Pub Date: Monday, Oct 02, 2023
Author: Peter Henke, MD, FAHA
The accompanying Scientific Statement by Smolderen et,al,1 is timely, well written and provides excellent guidance to holistically improve patient outcomes in those with peripheral arterial disease (PAD). The background, studies, and gaps related to the mental health burden of PAD are clearly presented. Most commonly, PAD is thought of as human ‘plumbing problem' – that is, an arterial blockage(s) cause leg symptoms, and with opening the blockage(s) by endovascular or open surgical techniques, the problem is solved for the patient. While this is certainly oversimplified, the medical therapies, and now highlighted here, the mental health burdens are not considered for standard assessment when the disease is diagnosed. Included in this more comprehensive patient assessment is also the social determinants of health such as poverty, lack of healthy food, lack of transportation, pollution, and ability to get physician for long term care.
Recently, our operating room teams underwent a visioning process and one of the goals of this exercise was to imagine, within a timeframe of two years, an idealized new state. A visioning statement does not provide ‘the how' to get to the stated endpoint but provides an endpoint to work towards. In the next several paragraphs, the idealized vision for PAD treatment is presented.
Here is one future state: For a newly diagnosed patient with symptomatic PAD, based typically on symptoms an abnormal ABI or TBI,2 the patient would enter a comprehensive clinical setting intake. At least an hour or more would be allotted, for the patient to meet with specialists in the medical, mental health, nutritional and potentially interventional arenas. This would be truly multidisciplinary and standardized. The patient would have an intake interview of the typical demographics and common illnesses such as diabetes and hypertension, tobacco and substance use, medicines, and prior vascular procedures, as well as details of their symptoms. In addition, they would also undergo depression screening, assessment of social support networks, transportation, and nutrition. An intake would include a psychologist or social worker depending on the pre-screening that could be done online or prior to the visit. Indeed, this could be part of a screening tool and referral tool that the referring doc provides to the clinic to allow triage to gage the number of specialists who would assess the patient.
Once the patient has passed through the intake, they would meet with the specialists, and then determine several important things. First, a standard assessment for both depression and anxiety is now recommended by USTSF,3 and would be performed. Early treatment for diagnosed depression could include medications such as SSRIs or other medications as deemed appropriate, as determined by the expertise of the team. Smoking cessation aids and counseling would be comprehensive, both with initial recommendations such as nicotine replacement as well varenicline, and then plans for definitive follow-up, realizing that many patients are not able to do this immediately. Medications would include the standard evidence-based therapies for PAD risk reduction, which are still not as well prescribed for this patient population, as shown in the BEST-CLI trial.4 Moreover, intensive blood pressure control as suggested by the SPRINT trial5 and lipid management could be done, as aggressive treatment is associated with reduced cardiovascular mortality, including use of ezetimibe and the PCSK9 inhibitors. Next, the patient would then go on a nutritional assessment including the ability to get healthy foods, if they reside in a food desert, and instruction on healthy diets, including salt reduction and perhaps the Mediterranean diet. In many patients, diabetes accompanies and accelerates PAD. Thus, for these patients, having a full foot exam by a podiatrist, and endocrinologist would be indicated, to provide state of the art blood glucose control and prevent foot problems, that directly contribute to the high amputation risk. Indeed, these patients are particularly high risk of amputation if they smoke and have poorly controlled diabetes.
Once the intake is completed, the patient would get recommendations, prescriptions for medicines, and a detailed plan for healthy behaviors, and scheduled intensive follow-up. To make this more operational, real time follow-up via a Smart phone, Facetime or simply a phone call for those who don't have that technology. A virtual walking coach system exists from the Society for Vascular Surgery6 and could be added. Another example of an intensive medical management follow-up ‘coach' program is illustrated by the CREST II trial medical arm,7 for improving compliance with best medical therapies for stroke reduction, which are essentially the same for PAD. Much mental health care follow-up can also be done virtually and with reasonable effectiveness as has been a necessity during COVID-19 pandemic. This would accompany the healthy lifestyle and walking coaching that would be part of the ideal PAD care.
Two other points – first, the document highlights that in some cases, palliative care is appropriate for end-stage PAD and those needing amputation for pain control or source control. These are life altering operations for patients and for which mental health support is essential. Second, how to mesh this integrated care with primary care and internists who may be caring for the patient's other issues needs to be considered. Here, having a direct line of communication is essential and where the EMR can be exploited.
This ideal vision for comprehensive PAD care is possible, and based on much of the direction provided in the Scientific Statement, is labor intensive but not costly. The ultimate goal of PAD therapy is to stabilize the disease, prevent the progression of claudication to CLTI, and amputation, and improve the patient's quality of life. It is the last aspect that this document provides guidance in many areas that are often neglected, but no less important. This multidisciplinary approach is easy to put on paper, but hard to do, without organization and local clinical leaders. The case scenario presented in the Scientific Statement brings forth the common fragmented and siloed care that is too often the rule rather than the exception. The holistic approach to patients with symptomatic PAD is also likely highly cost effective by reducing interventions of both endovascular and surgical modes, potentially preventing progression to CTLI, as well as avoiding amputations. The simplified idealized ‘vision' is something that we should strive for and could realistically be done in many integrated health care systems.
Smolderen KG, Samaan Z, Decker C, Collins T, Lazar RM, Itoga NK, Mena-Hurtado C; on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Lifestyle and Cardiometabolic Health; and Council on Quality of Care and Outcomes Research. Association between mental health burden, clinical presentation, and outcomes in individuals with symptomaticperipheral artery disease: a scientific statement from the American Heart Association [published online ahead ofprint October 2, 2023]. Circulation. 2023;148:e•••–e•••. doi: 10.1161/CIR.0000000000001178
- Smolderen KG, Alabi O, Collins TC, Dennis B, Goodney PP, Mena-Hurtado C, Spertus JA, Decker C, American Heart Association Council on Peripheral Vascular D, Council on L and Cardiometabolic H. Advancing Peripheral Artery Disease Quality of Care and Outcomes Through Patient-Reported Health Status Assessment: A Scientific Statement From the American Heart Association. Circulation. 2022;146:e286-e297.
- Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D and Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726-e779.
- Force USPST, Barry MJ, Nicholson WK, Silverstein M, Coker TR, Davidson KW, Davis EM, Donahue KE, Jaen CR, Li L, Ogedegbe G, Pbert L, Rao G, Ruiz JM, Stevermer J, Tsevat J, Underwood SM and Wong JB. Screening for Anxiety Disorders in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329:2163-2170.
- Farber A, Menard MT, Conte MS, Kaufman JA, Powell RJ, Choudhry NK, Hamza TH, Assmann SF, Creager MA, Cziraky MJ, Dake MD, Jaff MR, Reid D, Siami FS, Sopko G, White CJ, van Over M, Strong MB, Villarreal MF, McKean M, Azene E, Azarbal A, Barleben A, Chew DK, Clavijo LC, Douville Y, Findeiss L, Garg N, Gasper W, Giles KA, Goodney PP, Hawkins BM, Herman CR, Kalish JA, Koopmann MC, Laskowski IA, Mena-Hurtado C, Motaganahalli R, Rowe VL, Schanzer A, Schneider PA, Siracuse JJ, Venermo M, Rosenfield K and Investigators B-C. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. N Engl J Med. 2022;387:2305-2316.
- Group SR, Wright JT, Jr., Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC, Jr., Fine LJ, Cutler JA, Cushman WC, Cheung AK and Ambrosius WT. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373:2103-16.
- Aalami OO, Lin J, Savage D, Ho V, Bertges D and Corriere M. Use of an app-based exercise therapy program including cognitive-behavioral techniques for the management of intermittent claudication. J Vasc Surg. 2022;76:1651-1656 e1.
- Lal BK, Meschia JF, Roubin GS, Jankowitz B, Heck D, Jovin T, White CJ, Rosenfield K, Katzen B, Dabus G, Gray W, Matsumura J, Hopkins LN, Luke S, Sharma J, Voeks JH, Howard G, Brott TG and Investigators C-. Factors influencing credentialing of interventionists in the CREST-2 trial. J Vasc Surg. 2020;71:854-861.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --