Use of angiotensin-converting enzyme inhibitors and freedom from amputation after lower extremity revascularization

Vascular Health and Risk Management Dovepress open access to scientific and medical research Original Research Vascular Health and Risk Management downloaded from https://www.dovepress.com/ by 54.37.111.135 on 08-Nov-2018 For personal use only. Open Access Full Text Article Use of angiotensin-converting enzyme inhibitors and freedom from amputation after lower extremity revascularization This article was published in the following Dove Press journal: Vascular Health and Risk Management 14 July 2017 Number of times this article has been viewed Jared E Kray 1 Viktor Y Dombrovskiy 2 Todd R Vogel 1 1 Department of Surgery, Division of Vascular Surgery, School of Medicine, University of Missouri, Columbia, MO, 2 Department of Surgery, RutgersRobert Wood Johnson Medical School, New Brunswick, NJ, USA Objective: Angiotensin-converting enzyme inhibitors (ACEIs) have not been well evaluated in conjunction with lower extremity revascularization (LER). This study evaluated freedom from amputation in patients who underwent either an open (OPEN) or endovascular (ENDO) revascularization with and without utilization of an ACEI. Materials and methods: Patients who underwent LER were identified from 2007–2008 Medicare Provider Analysis and Review files. Demographics, comorbidities, and disease severity were obtained. Post-procedural use of an ACEI was confirmed using combining them with National Drug Codes and Part D Files. Outcomes were analyzed using chi-square analysis, Kaplan–Meier test, and Cox regression. Results: We identified 22,954 patients who underwent LER: 8,128 (35.4%) patients with claudication, 3,056 (13.3%) with rest pain, and 11,770 (51.3%) with ulceration or gangrene. More patients underwent ENDO (14,353) than OPEN (8,601) revascularization and 38% of the cohort was taking an ACEI. Overall, ACEI utilization compared to patients not taking ACEI was not associated with lower amputation rates at 30 days (13.5% vs. 12.6%), 90 days (17.7% vs. 17.1%), or 1 year (23.9% vs. 22.8%) (P>0.05 for all). After adjustment for comorbidities, ACEI utilization was associated with higher amputation rates for patients with rest pain (hazard ratio: 1.4; 95% confidence interval: 1.1–1.8). Conclusion: ACEI utilization was not associated with overall improved rates of amputation-free survival or overall survival in the vascular surgery population. However, an important finding of this study was that patients presenting with a diagnosis of rest pain and taking an ACEI who underwent a LER had statistically higher amputation rates and a lower amputation-free survival at 1 year. Further analysis is needed to delineate best medical management for patients with critical limb ischemia and taking ACEI who undergo vascular revascularization. Keywords: angiotensin-converting enzyme inhibitor, lower extremity revascularization, amputation Introduction Correspondence: Todd R Vogel Department of Surgery, Division of Vascular Surgery, School of Medicine, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA Tel +1 573 882 1308 Fax +1 573 884 5049 Email 269 submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2017:13 269–274 Dovepress © 2017 Kray et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/VHRM.S137698 Powered by TCPDF (www.tcpdf.org) Peripheral arterial disease (PAD) is estimated to affect the lives of over 8 million people in the USA.1 In patients older than 60 years, ~12%–20% have signs or symptoms of peripheral vascular disease.2 Commonly associated comorbid conditions frequently seen in patients with PAD are tobacco abuse, hypertension, diabetes, dyslipidemias, and other atherosclerotic manifestations such as coronary artery disease. In general, intervention in patients is reserved for patients who can be subcategorized by symptoms: claudication, rest pain, or tissue loss/gangrene. Angiotensin-converting enzyme inhibitors (ACEIs) were originally intended for the management of hypertension. Early experience with these drugs demonstrated benefits Dovepress Vascular Health and Risk Management downloaded from https://www.dovepress.com/ by 54.37.111.135 on 08-Nov-2018 For personal use only. Kray et al in a wide range of patients and then expanded indications for patients with diabetic nephropathy, as well as a positive effect on cardiac patients showing improved remodeling of heart tissue.3 Some studies have even shown all-cause mortality, stroke, and myocardial infarction to be lower in any patient with left ventricular dysfunction even without heart failure symptoms.4 This has led a large number of PAD patients undergoing lower extremity revascularization (LER) to take these medications. To date, very few have looked at the correlation of ACEIs and outcomes after LER. The objective of this analysis was to evaluate the outcomes in patients under ACEI medications and who underwent LER. Materials and methods Using the Centers for Medicare & Medicaid Services (CMS) files for the years 2007–2008 – Medicare Provider Analysis and Review (MedPAR) File, Carrier Claim File, Part D Drug Event (PDE) File, and Beneficiary Summary File – we identified patients aged 65 years and older who underwent LER. These files contain information from inpatient hospital records including sociodemographic characteristics, International Classification of Diseases – Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes, Current Procedural Terminology, Fourth Edition (CPT-4), codes for all procedures during hospitalization, hospital length of stay and cost, patient outcomes as discharge, and others. The PDE file includes information about all prescription drugs for Medicare beneficiaries such as National Drug Code (NDC) in the NDC11 format to identify drugs and their dosage, dispensed quantity and supply, and drug cost. All these data collected were then linked by a unique personal identifier to each Medicare beneficiary through CMS data. Patient who underwent LER in 2007 and 2008 years were identified by CPT codes 35556, 35583, 35656, 35566, 35585, 35666, 35556, 35583, 35226, 35256, and 35286 for open (OPEN) revascularization and 35473, 35474, and 35470 for endovascular (ENDO) revascularization. Among them, we selected those with Part D coverage during the whole year. Using the ICD-9-CM diagnosis codes, these patients were allocated to one of the three g (...truncated)