Recent trials have demonstrated the efficacy of the sodium-glucose cotransporter inhibitor drug class as well as glucagon-like peptide-1 receptor agonists in controlling glucose and preventing major adverse cardiovascular events (MACE), and as a result, endocrinologists and cardiologists see their disciplines converging.1 In the case of peripheral artery disease (PAD), interdisciplinary teams working in concert can achieve better outcomes by helping patients with diabetes avoid PAD and amputations.1

EUCLID Highlights the Link Between PAD and Diabetes

Diabetes is an independent risk factor for many poor outcomes that occur in PAD.1,2 The EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) study has contributed a wealth of data strengthening the association between diabetes and PAD. The 13,885-patient study examined the effects of the antiplatelet therapies ticagrelor vs clopidogrel in patients with symptomatic PAD with and without diabetes and assessed the risk for cardiovascular events, limb symptoms, and amputations.2

In patients with diabetes, 15.9% reached the primary end point for MACE (cardiovascular death, myocardial infarction [MI], or ischemic stroke) compared with 10.4% of patients without diabetes (unadjusted hazard ratio [HR], 1.56; 95% CI, 1.41-1.72; P <.001).2 For patients with both PAD and diabetes, every 1% increase in hemoglobin A1C level conferred a 14.2% increase in relative risk for MACE (HR, 1.14; 95% CI, 1.09-1.20; P <.0001), indicating a strong link between increased blood glucose level and vascular disease risk.2

Diabetes Increases Risk for Revascularization Procedures

In a post-hoc analysis of the EUCLID trial, researchers sought to determine which risk factors were associated with lower extremity revascularization for PAD after randomization.3 The study also evaluated major adverse limb events such as acute limb ischemia and major amputations.3

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Patients who had lower extremity revascularization were more likely to have had a previous lower extremity revascularization, particularly if they had both surgical and endovascular revascularization (HR, 3.99; 95% CI, 3.42-4.66).3 Other predictors for lower extremity revascularization were residing in North America, having diabetes, smoking, and having limb symptoms at baseline. Patients who had lower extremity revascularization had an increased risk for MACE (HR, 1.60; 95% CI, 1.35-1.90; P <.0001) and major adverse limb events (HR, 12.0; 95% CI, 9.47-15.3; P <.0001).3

“What is striking is that lower extremity revascularization was associated with a 60% increased risk for the primary end point (MI, ischemic stroke, or cardiovascular death) and 38% increased risk for death,” explained vascular specialist William R. Hiatt, MD, a coauthor of the EUCLID analysis, professor of medicine at the University of Colorado School of Medicine, and president of the Colorado Prevention Center in Aurora, Colorado. “The risk for a major adverse limb event was increased 12-fold, including a 14-fold increased risk for acute limb ischemia, and 10-fold increased risk for major amputation.”

“The key message is that lower extremity revascularization is not a totally benign procedure and I do not think that knowledge is very widespread,” Dr Hiatt said. “As someone who practices vascular medicine, my approach is to only refer the most symptomatic patients, particularly those with chronic limb threatening ischemia, for a procedure. The asymptomatic patient or those with minimal claudication should be treated medically.”

To provide patients with a range of treatment options, Dr Hiatt described his practice’s team approach. “Our multispecialty practice includes vascular surgery, interventional radiology, interventional cardiology, and vascular medicine. We have a number of medical and exercise treatment options that we employ, not just lower extremity revascularization,” he said.

This article originally appeared on The Cardiology Advisor