title: Invasive treatment of claudication is indicated for patients unable to adequately ambulate during cardiac rehabilitation.
abstract: BACKGROUND
  Cardiac rehabilitation (CR) is of proven benefit for patients with coronary artery disease. Patients who successfully complete CR have a statistically significant reduction in the risk of fatal myocardial infarction (MI) and all-cause mortality. Peripheral arterial disease (PAD) is common in patients with coronary artery disease.
  
  
  OBJECTIVE
  We investigated whether PAD prevents the successful completion of CR and cardiac risk reduction and whether invasive treatment of claudicant patients who cannot walk sufficiently to successfully complete CR is indicated.
  
  
  METHODS
  The records of 230 consecutive CR patients were reviewed for attendance, target heart rate, and Walking Impairment Questionnaire (WIQ) values to compare PAD among successes and failures. Failure of CR was defined as inability to walk sufficiently to achieve target heart rate. Markov decision analysis using published data for endovascular and open intervention for claudication was used to compare outcomes of treatment strategies in which PAD is untreated (current standard), PAD is treated only if it interfered with CR, and treatment of PAD in all patients before initiating CR.
  
  
  RESULTS
  Of 230 patients, 126 had complete records for analysis. Ankle-brachial indices (ABIs) were documented for 39 patients. Overall, 40% of patients failed CR. Failure was significantly more common in patients with claudication (76%) than in those without (26%; odds ratio [OR], 8.9; 95% confidence interval [CI], 3.7-21.7; P < .001). The presence of PAD, determined by the WIQ walking distance score, was significantly higher in the failure group (34%) vs the success group (17%; OR, 2.5; 95% CI, 1.1-6.0; P = .03). The presence of PAD, determined by ABI, was higher in the failure group (39%) vs the success group (14%; OR, 3.8; 95% CI, 0.8-17.9; P = .08). Logistic regression analysis when CR failure was adjusted for age and gender was significantly associated with presence of PAD based on WIQ walking distance score (OR, 2.8; 95% CI 1.1-7.1; P = .03). A strategy of invasive therapy only if PAD interfered with the successful completion of CR would save an additional 54 lives per 10,000 patients compared with no intervention.
  
  
  CONCLUSIONS
  PAD is a significant cause of CR failure, preventing patients from successfully completing the program and achieving a reduction in risk of fatal cardiac events. Invasive treatment of PAD in patients who fail CR is indicated, with an expected lifesaving outcome.
authors.affiliation: Department of Epidemiology and Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Sandra
authors.initials: S
authors.lastname: Spronk
authors.forename: John V
authors.initials: JV
authors.lastname: White
authors.forename: Connie
authors.initials: C
authors.lastname: Ryjewski
authors.forename: Judy
authors.initials: J
authors.lastname: Rosenblum
authors.forename: Johanna L
authors.initials: JL
authors.lastname: Bosch
authors.forename: Myriam G M
authors.initials: MG
authors.lastname: Hunink
mesh_terms: D000368:Aged; D003324:Coronary Artery Disease / Q000150:complications / Q000503:physiopathology / Q000534:rehabilitation*; D020000:Decision Support Systems, Clinical; D004185:Disability Evaluation; D005260:Female; D006339:Heart Rate; D006801:Humans; D007383:Intermittent Claudication / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008390:Markov Chains; D051346:Mobility Limitation; D009203:Myocardial Infarction / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D016017:Odds Ratio; D018579:Patient Selection; D016491:Peripheral Vascular Diseases / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D020127:Recovery of Function; D018570:Risk Assessment; D012307:Risk Factors; D017211:Treatment Failure; D014656:Vascular Surgical Procedures; D016138:Walking