Lawrence Garcia, MD, presented on hypertension and hyperlipidemia treatment in critical limb ischemia (CLI) patients at the 2019 AMPutation Prevention Symposium in Chicago, Illinois. Dr. Garcia is Chief of the Section of Interventional Cardiology and Vascular Medicine Programs, St. Elizabeth's Medical Center, at Tufts University School of Medicine in Boston, Massachusetts. His presentation covered hypertensive therapy for CLI patients, as well as the importance of managing CLI patients from a global perspective.
When should hypertensive therapies be administered to CLI patients?
Hypertension is very critical to treat because it has so many secondary effects, including cerebrovascular, cardiovascular, and vascular effects. All those areas play a huge role in protecting and prolonging lives. However, in the past, many people have thought that lowering blood pressure in patients with CLI would reduce the pressure gradient to the limb, and potentially put the limb at risk. In the consensus document in the recent guidelines, there is a stipulation that says there have been no data to suggest that lowering blood pressure puts the limb at risk for patients with CLI.
How do recent updates to blood pressure guidelines affect which patients qualify for treatment?
The guidelines have recently shifted to include more people in the range of hypertension. According to the recent guidelines, approximately half of the U.S. population is hypertensive. This shift has been challenging with regards to treatments, but treating to a more aggressive level allows us to protect a wider swath of the population and reduce the amount of progressive carotid disease, cardiovascular disease, and vascular disease in the current population. The shift in guidelines and more aggressive treatment benefits patients with significant peripheral arterial disease (PAD) in that we now tend to treat early and long term in patients at most risk for progressive cardiovascular disease.
How do angiotensin-converting enzyme (ACE) inhibitors affect patients with CLI?
ACE inhibitors and angiotensin-receptor blockers (ARBs) have pleiotropic effects that are essentially the same pleiotropic effects seen in statin therapy. These drugs tend to lower the inflammatory state. We used to think that the pathway to atherosclerosis was simple, a result of oxidative stress that grew the plaque burden and ultimately created the stenosis. That pathway remains true, but one of the final common pathways to failure of an artery is through inflammatory markers and cytokines. Guidelines stipulate that ARB and ACE inhibitors are beneficial to our patients with atherosclerotic burden because these medications tend to reduce the inflammatory burden as statin medications also do.
What do the guidelines say about who should be treated with statins?
In the old days, we waited for people to have disease before commencing treatment, but then we realized that primary prevention in patients who are most at risk is a far better strategy. We can limit mortality in these patients and help them to be productive members of society for a longer time while treating with primary prevention. To get to this point as a field, we needed to improve our ability to identify high-risk patients. We developed calculators to assess risk based on a number of factors, including race, gender, blood pressure, LDL, and comorbidities. Patients who have risk but no overt disease should be taking a statin, and anyone who is higher risk/has overt cardiovascular disease should already be on a statin. Thus, any patient with coronary disease, PAD, or carotid disease should already be on a high dose statin.
What is the role of revascularization in treating patients with CLI?
Although we have surrogate therapies such as aspirin and dual antiplatelet therapy, returning blood flow is absolutely necessary to maintain the limb. If blood flow is not returned to the limb, statins and ACE inhibitors will not salvage that limb. The risk of limb loss for patients with CLI is probably around 50% at 2 to 3 years, even with significant revascularization. Patients with CLI need to be treated early, and in some cases often, with revascularization in order to avoid losing the limb. CLI remains a terrible disease.
Are there any areas in which patient care could be improved?
In many respects, we tend to take on the role of being only “the plumber” or the role of being a “technician” who opens up the artery. However, at the end of the day, we need to take ownership of the patient, which means that we need to not only be a plumber or a technician, but also take global care of the patient. We need to ensure that patients have appropriate follow-up, including podiatric care, wound care, and nutritional care. We need to follow patients from a global perspective and take into account all their cardiovascular risks, as well as hypertension, diabetes, and statin therapy. It takes a village to care for CLI patients, and we in the village need to be in close communication with all stakeholders in their care.
How do medical management and revascularization align?
Medical management and revascularization should go hand in hand. Our role is not limited or exclusive to performing revascularization. We also need to review patient medications and fix medication issues. Sometimes, our role is to revascularize the patient and then transfer care back to the primary vascular specialist. In that scenario, a follow-up phone call with the primary vascular specialist is important. At other times, it may be appropriate for us to hand care back to the primary physician while at the same time proactively scheduling a follow-up appointment for the patient to ensure that everything is proceeding optimally post revascularization. Patients with CLI need a near continuous follow-up.
Any final thoughts?
If we revascularize without considering other aspects of patient care, patients are still going to lose a limb and ultimately a potential life. Patient outcomes improve when we become global physicians and advocates for the patient in terms of surrogate issues such as hypertension, diabetes, statin control, and cholesterol control. Becoming a global physician is a great service to all our patients.
Disclosure: Dr. Garcia reports consulting for Abbott Vascular, Boston Scientific, and Medtronic; grant/research support for Abbott Vascular and Medtronic; being a major stock shareholder of CV Ingenuity, Essential Medical, Syntervention, Orchestra, and Transit Medical.
Dr. Garcia is the founder of Innovation Vascular Partners Consulting..
Address for correspondence: Lawrence Garcia, MD, can be contacted at firstname.lastname@example.org