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Revascularization plus exercise is most effective for intermittent claudication

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Important questions remain, commentators report

One question that remains from the current study is whether revascularization plus exercise changes the rates of adverse events seen among patients with intermittent claudication.

While results of the network meta-analysis showed benefit for combination percutaneous transluminal angioplasty and supervised treadmill exercise therapy in terms of efficacy, no data on adverse events were reported. Other studies have revealed that exercise therapy does not increase rates of adverse events in patients with peripheral arterial disease, but this may not be the case with PTA.

A recent study showed the rates of serious adverse events, such as adverse limb events, myocardial infarction, stroke, or death, in a group of patients with intermittent claudication who underwent PTA. While the event rates were low, the follow-up period was short (30 days). Further studies have also shown that responses to PTA alone may not be long lasting.

In a similar manner, the long-term efficacy and safety of PTA plus SET remains unknown. In addition, questions surrounding the statistical significance of quality of life measures from the network meta-analysis also remain.

Rather than encouraging more PTA procedures, results of this network meta-analysis should encourage increased participation in SET by patients with PAD.

Mary M. McDermott, MD, professor of medicine at Northwestern University in Chicago, made these comments in an editorial. She reported financial affiliations with the National Heart Lung and Blood Institute, the National Institute on Aging, and Regeneron (JACC Cardiovasc Interv. 2019 May 29).



Alongside best medical therapy, percutaneous transluminal angioplasty (PTA) plus supervised treadmill exercise therapy (SET) could be the most beneficial first-line treatment option for intermittent claudication, according to a systematic review and network meta-analysis of 37 randomized clinical trials.

The meta-analysis “has shown that in addition to best medical therapy, angioplasty combined with supervised exercise appears to be the optimal initial treatment strategy for patients presenting with claudication,” wrote Athanasios Saratzis, MBBS, PhD, of Guy’s and St Thomas’ Hospital in London, and colleagues.

They searched major databases for studies that compared all potential treatment options for patients with intermittent claudication. After applying the search criteria, the team found 37 clinical studies that included a total of 5 multi-arm randomized trials.

The primary outcome measure used was the improvement in Maximum Walking Distance (MWD). The secondary outcome included in the analysis was patient-reported Quality of Life (QoL).

Overall, four different treatment options for peripheral arterial disease (PAD) with intermittent claudication were compared: SET alone, PTA alone, PTA plus SET, or best medication therapy (lacking SET or PTA). In all, 2,983 patients with intermittent claudication were included.

After analysis, the researchers found that PTA plus SET was associated with a larger improvement in maximal treadmill walking distance (MWD), compared with best medication therapy alone, with an increase of 290 meters (95% confidence interval, 180-390 meters; P less than .001).

With respect to quality of life, PTA plus SET was associated with better improvement in quality of life versus best medical therapy.

The researchers acknowledged that a key limitation of the study was the lack of patient level data. As a result, detailed analyses exploring interactions between various risk parameters were not performed.

No funding sources were reported. Dr. Saratzis reported financial affiliations with the National Institute of Healthcare Research, the Academy of Medical Sciences, Amgen, Medyria Medical AG, and Regeneron.

SOURCE: Saratzis A et al. JACC Cardiovasc Interv. 2019 May 29. doi: 10.1016/j.jcin.2019.02.018.

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