, BP reduction, exercise, diabetes medications if necessary, foot care instructions and cilostazol if eligible, he said.
However, “the pace of change of what we’ve been able to do with medical therapy for PAD has exploded in the last 12 months, and if this is any indication of what’s coming, I think the story is going to change.”
Recent advancements in medical therapy include vorapaxar (Zontivity, Aralez Pharmaceuticals), which Jaff said “completely reduced the risk of progressing from chronic critical limb ischemia to the need for hospitalization for limb ischemia, acute limb ischemia and limb loss.”
In the PCSK9 inhibitor realm, a substudy of the FOURIER trial of evolocumab (Repatha, Amgen) showed that in high-risk patients with PAD already on optimal medical therapy, treatment with evolocumab was associated with a number needed to treat of 29 to prevent one case of MACE over 2.5 years, Jaff said.
Then, in the COMPASS trial, which was presented at the 2017 European Society of Cardiology Congress, the direct oral anticoagulant rivaroxaban (Xarelto, Janssen) plus aspirin reduced major adverse events in patients with PAD vs. aspirin alone. “This is a treatment I suspect most of you would never have considered,” he said.
In the complex population of patients with diabetes and PAD, who are particularly difficult to treat, the diabetes drug empagliflozin (Jardiance, Boehringer Ingelheim) “showed a first-time-ever dramatic reduction in heart attacks, strokes and vascular death among patients with peripheral artery disease” and type 2 diabetes, according to Jaff.
“I can’t tell you that medical therapy is going to completely replace endovascular therapy in patients with peripheral artery disease, but this is coming,” he said. – by Erik Swain
References:
Jaff MR. Townhall: Innovation and the Future. Presented at: the 2018 International Symposium on Endovascular Therapy (ISET); Feb. 3-7, 2018; Hollywood, Fla.
Bonaca MP, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032235.
Eikelboom JW, et al. N Engl J Med. 2017;doi:10.1056/NEJMoa1709118.
Franchi F, et al. Nat Rev Cardiol. 2015;doi: 10.1038/nrcardio.2014.156.
Verma S, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032031.
Disclosure: Jaff reports he is a consultant for Abbott Vascular, the American Orthotics and Prosthetics Association, Boston Scientific, Cordis/Cardinal Health, Medtronic, Micell and Philips/Volcano, holds equity in Embolitech, Janacare, PQ Bypass, Primacea, Sano V, Vactronix, Vascular Therapies and Venarum, and serves on the executive committee of the BEST-CLI trial.