Editor's Choice - A Systematic Review of Interventions to Improve Guideline Directed Secondary Cardiovascular Risk Reduction in Patients with Peripheral Arterial Disease.

Abstract

There is a persistent evidence to practice gap in implementing guideline directed secondary cardiovascular risk reduction for patients with peripheral arterial disease (PAD). Cardioprotective medications are significantly underused, and effective strategies to support clinician and patient adherence to guideline directed management are poorly understood. This systematic review synthesised evidence on interventions that enhance cardiovascular risk reduction and treatment adherence among patients with PAD. MEDLINE, Embase, and clinical trial databases (2000 - 2024) were searched for studies on interventions to reduce cardiovascular risk in patients with PAD. This included medication prescription and adherence, management of modifiable risk factors (lipids, hypertension, diabetes, smoking), or measures of composite cardiovascular risk (e.g., Framingham Risk Score). Independent reviewers extracted data and assessed study quality as per a pre-defined protocol. Primary outcomes were measured changes in cardiovascular risk. Secondary outcomes were intervention components contributing to behaviour change. Meta-analysis was not feasible due to heterogeneity. Twenty studies were included, encompassing 52 603 patients with PAD. Interventions were most effective in reducing low density lipoprotein cholesterol and increasing medication prescription, particularly statins and antithrombotics. Interventions were classified as nurse led care, patient or provider education, audit participation, and interprofessional care, or as multifaceted if there were multiple components (n = 7). Multifaceted interventions involved combinations of education, interprofessional, protocolised (e.g., algorithms, checklists), personalised, and integrated care, and were superior at improving cardiovascular risk reduction and associated with improved survival and reduced major adverse cardiovascular and limb events. Interventions aimed at changing patient behaviour alone were largely ineffective. Study quality was limited, and consistent outcome measurements were lacking. Multifaceted interventions that restructured care delivery systems were more effective than single component strategies to improve cardiovascular risks in patients with PAD. Interventions targeting both clinician support and patient access were most effective at improving medication prescription and reducing lipids.