Sreekanth Vemulapalli1,2, Rowena J Dolor2,3,4, Vic Hasselblad4, Sumeet Subherwal2, Kristine M Schmit5, Brooke L Heidenfelder6, Manesh R Patel1,2, W Schuyler Jones1,2. 1. Division of Cardiology, Duke University Medical Center, Durham, North Carolina. 2. Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina. 3. Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina. 4. Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University, Durham, North Carolina. 5. Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina. 6. Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina.
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). HYPOTHESIS: 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.
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). HYPOTHESIS: 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: Marie D Gerhard-Herman; Heather L Gornik; Coletta Barrett; Neal R Barshes; Matthew A Corriere; Douglas E Drachman; Lee A Fleisher; Francis Gerry R Fowkes; Naomi M Hamburg; Scott Kinlay; Robert Lookstein; Sanjay Misra; Leila Mureebe; Jeffrey W Olin; Rajan A G Patel; Judith G Regensteiner; Andres Schanzer; Mehdi H Shishehbor; Kerry J Stewart; Diane Treat-Jacobson; M Eileen Walsh Journal: Circulation Date: 2016-11-13 Impact factor: 29.690
Authors: Maria Teresa B Abola; Jonathan Golledge; Tetsuro Miyata; Seung-Woon Rha; Bryan P Yan; Timothy C Dy; Marie Simonette V Ganzon; Pankaj Kumar Handa; Salim Harris; Jiang Zhisheng; Ramakrishna Pinjala; Peter Ashley Robless; Hiroyoshi Yokoi; Elaine B Alajar; April Ann Bermudez-Delos Santos; Elmer Jasper B Llanes; Gay Marjorie Obrado-Nabablit; Noemi S Pestaño; Felix Eduardo Punzalan; Bernadette Tumanan-Mendoza Journal: J Atheroscler Thromb Date: 2020-07-04 Impact factor: 4.928
Authors: Marie D Gerhard-Herman; Heather L Gornik; Coletta Barrett; Neal R Barshes; Matthew A Corriere; Douglas E Drachman; Lee A Fleisher; Francis Gerry R Fowkes; Naomi M Hamburg; Scott Kinlay; Robert Lookstein; Sanjay Misra; Leila Mureebe; Jeffrey W Olin; Rajan A G Patel; Judith G Regensteiner; Andres Schanzer; Mehdi H Shishehbor; Kerry J Stewart; Diane Treat-Jacobson; M Eileen Walsh Journal: Circulation Date: 2016-11-13 Impact factor: 29.690