title: Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is associated with reduced major adverse cardiovascular events among patients with critical limb ischemia.
abstract: Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are recommended for secondary prevention in peripheral artery disease, but their effectiveness in patients with critical limb ischemia (CLI) is uncertain. We reviewed 464 patients with CLI who underwent diagnostic angiography or endovascular intervention from 2006-2013 at a multidisciplinary vascular center. ACEI or ARB use was assessed at the time of angiography. Major adverse cardiovascular events (MACE), mortality, and major adverse limb events (MALE) were assessed during three-year follow-up. Propensity weighting was used to adjust for baseline differences between patients taking and not taking ACEIs or ARBs. ACEIs or ARBs were prescribed to 269 (58%) patients. Patients prescribed ACEIs or ARBs had more baseline comorbidities including diabetes and hypertension (p<0.05). Patients prescribed ACEIs or ARBs had lower three-year unadjusted rates of MACE (40% versus 47%) and mortality (33% versus 43%). After propensity weighting, ACEI or ARB use was associated with significantly lower rates of MACE (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.58-0.99, p=0.04) and overall mortality (HR 0.71, 95% CI 0.53-0.95, p=0.02). There was no significant association between ACEI or ARB use and MALE (HR 0.97, 95% CI 0.69-1.35, p=0.2) or major amputation (HR 0.74, 95% CI 0.47-1.18, p=0.1). ACEI/ARB use is associated with lower MACE and mortality in patients with CLI, but there was no effect on limb-related outcomes.
authors.affiliation: Section of Cardiology, VA Eastern Colorado Healthcare System and Department of Medicine, University of Colorado, USA.
authors.forename: Ehrin J
authors.initials: EJ
authors.lastname: Armstrong
authors.affiliation: Vascular Center and Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, USA.
authors.forename: Debbie C
authors.initials: DC
authors.lastname: Chen
authors.affiliation: Vascular Center and Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, USA.
authors.forename: Gagan D
authors.initials: GD
authors.lastname: Singh
authors.affiliation: Vascular Center and Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, USA.
authors.forename: Ezra A
authors.initials: EA
authors.lastname: Amsterdam
authors.affiliation: Vascular Center and Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, USA john.laird@ucdmc.ucdavis.edu.
authors.forename: John R
authors.initials: JR
authors.lastname: Laird
mesh_terms: D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000209:etiology* / Q000517:prevention & control*; D016638:Critical Illness; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia / Q000150:complications*; D007866:Leg / Q000098:blood supply*; D008297:Male; D000090063:Proto-Oncogene Mas; D011518:Proto-Oncogene Proteins; D043562:Receptors, G-Protein-Coupled; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000090063:Proto-Oncogene Mas; D011518:Proto-Oncogene Proteins; D043562:Receptors, G-Protein-Coupled
keywords: adherence; angiotensin converting enzyme inhibitor; angiotensin receptor blocker; critical limb ischemia; guideline therapies; peripheral artery disease; prevention