title: Comparative Effectiveness of Medical Therapy, Supervised Exercise, and Revascularization for Patients With Intermittent Claudication: A Network Meta-analysis.
abstract: BACKGROUND
  There are limited data on the comparative effectiveness of medical therapy, supervised exercise, and revascularization to improve walking and quality of life in patients with intermittent claudication (IC).
  
  
  OBJECTIVE
  Supervised exercise and revascularization was superior to medical therapy in IC.
  
  
  METHODS
  We studied the comparative effectiveness of exercise training, medications, endovascular intervention, and surgical revascularization on outcomes including functional capacity (walking distance and timing), quality of life, and mortality. We searched PubMed, EMBASE, and the Cochrane Database of Systematic Reviews from January 1995 to August 2012 for relevant English-language studies. Two investigators independently collected data. Meta-analyses with random-effects models of direct comparisons were supplemented by mixed-treatment analyses to incorporate data from placebo comparisons, head-to-head comparisons, and multiple treatment arms.
  
  
  RESULTS
  Thirty-five unique studies evaluated treatment modalities in 7475 patients with IC. Compared with usual care, only exercise training improved both maximal walking distance (150 meters; 95% confidence interval: 35-266 meters, P = 0.01) and initial claudication distance (39 meters; 95% confidence interval: 9-65 meters, P = 0.003). All modalities were associated with improved quality of life (Short Form-36 physical functioning score) compared with usual care, but there were no differences between treatments. There were insufficient safety data to assess treatment-related complications. All-cause mortality was not significantly different between modalities.
  
  
  CONCLUSIONS
  Evidence is insufficient to determine treatment superiority for improving quality of life and walking parameters in IC patients. Further studies with attention to study design, standardized efficacy and safety endpoints, and appropriate subgroup reporting are necessary to determine comparative effectiveness.
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina.|Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Sreekanth
authors.initials: S
authors.lastname: Vemulapalli
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.|Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina.|Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors.forename: Rowena J
authors.initials: RJ
authors.lastname: Dolor
authors.affiliation: Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors.forename: Vic
authors.initials: V
authors.lastname: Hasselblad
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Sumeet
authors.initials: S
authors.lastname: Subherwal
authors.affiliation: Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Kristine M
authors.initials: KM
authors.lastname: Schmit
authors.affiliation: Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Brooke L
authors.initials: BL
authors.lastname: Heidenfelder
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina.|Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Manesh R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina.|Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: W
authors.initials: W
authors.lastname: Schuyler Jones
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000077407:Cilostazol; D057186:Comparative Effectiveness Research; D005081:Exercise Therapy / Q000379:methods*; D006801:Humans; D007383:Intermittent Claudication / Q000503:physiopathology / Q000628:therapy*; D035002:Lower Extremity / Q000098:blood supply*; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011788:Quality of Life; D013777:Tetrazoles / Q000627:therapeutic use*; D016138:Walking / Q000502:physiology*; D055815:Young Adult
chemical_list: D010975:Platelet Aggregation Inhibitors; D013777:Tetrazoles; D000077407:Cilostazol