Use of pharmacologic guideline-directed medical therapy for peripheral artery disease by sex among patients undergoing revascularization.

Abstract

Pharmacologic guideline-directed medical therapy (GDMT) for peripheral arterial disease (PAD) includes statin and antiplatelet agents, which has shown to decrease rates of major adverse cardiac and limb events. Despite this, historical use of pharmacologic GDMT has been low. Our objective was to evaluate the association of patient sex with the use of and trends in pre- and postprocedural pharmacologic GDMT among individuals undergoing intervention for infrainguinal PAD. We performed a retrospective cohort study of the Vascular Quality Initiative, a national vascular surgery quality improvement registry. The study population included patients with claudication or critical limb-threatening ischemia who underwent index infrainguinal open or endovascular intervention for PAD between 2013 and 2023. The primary exposure was self-reported sex, male or female. The primary outcome was the use of a statin and antiplatelet agent, either aspirin or P2Y12 inhibitor. Secondary outcomes include use of anticoagulants and angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers among individuals with hypertension. We studied the association of sex with pharmacologic GDMT use over time using descriptive statistics and multilevel multivariable logistic regression accounting for clustering by center. Our study cohort included 257,129 patients of whom 38% were female. Although preoperative use of statin and antiplatelet remained steady at 62% over the study period, postoperative use increased from 68% in 2013 to 81% in 2023. Compared with females, males were more likely to be on statin and antiplatelet preoperatively (P < .001) and postoperatively (P < .001) each year. Females had lower odds of statin and antiplatelet use preoperatively [odds ratio (OR), 0.88; 95% confidence interval (CI), 0.86-0.89] and postoperatively (OR, 0.84; 95% CI, 0.83-0.86), even after risk adjustment. Non-Hispanic Black patients (OR, 0.96; 95% CI, 0.94-0.99), increased disease severity (tissue loss vs claudication: OR, 0.60; 95% CI, 0.58-0.61), and emergent presentation (OR, 0.67; 95% CI, 0.62-0.73) were associated with lower odds of preoperative statin and antiplatelet use. Although the proportion of patients on pharmacologic GDMT postoperatively has increased over time, preoperative use has stagnated despite strong evidence supporting its use. Furthermore, sex-based differences persist at both time points, which may require targeted, multispecialty collaboration in quality improvement efforts to close this gap.